Social Media and Physicians’ Online Identity Crisis

Abstract

Physicians are increasingly counted among Face-book’s 1 billion users and Twitter’s 500 million members. Beyond these social media platforms, other innovative social media tools are being used in medical practice, including for online consultation,¹ in the conduct of clinical research,² and in medical school curricula.³ Social media content is brief, characterized as “many-to-many” communication, and able to spread rapidly across the Internet beyond a person’s control. These and other features of social media create new dimensions to traditional ethical issues, particularly around maintaining appropriate boundaries between physicians and patients.

Recognizing this challenge and given reports of physician misconduct online, institutions, medical boards, and physician organizations worldwide have promulgated recommendations for physician use of social media. A common theme among these recommendations—with a recent example from the American College of Physicians and Federation of State Medical Boards⁴—is that physicians should manage patient-physician boundaries online by separating their professional and personal identities. In this Viewpoint, we contend that this is operationally impossible, lacking in agreement among active physician social media users, inconsistent with the concept of professional identity, and potentially harmful to physicians and patients. A simpler approach that avoids these pitfalls asks physicians not whether potential social media content is personal or professional but whether it is appropriate for a public space.

Operationally Impossible

In ethics, “ought implies can,” meaning that an ethical claim is binding only if a person is actually able to carry out the required action. Separation of identities online is operationally impossible. With minimal information, searching the web can quickly connect professional and personal content. Ironically, recommendations acknowledge this but continue to recommend separating identities.⁴ Despite the increasing availability of paid services to monitor and control a person’s web presence, no current technology exists to overcome fully this practical barrier.

Lack of User Consensus

Separating professional and personal identities has been received with considerable skepticism, particularly among active physician users of social media. For many of these physicians, part of the draw of social media communication is this intentional blurring of boundaries, the leveling of hierarchies, and the value of transparency.⁵ Some might see social media as analogous to historical conceptions of the small-town physician or the psychiatrist with an in-home practice but on a new and grander scale. Disagreement with recommendations alone cannot settle the debate about separation of identities, but it suggests a significant barrier to physician endorsement and adoption.

Inconsistency With Professional Identity

Most fundamentally, separating professional and personal identities is inconsistent with the general concept of professional identity.⁶ In sociopsychological terms, professional identity is—empirically and theoretically—a sense of the professional self arising from a complex interplay of internal factors (eg, personal values) and external factors (eg, social contexts, roles, expectations). Applied to medicine, professional identify formation is necessary for success yet diverse in definition. Medical students adopt different identities over time (eg, from student to professional, from consumer of services to provider of services). Similar identity changes also occur for residents and experienced physicians, sometimes precipitated by changes in the external environment, including the emergence of social media.

Professional identity constitutes and is constituted by personal identity, perhaps as one of the many “subidentities” or roles individuals might have, such as spouse, parent, and so on. Separation therefore verges on nonsensical. Moreover, when recommendations fail to acknowledge the complex, mutable nature of professional identity and its inherent connection to personal identity, the recommendations fail to offer the unambiguous, practical guidance that is needed.

Potential Harms and Unrealized Benefits

Attempts to separate professional and personal identities online also may be inadvertently harmful. For physicians, harms might include the psychological or physical burden of trying to maintain 2 identities. Physicians are not required to avoid interacting personally with patients in other contexts. These interactions can be unavoidable (as in small or rural communities), personally rewarding, or even encouraged as part of community engagement. The scale of the online world is vastly greater, but the amount or type of personal elements shared can be limited through various technological controls.

Patients—many of whom come to appreciate their physicians as individual persons through office photos, books, and conversations—might miss out on certain benefits when their physicians choose to separate their personal identity online. A depersonalized online interaction might be less effective than it could be, for example, at normalizing difficult, shared emotions or at expressing empathy. It might also reduce trust in the patient-physician relationship more generally if patients sense that their physician is intentionally hiding something. To the extent that guidelines are concerned about trust and perceptions of the profession on social media, the image of a depersonalized or aloof physician is hardly preferred.

Resolving the Online Identity Crisis

Controversy regarding the line between professional and personal boundaries is not new. Both the lived experience of the small-town physician and the classic psychoanalytic debate between Freud (who favored distance and neutrality in the clinical encounter) and Ferenczi (who favored self-disclosure and co-participation) reflect this debate. What is new is social media’s capacity to expand these potential interactions. If complete separation of identities online is not a viable solution, what is?

The solution is not to eliminate boundaries and suggest that anything goes. Licensing boards universally and reasonably hold physicians to higher standards of behavior than the general public. Physicians also have privacy rights related to their personal lives that deserve protection. Nor is the solution to discard professional identity. Recent reforms in medical education increasingly and rightly focus on cultivating professional identity. Related as it is to character and virtue, professional identity should provide a foundation for ethical behavior in rapidly changing circumstances, such as social media, where permissible behaviors or competencies remain undeveloped.⁷

Resolving the online identity crisis requires recognizing that social media exist in primarily public or potentially public spaces, not exclusively professional or exclusively personal ones. Boundaries exist; they simply are not drawn around professional and personal identities, nor can they be. When a physician asks, “Should I post this on social media?” the answer does not depend on whether the content is professional or personal but instead depends on whether it is appropriate for a physician in a public space.

This approach has several advantages. First, it does not ask physicians to do the impossible, nor does it rely on an incorrect concept of professional identity. Second, it is likely to be more accepted by active physician social media users, in part by building on the vast experience physicians already have in navigating public spaces, rather than asking them to do something new or unfamiliar.

Third, this approach fits well within existing general professionalism curricula at medical schools, which encourage students to be mindful of professional identity in public and private spaces, not to fully separate their identities. This both highlights the incongruence between current guidelines and medical education and positions existing professionalism curricula to begin addressing ethical issues in social media. Medical training is a critical developmental period when social media can positively shape professional identity and vice versa. Resolving the supposed online identity crisis therefore requires explicitly incorporating social media into medical education and professionalism curricula. Absent this approach, the professional transgressions motivating guidelines will persist and the potential benefits of social media will remain unrealized.