This is an excerpt from my complete, downloadable policy here.
Introduction:
Medical students are unique users of social
networking tools like Facebook and Twitter, among others. In brief, I describe
five reasons for this: 1) The information that medical students steward is particularly
sensitive, the privacy of which is protected by federal legislation (HIPAA). 2)
Sharing patient information is central to both the practice and culture of
medicine. 3) Medical students have a lot to lose, both in terms of resources
invested and future career ramifications, if found in violation of privacy
rules. 4) Having matured entirely in the internet age, most today’s medical
students have deeply ingrained information sharing habits that are
incommensurate with the traditions of their profession. 5) There is a growing
body of MD’s, healthcare workers, pharmaceutical representatives, information
technology firms, and others, many with unclear motivation, who encourage
medical students to engage with social media without adequately preparing them
to be responsible.
In hopes of addressing these risks, this document discusses
separately the means to protect students themselves, their patients, and their
home institutions (medical schools, hospitals, and clinics), organized into 46
distinct points that deserve a thorough inspection and understanding.
Protecting Patients:
While upholding the legal responsibilities of patient
information is of primary importance, students must understand that they have
ethical and professional obligations above and beyond the requirements of HIPAA
legislation. These three areas are addressed separately.
Legal Obligations:
1- Students may not share any “‘individually identifiable health
information’… that relates to the individual’s past, present or future
physical or mental health or condition… for which there is a reasonable basis
to believe it can be used to identify the individual.”1 (Appendix A)
2- In addition, any shared
information must be expunged of 18 identifiers, the most common of which are
the following: (See appendix A for complete list)
- Name
- Location:
All subdivisions smaller than state (street, city, county, zip code, etc.)
- Date:
Birth dates, admission/discharge dates, encounter dates, surgery dates, etc.
- Images:
Full face photographic images and any comparable images
- Age if Above
90 Years
3- Since the specifics of a case
are protected, general comments about the uniqueness or other interesting
features of a presentation are unacceptable.
Examples:
“I
saw my first case of Guillain-Barre
syndrome today.”
“I
got to assist in the repair of a total anomalous pulmonary venous return!”
“This
lady had a birthmark that looked like China.”
“I
saw a guy with a tattoo of Gandhi.”
4- Since location is protected,
no information about patients may be shared on services that are location-aware,
such as a Facebook profile that includes the student’s city, or tweets that are
geo-tagged.
5- Since dates are protected, no
postings may be referred to by time, including use of the word “today,” as in,
“I participated in my first birth today!”
6- Pictures, even if not
including faces or any other identifying information, are unacceptable if they
relate to unique features.
7- Since age above 90 is
protected, one must describe encountering a 92 year-old as “a patient over 90
years old.”
Ethical Obligations:
Even if the patient information has been de-identified and
is therefore lawful to share, it may still be unethical or unprofessional. A
student should have an adequate grasp of the special ethical issues surrounding
patient care before engaging in any online discussion of experiences. The
following guidelines are addressed for each major ethical principle.2
Dignity- Student doctors should
empathize with patients as individuals capable of making choices based on their
particular values. Patients are vulnerable by definition, and especially
vulnerable when being discussed in public without the ability to represent
themselves.
8- Display empathy with shared
feelings rather than pronouncing judgments.
9- Don’t objectify patients as
disease states; use “patient with diabetes” rather than “diabetic.” Be
especially careful to avoid derisive terminology, for example “cabbage patch,”
a term sometimes used in the cardiac critical care unit.
10- Don’t demean choices that
patients make or the values that drive those choices. For example, never judge
the cause of a patient’s obesity or motivations for smoking.
Compassion- Student doctors
should demonstrate sympathy for suffering and misfortune and efforts to provide
relief, without prejudice. Casually discussing experiences in the day-to-day
jargon common among physicians demonstrates a lack of compassion to those
patients and their families, to others suffering with those same conditions,
and to all those in the caring community who empathize.
11- Don’t trivialize suffering by
speaking casually about a patient experience. Comments about an operation being
“cool” or showing excitement at seeing an exotic condition are inappropriate in
public.
12- Even if de-identified,
publicly sharing the gory details of a case, including pictures, show a lack of
concern for suffering.
13- Avoid including unnecessary
details (demographics, ethnicity, etc.) in support of stereotypes of certain
conditions.
Confidentiality- Although
confidentiality is protected by law, doctors must still pro-actively assure
patients of this. A student doctor maintaining an online presence gives cause
for doubt, which may discourage patients from seeking treatment and from being
open about sensitive details. Therefore, such practitioners should take the
extra effort to assure that their online behavior can’t be perceived as
violating confidentiality.
14- Don’t make jokes or other
comments that may be misinterpreted as a lapse in confidentiality.
15- Only share powerful, intimate
experiences to make a powerful point for an upright cause.
16- Be extra careful to identify
when you have been given permission to share information.
Honesty- Doctors are knowledge
workers, and their service to society depends on trust. It is important to
maintain a consistent message in the office and in public, including online.
17- Never write something that
you are not confident is true. Do not promote anything that you do not truly
support. Do not publish partial truths that may mislead. Do not make promises
you cannot keep. When possible, offer references.
Act in the Best Interest of
Patients.
18- Don’t be selfish- Online
content about patients should only be shared for their ultimate benefit. As in
all walks of medical life, you should always ask yourself if and how this
serves patient interests before posting.
19- Don’t post details in order
to impress, to achieve credibility or gravitas, to entertain, to shock, or to
ridicule.
20- Be open about conflicts of
interest.
21- Competence- Only offer
services that you can safely and effectively provide. Do not try to offer
interventions online if you lack the means to competently follow through.
22- Do not attempt to establish a
therapeutic relationship online. Instead, wait until guidelines for “best
practices” are established.
23- A special note on
“friending”- There is no reason, at least for a student doctor, to establish a
close relationship with select patients (i.e. friending on Facebook), unless
you previously know the person in a personal context outside of patient care.
If so, you should not discuss that patient’s care in any way.
Professional Obligations:
Unlike other industries, doctors have a contract with
society wherein they agree to provide services in their patients’ best
interests, superseding doctors’ own gains, financial or otherwise. Doctors have
a fiduciary responsibility not only to provide care at the bedside, but to
advocate for patients in the public space on social justice issues like access
to care and fairness of distribution and allocation of healthcare resources.
This translates to several obligations in the online space.
24- Social Justice: Student
doctors must develop an understanding of healthcare issues and work toward
becoming comfortable in advocating for their position. Online comments about
public policy should be restricted until this comfort has been reached, lest
impulsive opinions both mar the discourse and come back to haunt the student
later in their career.
25- Discipline: Just as society
relies on the medical profession to regulate itself, student doctors should
take action when they see others behave inappropriately online. When doing so,
students should be mindful to communicate only with those directly involved, in
private, and with great discretion. Additionally, students must recognize that
they may be taking online content out of context and should therefore approach
their colleagues delicately.
Protecting Institutions:
Medical schools and hospitals have special relationships
with their communities, forged on years of intense experience, sacrifice,
dedication, volunteerism, and shared community identity. As a member of such an
institution, a medical student represents a variety of groups, some obvious and
others less so. Since perception is reality online, students may easily find
themselves unintentionally speaking on behalf of groups in inappropriate ways.
Referent Groups that student doctors implicitly represent:
Medical School: Student’s class, entire student body, faculty and
staff, administration, and alumni.
Hospital: Patients—both current and past, staff, volunteers,
administration, and donors.
Community: All community members who identify with the hospital and
medical school as part of the place wherein they live.
The future: Since online text never dies, your comments also
represent the future members of each of these groups—future students, faculty,
community members, etc.—for untold years and amid shifting contexts.
26- Be familiar with your
institution’s online presence and refer comments with direct links to those
sources (homepage, Facebook page, etc.).
27- Check with the marketing
department before conducting online activities for a group within the
institution. Make sure that the presentation is in-line with the institution’s
public face.
28- Refrain from any comments
that you are not entirely comfortable making on behalf of the referent groups
listed above.
29- Be particularly respectful
when referencing your institutions. Since you are speaking in a mixed audience
on behalf of a mixed audience, always reflect on how each group that you
represent could interpret your comments.
30- Be polite. Address people
formally, avoid casual and inappropriate language, especially when offering
disagreement.
31- Be serious. Avoid spam or
other off-topic content.
32- Be supportive. Avoid
self-promotion for its own sake. Avoid cynicism. Be aware of your institution’s
values and standards.
33- Be responsible. Avoid posting
private material about any group members, including pictures or stories. Complaining
about members of your provider team on Facebook is a particularly common
transgression.
34- Be accurate. Make sure your
statements are in accordance with actual facts and refrain from speculation. If
you are not particularly knowledgeable, do not comment. If you make a mistake,
address it quickly, honestly, and openly.
35- Offer content that is high
quality and unique to your particular area of experience or expertise.
36- Be clear. Explicitly state
that you speak only for yourself, as in “opinions are my own.” If you do weigh
in on a topic related to the institution, state your role and relationship with
that institution. Do use your institution’s email address for within-group
correspondence so your identity is clear. Otherwise, use your personal email
address.
37- If dissatisfied with an
institution’s policy or action, discuss it first only with the people or
representatives responsible.
Protecting Students
Themselves:
All content posted online must be considered permanent,
searchable, and traceable. Additionally, comments on third party services like
Twitter and Facebook must be considered someone else’s intellectual property,
and they are free to distribute it or otherwise utilize it as they please.
38- First and foremost, to
protect yourself and your reputation, you must adhere to the above
recommendations, particularly patient privacy.
39- Establishing a robust,
quality online presence can create a visibility buffer, where positive content
about you rises to the top of search results.
40- Do not offer medical advice,
or anything that could be interpreted as medical advice.
42- Do not solicit, or interact
in a way that could be interpreted as soliciting, protected health information.
43- Reflect before you post.
Think about the different ways your content may be misconstrued. One mistake
may be sufficient to terminate an entire career.
44- As a future physician,
impulsive and uninformed comments made during training may be considered to
represent you at any point later in your career.
45- Comments on topics unrelated
to medicine may be considered reflective of your medical judgment and
trustworthiness.
46- Comments left on other
people’s content, such as blog posts, may be attached to the sentiment of those
posts, even if you are expressing disagreement.
