Survey of Individual and Institutional Risk Associated With the Use of Social Media

Manish Garg, MD; David A. Pearson, MD, MS; Michael C. Bond, MD; Michael Runyon, MD; M. Tyson Pillow, MD, Med; Laura Hopson, MD; Robert R. Cooney, MD; Jay Khadpe, MD; Jason T. Nomura, MD; Pholaphat C. Inboriboon, MD, MPH


Western J Emerg Med. 2016;17(3):344-349. 

In This Article


The practice of medicine mandates a high level of professionalism to ensure continued societal confidence in the profession and the physicians who deliver care. The EM Milestone project created by the ACGME includes two professionalism milestones. The first is "Professional Values," which asks that the EM physician "demonstrates compassion, integrity, and respect for others as well as adherence to the ethical principles relevant to the practice of medicine." The second is "Accountability," which asks that the EM physician "demonstrates accountability to patients, society, profession and self." The basic level of this second milestone requires that the EM resident "maintains patient confidentiality" and "uses social media ethically and responsibly."[4] Although these milestones are intended for the clinical care of patients, we believe it is equally important to ensure resident education regarding behavior outside the hospital setting. Due to the high number of inappropriate posts reported in this study, it is important that residents understand the potential pitfalls associated with the use of SM. Once SM posts are in the public sphere, it is often difficult, if not impossible, to remove them.

Institutional risk introduced by the personal use of SM has not been investigated in the literature. Half of the PDs who completed our survey reported being aware of at least one occurrence of the sharing of identifiable patient information by NRPs or residents during the last year. Interestingly, 25% of participating residents knew about similar postings by their peers and nurse colleagues of information that allowed a patient to be identified. Collectively, 207 survey respondents reported awareness of postings that allowed patients to be identified. It is impossible to know if these are distinct events, but it is clear that breaches of patient information on SM occur.

Confidentiality and privacy are fundamental expectations of the patient–physician relationship. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) has privacy, security, and breach notification rules that are enforced by the Office for Civil Rights within the U.S. Department of Health and Human Services.[5] Some of the observations and occurrences documented in our study fall within the scope of HIPAA and put individuals and institutions at risk.

In addition to federal ramifications for medical institutions in regard to unprofessional conduct on SM by employees, the individuals responsible for the HRTPE face state licensing consequences. In 2012, a national survey of state medical boards investigated physician violations of online professionalism and documented the subsequent disciplinary actions. For example, approximately 15% of state medical boards reported known physician violations resulting from online depiction of intoxication. Disciplinary consequences for all types of violations included letters of reprimand or probation; restriction, suspension or revocation of licensure; mandated education or community service; or monetary fines.[6] Our results are more serious than those reported in this investigation. From the viewpoint of a residency PD, having nearly a quarter of the residents reporting seeing SM misuse should be cause for program-wide education and policy.

Consequences for individuals were reported by the participants in our study, but institutional consequences were never mentioned in the free-text responses. A few lawsuits have been filed against teaching institutions based on inappropriate SM utilization. The first is based on a posting, by a non-EM physician, of private information on Facebook™ and Instagram™ after evaluating an intoxicated female patient in the ED.[7] The lawsuit names the physician, the hospital, and the affiliated medical school and is seeking $1.5 million in damages. The second suit occurred after non-physician hospital employees (allegedly including one nurse) posted a diagnosis of maternal syphilis on a Facebook™ group with a large distribution.[8] The lawsuit names the hospital employees and the medical center and is seeking more than $25,000 in damages. Though the number of serious violations is low, the incidence is likely to increase with larger payouts unless the responsible use of SM becomes a part of medical education either at the undergraduate or graduate level.

Regulation of the use of SM in residency training programs is hampered by the lack of clear guidelines from the accrediting body. The ACGME has not yet issued formal SM standards or guidelines for residency training programs, but the American Medical Association (AMA) has SM guidelines for physicians.[9] Guidance tailored to the residency training environment is available from the CORD's Social Media Task Force.[10] The authors believe the AMA and CORD recommendations can help residency training programs use SM professionally and minimize personal and institutional risk. Professional use would include using SM for educational purposes, announcement of accolades and professional accomplishments while ensuring nothing unprofessional (e.g.: images of colleagues intoxicated, protected patient information, or posts that could be considered offensive by distinct groups) is posted.

Responsible SM use has many advantages for resident education. SM is interactive, brings together a geographically diverse distribution of information, and has near real-time peer review. If it is used unprofessionally or irresponsibly, SM can lead to serious personal, professional, and institutional consequences, including employment termination, fines, and federal violations. Our survey revealed violations of patient privacy and other inappropriate use of SM, and these represent risks to the residents and institutions that cannot be ignored as SM expands.