Navigating Online and Social Media Relationships With Patients

Question: Should youth discharged from residential care be allowed to stay in contact with the caregivers/clinicians/staff/providers from the facility with whom they have built a trusting relationship and consider supportive adults via social media? 

Answer: There are two perspectives to consider in this important question. The first is the patient’s. The second is the provider perspective, and how providers can best navigate online and social media relationships with clients or patients. 

Generally, interaction with a patient happens in clinical settings, such as inpatient, clinics, and residential care. Connecting in more personal spaces, such as via social media profiles or a provider’s non-work settings, can blur the lines between personal and professional relationships and potentially violate HIPAA privacy protections. The blurring of these lines can be detrimental to a patient’s mental and physical health as social media can lead to oversharing or to an exchange of information in a manner that would be better managed in an office setting or through telemedical technology - consider the potential impact of frequency of contact (e.g., delayed responses or frequent messaging) and/or types of interactions (e.g., “likes” or sharing of posts). Institutions, hospitals and clinics are very careful around guidelines for how providers interact with patients outside the traditional clinical setting. Many of these recommendations state that connecting in a personal way, using a provider’s personal social media profile, has the potential for risk for patients and families. Large national, professional bodies such as the American Medical Association, American Psychological Association, and Federation of State Medical Boards have produced position statements related to social media. Though these statements may vary, their purpose is the same, to protect the health of patients. 

While it might be tempting to want to maintain supportive relationships beyond the bounds of treatment, providers, including physicians and mental health professionals, have a critical priority to support the patient’s mental and physical health as well as to operate with the bounds of their professional standards and ethics, and the law.  

From the provider standpoint, use of social media by physicians raises concerns related to self-disclosure or revealing too much personal information about that themselves. Studies have shown that physician self-disclosure may not be helpful even in an in-person clinical encounter. Even if a physician’s social media disclosure is appropriate, the personal nature of that disclosure may impact the physician-patient relationship, especially if it involves disparate views of topics related to religion, politics, etc. 

A second area to consider is how providers can navigate social media spaces more broadly in their professional roles. Given the rise of popularity in social media, many provider groups, including the American Academy of Pediatrics, have shared best practices for how to interact with patients and families via social media. Current recommendations note that providers and physicians should make a sharp distinction between their professional online identity and their personal one. Often this means that a provider would establish a professional social media profile separate from their personal one. And for provider’s personal social media, it is recommended that conservative privacy settings should be used.  

We recommend clinicians review the recommendations and guidelines shared by relevant professional bodies when deciding how to approach social media. Several of the recommendations have been shared below. 

Recommendations for Pediatricians outlined by Macauley and colleagues’ (2021) AAP Clinical Report: 

1. Pediatricians who choose to use social media should have separate personal and professional social media pages, with patients and their parents directed to the professional page. 
2. A pediatrician’s personal page should have adequate privacy settings to prevent unauthorized access. Professional pages should be set to prevent tagging. 
3. It is wise to pause before posting, given that information posted online can exist in perpetuity and can be captured and redisseminated by viewers before it can be deleted. 
4. Pediatricians should follow state and federal privacy and confidentiality laws as well as the social media policies of their health care organization and any professional society to which they belong. 
5. Independent practitioners should develop social media policies for their practices to protect patients and clarify expectations. These policies should be in writing and widely distributed to all staff and clinicians. If restrictions on communicating with patients are in place in such policies, this should be shared with patients. Given advances in technology, these policies should be reviewed regularly and updated as needed. 
6. Conflicts of interest, including in tweets, blog postings, and media appearances by pediatricians, should be disclosed. 
7. Pediatricians should use a HIPAA-compliant secure site with encryption when communicating about health care or rendering advice directly to patients or families. Individually identifiable protected health information should not be shared through social media without documented authorization from the patient or guardian. 
8. Before posting on social media, protected health information should be deidentified (and clearly noted to be so) and presented respectfully. 
9. Professional boundaries should be maintained in the use of social media. Accepting (and certainly initiating) friend requests from current patients is discouraged. It is up to the pediatrician’s discretion whether to accept such requests from former patients. It may be appropriate to accept a friend request from a patient’s parent if the physician’s relationship to that person extends beyond the clinical environment. 
10. Searching for patient information through the Internet or social media should have a specific purpose with clear clinical relevance. Any information obtained through this route should be shared directly with the patient to maximize transparency and before recording any such information in the patient’s chart. 
11. Pediatricians should monitor their online profile to protect against inaccurate postings. Negative online reviews warrant a thoughtful response that honors confidentiality requirements, including the fact that the reviewer is or was the physician’s patient. 
12. Pediatricians should recognize that providing specific medical advice to an individual through social media may create a physician-patient relationship that may have documentation, follow-up, state licensing, and liability implications. 

Social Media and Electronic Communications: Report and Recommendations of the Federation of State Medical Boards Ethnics and Professionalism Committee (April 2019): 

Relevant guidelines: 

• Politely turn down requests from patients to connect on social networking sites. It may be acceptable to accept requests on professional accounts, provided that the account is used for professional purposes only.  
• Communicate and engage in social media in personal and professional settings with civility and respect for others.  
• Comport yourself professionally, even when communicating or posting in a personal capacity. If you discover unprofessional or inappropriate content online posted by a professional colleague, notify the individual so that they may remove the post or change their methods of communicating. If the situation does not improve, report the behavior to the state medical board or other relevant authority. 
• Do not engage in disruptive behavior online such as cyberbullying, and report instances of such behavior by professional colleagues to the state medical board or other relevant authority. 
• Consider all online content as open and accessible to anyone, regardless of whether it is posted in a closed or private forum and regardless of privacy settings and levels of encryption used. 
• Consider any social media post as permanent, even after it has been deleted. 
• Do not provide medical advice to specific patients online, unless this is done via the secure patient portal of a practice or institution. 

AMA Code of Medical Ethics: 2.3.2 Professionalism in the Use of Social Media 

• (d) If they interact with patients on the Internet, physicians must maintain appropriate boundaries of the patient-physician relationship in accordance with professional ethics guidance just as they would in any other context.  
• (e) To maintain appropriate professional boundaries physicians should consider separating personal and professional content online. 

American Psychological Association Guidelines for the Optimal Use of Social Media in Professional Psychological Practice (October 2021)  

Relevant Guidelines: 

• Guideline 2.1: Psychologists are mindful of the public nature of social media and that their privacy and confidentiality often are not protected nor expected on social media.  
• Guideline 2.2: Psychologists are mindful of ethical and legal obligations to maintain client privacy and confidentiality at all times.  
• Guideline 2.4: Psychologists consider the need to avoid contact with their current or past clients on social media, recognizing that it may blur boundaries of the professional relationship. 
• Guideline 2.5: Psychologists are aware of the benefits of establishing a policy regarding their participation in social media and discussing this policy and their use of social media as part of the informed consent process with clients. 
• Guideline 3.2: Psychologists are aware of the need to educate and train students and staff under their supervision in the ethical and professional use of social media appropriate to their roles and responsibilities.  
• Guideline 3.3: Psychologists consider the needs for education, training, and professional development among their professional colleagues and collaborators regarding the ethical and professional use of social media. 

GoodTherapy: A Therapist’s Guide to Ethical Social Media Use: Includes information on setting boundaries, how to handle when a person in therapy sends a friend request, marketing on social media, and what to do when you make a post you regret.  

Social media guidelines: A review for health professionals and faculty members: Hennessy, Catherine M., Claire F. Smith, Sue Greener, and Gordon Ferns. "Social media guidelines: a review for health professionals and faculty members." The clinical teacher 16, no. 5 (2019): 442-447.  

References 

1. Shore, R., et al., Report of the AMA Council on Ethical and Judicial Affairs: professionalism in the use of social media. J Clin Ethics, 2011. 22(2): p. 165-72.
2. Snyder, L. and American College of Physicians Ethics Professionalism and Human Rights Committee, American College of Physicians Ethics Manual: sixth edition. Ann Intern Med, 2012. 156(1 Pt 2): p. 73-104.
3. Federation of State Medical Boards Special Committee on Ethics, Model Policy Guidelines for the Appropriate Use of Social Media and Social Networking in Medical Practice. 2012.
4. Fisher, J. and M. Clayton, Who gives a tweet: assessing patients' interest in the use of social media for health care. Worldviews Evid Based Nurs, 2012. 9(2): p. 100-8.
5. McDaniel, S.H., et al., Physician self-disclosure in primary care visits: enough about you, what about me? Arch Intern Med, 2007. 167(12): p. 1321-6.
6. Suler, J., The online disinhibition effect. Cyberpsychol Behav, 2004. 7(3): p. 321-6.
7. Guseh, J.S., 2nd, R.W. Brendel, and D.H. Brendel, Medical professionalism in the age of online social networking. J Med Ethics, 2009. 35(9): p. 584-6. 

Age: 10-24,  

Topics: Privacy, relationships, professional issues 

Role: Clinician