Social Media as a Tool in Medicine
Social Media and Clinical Care
Ethical, Professional, and Social Implications
Katherine C. Chretien, MD; Terry Kind, MD, MPH
I t is an exciting time to practice medicine during our digital
“coming of age.” Social media, the freely available Web-
based platforms that facilitate information sharing of user-gen-
erated content, such as social networking sites, media-sharing
sites, blogs, microblogs, and wikis, have transformed the way
we communicate as a society. Through community building,
message amplification, rapid dissemination, and engagement,
social media has changed our interactions with others and, by
direct consequence, our relationships. For health care, this
represents a veritable social revolution. 1
Indeed, medicine is constantly evolving to adapt to new
technologies. These advances have led to new therapies, diag-
nostic tools, and ways of communicating. As physicians and
lifelong learners, it has been imperative to embrace the new
when it has meant better and more efficient patient care while
holding on to the stable tenets of medicine that root our profes-
sion: humanism, integrity, ethics, professionalism, and trust.
Patients have been active on social media to find health
information, find support through discussion groups and
forums, and chronicle their illness journeys.2 Naturally, they
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are also interested in using social media to facilitate commu-
nication between themselves and their providers. In a survey
of patients of an outpatient family practice clinic, 56% wanted
their providers to use social media for appointment setting and
reminders, diagnostic test results reporting, health informa-
tion sharing, prescription notifications, and answering general
questions.3 For those patients who do not use social media,
many would start if they knew that they could connect with
their providers there.3
Physicians are also exploring ways to use social media, both
personally and professionally, although personal use is more
common.4–6 Some physicians use social media professionally
to find and share health information, communicate/network
with colleagues and trainees, disseminate their research, mar-
ket their practice, or engage in health advocacy. In addition,
a growing minority use social media to directly interact with
patients or in other ways that augment clinical care.
In this article, we review ways that social media are being
used for clinical care and the potential implications that this
has on ethics, professionalism, and society. As with all innova-
tions and technological leaps forward, it is time to be mindful
and reflective of our professional commitments while discov-
ering better ways to engage and care for our patients.
From the Washington DC Veterans Affairs Medical Center (K.C.C.); George Washington University School of Medicine and Health Sciences(K.C.C.,
T.K.); and Children’s National Medical Center, Washington, DC (T.K.).
The online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA.
112.128017/-/DC1.
Correspondence to Katherine C. Chretien, MD, 50 Irving St, NW, Medical Service (111), Washington, DC 20422. E-mail Katherine.Chretien@va.gov
(Circulation. 2013;127:1413-1421.)
© 2013 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org
1413
Social Media in Clinical Care
Peer-to-peer healthcare is emerging as a source for patient
information and support. In a 2011 survey, 23% of US adult
Internet users with chronic medical conditions (eg, hyper-
tension, diabetes mellitus, or cancer) had gone online to find
others with the same medical conditions compared with 15%
of users without a chronic condition.2 Qualitative analysis of
posts and discussion forum topics on the 10 largest diabetes
management groups on Facebook revealed that patients, as
well as family members and friends, share personal clinical
information, receive emotional support, and request diabetes
management guidance from other group members.7 Patients
can tap into various “health subcultures” on the microblog-
ging and social networking site Twitter, including weight-loss
communities that can provide accountability, encouragement,
and advice from health professionals.8 For those patients with
rare diseases, peer-to-peer health care can result in meaningful
online relationships and support in ways not possible before
the advent of the Internet for both patients and their caregivers.2
Some patients and/or family members use social media to raise
money for their illness or for their personal healthcare costs.9
Other social networking online communities are built
around data-sharing platforms, where patients share
quantitative information about their medical conditions to
learn from the aggregated data reports to improve their own
outcomes.10 Here, patients share their conditions, symptoms,
and treatment outcomes; track their own health; and connect
with patients who share the same health conditions while
contributing to the community data cache.11.12 Members have
reported benefits from participation including better informed
treatment decisions, symptom management, higher quality
of life, and perceived control over their condition; a minority
use their data in their visits with their healthcare providers,
although it is unclear in what ways and to what utility.10 This
self-reported patient data have also led to new clinical research
insights. For example, researchers using observational data
housed on such a platform found that lithium therapy had no
impact on amyotrophic lateral sclerosis disease progression,
later confirmed by subsequent randomized trials.13
Physicians can also use social networking to crowdsource
answers to clinical questions. For example, on Sermo, an online
physician-only social networking community, credentials are
verified during registration of new members and “physicians
DOI: 10.1161/CIRCULATIONAHA.112.128017
 1414  Circulation  April 2, 2013

across all 50 states representing 68 specialties come to net-

work, discuss treatment options, and curbside peers for expert
advice whenever they need it.”14 Doctors rank postings on the
basis of the perceived credibility of the information posted.15
Another newer physician-only social networking com-
munity, Doximity, boasts Health Insurance Portability and
Accountability Act (HIPAA)-compliant messaging of text and
images, supporting point-of-care crowdsourcing.16
Social media, offering a public reservoir of information,
may serve as a source of patient information to aid clinical
care. One report in the literature describes how emergency phy-
sicians were able to contact the spouse of an amnestic patient Figure 1.  Key social media interactions among patients,
using the popular social networking site Facebook when other ­physicians, and the public. Solid line circles denote secure
interactions. Dotted line circles denote personal networking
traditional sources of information were exhausted.17 A study interactions.
of pediatric faculty and trainees found that 14% to 18% of
trainees (but no faculty) had conducted an Internet or social
base. Physician practices are also using Facebook pages,
media Web site search for information about a patient; 14%
Twitter accounts, and blogs in hopes to grow their practice
of faculty stated they would conduct an Internet search for
and earn patient referrals.30 In addition, patients can now rate
additional patient information if necessary.18
their physicians on any of a multitude of physician rating sites,
Some physicians also make the deliberate decision to
enabling patients to enter reviews and ratings of their physi-
“friend,” or connect, on social networks with their patients to
cians, freely available for anyone to see. Most sites provide
engage patients and seem more approachable.19 Others have
some basic information about the physician, such as years in
done so with less certainty and have reflected on the complex-
practice and contact information, with some also including
ity of the situation.20,21 In a survey of practicing physicians,
training. In a US study, 37% had consulted physician rating
approximately one third of physicians who use social net-
sites when gathering information about a specific provider.31
working reported receiving a friend request from a patient or a
Figure 1 depicts key interactions among patients, physicians,
patient’s family member; however only a small minority (5%)
and the public.
had ever extended the friend request themselves.22
Social media-savvy practices have set-up closed social
Ethical and Professional Implications
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media platforms that allow for patients to be actively involved

in their own care coordination, to track their clinical progress,
and for greater access to their physicians. These have been
associated with concierge practices where patients pay an
enrollment fee in exchange for availability of appointments
when they need them or an instant message chat or cyber-visit
with their physician using social media or they may be part of
large integrated healthcare systems using Facebook-like pro-
file pages for their doctors.23
By transcending geographical boundaries, social media
has facilitated extension of clinical care to distant patients.
Telemedicine, broadly defined as using telecommunication
for patient care, has been around since the 1960s but has
only recently experienced rapid growth thanks to new tech-
nologies.24 Systematic reviews of telemedicine have found
telemedicine to be feasible, well accepted by patients, and
reliable.24,25 Data were lacking, however, to make many con-
clusions about its clinical effectiveness compared with face-
to-face care or cost savings.24 Many, including insurance
carriers, however, are hopeful that telemedicine may serve to
reduce health disparities in rural areas.26 In a 2011 US survey
of practicing physicians, 7% had used video chats to commu-
nicate with patients.27 International medical relief organiza-
tions working in remote areas have credited social networking
for helping to coordinate complicated medical and logistical
demands of their work, including gaining access to interna-
tional specialists.28 As telemedicine has grown, so has the use
of social media tools to create virtual clinics.29
Finally, hospitals have long recognized the power of social
media as a tool for marketing and engagement of their patient
The American Medical Association (AMA) principles of
medical ethics32 can serve as a framework to discuss ethical
implications of physician use of social media for clinical
care. Key elements of the principles that apply to social
media in clinical care are listed below, followed by discussion
of related social media issues. See Tables 1 through 3 for
recommendations pertaining to ethical and professional
conduct while using social media in several different contexts.
Uphold the Standards of Professionalism (AMA
Principle II)
Medical professionalism has been defined in many ways but
generally includes standards of competence and integrity,
placing the patient’s interest above those of the physician, and
providing expert advice to society on matters of health.33 It
is the basis of trust given to physicians and to the profession,
Table 1.  Recommendations if Directly Communicating With
Patients Using Social Media
Context Recommendations for Ethical and Professional Conduct
Platform Use secure closed systems with data encryption
Avoid third-party open systems (eg, Facebook and Twitter)
Establish norms Inform patients of privacy protections in place
Establish expectations of message response time, how
emergencies should be handled, and issues that should
be handled online vs in-person
Have patients agree to terms before use

the cornerstone of our therapeutic alliance. Inherent in these
professional codes is a higher standard of behavior expected
of physicians. Professionalism is now a standard part of US
medical school curricula;34 student professionalism is evalu-
ated by observation and, in a majority of medical schools, by
formal testing in structured clinical examination settings.35
Social media use by physicians for clinical and nonclinical
purposes poses some dilemmas with regard to professionalism
as physicians are traditionally taught. Online, the boundaries
of our professional interactions are less clear (previously con-
fined to the outpatient office or the hospital). Professionals,
not limited to physicians, have had their professional charac-
ter judged on the basis of the way they represent themselves
online;36 to some extent, physicians will be viewed in their
professional role whenever they are in public, including when
using social media.37 With the blurring of personal and profes-
sional content online, there remains less certainty about what
constitutes appropriate professional behaviors online, and
these opinions differ between medical students and faculty
and even among medical education faculty.5,6,38 For instance,
a photograph posted on a personal social networking site of
a physician appearing inebriated during off hours may be
deemed inappropriate by some and not of concern to others.
There may be generational differences, with older genera-
tions espousing more conservative views about what a medi-
cal professional should and should not post.5 Published social
media guidelines by national medical organizations and medi-
cal school social media policies often lack specific behavioral
guidance or definitions of professionalism as applied to the
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online space.39,40 Physicians active in social media have offered
their own guiding principles for online professionalism, such
as “be honest, forthright, helpful and compassionate” and
“recognize that you represent your profession, and help others
recognize that they do, too.”41 Some patients may view a phy-
sician’s online activity as a proxy for the common sense and
trustworthiness required for patient care.36 Most physicians
will want to clearly identify themselves to lend credibility
and accountability to their online communications; those who
choose to use social media anonymously should be mindful
that anonymity can breed disinhibition, and true online ano-
nymity may be difficult, if not impossible, to achieve.
Clearer are the opportunities that exist for physicians to
promote medical professionalism using social media. Sharing
credible health information and resources, using social media
for health advocacy, and developing innovations that improve
delivery of care using social media are all ways to harness
its power for communication.36 See the section titled Make
Relevant Information Available to Patients, Colleagues, and
the Public (AMA Principle V) for further discussion.
Be Honest in All Professional Interactions
(AMA Principle II)
Online misrepresentation of credentials was one of the most
common online professionalism violations reported to state
medical boards, with many resulting in serious disciplinary
actions.42 In addition, conflicts of interest, including receiv-
ing financial compensation for the promotion of any product
or paid advertisement on a blog or other Web site, should be
disclosed. When researchers analyzed the content of blogs
Chretien and Kind   SoMe Ethics   1415
written by health professionals, 11% contained product
endorsement of specific healthcare products; none provided
conflict of interest disclosures.43 Some physician tweets also
contain suspect product promotions.44 Of note, Federal Trade
Commission regulations released in 2009 require material
connections (sometimes payments or free products) between
advertisers and endorsers to be disclosed. A blogger who
receives cash or in-kind payment to review a product is con-
sidered an endorser. In addition, both advertisers and endors-
ers may be liable for false or unsubstantiated claims made in
an endorsement.45
Report Physicians Deficient in Character or
Competence, or Engaging in Fraud of Deception,
to Appropriate Entities (AMA Principle II)
The ethical duty of reporting the impaired, negligent, or
otherwise unprofessional physician applies to the social
media space when physicians see content posted by other
physicians that may be harmful to patients or the public. This
may include advertising false claims, misrepresentation of
credentials, or posting grossly unprofessional content online.
In their guidance on professionalism in the use of social
media, the AMA advises physicians, “When physicians see
content posted by colleagues that appears unprofessional, they
should bring it to the attention of the individual or report it
to the authorities.”40 We agree that it is part of a physician’s
ethical duty to report harmful content (however one defines
this), either by discussing with the individual directly or by
informing the individual’s employer or state licensing board.
Among violations of online professionalism reported to state
medical boards, half were reported to the board by another
physician.42
Safeguard Patient Confidences and Privacy Within
the Constraints of the Law (AMA Principle IV)
A major challenge of using social media is ensuring that digi-
tal communication is secure. Stemming from HIPAA enacted
by Congress in 1996, the Department of Health and Human
Services (HHS) issued the Privacy Rule, which provided the
first-ever federal privacy standards to protect patient health
information provided to doctors and other healthcare provid-
ers, hospitals, and health plans, so-called covered entities.46
The Privacy Rule, in effect since 2003, levies heavy fines
and potential criminal charges on unauthorized disclosure of
individually identifiable health information, also known as
protected health information, by covered entities. Protected
health information applies to health information in oral, paper,
or electronic forms.46 There have been many well-publicized
breaches of HIPAA involving social media;47,48 in many of
these cases, disclosure was inadvertent.
The HIPAA Privacy Rule includes a safeguards standard
that requires covered entities to reasonably safeguard pro-
tected health information from unauthorized disclosure, both
intentional and inadvertent, using physical, administrative, and
technical safeguards.49 These standards are somewhat flexible
and accommodate entities of different sizes and resources. For
instance, e-mail communication between patient and provider
using unencrypted e-mail could be permissible, provided there
were some protections followed, such as limiting the amount
 1416  Circulation  April 2, 2013
and specificity of information transmitted this way. Individual
states may have their own separate privacy laws; for instance,
states vary on who may grant permission to release medical
charts.50
Communicating Directly With Patients
When using social media for clinical care, great care must
be made to ensure that protected health information is safe-
guarded. Patient privacy breaches can cause much greater
harm when occurring online than when face-to-face given
the potential wide reach of social media and the permanency
of digital information.36 Patients who desire to communicate
with their healthcare provider via social media should be
made aware of the privacy protections put in place by their
physician or physician’s practice and should provide consent
to participate given these provisions (Table 1). Closed, secure
systems with data encryption can maximize safeguards. Atten-
tion should always be paid to the security (vulnerabilities to
external security threats), access, and permissions involved in
any social media tool used for clinical care. On unsecure open
sites, such as popular third-party sites Facebook and Twitter,
postings, whether open to the public or private message, may
ultimately belong to the third party,51 and security breaches
have been known to occur.52
Writing About Patients on Social Media
Outside of communicating directly with patients, writing
about specific patients on social media sites without their con-
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sent, such as writing a narrative about a patient on a blog or
mentioning an interaction with a patient as a status update on
Facebook or Twitter, requires additional ethical consideration.
Stevenson and Peck53 propose the model of double-effect rea-
soning when deliberating ethical cases in social media. This
model is based on the moral norms of doing good and avoiding
evil and takes into account an agent’s intent and the foreseen
and unforeseen effects of one action.54 On the basis of Cavana-
ugh’s original criteria,54 Stevenson and Peck53 offer modified
criteria for evaluating social media actions (Figure 2).
Applying these criteria to the example of writing a
respectful patient narrative on a blog, we start with the
following question: is it ever ethical to write publicly about
specific patients without their expressed consent? Clearly, if
it is written in such a way that the patient could be identified
by the patient or someone else, it violates the ethical principle
of patient privacy (as well as being a HIPAA transgression).
1. The act considered separately from its unintended harmful effect is in
itself not wrong.
2. The agent intends only the good and does not intend harm as an end or
as a mean.
3. The agent reflects upon his/her relevant dues, considering accepted
norms, and takes due care to eliminate or alleviate any foreseen harm
through his/her act. (Consider: security of communicaon, paent
consent, ability to idenfy paent, potenal audience, professional
reputaon and responsibilies, tone.)
Figure 2.  Ethical criteria to evaluate social media actions by
healthcare providers. Adapted with permission from Stevenson
and Peck.53
However, what are the ethical implications if the patient was
properly deidentified? The answer to this question may be
debated. When medical educators were asked to rate a list of
specific online behaviors on appropriateness, the majority felt
that it was rarely or never acceptable to write a deidentified
patient narrative using a disrespectful tone (86-88%).5,6
Fewer, but still a majority, felt that writing this deidentified
patient narrative using a respectful tone was never or rarely
acceptable (61%).5,6 It is our view that writing a deidentified
patient narrative using a respectful tone on a blog or other
social media site, similar to narratives published in books
and medical journals, is not itself wrong. Next, the intent is
examined. If the intent of writing and sharing the narrative is
to stimulate understanding or empathy without intent to harm
the patient, the second criterion is fulfilled. Finally, if there
is a reflection about the physician’s professional and ethical
duties and due care is taken to limit any foreseen harm (patient
deidentification, use of a respectful tone, and unlinking the
narrative to a specific institution), then the action would
seem to be ethically justifiable. However, publicly posting a
status update about a specific patient to release frustrations
or to entertain others with a humorous anecdote places a
physician’s self-interest above the patient’s and may not be
ethically justifiable despite a lack of identifying details, even
if there was no intent to harm the patient.
Writing about individual patients and protecting their iden-
tity may be more difficult than physicians think. A study of
271 medical blogs written by health professionals found that
individual patients were described in 42% of blogs. Of these,
17% included sufficient information for patients to identify
their providers or themselves, and 3 included recognizable
photographic patient images.43 Potential patient privacy viola-
tions have also been reported in medical student online post-
ings55 and by self-identified physicians on Twitter.44 In most of
these cases, there was no malicious intent to violate patient’s
privacy. When possible, obtain a patient’s permission before
writing about his or her online. Because both real and supposed
(ie, a patient thinks that he or she is being written about or a
reader thinks a narrative identifies a specific patient) privacy
violation could be damaging to both physicians and patients,
it is important to explicitly state that narrative accounts have
been fictionalized or that consent from the patient or patient’s
family had been obtained. Deidentification can be accom-
plished by omitting or changing key patient details, avoiding
description of rare medical problems, and not including a spe-
cific time frame or location when and where the encounter
occurred (Table 2).
Looking Up Information About Patients on the
Internet
Use of the social media double-effect reasoning model53 can
help in determining whether it is ethical to look up informa-
tion about patients on the Internet for diagnostic or treatment
purposes. The act in of itself is not wrong, because the search
accesses public information. The intent is to help the patient.
However, if aware, some patients could experience this as a
boundary violation and compromise of trust.37 Limiting fore-
seen harms could mean asking the patient or other relevant
party for consent to access information. If, however, the intent

Table 2.  Recommendations for Physicians Who Have Blogs
or Practice Websites
Context Recommendations for Ethical and Professional Conduct
Writing about Avoid writing about specific patients when possible or
patients obtain patient permission and state explicitly
Protect identity of patients through deidentification or
fictionalize encounters and state explicitly
Use respectful tone
Health-related Share credible health information and resources
content Counter inaccuracies in the media
Place results of recent studies in context
Use patient education videos
Endorsements and Disclose any in-kind or financial compensation received
advertisements Beware of making false or misleading medical claims
Identification Avoid anonymity
Accurately state credentials
State whether you are or are not representing your
employer or institution
was, even in part, voyeuristic, then the action would not be
ethically justifiable.
In general, healthcare providers do not believe that it is
an invasion of privacy to conduct an Internet or social media
site search for people that they know or work with, and they
believe that publicly accessible social media profiles are pub-
lic information.18 However, significant variation exists in how
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providers would respond to accessed information. For exam-
ple, when pediatric trainees and faculty were given a series
of hypothetical vignettes involving concerning information
(eg, suicidal ideation or reference to drug use) gleaned from a
patient’s public social media site profile, respondents differed
on how they would use that information, from immediately
contacting the parents/guardians or law enforcement to using
that information at the next clinical visit to doing nothing.18
So, while the initial action of looking up patient information
may be ethically sound, there lacks consensus about how best
to use this information in clinical care. It is also unclear how
routine use of patient search information might impact the
patient-physician relationship.
Make Relevant Information Available
to Patients, Colleagues, and the
Public (AMA Principle V)
Sharing Credible Health Information and Patient
Education
By using blogs or social networking sites to share credible
health information, social media can help physicians fulfill
the professional obligation to share relevant information with
patients, colleagues, and the public and help the public place
the results of medical studies or other health-related current
events in proper context. Some physicians assert that it is an
ethical obligation for physicians to lend their voices to public
discourse on healthcare topics online.56
Social media can allow individual physicians to reach many
for the purposes of patient education. For example, through
Chretien and Kind   SoMe Ethics   1417
blogging and recording videos, physicians are instructing
patients on everything from dosing liquid medication for infants
and children57 to explaining rotator cuff injuries.58 Medical
students across multiple continents have used social media to
help their institutions adopt patient safety tools.59 Physicians
and physicians-in-training who use their presence on social
media to broadcast their professional commitments and values
can become high-impact contributing members of the medical
profession who can promote trust in the profession. They also
combat the unscientific but amplified voices in the media who
may spread misleading and sometimes dangerously inaccurate
statements regarding health.56
Physician Rating Sites
In making relevant information available to patients, physi-
cian rating sites allow a greater amount of information to fac-
tor into an individual’s decision of which physician to choose
for his or her care. Although the helpfulness of these ratings
has not been proven, these sites could theoretically contrib-
ute to health literacy, engagement in patients’ own care, and
ability to perform quality assessment.60 Many, however, ques-
tion whether reviews provide constructive feedback; although
most online physician reviews are positive,61,62 there are those
reviews that appear disproportionately poor or even consti-
tute possible acts of sabotage from competing providers.62 As
quality of healthcare becomes more transparent to the pub-
lic, there needs to be ongoing discussion on conduct of these
sites to provide the most benefit to patients and their provid-
ers through constructive information exchange, while limiting
physician harm from defamation or inaccurate reviews.
Regard Responsibility to the Patient as Paramount
(AMA Principle VIII)
In the social media sphere, the concept of responsibility to
the patient appears when thinking about social media relation-
ships between physicians and patients and the related concept
of patient exploitation.
Trust and Social Media Relationships Between
Physicians and Patients
The patient-physician relationship is nurtured when physi-
cians provide information, encourage autonomous decision-
making, act respectfully and in a timely manner, preserve
confidentiality, and facilitate access to care.63 Social media
can help physicians accomplish some of these goals through
facilitation of information sharing and improving accessibility
to their providers, thereby building trust. Trust may be com-
promised if there are conflicting expectations of how clinical
care using social media will be conducted.64
Establishing Patient-Physician Relationships Using
Social Media
Just as establishing a patient-physician relationship via email
outside of a preexisting relationship may be medically and eth-
ically objectionable because of questions about the integrity
of the patient-physician relationship, trust, and the patient’s
best medical interests,65 so comes into question establishing
a relationship solely via social media. Use of social media to
 1418  Circulation  April 2, 2013
provide specialized care in resource-poor areas, however, may
be an exception, when no other options exist.
Online “Friendships” With Patients on Social
Networking Sites
Preservation of professional boundaries online is important
to the integrity of the patient-physician relationship, because
online “friendships” may create a dual relationship, that is,
having any relationship with a patient, whether it be social,
financial, and so on, in addition to the therapeutic one, that
may compromise medical care provided to the patient and/or
introduce interactions extraneous to the relationship.66 Such
friendships may also lead to problematic self-disclosures (by
patients and/or by physicians) that could threaten the thera-
peutic relationship. Research suggests that physician self-
disclosures in the clinical setting may not help patients and,
in some cases, may be a disruptive influence.67 Meanwhile, in
the online setting, particularly on sites that contain personal
content, there is much more disclosure, intentional and/or
inadvertent, at risk.
Given these risks, Guseh et al66 advise physicians to never
extend a request to become a social networking friend with a
patient. In cases where the invitation is extended by the patient,
physicians are advised to avoid accepting the invitation and
to have a face-to-face discussion of why it would be unethi-
cal if actively declining the invitation might be damaging to
the therapeutic relationship. The view that physicians should
not be online friends with patients is supported by the AMA
and others.40,68 These guidelines are appropriate if the social
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networking site in question is used primarily for personal pur-
poses, such as Facebook or an online dating site. However,
in other cases, such as professional social networking sites
where limited personal content is shared, physicians may be
able to connect with patients and still maintain the profes-
sional nature of the relationship. Initiating a social network-
ing connection with a patient on any type of site, however,
can cause the patient to feel coerced or pressured to accept
the request because of the inherent power differential within
the relationship. This is especially true in the case of pediatric
patients, those with special needs, and vulnerable populations.
When medical educators in internal medicine and pediatrics
were asked to rate the appropriateness of certain online phy-
sician behaviors, 82% to 84% felt that it was never or rarely
acceptable to become social networking friends with a current
patient.5,6 However, the distinction between personal and pro-
fessional social networking sites was not made in these stud-
ies. In another study involving a sample that included medical
students, resident physicians, and practicing physicians, the
majority of respondents felt that it was equally unethical to
interact with patients using online social networks for either
social or patient-care reasons.22 This may have been because
respondents assumed that interactions would be occurring on
public sites and not secure patient-provider portals (Table 3).
Commercial Interests and Patient Exploitation
Of note, patient members of for-profit social networking
communities involving data-sharing platforms may have
their deidentified data shared with various research and
academic institutions, as well as corporate pharmaceutical
Table 3.  Recommendations for Physicians Who Use Social
Networking
Recommendations for Ethical and Professional
Context Conduct
Writing about patients Avoid writing about specific patients
Privacy settings Opt for highest privacy settings
Keep in mind that all content may be discoverable
Social networking Avoid extending “friend requests” to patients
connections with Respond to friend requests from patients to access
patients physician’s personal social networking page
by redirecting them to more secure means of
communication or to a physician’s professional social
networking page
Identification Avoid anonymity
Accurately state credentials
Specifically state whether you are or not representing
your employer or institution
Giving medical advice Avoid giving specific medical advice to nonpatients
sponsors. Although this is disclosed to members as a matter
of transparency, the practice has brought into question
whether patients are being exploited for the purposes of more
targeted drug marketing, alongside contributions to scientific
research.69 One site, for example, provides corporate sponsors
with analysis of member conversations about their brand.11
Because these companies are not covered entities, they are not
subject to HIPAA.
Similar concerns for patient exploitation arise in patient-
learning communities on social media sites with regard to
marketing influences. Greene et al7 found that a significant
proportion (27%) of posts on Facebook diabetes management
support groups appeared to be promotional in nature, typically
in the form of testimonials. In addition, although clinically
inaccurate recommendations were infrequent, they were usu-
ally associated with promotion of a specific product.7
Support Access to Medical Care for All People
(AMA Principle IX)
Social media use among all age demographics is growing;
however, use is skewed toward the wealthier and more edu-
cated. For example, a 2012 survey found that 97% of US col-
lege graduates use the Internet compared with 45% without
a high school diploma.70 Health literacy, computer literacy,
computer access, and language barriers can all play a role in
limiting the reach of social media in clinical care. Addressing
these barriers is pivotal to social media advances in healthcare
delivery and communication to benefit all.71
Yet, social media may mediate an increase in healthcare
access to those in rural or underserved areas with expansion
of telemedicine programs. There is evidence that telemedicine
provides at least comparable care in emergency department
settings, as well as benefit in surgical and neonatal intensive
care unit settings, among others.25
Other Legal Issues
An in-depth discussion of legal implications of social media
use in clinical care is beyond the scope of this article. However,

beyond HIPAA and privacy law, there are several other legal
issues that deserve mention.
Discoverability
Content posted on social networks, regardless of whether
privacy settings are used, is discoverable and can be used to
judge an individual’s character in lawsuits.51,72 The Facebook
data use policy informs users that “we may access, preserve
and share your information in response to a legal request” both
within and outside of US jurisdiction.51 The policy also states
that information may be shared for any number of reasons,
including to aid investigations, prevent fraud or illegal activ-
ity, or to protect Facebook, the user, or anyone else.51 Despite
this, we believe that opting for the highest privacy settings for
personal social networking site pages helps to create boundar-
ies between personal and professional content and limits any
undesired contact with patients.
Giving Medical Advice
While using social media (or e-mail), it is possible that a non-
patient asks a physician for medical advice. Terry warns that
any personalized response may imply the creation of a physi-
cian-patient relationship regardless of whether a disclaimer is
given. He states:
…the only legally sound approach is for the physician to
respond to an electronic inquiry with a standard form response,
that in no way refers to the specific sender or the sender’s dis-
closed information, which (1) informs the questioner that the
physician does not answer such online questions, (2) supplies
Downloaded from http://ahajournals.org by on March 14, 2019
the questioner with the physician’s offline office information
in case the questioner would like to make an appointment, and
(3) provides contact information for the emergency services
and suggest the questioner contacts same if he or she cannot
wait for an appointment during regular business hours.72
In circumstances where a patient-physician relationship
already exists, informed consent, as mentioned above,
with careful discussion of potential risks of this form
of communication, response times, and the handling of
emergencies, should take place before any clinical interactions
by physicians with patients online. These interactions would
also need to be documented and included as part of the
patient’s medical chart.
Social Implications
With a greater amount of time spent interacting online, there is
concern that the corresponding decrease in face-to-face inter-
actions between physicians and patients may result in less
ability to relate to others and a decline in empathy. Relation-
ships online lack critical nonverbal cues, and communication
can be easily misinterpreted. Nonverbal cues, as opposed to
verbal utterances, are thought to carry the majority of mean-
ing when communicating messages regarding feelings and
attitudes.73 An effort to maintain authentic communication
will be important as social media is used more and more in
clinical medicine. This means using social media as a tool to
augment in-person care and not as a replacement. Also, the
use of 2-way video can provide more authentic communica-
tion than instant messages, e-mail, texting, or 1-way video.
Chretien and Kind   SoMe Ethics   1419
Patients desire ease of communication with their doctors; as a
profession, we must be cognizant of not trading communica-
tion quantity for quality.74
Similar to e-mail, social media use by clinicians for clini-
cal care brings the concepts of time and reimbursement to
the forefront. Marketing one’s practice on social media may
bring a return on investment, but time spent on social media
for the purposes of providing patient care must be accounted
for–will this occur during the work day and/or after tradi-
tional clinic hours? If caring for patients online, how will this
time spent be reimbursed, and what will the incentives be for
using this technology? Because time and space boundaries
are lifted with social media technologies, how will clinicians
incorporate its use into the flow of the typical work day while
maintaining sustainable and desirable work-life balance?
Here, thoughtfully constructed individual boundaries for
social media use for clinical care must be put into place and
communicated with patients so that expectations are shared.
Future Possibilities
The potential of social media to improve healthcare, health
communication, and health information sharing cannot be
underestimated. With patient networks sharing their data and
experiences and physician networks facilitating discussion
about therapies and studies, might social media lead to bet-
ter medicine? Regional variations in medical treatment have
been demonstrated,75,76 with both patients and physicians
not always aware of the current best practices. Could social
media drive evidence-based standards in medical care through
greater transparency, expert discussion, quality improvement,
and information sharing? Increased standardization of treat-
ment, while acknowledging the need for individualization of
treatment plans on the basis of patient preference and other
factors, might also lead to better cost containment, because
physician behavior has been shown to be a factor in varia-
tions in regional healthcare spending.76 Moreover, could social
media decrease the gap between clinical research and actual
practice, facilitating translational research and applicability
to patients? The much lamented gap depends on a number
of factors, including the quality, magnitude, and relevance
of research, as well as the incentives to adopting practice
changes.77 However, certainly contributing is the time it takes
for research to disseminate, expert opinions to be voiced, and
important discussions to take place. Social media may stream-
line this process and lead to faster translation of evidence to
current practice.
Conclusions
Social media has transformed communication and is on its
way to transforming healthcare. As its uses in clinical care
grow, so must physician awareness of the implications this
has on our ethics, professionalism, relationships, and profes-
sion. Abiding by our ethical and professional commitments to
maintain the foundations of public trust in the medical profes-
sion will be absolutely necessary to successfully incorporate
social media in clinical care. Those who share this vision will
be poised to lead this social revolution in healthcare.
 1420  Circulation  April 2, 2013
Disclosures
None.
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Key words: internet ◼ medical ethics ◼ social media ◼ social networking