Social media allows physicians to reach far larger audiences than was possible through traditional media outlets in the past. Many are using it to benefit patients by disseminating accurate health and medical information and countering false health claims. However, ethical issues can arise when influencers with large followings reap significant profits from endorsements or advertising revenue.
“I wouldn't say that physicians should never receive any kind of reimbursement related to their social media use, but if they do, it should always be disclosed,” said Matthew DeCamp, MD, PhD, FACP, associate professor in the Center for Bioethics and Humanities at the University of Colorado in Aurora. “And there is a probably a point where the profit is too high and a conflict shouldn't be permitted, but where to draw that line is a subject of much debate.”
A recent case study from ACP's Center for Ethics and Professionalism, accessible on Medscape (login required), noted that the definition of professionalism demands that “physicians put patient care above their own self-interest,” a principle that can't be upheld when influencers “effectively put their medical credential up for sale.” The case describes a hypothetical second-year resident who receives compensation for promoting several health-related products through his Instagram account, where he shares personal and professional anecdotes with about 40,000 followers.
Case commentators acknowledged the benefits of social media when used in the service of promoting public health and education, or sharing professional experiences. However, reaping financial or nonfinancial rewards from such activity clearly falls in the category of self-interest, without any obvious benefit to patients or the community.
“Once we start to stray from our professional persona and use it to influence audiences on social media, the ethical waters become more tricky to navigate,” said ACP Resident/Fellow Member Vishal Khetpal, MD, MSc, an internal medicine resident at Brown Medical School in Providence, R.I., and a coauthor of the case study. “When in doubt, ask yourself whether whatever you're posting on social media really relates to your practice of medicine.”
Ethics of profiting online
Physicians with the largest social media followings earn high financial returns, notes the ACP case study. But even influencers in the lowest tier, with 1,000 to 5,000 followers, make an estimated $30,000 to $60,000 annually.
While extremely high earnings may appear to cross the ethical line of promoting the public before self-interest, there are nuances to consider, said New York-based internist Dana Corriel, MD, founder of the website SoMeDocs, which helps physicians establish an online presence as thought leaders.
“Medicine is an altruistic field that we all went into with the intention of doing right by the patient,” said Dr. Corriel, who left private practice about a year ago to run SoMeDocs full time. “However, we live in a capitalistic society where businesses move ideas and messages, and the health of our patients is clearly affected by social media.”
As a result, physicians should be judged on how and why they use social media rather than solely whether they earn a profit, she said. In building SoMeDocs, for example, Dr. Corriel saw social media as both an alternative career path and a way to have a much broader impact on patients than would have been possible in her private practice.
“As a practicing primary care physician, I was feeling the pressure of what I saw as a broken health care system,” she said. “At the same time, social media had huge potential to benefit the patient-physician relationship. It offered me a chance to create a new space that empowers physicians to impact health care and public health in a positive way.”
Ethical considerations around influencer accounts should focus on how physicians conduct themselves online versus purely profits, agreed Austin Chiang, MD, MPH, a gastroenterologist and chief social media officer for Jefferson Health in Philadelphia.
“First and foremost we must beware of promoting anything that carries health risk. Physicians should never back products or services that are not evidence based or that pose potential harm,” said Dr. Chiang, who also started the nonprofit Association for Healthcare Social Media, a social media resource for health care professionals. “Beyond that, there should be transparency about how the physician is profiting from such promotions.”
Physicians should adhere to the Federal Trade Commission's rules of disclosure, which place the onus on the influencer to make followers aware of their connection to brands or sponsors, said Dr. Chiang. Physicians can also look for guidance from employers, although most corporate or institutional policies tend to be broad, with much left open to interpretation, he said.
Social media companies themselves have also developed ways to help readers sort through health-related information, said Dr. Chiang. Twitter and Instagram now award an official blue check mark to influencers who satisfy certain criteria, including verification of their professional credentials.
In addition, physicians can independently signal their support of accuracy and transparency by using certain hashtags or linking to outside verification sites (such as the American Board of Medical Specialties' Certification Matters, which allows readers to quickly check on a doctor's board certification). Dr. Chiang launched the #verifyhealthcare campaign on Twitter and Instagram in 2018, which urges readers to check credentials and asks physicians to disclose their qualifications.
To some extent, however, physicians must rely on their own best judgment informed by standards of conduct set by ACP and other professional societies, said Thomas Bledsoe, MD, FACP, clinical associate professor at Brown Medical School and chair of the Rhode Island Hospital Ethics Committee in Providence. He advised physicians to remember that even the appearance of impropriety can undermine public trust in the medical profession as a whole.
“As physicians, we have a responsibility to seek trust and be deserving of it. If you're selling the latest thing for profit and it's not based on science, or if you're using social media only to make money or become famous, you're not following that code,” said Dr. Bledsoe. “Social media offers useful tools to get the word out about important topics but when people present themselves as physicians in problematic ways, it's bad for all of us.”
Many physician influencers are using social media in positive ways to educate and inform the public, said Dr. Chiang. That's been especially apparent during the COVID-19 pandemic. Twitter and Instagram tend to be the most popular platforms with physician influencers, with many younger physicians also favoring TikTok, he said.
“Social media allows physicians a convenient tool to assemble facts and explain them in a digestible way that provides context, which has been really important during the pandemic,” he said. “When people hear rumors that COVID is a hoax, for example, we can speak to our actual experiences treating patients in the hospital.”
Physician influencers can add context to sensational headlines, such as those containing misleading information about the effectiveness of or adverse reactions to new vaccines, said Dr. Khetpal. By posting regularly, physicians can help followers interpret and sort through rapid developments in a fast-moving health crisis.
Social media has also been helpful in reaching people who may be hesitant to get the vaccine, added Dr. Bledsoe, who serves on Rhode Island's COVID-19 Vaccine Subcommittee. “Social media is an efficient way to talk to lots of people, to make recommendations as physicians, and share accurate medical information with people who need to hear it,” he said.
Besides posting timely information, physicians should remember to correct past posts that may no longer be correct, in general as well as with COVID-19, said Dr. DeCamp. “The evidence base with COVID-19 is coming about so quickly and changing so rapidly that it can be challenging to be sure one's content is accurate,” he said. “Although we like to think of social media as transient and fleeting, it actually has incredible longevity and posts can be continuously rediscovered.”
At the same time, physicians should be honest about what is and isn't known about COVID-19 as well as other important medical topics and be prepared to lend their perspectives to ongoing issues and debates, said Dr. Khetpal.
“Physicians should have a voice on the platforms where the latest medical topics are being discussed,” he said. “In a way that's what we're here for, and one could argue that when we represent ourselves as doctors on these platforms we have an ethical responsibility to engage in content and counter false claims of public health.”