The use of social media by physicians has increased substantially in recent years, with some estimates reporting increases from 41.6% in 2010 to as high as 90% in 2011.
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While personal use is more common, approximately 65% of physicians interact with various social media platforms for professional reasons.1
For example, some physicians use social media to promote positive health behaviors, debate health care policy, network with colleagues, and to educate their patients, peers, and students.As such, there is great potential for physician use of social media to improve health outcomes. However, protection of patient and physician privacy, distribution of inaccurate health care information, violation of personal–professional boundaries, misrepresentation of credentials, and bias in physicians' recommendations on social media remain significant concerns. Recognizing this, in 2010, the American Medical Association and, in 2013, the American College of Physicians (ACP) and the Federation of State Medical Boards (FSMB) published guidelines for the ethical use of social media by physicians.
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The ACP/FSMB policy statement advises that physicians must disclose any potential conflicts of interest (COI) when discussing their professional experiences online. These recommendations were (and to our knowledge remain) innovative; we are not aware of similar recommendations applying to other professional groups using social media (eg, lawyers and scientists). Despite this recommendation, data suggest that lack of disclosure by physicians continues to be a significant problem. In this commentary, we examine the challenges of disclosure on social media and propose potential solutions.The Importance of Disclosure
Industry relationships may explicitly or implicitly bias physicians in their reporting of research study results and in their declared medical management recommendations. Such conflicts may create risks for individual patients and can also undermine the integrity of the doctor–patient relationship. Disclosure of potential COI ensures such influences can at least be acknowledged and incorporated into the interpretation of online information. Physicians are already required to disclose potential COI during conference presentations, on submissions to medical journals, and to their employing institutions (eg, academic medical centers). While some may argue that disclosure can lead to misguided trust in the discloser,
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in general, disclosure serves to 1) caution readers, and 2) serve as a deterrent from engaging in these relationships when unethical.Current Status in Social Media
Are physicians following the ACP/FSMB policy recommendation on disclosure, and should consumers of social media be concerned about potential COI amongst physicians distributing health care information on these platforms? Available studies raise concerns.
Data about physicians' failure to disclose potential conflicts online predate the 2013 ACP/FSMB policy statement. In a 2012 survey of osteopathic and medicine boards in the United States, 92% indicated that at least one online professionalism violation had been reported to their board, and approximately 20% of these violations related to failure to disclose COI online.
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Data in the wake of the ACP/FSMB recommendations suggest that the current state of disclosure online is no better. In a study of US hematology-oncology specialists using Twitter, 79.5% had at least one financial COI.
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In a subsequent study, researchers analyzed the contents of the tweets of 156 hematology-oncology physicians with a financial COI of at least $1000 in general payments in 2014.7
Eighty-one percent of physicians mentioned at least one drug from a company for which they had a COI.7
Comparing 100 tweets about potentially conflicted drugs with 100 tweets about nonconflicted drugs at random, conflicted tweets were more likely to be positive, similarly likely to be neutral, and less likely to be negative.7
Of utmost concern, only 1.3% of these physicians included disclosures of their payments.7
Whether such potential biases exist among other specialties warrants further study.Future Directions
Current evidence suggests that physicians using social media commonly have potential COI, often discuss medications from a company for which they have a financial COI, are more likely to discuss these medications in a positive manner, and are rarely reporting their potential COI. In an era where disclosure of potential COI is standard in medical journals and conference presentations, why has it been so challenging to get physicians to disclose on social media, which has the potential to influence millions? Several possible explanations exist, each of which suggests a way forward to improve disclosure.
One explanation is simply that disclosure online is difficult because social media pose inherent challenges for disclosing potential COI. Content is often brief, with character limits often making it difficult to report disclosures. Furthermore, information distributed and shared by users of social media may not necessarily contain the original disclosure present in the initial post or physician's profile, if it was included. Lastly, a layperson may not fully comprehend potential conflicts in a manner similar to other physicians and scientists. Yet, these technical challenges are not insurmountable. On weblogs this may be achieved by explicitly reporting disclosures in the relevant post. Ideally, this should be reported in simplified language that a layperson could interpret. When using social media platforms where character limits apply (eg, Twitter), disclosure could be accomplished by providing an electronic “tag” or link to a standardized disclosure form, for example, International Committee of Medical Journal Editors, or to a public reporting database.
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Links could be made to publicly available online databases, such as the Centers for Medicare and Medicaid Services Open Payments system.Another explanation could be that physicians are unaware of recent ethics guidelines. Just as uptake of new clinical guidelines is notoriously delayed, so too might be uptake of ethical guidelines. However, this explanation is unconvincing. Ethics guidelines for disclosure on social media did not create a new ethical obligation; they applied an existing and well-established obligation to a new form of media. Nevertheless, additional educational efforts highlighting the importance of conflict of interest disclosure and management among physicians using social media could increase awareness of the requirement to disclose. These efforts should be developed with special attention to the undergraduate medical school level (as these future physicians are more likely to use social media and are at a critically impressionable period of their professional development).
A third explanation is the lack of enforcement online. Perhaps, as an unintended consequence of COI disclosure policies being formalized and enforced at conferences, in journal publications, and at physicians' institutional employers, physicians have a blind spot about social media. The blurred boundaries of social media between the personal and professional realms may also contribute to this. The absence of enforcement online only makes physicians' self-regulation as a profession more important. Medical professionals using social media must realize that the obligation to disclose is fundamentally an ethical one, independent of whether they are required to disclose as a matter of policy. Physicians should not post content for which they have a potential conflict when they cannot assure adequate disclosure. In certain circumstances, physicians may also need to consider reporting other physicians whom they know fail to disclose, perhaps to their professional associations.
With mounting evidence that industry relationships may bias the content of social media content, physicians who post must recognize their fundamentally ethical duty to disclose and manage potential COI in social media. In the meantime, more research examining the prevalence, impact of physicians' COI on social media content, and appropriate management strategies are clearly warranted.
Without improvements in COI disclosure and management on social media networks, trust in the medical profession and the validity of social media as an outlet for medical education are both in danger.
References
- Doctors, patients & social media.(Available at)
- Opinion 9.124. Professionalism in the use of social media.(AMA Code of Medical Ethics; Available at)
- Online medical professionalism: patient and public relationships: policy statement from the American College of Physicians and the Federation of State Medical Boards.Ann Intern Med. 2013; 158: 620-627
- Effect of physician disclosure of specialty bias on patient trust and treatment choice.Proc Natl Acad Sci USA. 2016; 113: 7465-7469
- Physician violations of online professionalism and disciplinary actions: a national survey of state medical boards.JAMA. 2012; 307: 1141-1142
- Financial conflicts of interest among hematologist-oncologists on Twitter.JAMA Intern Med. 2017; 177: 425-427
- Conflicts of interest in Twitter.Lancet Haematol. 2017; 4: e408-e409
- Physicians, social media, and conflict of interest.J Gen Intern Med. 2013; 28: 299-303
Article info
Publication history
Published online: March 09, 2018
Footnotes
Funding: JWM is supported by the following grants: National Institutes of Health (NIH)/National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)-R01DK089174, NIH/NIDDK-R01DK108784, and American Heart Association (AHA)-17MCPRP33400031.
Conflicts of Interest: All authors have nothing to disclose.
Authorship: All authors have had access to the data and have contributed to the preparation of the manuscript.
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