Social Media guidelines for Mayo Clinic Internal Medicine residents

1. Social Media and
e-Professionalism for Residents
Vandana Y. Bhide, MD
www.VeeMD.com
@VeeMD
VeeMD
#MayoClinicFL #HCSM #MedEd
©2010 MFMER | slide-1

2. Mayo Clinic Social Media Policy
• Strongly discourages ―friending‖ of patients on
social media websites
• Does not endorse people, products, services and
organizations.
• On social media websites such as LinkedIn,
where affiliation to Mayo Clinic is known,
personal recommendations should not be given
or requested
• Write in the first person…make it clear that you
are speaking for yourself and not on behalf of
Mayo Clinic
http://sharing.mayoclinic.org/guidelines/for-mayo-clinic-employees/

3. What would you
think if you saw this
picture on
Facebook and
realized he was
your doctor?
Collier, Roger Professionalism: Social
Media Mishaps CMAJ, September 4,
2012, 184(12)

4. Should physicians be held
to a higher standard than
the general public?
What do you think?

5. Physicians are held to a higher standard,
because of the trust placed on them by
patients and society

6. Medical Professionalism in the New
Millennium: A Physician Charter
• Professionalism is the basis of medicine‘s
contract with society
• Principle of primacy of patient welfare
• Commitment to patient confidentiality
• Commitment to maintaining appropriate relations
with patients
• Commitment to professional responsibilities
American Board of Internal Medicine, American College of Physicians,
European Federation of Internal Medicine Ann Intern Med. 5
February 2002;136(3):243-246

7. ―Physicians certainly have the right to have
private lives and relationships…but they must
also be mindful that their patients and the
public see them first and foremost as
professionals rather than private individuals
and view physician conduct through the lens
of their expectations about how an esteemed
member of the community should behave.‖
McMahon Sr, John W., Chair AMA
Professionalism in the Use of Social Media

8. AMA Professionalism in the Use of
Social Media
―Participating in social networking and other
similar Internet opportunities can support
physicians‘ personal expression, enable
individual physicians to have a professional
presence online, foster collegiality and
camaraderie within the profession, provide
opportunity to widely disseminate public
health messages...‖
McMahan, John W. , Chair.
Professionalism in the Use of Social
Media, June 2011

9. Intern writes about patient‘s
Facebook ―Friend Request‖
In an e-mail to students and faculty of Harvard
Medical School, Dean for Medical Education Jules
Dienstag wrote: ―Caution is recommended. . . in
using social networking sites such as Facebook…
Items that represent unprofessional behavior that
are posted by you on such networking sites reflect
poorly on you and the medical profession. Such
items may become public and could subject you to
unintended exposure and consequences.‖
Becoming a Physician: Practicing Medicine in the Age of Facebook
Sachin H. Jain, M.D., M.B.A. N Engl J Med 2009; 361:649-651August 13, 2009DOI:
10.1056/NEJMp0901277
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10. Federation of State Medical Boards
• Protect the Privacy and Confidentiality of
their patients
• Avoid requests for online medical advice
• Act with professionalism
• Be forthcoming about employment,
credentials and conflicts of interest
• Be aware that information posted online
may be available to anyone, and could be
misconstrued
Rhyne JA et al Federation of State Medical Boards Model Policy Guidelines for the
Appropriate Use of Social Media and Social Networking in Medical Practice
www.fsmb.org

11. Federation of State Medical Boards
• Protect the Privacy and Confidentiality of
their patients
Rhyne JA et al Federation of State Medical Boards Model Policy Guidelines for the
Appropriate Use of Social Media and Social Networking in Medical Practice
www.fsmb.org

12. ―Blatant violations
of patient privacy
and confidentiality
have occurred
when physicians
have posted
photos of patients
or described
situations with
enough identifying
information that
others may
decipher the
patient‘s identify.
http://www.ama-assn.org/resources/doc/codemedical-ethics/9124a.pdf

13. ―It seems that many of
these violations take place
because the Internet is
widely perceived to be
different from other public
environments, like hospital
corridors.‖
http://www.ama-assn.org/resources/doc/codemedical-ethics/9124a.pdf

14. ―Whereas in the past a physician may have been
concerned about a conversation being overheard
in an elevator by a handful of people, now a post
on a social networking site may reach millions of
people within a matter of minutes. Internet users
often experience a lack of inhibition and feeling of
anonymity.‖
McMahon Sr, John W., Chair, http://www.ama-assn.org/resources/doc/code-medicalethics/9124a.pdf
©2010 MFMER | slide-14

15. Physician Obligations—Same in person & online
• Privacy—to prevent unauthorized access to
patient data and to ensure that ―de-identified‖
data cannot be linked to the healthcare
professional or patient
Rhyne JA et al Federation of State Medical Boards Model Policy Guidelines for the Appropriate Use of Social
Media and Social Networking in Medical Practice www.fsmb.org
• The Online Conversation is the same as the
conversation in the Elevator or Hallway

16. "Physicians should be
cognizant of standards
of patient privacy and
confidentiality that must
be maintained in all
environments, including
online, and must refrain
from posting identifiable
patient information
online.‖
AMA Policy: Professionalism in the Use of Social
Media (June 2011)

17. ER Doc Violated
Patient Privacy
•
Westerly, Rhode Island
Dr. A.T., who worked at Westerly
Hospital, ―did not include the
patient‘s name [in Facebook], but
she wrote enough that others in
the community could identify the
patient‖ (Boston Globe).
•
An ―unauthorized third party‖ determined
the identity of the patient
•
Dr. A.T. deleted post and her Facebook
account, apologized
•
Fired from position as ER physician, fined
$500

18. ImpactedNurse.com
―An incident occurred where I unintentionally, but
very foolishly breached patient confidentiality and
hospital policy. I published a de-identified image
of an ‗interesting‘ skull x-ray on my Facebook
page, (in fact there was absolutely no information
attached to this image, and even I had no idea
who it belonged to, or what the clinical story
behind it was). Incredibly…this x-ray was in fact
correctly identified by a reader, who made an
official complaint. The resulting disciplinary
action brought my whole website/ Facebook
presence to an uncomfortable, and personally
distressing head‖

19. Avoid 18 HIPPA (Health Insurance Portability and
Accountability Act of 1996) Identifiers
1. Names
2. All geographical subdivisions smaller than a State
3. All elements of dates (except year) directly related to an individual, including birth date
4. Phone numbers
5. Fax numbers
6. Electronic mail addresses
7. Social Security numbers
8. Medical record number
9. Health plan beneficiary numbers
10. Account numbers
11. Certificate/license numbers
12. Vehicle identifiers and serial numbers, including license plate numbers
13. Device identifiers and serial numbers
14. Web Universal Resource Locators (URLs)
15. Internet Protocol (IP) address numbers
http://cphs.berkeley.edu/hipaa/hipaa18.html
http://privacyruleandresearch.nih.gov/
16. Biometric identifiers, including fingerprints
17. Full face photographic images and any comparable images
18. Any other unique identifying number, characteristic, or code
©2010 MFMER | slide-19

20. Online discussions of specific patients should be
avoided, even if all identifying information is
excluded. It is possible that someone could
recognize the patient to which you are referring
based upon the context
University of Utah Health Sciences Center: Office of
Graduate Medical Education Social Media Policy December
3, 2012

21. • Need to get
consent for
Photography
• Ask Mayo
Photographer to
take photo
• No Cell phone
pictures
• Don‘t let patients
email you their
photographs
• Wounds
• Cellulitis
borders

22. My Recommendation:
• Don‘t discuss patients (even if de-identified) on
social media platforms
• Don‘t discuss aspects of your professional life
(how many central lines you placed, how many
admissions you had, how hard you had to work,
how many times you were paged, how grateful a
patient was for your care, etc.)
• OK to discuss what you ate for dinner!

23. Federation of State Medical Boards
• Protect the Privacy and Confidentiality of
their patients
• Avoid requests for online medical advice
Rhyne JA et al Federation of State Medical Boards Model Policy Guidelines for the Appropriate Use of
Social Media and Social Networking in Medical Practice www.fsmb.org

24. Avoid Giving Advice Online
• Disclaimers that what you are writing
online does not constitute medical advice
may not be judicially sound
• It‘s easy to develop a physician-patient
relationship but hard to break it
--Arthur R. Derse, MD, JD, Director of the Center for Bioethics and Medical
Humanities, Medical College of Wisconsin
• Ok to discuss health topic in a general
way that would be applicable to a wide
number of patients

25. Make sure that you differentiate medical
opinions from medical facts. The world of
medicine is foreign to many, so readers
may take your words at face value. Try to
make clear what statements reflect your
personal beliefs
University of Utah Health Sciences Center: Office of
Graduate Medical Education Social Media Policy
December 3, 2012

26. Physician Blogs
• Study of 271 medical blogs:
three blogs showed recognizable
photographic images of patients
• 45 blogs included sufficient
information for patients to identify
their doctors or themselves
• Healthcare products were
promoted, either by images or
description in 31 blogs
Lagu Tara et al Content of weblogs written by health
professionals. J Gen Intern Med 23(10):1642-6
©2010 MFMER | slide-26

27. No Such Thing as an Anonymous Blog
• Defendant in a malpractice suit involving the death
of a 12-year-old patient was Ivy League-educated
pediatric pulmonologist RPL
• Opposing attorney discovered that RPL had
blogged about the case under the pseudonym
―Flea.‖ Attorney asked RPL in court if he was ―Flea‖
• ―In his blog, Flea had ridiculed the plaintiff's case
and the plaintiff's lawyer. He had revealed the
defense strategy. He had accused members of the
jury of dozing.‖ Jonathan Saltzman, Boston Globe 2007
http://www.boston.com/news/local/articles/2007/05/31/blogger_unmasked_court_case_upended/?page
=full
• Next day, Flea agreed to pay a ―substantial‖
settlement

28. How NOT to Blog About Your Job.
Especially If You Are a Doctor
―When you blog, think as if your boss is reading
it. If you feel uncomfortable about it, just don't
post it. Blogging is a public activity, every single
word can be potentially scrutinized and inspected
for adverse meaning.‖
Ves Dimov, M.D., Assistant Professor at University of Chicago, Board-certified in
Allergy/Immunology (Med/Peds) and Medicine
http://casesblog.blogspot.com/2005/08/simply-fired-how-not-to-blog-about.html

29. Why do intelligent
people do this?
• ? Free Speech or Patient
Privacy?
• Online Disinhibition effect:
• You don‘t know me
• You can‘t see me
Suler, J. (2004). CyberPsychology and Behavior, 7, 321-326
• Talking on the Internet, people
regress. It's that simple…People
regress, expressing sex and
aggression as they never would
face to face
Norman N. Holland, The Internet Regression John Suler‘s The
Psychology of Cyberspace Jan 1996
©2010 MFMER | slide-29

30. • Protect the Privacy and Confidentiality of
their patients
• Avoid requests for online medical advice
• Act with professionalism
Rhyne JA et al Federation of State Medical Boards Model Policy Guidelines
for the Appropriate Use of Social Media and Social Networking in Medical
Practice www.fsmb.org

31. ―The-Not-So-Private-Parts‖ (Kashmir Hill, Forbes)
• 4 nursing students,
including DB, were
expelled from
school for posting
photograph of
human placenta
• School claimed DB
displayed poor
judgment and failed
to live up to the
nursing
profession‘s ethical
standards

32. ―Placenta Lawsuit Gives Birth to Outrage‖
(Kashmir Hill, Forbes)
• ―Does this bit of over sharing warrant
expulsion? The placenta isn‘t identifiable in any
way…(it) disturbingly looks a bit like a small
roasted turkey. (I couldn‘t even tell it was a
placenta.)‖
• Kansas Judge Eric Melgren ruled that expulsion
was not warranted since her teacher allowed
photographs taken and should have expected
that the photographs would be viewed.
• (Including by the whole world on the internet I
guess!)

33. The Placenta Precedent
Federal District Judge Eric Melgren wrote:
Photos are taken to be viewed. When
[nursing student supervisor] D. granted
permission to take the photos, it was
unreasonable to assume that they would not
be viewed. If the photos were
objectionable…then it would not have
mattered whether the photos were viewed on
Facebook or elsewhere.

34. HIPPA Violation?
―No word on whether the placenta plans to
sue for invasion of its privacy.‖
--Kashmir Hill, Forbes
©2010 MFMER | slide-34

35. Online Posting of Unprofessional Conduct by Medical
Students Chretien KC et al JAMA. 2009;302(12):1309-1315. doi:10.1001/jama.2009.1387
• 78/130 US medical schools responded to survey
• 60% of schools reported students posting
inappropriate content on internet
• 13% reported patient confidentiality violations
• 48% reported racist remarks made by students
• 52% reported profanity online by students
• 39% reported photographs of intoxication
• 38% reported sexually suggestive content
• Only 38% of schools had online content policy
• 3 schools reported expulsion of a student
©2010 MFMER | slide-35

36. University of Florida Facebook Profiles
Thompson LA et al J Gen Intern Med. 2008 July; 23(7): 954–957
• Study evaluated 501 medical students (44.5% of
students) and 312 resident Facebook profiles
• Only 1/3 of accounts were private
• Qualitative review of 10 random profiles:
• Included profanity (―PIMP—Party of important male
physicians‖), ―Keep your ____ hand down in lecture‖
• Sexist comments (―Physicians looking for trophy
wives in training‖)
• Racial comments (―I should have gone to a Blacker
college‖)
©2010 MFMER | slide-36

37. “When you’re young, you know,
you make mistakes and you do
some stupid stuff. I want
everybody here to be careful
about what you post on
Facebook, because in the YouTube
age, whatever you do will be
pulled up again later somewhere
in your life.”
President Barack Obama to 9th grade class,
Wakefield High School, Virginia
©2010 MFMER | slide-37

38. Dr. Ryan Greysen, Assistant
Professor Hospital Internal Medicine
UCSF (R), staged a hypothetical
picture depicting alcohol without
intoxication. According to a survey of
State Medical Boards, SMB, this type
of online physician behavior could
potentially prompt investigation of
physician professionalism
A Word of Caution about
photographs depicting alcohol:
•It is better to avoid all pictures and
mentions of drinking
•Even when done on personal time
away from Mayo Clinic
•Even when ―drinking responsibly‖
©2010 MFMER | slide-38

39. • If they interact with patients on the Internet,
physicians must maintain appropriate
boundaries of the patient-physician
relationship
• Physicians should consider separating
personal and professional content online
AMA Policy: Professionalism in the Use of Social Media
©2010 MFER | slide-39

40. Depiction of
alcohol
Real Life
MASH?
©2010 MFMER | slide-40

41. 99 bottles of
rum on the
wall, 99
bottles of
rum…
©2010 MFMER | slide-41

42. • More drinking…
• Facebook
Groups:
Community
• Tags: Partying
doctors Haiti
©2010 MFMER | slide-42

43. Haiti
earthquake
relief
physician
volunteers
©2010 MFMER | slide-43

44. Facebook
pictures
denounced
by readers
for being in
poor taste
©2010 MFMER | slide-44

45. Smiling
before an
amputation
©2010 MFMER | slide-45

46. At least the
face is
obscured…..
would you
want this
picture of you
or a family
member
shown on
Facebook?
Does HIPPA
count in
Haiti?
©2010 MFMER | slide-46

47. YouTube Video of Physicians/Nurses
Laughing
• Unauthorized 3 minute YouTube video of
foreign object being removed from patient‘s
rectum
• Doctors and nurses laughing and cheering
YouTube surgery video spells trouble for docs: Philippine surgeons cheer after
removing object from patient's rectum Associated Press 4/16/2008 MSNBC.com
• Many other examples of YouTube videos, too
numerous to recount
©2010 MFMER | slide-47

48. This goes under the heading of Yes,
You can buy anything on eBay
• Dr. CEA, a surgeon in St. Augustine, FL, failed
American Board of Surgery exam in 2002
• Was allowed to review test results at the Board‘s
Philadelphia office
• Memorized test questions and answers
• Passed Surgery board exam in 2003
• August 2004 sold 86 questions (out of 290) on
eBay, registered through a friend
Doctor sold exam questions on eBay
The Florida surgeon has agreed to pay $36,000 in restitution. By Damon
Adams, amednews staff. June 20, 2005. http://www.amaassn.org/amednews/2005/06/20/prsf0620.htm

49. For Sale on eBay: General Surgery
Board Exam Review Questions
―These are the actual
certifying general surgery
board questions with
correct answers,
guaranteed to improve
your test score. A friend of
mine failed this written
exam, paid the $100 sitting
fee and flew to
Philadelphia to review his
test. ... Why take the
chance at failing, getting a
year behind your peers...?
Get an advantage now!"
Photograph by Ken Cole Dreamstime.com
http://www.florida-fishing-vacations-advisor.com/staugustine-fishing.html

50. Oh Boy, ebay error
• American Board of Surgery sued for copyright
infringement
• CEA relinquished his notes, was fined $36,000,
lost his board certification, lost his job in St.
Augustine
Photograph of St.
Augustine from The
Palm Beach Post
http://www.palmbeach
post.com/news/travel/
st-augustine-floridaspend-your-holidaysup-north/nLx6g/

51. • The internet is like Vegas: What happens
there stays there…
• Forever
• You can take it down but you can‘t take it
back

52. ―When you post something publicly online, it‘s
something that could be online in perpetuity‖
Humayan Chaudry, DO, President and CEO of the Federation of State Medical Boards

53. Physicians must recognize that
actions online and content posted
may negatively affect their reputations
among patients and colleagues, may
have consequences for their medical
careers (particularly for physicians-intraining and medical students), and
can undermine public trust in the
medical profession
AMA Policy: Professionalism in the Use of Social Media

54. ―something as seemingly innocuous as humor,
when taken out of context, could reach and be
misinterpreted by an unintended audience
(patients, superiors, future employers) and lead
to a tarnished reputation.‖
http://www.ama-assn.org/resources/doc/code-medical-ethics/9124a.pdf
©2010 MFMER | slide-54

55. Residents should consider that everything they post
online contributes to a lifetime record that is readily
accessible to others. Potential employers may use
social media to access this record to evaluate
applicants. Posting distasteful, immature, or offensive
content may eliminate job or other professional
opportunities. Residents must convey a professional
and ethical presence to all who might view their online
University of Utah Health Sciences Center: Office of Graduate Medical
Education Social Media Policy December 3, 2012

56. Use privacy settings to safeguard personal
information and content to the fullest extent
possible on social networking sites
AMA Policy: Professionalism in the Use of Social Media
©2010 MFMER | slide-56

57. Know Your Online Privacy Settings
―You can manage the privacy of your status
updates, photos and information using the
inline audience selector — when you share or
afterwards. Remember: the people you share
with can always share your information with
others, including apps.‖
Facebook.com
©2010 MFMER | slide-57

58. Facebook Privacy Settings
• Public (anyone in the world can see
your post)
• Remember you may be tagged in
photographs without knowing it
• Photographs/updates can be
downloaded or forwarded
• Make this visible to:
• Hide this from:
• (Your mother)
• (Your Attending)
©2010 MFMER | slide-58

59. Custom Privacy Settings on Facebook

60. Why I Can‘t Spend Time on Facebook

61. Questions?

62. Thank You

63. Social Media and e-Professionalism
for Residents
Vandana Y. Bhide, MD
Vitamin Vee Blog www.VeeMD.com
@VeeMD
VeeMD Channel
Vandana Bhide