Neurologists and technology

Summary

Social and traditional media are revolutionizing health care. Medicine, once an art practiced behind closed doors, is now part of the public domain. This article will help neurologists navigate a complex maze of technology to optimize patient care without compromising privacy. We offer ideas for improving our digital “footprint.” Guidance is given on maintaining professional demeanor in all private and public interactions to help us avoid personal or patient insult and injury. Acknowledging that neurology is becoming a specialty of increased personal and social education, we outline ways to proactively improve our patient care and education locally and globally.

The expanding body of available information on neurologic issues, coupled with a populace seeking to remain well-informed, has created more opportunities for neurologists to educate the public. Patient care has expanded far beyond the office setting. Advocacy for our patients, their caregivers, and our colleagues remains one of our foremost responsibilities. Recognizing this, the American Academy of Neurology (AAN) has prepared hundreds of neurologists for more effective and informed advocacy through the Donald M. Palatucci Advocacy Leadership Forum (http://www.aan.com/go/advocacy/active/palf). A portion of this program trains advocates to interact with traditional and social media outlets, a critical element in both individual and collective advocacy.

Neurologists have more opportunities than ever to make use of traditional media for education and advocacy. Web-based media is revolutionizing health care delivery. A wealth of neurologic information is available at an individual's fingertips courtesy of “Google medicine.” Our patients may not be able to discern the wheat from the chaff and it behooves us to guide them to our AAN Web site and other valuable sources for credible content.

Recent research has shown that physicians are increasingly employing social media outlets (e.g., Facebook, Twitter, LinkedIn, Blogger, YouTube, MySpace, Foursquare). Some 90% of physicians utilize at least one social media modality in their personal lives, and 67% use one professionally. Facebook currently boasts over one billion active users, while Twitter claims more than 360 million, with tweets in the millions-per-minute range and climbing. Some 1,300 physicians are registered users of TwitterDoctors.net, a database of doctors who tweet health information. Another recent survey reported that for about 20% of US consumers, social media outlets are popular sources of health information.1 According to Pew data, 29% of cell phone owners ages 18–29 surveyed have used their phone to look up health or medical information and 15% of those ages 18–29 have software applications or "apps" on their phones that help them track or manage their health.2

A double-edged sword

Increased physician media presence has the potential to be a double-edged sword. Certainly, Internet-based communication can improve health care delivery through increased access to care and improved perception of health care quality.3 Blogging on patient and caregiver Web sites can also offer professional satisfaction and foster relationships that provide far-reaching benefits.

Maintaining professionalism in the face of widespread social media is particularly challenging.3 Published studies describing health professionals' use of blogs, Facebook, Twitter, and other social media outlets report that online posting of unprofessional content is common and includes violations of patients' privacy and confidentiality, as well as inappropriate language, sexually explicit material, and discriminatory statements.3 Some 90% of recently surveyed executive directors of medical and osteopathic boards indicated that at least one of several types of online professionalism violations had been reported to their board. The most common of these were inappropriate patient communication of a sexual nature, use of the Internet for inappropriate practice such as prescribing without an established clinical relationship, and online misrepresentation of credentials.4

Professionalism is a core competency required for maintenance of licensure and certification, and it has been suggested that consensus-driven, broadly disseminated principles should be developed to guide physicians toward high-integrity online interactions.4 Care should be taken to clearly describe certification and licensure on medical sites. Misrepresentation can contribute to legal consequences. Promotion of medications and treatments that are not Food and Drug Administration–approved should be avoided unless a full disclosure is provided. A 2009 study found 60% of medical school deans surveyed reported incidents where students had posted unprofessional content online.5 This certainly has many potential consequences, including negatively impacting future employment, as 70% of employers currently peruse social media sites prior to hiring.5 Vanderbilt University Medical Center is among the hospitals that have created a social media policy for faculty and students that does not discourage use of these media but provides boundaries if a person self-identifies as a medical center employee.6

What happens to us when we go online?

Why do online violations occur? Physicians are not immune to mistakes but this public venue magnifies transgressions and allows them to have a wider negative impact. In addition, individuals may not be aware that a response intended for one person may be forwarded to others. E-mail communications and postings leave a permanent residue in cyberspace. There is a false sense of privacy and anonymity inherent to online interactions, which may foster disinhibition.4,5 Second, a certain amount of user control is given up once material is posted online. While most social media accounts have privacy settings that allow the user to determine who is able to access postings, these have proven somewhat difficult to navigate. For instance, Facebook privacy settings may be set so that only “friends” may see one's general profile, though particular postings may be set to “public” so that anyone with an account may have access. Twitter allows the retweeting of postings, so that a single offhanded inappropriate tweet can circulate immediately and indefinitely.4 Third, private thoughts, writings, or photographs can rapidly become public through social media.4 Physicians' use of social media creates situations in which personal and professional lines may be blurred, and in which reputations among colleagues and patients may be affected adversely. Furthermore, actions taken online may affect the public's vision of and trust in the medical profession as a whole.7 Physicians should not do or say things online that they would not want disseminated to the world.

The code of medical ethics

The American Medical Association (AMA)'s Code of Medical Ethics gives guidance to physicians regarding professional interactions with their patients that applies to all communication settings.7 Such ethical mandates include upholding standards of professionalism and honesty in all interactions, respecting the rights of patients and other health care professionals regarding privacy and confidentiality, maintaining ethical obligations even when assuming positions not directly involving patient care, placing patient welfare above self-interest, and fostering trust in the physician–patient relationship.7 These guidelines also help physicians adhere to the Heath Information Portability and Accountability Act. Given the unique challenges imposed by social media, in 2011 the AMA Council on Ethical and Judicial Affairs published recommendations for maintaining professionalism online.5

Acknowledging that “participation 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, and provide opportunity to widely disseminate public health messages and other health communication,”5 the report admonishes physicians to weigh a number of considerations when maintaining an online presence. Examples include the following:

• Do not post any identifiable patient information without written consent

• Use privacy settings to safeguard personal information and content

• Routinely monitor personal online “footprint” (the total online content to which the public may have access) to ensure its accuracy and appropriateness

• Maintain appropriate boundaries in the physician–patient relationship

• Consider separating personal and professional content online (maintaining separate personal and professional social media profiles)

• Notify colleagues of any unprofessional content they see posted regarding that colleague, and notify the authorities if that content breaches professional norms

• Realize that actions taken online and content posted may negatively affect one's reputation among patients and colleagues, can have consequences for burgeoning medical careers, and can undermine public trust in the medical profession as a whole.7

Though caution should be exercised, physicians have the right to private lives and relationships in which they can express themselves freely. Physicians, in large part by virtue of their traditional role as trusted healers and esteemed members of society, have been held to a higher standard of professional conduct.8 In an editorial accompanying the above recommendations, medical ethicist Norman Quist8 suggests that the “democratization of medical information, the ‘friending’ of physicians by patients and other non-physicians, and the self-selected participation of physicians on social networks may contribute to a change in social status in keeping with society's desire to give up some professional vestiges in favor of interpersonal physician-patient relationships. It has been suggested that one effect of the undoing of the medical ‘God complex’ has been to humanize medicine and populate it with doctors who are fallible but professional.”9

Perhaps a good rule of thumb is that we should make sure that our conduct at all times justifies our patients' trust in us and the public's trust in the profession.9

Guide to creating and maintaining a “digital footprint”

Taking the “social media plunge” can have consequences regarding one's exposure and digital persona. Following are some recommendations:

• Be careful in maintaining control of your online profile. Think about the personal/professional image that is most accurate for you, and upload content that portrays this image.

• Institute strict privacy settings upon creation of social media accounts, and periodically check and update them. Remember that Facebook, for instance, enables one to change the privacy settings of individual postings or status updates, so that public posts that are visible to all users may be made from private accounts.

• Consider separate professional and personal accounts and try not to overlap. Some publications recommend physicians not “friend” their patients, though there may be some acceptable circumstances as long as professional boundaries are maintained.

• Frequently review online media presence by typing your name in a Google search. Remember to search your name in any form it might appear (e.g., Dr. Jones, John Jones, MD, Dr. John Jones).

• Monitor the content of physician rating Web sites, many of which give the opportunity for physician response to the reviews posted. Be careful not to respond or justify your actions with private patient information.

• Clearly identify that your opinions are yours alone and not endorsed by your employer.

• For a professional site, consider posting information about background, training, research, and business contact information.

• Consider a professional Twitter account to notify patients of upcoming educational opportunities and the latest research information.

• When communicating with patients, utilize the telephone for confidential information or a secure e-mail system that is regularly accessible. Some electronic medical records also allow for secure patient communication. Notify the patient that he or she should call 911 or go to the emergency room for an emergency. Indicate your average time to response and your coverage if away.

• Telemedicine is being used with increasing frequency in neurology. This is especially true with stroke cases, where interventions are often time-sensitive. Telemedicine rules and restrictions vary from state to state. Licensing and malpractice issues need to be clarified prior to initiation.

Finally, consider seeking the expertise of companies such Reputation.com (http://www.reputation.com/), which are developing a track record for helping shape personal and business presence online.

Improving patient care through the use of technology

Increasing one's media profile and patient interactions involves expenditures both in time and money. There are a variety of sources for educational material such as Medscape and Sermo. The AAN Web site (aan.com) and state medical society Web sites may also be helpful. Online sites such as OrganizedWisdom.com develop individual professional Web sites. These Web sites can contain links to patient education materials, educational videos, publications you have authored, and information about obtaining an appointment at your office. There are also online physician discussion lists such as Neurolist (www.neurolist.com), which can be helpful. Linking together of social media accounts and Web sites for broader reach and greater efficiency is recommended (e.g., Twitter to LinkedIn, Facebook to Twitter, professional Web site to all social media accounts so that one post goes to all outlets). Investing in portable “smart” devices such as iPad and iPhone may also aid in time management and efficiency.

Global implications for medical technology

Expansion of wireless Internet access to the most remote locations in the world opens the doors for the delivery of cutting edge health care to the underserved in those regions. Organizational partnerships among the World Federation of Neurology, AAN, and the WHO facilitate this effort. These organizations are developing specific strategies to evaluate and disseminate up-to-the-moment neurologic information. Opportunities for neurologists to educate the public, to develop wireless neurologic protocol applications, to help shape health care policy, and to otherwise collaborate to improve global brain health will continue to increase. Technology allows for improved national and international collaborations to improve care and research. It increases patient access to care and education. These interactions then also serve to improve our cultural understanding of neurologic disorders.

Remembering our roots

Advocating for our patients and our profession has never been more important. The future of neurology is limitless. We may no longer be hampered by our physical location and may be able to improve the care of patients virtually. Word of mouth will become more important as news of our successes and failures is disseminated widely through patient rating scales. We will have an opportunity to increase our collaborations for research and patients will become a more powerful force in their own health care education and decision-making. With this exposure comes both the opportunity to affect beneficial change and the responsibility to behave ethically and professionally so that trust is maintained.

STUDY FUNDING

No targeted funding reported.

DISCLOSURES

The authors report no disclosures relevant to the article. Go to Neurology.org/cp for full disclosures.

Correspondence to: dpotts@nctpc.com