A decade ago, few retina specialists worried about whether to invest time or energy in cultivating a social media presence. Having a static, easy-to-maintain professional website was not unusual, but there was a significant lag between the launch of popular social media sites such as Facebook (launched in 2004) and Twitter (launched in 2006), and their business-oriented use by physicians.

Today, however, the question of whether to participate in social media is one that nearly every physician must entertain. And the list of social media options just keeps expanding — for example, Instagram, now one of the most popular platforms, joined YouTube (launched in 2005), LinkedIn (launched in 2003), Facebook, and Twitter in 2010. The temptation — as well as the pressure — to participate in 2019 can be strong because of widely recognized rewards.

“Well before the era of ubiquitous social media, when I was still a medical student, I was interested in how late-breaking research advances can quickly change the way we understand biology, disease, and patient care,” says Rajesh C. Rao, MD, Leonard G. Miller Professor of Ophthalmology and Visual Sciences at the University of Michigan, and a social media editor for American Academy of Ophthalmology journals, including Ophthalmology and Ophthalmology Retina. “And real-time innovations are much more satisfying when they can be shared with friends or colleagues in the field, who help to give them context and perspective. Social media allows for the immediate transfer and discussion of new knowledge. Sudden developments — such as clinical trial results, unusual presentations or visuals of a common disease, or advances in technology, such as the huge drop in costs to sequence genetic information — often break first on social media.”

As a social media editor, Dr. Rao frequently posts thought-provoking research summaries and images on Twitter, Instagram, and LinkedIn, which provide opportunities to engage not only a journal and its authors, but people involved in or affected by particular research. It also allows experts to share decision-making processes with a wider community.

“And we can do it quickly,” says Dr. Rao. “It doesn’t take several hours to post 280 characters on Twitter or an image on Instagram. The number of people reached or level of engagement on social media often exceeds the circulation of the biggest journals, so disseminating your message can have a more immediate, and a larger impact. And, since your latest tweet or Instagram post might be the first thing that pops up when someone ‘Googles’ you, it also shows the wider community that you are an active and engaged physician or researcher in your field.”

Jayanth Sridhar, MD, the creator and host of Straight From The Cutter's Mouth, an engaging retina podcast and website, says that in the process of sharing information, a physician also can actively shape his or her online image.

“Social media for physicians has become a necessity in this day and age, where information is most accessible and available to patients and providers online,” says Dr. Sridhar, assistant professor of clinical ophthalmology at the Bascom Palmer Eye Institute in Miami. “I use social media for 2 reasons. First, it empowers me to create an online brand that allows me to take initiative and define my own online persona. Regardless of whether a physician participates in social media, digital content exists for each and every medical provider. Rather than leave one's reputation to fate — or worse, to a single unhappy patient review — it makes sense to take control of it. Second, social media is a terrific way to build relationships, educate patients and providers, and stay up to date on the latest news and developments in the field of medicine.”

Being an “Influencer”

Whether “micro-,” “nano-,” or “mega-” influencers, physicians active on social media often are aware that their degree of influence can translate into economic value — for example, in the form of opportunities to sponsor products or services. But for Drs. Rao and Sridhar, social media is simply a vehicle for conveying relevant, useful, and often fascinating content for the intellectual enrichment of their colleagues.

“I tend to think of an influencer as someone who has built a large following online,” says Dr. Rao, “That is, someone who is able to connect across various forms of social media and traditional communications platforms, and whose opinions, recommendations, or endorsements are considered authentic and valued by those that follow them.”

In the field of medicine, he adds, social media influencers in ophthalmology can be akin to key opinion leaders (KOLs), who are sometimes sought after by industry because of the ease with which they can quickly and persuasively disseminate a message. However, Dr. Rao’s aim is to be free from commercial bias, much like a teacher or “amateur journalist” who is intent on sharing new research advances in ophthalmology and biology.

Dr. Sridhar, who posts his podcasts on Twitter, Instagram, and Facebook, views his social media activity in much the same way.

“I believe that everyone who participates in social media is to some extent an influencer — whether a microinfluencer or macroinfluencer, such as certain celebrities or political figures with millions of followers on Twitter,” says Dr. Sridhar. “People have described the digital landscape as democratic, as an arena in which any individual with useful or interesting information can make use of an unlimited forum for sharing and expressing ideas. Certainly influence also can be monetized, although like most physicians, I prefer to abstain.”

Taking Precautions

Before posting images of patient cases, Dr. Rao seeks guidance from his health system’s department of communications.

“They integrate guidelines from legal counsel, leaders, and other stakeholders in our health care system,” says Dr. Rao. “I follow their rules, which includes removing any HIPAA-related information or photos that might identify a patient, and excluding information that is not required to understand the case — such as gender, exact age, dates of service, and race or ethnicity.”

Dr. Rao adds that when he posts content from journals, such as The New England Journal of Medicine, JAMA, or Nature he knows that it has been vetted through the peer-review and consent process, and that appropriate permission has been obtained for images already published. Dr. Rao also cites the original source of all shared material.

Dr. Sridhar says that he sought detailed advice from a lawyer before engaging in social media activity.

“It’s critical to understand that digital media, and the internet in general, are written in permanent marker, not in pencil,” says Dr. Sridhar. “Physicians are required by HIPAA to maintain patient privacy, so when you are enthusiastic about sharing a patient story or case, it’s essential to observe the same rules about privacy that one would observe in more traditional media formats, such as a local newspaper or a flyer. Beyond privacy, social media defines your digital brand, and with that great power comes great responsibility. Controversial, inappropriate, or unprofessional tweets, photos, or videos linked to your professional name can doom your professional career, and are nearly impossible to erase from the digital ledger. It’s dangerous to quickly post media without stopping to think, ‘Is this something I should be sharing?’”

A Lawyer’s Advice

Social media can destroy careers even more quickly than it can build them. Inadvertently spreading misinformation or making a careless remark can have devastating and near-instantaneous consequences. The American Medical Association recommends that physicians carefully review its Code of Medical Ethics, which contains social media-related advice, including Opinion 2.3.2: Professionalism in the Use of Social Media (https://www.ama-assn.org/delivering-care/ethics/professionalism-use-social-media ). Physicians who decide to have a social media presence also should seek legal counsel before proceeding.

“The number one concern that a physician must have when engaging in social media is patient privacy,” says Thomas W. Brooke, an intellectual property lawyer with Holland & Knight LLP in Washington, DC, “Doctors must make sure that nothing they share will violate their confidential relationships with their patients. Most physicians are wise enough to understand this — there are plenty of smaller problems that are much more likely to happen — but violating patient confidentiality or in any way running afoul of HIPAA can put a doctor’s license at risk and really cause enormous trouble.”

The number two concern, notes Brooke, has to do with something that occurs much more frequently: the misuse of third-party material.

“That would include using photos, articles, or any material that you don’t own,” he says. “This mistake is made all the time, even by major corporations. Someone decides that he or she likes a photo and just adds it to a website or social media platform. If you don’t own the image, and don’t have a license to use it, don’t do that because copyright laws will bite you, and bite you hard, anytime you use someone else’s proprietary material.”

Brooke also recommends that physicians receive counseling on the best and safest way to build a personal brand, and learn to be very careful when it comes to making statements about themselves.

“The US Supreme Court has determined that some types of speech, for example purely political or educational speech, is highly protected. But commercial speech does not have the same protections. You can’t make random statements without proof. So, for example, implying that you are the best retinal surgeon in your area can put you at risk.”

What if you are just sharing information on social media, and not trying to make a profit?

“Even if your social media activity is purely informational, if you should ever be in a situation of defending yourself,” says Brooke, “your accuser could make a case that your social media presence is indeed commercial. If you are making a name for yourself on social media, and developing a following, it could be construed that your activity leads to increased business.”

Brooke notes that once a physician makes any effort to actively generate income from a social media platform (including soliciting patients), the potential for trouble begins to multiply exponentially. Even the use of enough advertising to cover the cost of maintaining a website is potentially problematic.

“Once physicians decide to have any sort of commercial activity in connection with a social media platform,” says Brooke, “It’s essential that they check with a state licensing agency and find out about the laws in that state. Even if you just have a button that reads ‘click here for a consultation,’ you have to be extremely careful.” RP

Editor’s note: Follow Rajesh Rao, MD, at @surgeonretina and www.facebook.com/surgeonretina/ . Follow Jayanth Sridhar, MD, at www.retinapodcast.com , @retinapodcast, www.facebook.com/retinapodcast/ . Contact Thomas W. Brooke via https://www.hklaw.com/thomas-brooke/ .