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www.elsevier.es/rmuanl

REVIEW

ARTICLE

Social

networks

in

medical

practice

B.E.

Ibarra-Yruegas

a,∗

,

C.R.

Camara-Lemarroy

b

,

L.E.

Loredo-Díaz

a

,

O.

Kawas-Valle

a

aDepartmentofPsychiatryatthe‘‘Dr.JoséEleuterioGonzález’’UniversityHospitalattheAutonomousUniversityofNuevo

León,Monterrey,Mexico

bNeurologyServiceatthe‘‘Dr.JoséEleuterioGonzález’’UniversityHospitalattheAutonomousUniversityofNuevoLeón,

Monterrey,Mexico

Received28October2014;accepted27January2015 Availableonline14May2015

KEYWORDS Socialnetworks; Medical

professionalism; Medicalethics

Abstract Thenumberofsocialnetworkusersisrisingmeteorically,atrendthatalsoincludes health-careworkers.Eventhoughsocialnetworkingcanserveeducationalfunctionsandisan effectivemeansofcommunicatingmedicalresources,itisassociatedwithavarietyof impor-tantchallenges.Misuseofsocialnetworksbyhealth-careworkerscanhavedireconsequences, rangingfromseeminglysimpleissuessuchasaffectingthedoctor’sreputationtoseriouslegal matters.Maintainingprofessionalismandpreservingtheconceptsofconfidentialityandprivacy isessential.Inthisreviewwewillanalyzesomeofthedilemmasthathavebeenbroughtabout bytheuseofsocialnetworksinthehealthcareenvironment,aswellasexistingguidelineson thematter.

©2014UniversidadAutónomadeNuevoLeón.PublishedbyMassonDoymaMéxicoS.A.Thisis anopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/ by-nc-nd/4.0/).

Introduction

Theuseofelectronicinformationtools,includingtheuseof socialnetworks(SNs), haveleddoctorstoreconsider how

Correspondingauthorat:DepartamentodePsiquiatría,

Hospi-talUniversitario‘‘Dr.JoséEleuterioGonzález’’delaUniversidad AutónomadeNuevoLeón,Monterrey,MaderoyGonzalitosS/N, Mon-terrey,NL64460,Mexico.Tel.:+528183480585;

fax:+528183480585.

E-mailaddress:bettiyruegas@hotmail.com (B.E.Ibarra-Yruegas).

toapplythecodeofethicsthatgovernthedoctor---patient relationshipandmaintaintheirprofessionalbehavior.Even though these mediums present interesting possibilities of beneficial interactions, they also bring with them differ-ent ethicaland professionaldilemmas. Some of themain challengeswe facewhenusingthesetechnologiesarethe preservationofconfidentialityandprivacyandmaintaining theboundariesofthedoctor---patientrelationship,aswellas reducingthepossibilityofmakingpublicinformationwhich maybeunprofessional,improperandevenillegal.1,2

There are many SNs, among which the most popular areFacebook,TwitterandLinkedIn(Table1).Togetherthis groupoftechnologieshasbeendefinedas‘‘Web2.0’’.1,2In

http://dx.doi.org/10.1016/j.rmu.2015.01.008

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Table 1 Social networks and other electronic mediums (non-exhaustivelist).

•Facebook

•LinkedIn •Youtube

•Twitter •Instagram

•MySpace •Flickr

recentyears,theriseinpopularityanduseofsaidSNshas beenexponential.UptoJune2014,Facebookreported1.32 billionmonthlyusers.3Inthisreview,asummaryofthe avail-ableinformationontheimpactofSNs onmodernmedical practicewillbemade,highlightingtheethicalcomplexities thatthesemayinvolve.

Health

2.0

‘‘Health 2.0’’ is a new concept which comprises the use of technology to promote and facilitate the interaction betweenhealthcareprovidersandpatients.

Itincludesthesearchforinformation,medicaladvances, updates and education in the field of healthcare.4 Even though this definition is not universally accepted, the conceptappearsindifferentscientificpublications,andthe impactthat this will have onthe evolution of healthcare serviceshasnotyetbeenfullyestablished.5

The use of SNs can bring benefits to the institutions in charge of healthcare as well as the patients and the clinicians.Theinstitutionsmayusethemaspublicity, cus-tomerservice,andpatienteducation;ontheotherhand,the patientscanuseSNs toobtaininformation,evaluate their progressandreceivesupport.Finally,clinicianscanobtain updated information, providing facilities in the research areaafastmeansofcommunicationbetweencolleaguesin ordertocommentoncomplicatedcases.6

Inameta-analysisoftheliteratureontheuseofSNsby patients,resultsshowedthatalmost30%ofthenusesome kindofSNor‘‘blog’’relatedtotheirdisease.7Inthe major-ityof cases,theintentionof thisconductwastoeducate themselvesontopicsrelatedtoself-care.Infact,ithasbeen determinedthat thereare 757 pagesof SNs dedicated to groupsofpatientswithspecificdiseases.Someofthemost prevalent, according tothe International Classification of Diseases10,haveover300,000users.8

Use

of

social

networks:

benefits

and

challenges

Nowadays SNs are considered a useful tool for medical teaching and practice.9 Although using it brings benefits like facilitating information to patients, a quick commu-nicationchannel betweenthe doctor andthepatient and theestablishmentofnationalandinternationalprofessional networks,italsoconfrontsuswithdifferentchallengeslike preservingconfidentiality,privacy,maintaining the bound-aries in the doctor---patient relationship and maintaining

Table2 SomeofthepotentialdangersoftheuseofSNsby doctors.

•Lossofconfidenceinthedoctor---patientrelationship.

•Divulgenceofthepatients’confidentialinformation, whichmaybepunishablebylaw.

•Publicationofimpropermaterialwhichbringsintodoubt theprofessionalismandprestigeofthedoctoror institutionwhereoneworks.

•Associationwithfalseinformationorfraudulent treatments.

•Disappearanceofthedistinctionbetweenprofessional andsocialbehavior,publicandprivate,inthelifeofthe doctor.

professionalbehavior(inTable2thereisalistofsomeareas whereSNspresentdangersinthemedicalpractice).

Even though there are some cases where online ‘‘surveillance’’ of the current state of the patient has had beneficial results (notably in suicide watch cases, or a monitoring of neurological symptoms after a cere-bral concussion), these are anecdotal, and in everyday practiceelectronicdoctor---patientinteractionsbringmore complicationsthanbenefitsmostofthetime.10,11

(a) Confidentiality

Oneofthebasicprinciplesinthedoctor---patient relation-shipisconfidentiality.However,itisdifficulttomaintainin thecontextofelectronicregistries.Theretentionperiodof theseregistriesmaybeundeterminedandaccessmaynot alwaysberestricted.

The most common examples where the use of SNs comestoviolatemedicalconfidentialityincludecaseswhere images, where there is the possibility of identifying the patientbecauseofspecificcharacteristics,aremadepublic, eitherbyshowinghis/herface,some partofhis/herbody orobjectsmarkedwiththelogoofaspecificinstitution.12,13 Someexpertsconsiderthatevenwhenallinformationwhich mayleadtotherecognitionofthepatientisremoved,there is still the possibility that someone may recognize them throughcontext.Therefore,discussingclinicalcasesin an openforumshouldbeavoided.

Theuseofexpressionsorimproperlanguageinthe con-textof thepublicationofsaidimageshasevenledtothe termination of the doctors responsible. On this point, it isimportant toclarifythat insome countriesthe existing medical---legalguidelinesregardingmedicalconfidentiality alsoapply toinformationdisclosed online, and the viola-tionsof this classaresubjectto disciplinaryand/or legal action.

(b) Privacy

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published information. Once the information is published online,itmaybedifficulttoeliminate.

TherearemanyotherinstanceswheretheuseofSNsby healthprofessionalscanleadtosituationswhichviolatethe privacyofthepatients.

Beneficenceistheconceptthatthedoctoralwaystriesto dogoodforthepatients.Inpsychiatry,therearecaseswhere a therapist has obtained information about the patient throughhis/herSNpageswiththepurposeofmakinga bet-terallianceandtherapeuticplan(i.e.regardingatraumatic background). Nevertheless, the patient found out about this,feltaninvasionofprivacyanddecidedtoendthe ther-apeutic relationship.14 In this case the doctor may argue havingacted under theconcept of beneficence, but with consequencescompletelyoppositethanthoseexpected.To accessSNswiththepatient’sconsentmayofferthedoctor importantinformationanditmaybeproductiveforhis/her treatment,butdoingthiswithoutthepatient’sconsentmay leadtoalossofdoctor---patienttrust.11

TheuseofSNshassubstantiallyimpactedtheworkand privatelifeofhealthprofessionals.Agoodexampleofthisis thecompetenceforadmissiontogeneralmedicineprograms atahighereducationsystem,aswellasintheworking envi-ronment,withinterviewprocesses,personalorstandardized evaluationsandpanelsofrepresentativesthatusuallymake adecision, at the end of theprocess choosingthe candi-date witha certain group of characteristics desirable for aninstitution.Tomakeuseoftheinformationavailableon SNsconstitutesanotherareaofcontroversyintheselection processesmentionedabove.Almost70%ofhumanresources professionalsfromdifferentinstitutionsadmittedtohaving usedSNstoobtain informationabout acandidate, signifi-cantlyinfluencingtheiracceptance/rejectiondecisionfora professionalposition.15Inasurveyconductedamong direc-torsofprogramsofmedicalresidencies,17%hadusedaSN toassessacandidate,modifyingthecandidate’splaceina prioritylistin 33%of thesecases.16 Inourstudy of candi-datesforanorthopedicsurgeryresidency,itwasfoundthat nearhalf of them (200 candidates) had a SN profile. Our ofthese,85%didnothaverestricted accesstothem,and unprofessionalcontentwasfoundin16%.17

Candidatesshouldmakesuretheironlineprofilesreflect standards of professionalism, as well as stress their aca-demic strengths and personal accomplishments. This has certainlyraised ethicaland legalconsiderations,concepts likeprivacy,discriminationandprofessionalism.18

The use of portable smart deviceslike cellphones and tablets complicates the panorama regarding the preser-vation of privacy. In surveys, close to 20% of residents communicate with patients via email using their phones. Out of these, 73% did not have their device password-protected.19 This information, provided by the patient, wouldbe at riskof being madepublic ifthe devicewere lost.TheuseofappslikeWhatsapp,anextremelypopular communicationtoolamongmedicalcolleagues,alsoleaves an electronic trace of information for an undetermined periodoftime:legal implications tomakingthis informa-tionpublichavenotyetbeenestablished.Inarecentstudy, around95%ofmedicalstudentsadmittedtohavingusedtext messagingthroughtheirmobilephonestoreceivepatients’ information,andoutofthesejust50%hadsecuritymeasures toaccesstheirdevice.20Whiletextmessagingbetweenthe

doctor andthe patientsor other colleagues canfacilitate communication, most doctorsfeartheseinteractions may transgressprivacy.1,21

(c) Maintaininglimitsinthedoctor---patientrelationship

Ithasbeenproventhatpatientsaretheoneswhosend ‘‘friendrequests’’via Facebooktotheirdoctors,yetthey respondtotheserequestsononlyafewoccasions.22,23Ina recentstudy,around35%ofexternal doctorshadreceived afriendrequestonFacebook,whiletheratewascloserto 8%forresidents.23Inmostcases,thedoctorsconsideredthe requeststobeunethical,eitherformedicalorpersonal rea-sons.Indeed,allavailableguidelinessuggesttherejection ofthesetypesofrequests.

(d) Professionalismande-professionalism

Health institutions have developed disciplinary guide-lines with the purpose of ensuring an adequate public image.Someauthorshaveevendevelopedtheconceptof e-professionalism(estandsforelectronic).Cainetal.define thisconceptasthoseattitudesandbehaviors(someofwhich mayoccurinprivate)whichreflecttheparadigmsof tradi-tionalprofessionalism,manifested throughsocial media.24 This concept successfullytranslatesthe ideaof professio-nalism,usuallyconsideredonlyinthe‘‘realworld’’andin specificcontexts(work,academic),tothe‘‘online’’world. ItinvolvesthewayprofessionalspresentthemselvesinSNs andhowitshouldbesubjected tothesame exigenciesas theonesintheirworkenvironment.

Somefactorswhicharebelievedtopromotethelackof professionalisminSNsaretheapparentstateofanonymity andtheperceptionofprivacy bytheuser.25,26Information whichmayquestiontheprestigeofthedoctororinstitution whichhe/sheworksfor(forexample,avideowasuploaded toYoutubewhereagroupof medicalstudentswere danc-ingmockinglywithskeletonsanddrinkingfromskullsused as containers, making the logo of the implicated institu-tion visible)27 or any contentincluding explicit, sexualor offensiveimagesinvolvingalcoholordrugconsumptioncan negativelyaffecttheprestigeofadoctororstudent.Astudy of graduates of a medicalschool reports that 37% of the graduateswhouseanytypeof SNpublishinformationlike sexualorientation,maritalstatus,religionandpicturesof themselvesintoxicatedbydifferentsubstances.28

Emphasismust be madeon thefact that shared infor-mation through SNs is subject to the same standards of professionalismasanyotherinterpersonalinteraction.

Almost 60% of North American medical schools report incidentsinvolving students andthe publicationof unpro-fessionalcontentontheirSNs.29

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legallyresponsible.25,26 Nevertheless,the legalboundaries regardingtheconceptofprivacyarenotentirelyclear.18

(e) Regardingcolleagues

Considering that the main function of SNs is to pro-mote communication and interconnectivity among users, notsurprisinglymanytimesthefirsttonoticeprofessional transgressionsarecolleagues.This bringsawholenewset ofethicaldilemmasintothemedicalpractice.Shoulda doc-tor,residentorstudentreportthisactivitytotheauthorities oftheinstitution?Guidelinessuggestinthefirstinstanceto approachtheimplicatedcolleague,andturntothe author-itiesonlyif,despitetheintervention,thereisnochangein thecontentorconductoftheimplicatedperson.1,25,26

Anotherimportantpointregardingmedicalethicsisthat, undercertaincircumstanceswithintheprofessional medi-cal environment, it is considered an obligation to report anymedicaldisabilityorincompetence,whenthereis evi-dence.Disabilityreferstoaprocesswhichimpedesproper executionof themedicalpracticeasaresultof anillness (i.e.dementia)orsubstanceabuse(i.e.alcoholism),while incompetencereferstoa lackof knowledgeorthe neces-saryabilities.Whatwouldtheimplicationsbeofobtaining informationaboutacolleague’smedicalinabilityor incom-petence from a SN? For example, a surgeon may reveal, only to a few people throughtheir SN, that he hasearly Parkinson’sdisease.Basedontheprinciplepreviously men-tioned, one would be obliged to report this situation to the authorities of the institution, or in some cases the police.Thesecircumstancesrepresentethical,professional andlegaldilemmas,whicharestillintheprocessofbeing solved.

Social

networks

in

psychiatry

The incursion of SNs in medical practice has presented particularchallengesandbenefitsinpsychiatry.95%of psy-chiatry residentshave SN pages, about 10% ofthem have receivedfriendship requests fromtheir patients, and18% haveentered someoftheirpatients’ SNpages.23 Wehave commentedspecificcaseswhereprivacyandtrusthavebeen transgressedinthepatient---therapistrelationship.

ConceptslikeaddictiontoSNs,canbecomeanew diag-nosisandagreatchallengeinmodernpsychiatry.31On the other hand,theuseof socialmediahasopened newlines ofinvestigationandevaluationopportunities.Forexample, arecentstudyprovedthatSNactivity(numberofpictures, friendships,amount ofinformation,usagehours,etc.)can predict the type of personality disorder (schizotipy) in a groupofoutpatientsubjects.32

The impactofSNsonpsychiatryisvastandwillremain inconstantchangeandevolutionforyearstocome.

Guidelines

and

recommendations

Despite the uncertainty surrounding the use of SNs in a medical context, several professional associations have accomplished major advances in the regulation of these activities. Some have even published formal recommen-dations, as well as specific guidelines, like the American

Table3 Guidelinestofollowintheuseofsocialnetworks.

GuidelinesoftheUniversityofVanderbilt(Takenfrom Landmanetal.,2010)

•Monitortheironlinereputation

•Understandtheprivacymeasuresofthesocialnetwork theyutilize

•Keeptheiraudienceinmind

•Beconsciousofthepermanencyofonlinecontent

GuidelinesoftheAmericanCollegeofPhysicians(Taken fromFarnanetal.,2013)

•Applyethicalprinciplestopreserveconfidentiality, privacy,respectandthedoctor---patientrelationship •Keeptheprofessionalsphereandtheonlinesocialsphere

separate

•E-mailandotherelectronicmediumsshouldonlybeused bydoctorsinestablisheddoctor---patientrelationships, andunderinformedconsent

•Periodicallyreviewtheinformationavailableonline regardingyourperson

GuidelinesoftheAmericanMedicalAssociation(Taken fromShoreetal.,2011)

•Donotmakeidentifiablepatientinformationavailable online,keepingstrictstandardsofprivacyand confidentiality

•Monitortheironlinepresenceandusethehighest methodsofprivacywhenusingasocialnetwork •Beguidedbythesameethicprofessionalprinciplesin

interactionswithpatientsonlineasthosethatapplyto anyothercontext

•Separatesocialandprofessionalonlinecontent •Ifadoctorfindsinappropriateorunprofessionalcontent

madeavailablebyacolleague,hehastheresponsibility tobringittohisknowledgesothatcorrectiveactioncan betaken.Ifitisnottaken,orthecontentviolates professionalnorms,hehastheobligationtoreportitto thecorrectauthorities

•Doctorsmustbeconsciousthattheiractionsandcontent onlinemayaffecttheirownreputations,aswellastheir patients’,andmayaffecttheircareersaswellastheir credibilityasamedicalprofessional

CollegeofPhysiciansattheUniversityofVanderbiltandthe AmericanMedicalAssociation,amongothers.1,2,33However, theuniversalizationoftheseguidelineshasbeen slowand incomplete.

Inastudywherewebpagesfrom132accredited medi-calschools(intheUSA)werebeingevaluated,only10%had guidelinesorpolicieswhichmentionedinaspecificmanner theproperwayofutilizingSNsfortheirstudents.34 Summ-ariesofsomeoftheseguidelinescanbefoundinTable3.

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regarding the use of the highest and most strict privacy measures.

How

can

‘‘

e

-professionalism’’

be

taught?

Alloftheaboverecommendationsmake cleartheneed to include this topic in medical education programs. There havebeenstudiesconductedwhichhavemadeuseful rec-ommendationsfortheteachingofelectronicprofessionalism todoctorsandmedicalstudents.Asimplespreadingofthe guidelinesmay be insufficient. The use of scenario simu-lationwhere professionalismisviolatedonSNs, aswell as suggestionsofuse,canbevaluableinterventions.35Mentor observationandthepresentationofexamplesoftheproper useof SNs arean importantpart ofthe educationof stu-dentsofthemedicalfield.26Inastudy,itwasdemonstrated that after going toa class where they presented specific casesofviolationofonlineprofessionalism,explainingthe consequencesandthestepstofollowindetail,agroupof radiologyresidentshadacquiredabetterunderstandingof theprofessionalismandimportanceofpreservingthe con-fidentialityandprivacy oftheir patientsandcolleagues.36 Thesesimpleinterventionsseemtobeeffective,evenafter asingleacademicsession.

Conclusions

Itis clearthat thepopularityof SNs does notseemtobe slowing down. It is more and more common for doctors, residents,students and healthcareprofessionals to inter-act,onewayoranother,throughelectronicmediaandSNs, whetheramongthemselvesorwiththeirpatients.Thisfact hasbeen associatedwithdifferent ethical,legal and pro-fessional difficulties, some of which we have reviewed. However,therearespecific guidelinesformulated toface these challenges. Moreover, these mediums have opened newwaystoimprovemedicallearningandhealthcare man-agement. Institutions should adopt or create guidelines whichensureaprofessionalandproperuseofSNs,andits trainingshouldbearegularpartofthecurriculumin facul-tiesofmedicine.Thisway,healthcareprofessionalswillbe betterpreparedtofacethechallengewhichwearefacing inmoderntechnologyera.

Conflict

of

interest

Theauthorshavenoconflictsofinteresttodeclare.

References

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9.CartledgeP,MillerM,PhillipsB.Theuseofsocial-networking sitesinmedicaleducation.MedTeach.2013;35:847---57. 10.AhmedOH,SullivanSJ,SchneidersAG,etal.Ethical

consider-ationsinusingFacebookforhealthcaresupport:acasestudy usingconcussionmanagement.PMR.2013;5:328---34.

11.Ogburn KM,Messias E,Buckley PF. New-agepatient commu-nications through social networks. Gen Hosp Psychiatry. 2011;33:200.

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14.WhiteH.LocatingclinicalboundariesintheWorldWideWeb. AmJPsychiatry.2009;166:620---1.

15.ToorA.70%ofemployershaverejectedapplicantsoveronline info; 2010, January 28 http://www.switched.com/2010/ 01/28/happy-data-privacy-day-70-of-job-applicants-rejected-over-onli/

16.GoPH,KlaassenZ,ChamberlainRS.Attitudesandpracticesof surgeryresidencyprogramdirectorstowardtheuseofsocial networkingprofilestoselectresidencycandidates: a nation-widesurveyanalysis.JSurgEduc.2012;69:292---300.

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19.BaerW,SchwartzAC.Teachingprofessionalisminthedigitalage onthepsychiatricconsultation-liaisonservice.Psychosomatics. 2011;52:303---9.

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Figure

Table 1 Social networks and other electronic mediums (non-exhaustive list). • Facebook • LinkedIn • Youtube • Twitter • Instagram • MySpace • Flickr

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