COMMENTARY

Should Docs Tout Products and Personal Causes Online?

Arthur L Caplan, PhD; Jessica A. Gold, MD, MS; Hansa Bhargava, MD

Disclosures

April 16, 2019

This transcript has been edited for clarity.

Arthur L. Caplan, PhD: Hi. I'm Art Caplan and this is Both Sides Now. Doctors have a lot of authority and believability in our culture. I know some are saying, "Really? We seem to get bashed around a lot." Still, if you look at polls, if you listen to people talk about how they respect their individual physicians, you know that their views count.

In the past, doctors were told to keep their personal opinions to themselves—don't share personal views about politics, lifestyle, or anything, that it's just not appropriate for a doctor to do because it may exercise too much influence over patients on topics that have nothing to do with medicine.

More and more today, because of social media, doctors are sharing personal opinions on all sorts of topics, from politics, to healthcare reform, to endorsing certain ideas about healthcare, all the way to the personal hygiene products they might like or use.

I saw a recent Glamour magazine article in which medical students shared their picks for the best eye creams. Ten students and residents, many who were already running their own health and beauty blogs, told what they used and what they liked about individual, brand-name, over-the-counter products. We couldn't confirm whether anyone was paid for these endorsements, but they certainly were sharing their opinions about them.

Today we want to talk about whether that's right. Should doctors, residents, or medical students share their thoughts in this manner? Does it work against the overall medical authority in our society? Does it take advantage of the power and respect that physicians are accorded? Are you diminishing respect for medicine if you start talking about your personal views, a practice that the old-guard, old-school crowd used to worry about? Again, that was before social media.

Does it jeopardize an individual's professional reputation if someone says, "I saw my doctor endorsing a product on social media or talking about some personal family issue. I don't know if I want to see that doctor anymore. Too personal." What if you choose to go into politics? Is that a reasonable route to pursue in terms of sharing your political opinions?

All interesting, fun, and, I think, rich subjects. We have two guests who I believe will give us an interesting perspective on this subject. Hansa Bhargava is a pediatrician and a senior medical director for WebMD/Medscape, and Jessi Gold is a psychiatrist and an assistant professor in the department of psychiatry at Washington University in St Louis, Missouri. Both doctors have active social media accounts and both have a lot of followers. I believe we'll be hearing some interesting opinions about how and when you should express personal views.

Hansa, I'm going to come to you first. Tell me about your online presence and where you share opinions about issues other than medical practice subjects.

Hansa Bhargava, MD: Sure. First of all, thank you for having me here. This is a great topic and so very timely. I do have social media accounts, including one associated with my position at WebMD. I'll also point out that the American Academy of Pediatrics (AAP), of which I'm a very active member, has taken a stance on social media as well.

Caplan: Yes, I did see that. Tell us about that.

Bhargava: The AAP has Twitter and Instagram accounts, and has often asked us as spokespeople to tape public health messages.

Caplan: About vaccines and issues like that.

Bhargava: Yes. They've asked us to be active in promoting vaccines and taking a stance against the antivaxxers. For me, I believe social media is a double-edged sword. You can use it for good in terms of advocacy. You'll see on my social media accounts that I very actively use it for advocacy. But I have some hesitation about using it for product promotion.

Caplan: Jessi, you have a presence on social media too. What's the extent of your offering your views and opinions?

Jessica A. Gold, MD, MS: I primarily use Twitter as a professional resource. I started to use it as a way to promote some of my writings, because the freelance world likes you to get clicks on your articles. The first reason I went into using social media was an awkward mix of self-promotion, and I wasn't quite sure how to get into it. I quickly realized that I liked it as a platform to connect with other people.

Caplan: Just to clarify, you got in to help promote some of your editorials or opinion pieces. Where were they appearing?

Gold: I write popular-press pieces for magazines such as Glamour and InStyle. They're aimed at the public rather than physicians, so it was important for me to be out there promoting them, talking about them, saying why people should be reading them. That's why I went on it in the first place. I had kept private accounts before that. I was in the generation where Facebook was at my school but not at a lot of other schools. I had a private Twitter account before having a Dr Jessi Gold Twitter account, and I still have a private Instagram account.

When I think about actually talking about things on my Twitter account, I view it very much through a psychiatrist's lens. Psychiatry still tends to be on the side of limiting self-disclosure in any manner. We're still taught to try to mostly be a blank slate: Don't come up with things that could alienate any patient. It's not about you; it's about them. They shouldn't be feeling that it's about you.

When I think about what I'm posting, I think about it through that lens: If a patient saw anything I'm saying, would they think, I don't want to see that doctor, or that is too much information about that doctor? I believe that psychiatrists are still hesitant about using social media because of having such a strong stance previously regarding self-disclosure. I'm probably a little less afraid of that than some of my mentors and attendings were.

Caplan: Mental health does have that long tradition of keeping the doctor more anonymized or more of a blank slate, as you say. Do you ever talk about this with your patients? Do you get any feedback from them about your social media presence?

Gold: Lately it's been more about patients googling me. They will sometimes know things about me from googling me, having read an article. I also have a website because of my articles, and they've seen that. I see college students and graduate students mostly, so it tends to be cool and not a problem.

I don't bring it up unless they've seen it themselves, because it's not something I want to be putting out there. It does give them a lot more information about me than they would have otherwise. So I don't promote it. If they find it, we'll talk about it.

I did have a situation where I was on a dating app that one of my patients was on. We had to have that conversation.

Caplan: How did that work out? Did you date eventually?

Gold: No. Obviously I did not go on a date with my patient. It was very uncomfortable, because again, what you put on that kind of app is personal. I'm very conscious about not saying that I'm a psychiatrist. I say I'm a professor. If I see a patient and know they're a patient, I run for the hills pretty quickly. But it doesn't mean they didn't see my profile. It makes it complicated, for sure.

Caplan: What about you, Hansa? Do you talk about this with patients or prospective patients? Would you say, "I have to warn you, you might see me on Instagram."

Bhargava: Similar to Jessi, I don't bring it up actively. But I have had situations where someone will say, "I saw you on the Internet." I do segments for Fox with public health information. So patients may say, "I saw you on Fox, talking about this." Of course, I'll address it from that perspective.

I would point out that I think there was a survey that reported the percentage of patients who go online to find health information and also go online to see what doctors are in certain areas. In fact, I think over 54% of millennials were searching online for doctors.

The other side of it is that having an online presence may be good to drive patients to your practice. A lot of doctors are doing that, and I am certainly not against that at all.

Caplan: Did you ever google a patient?

Bhargava: No. I have never googled a patient.

Caplan: Jessi?

Gold: For the most part, absolutely not. I will say that in emergent situations it has happened. Sometimes, in the psychiatric emergency department, if a patient comes in and can say their name but they have no other contacts, and we are trying to get collateral information, there is a reason to google at that point. It's basically a phonebook. We used to just go through a phonebook to try to find people who were connected to the patient. We use it like that.

I used to work in Silicon Valley, and sometimes people would say that they ran so-and-so company. We thought it was grandiosity and then we found out it was true. Those are the only times that I have ever used the Internet in that way. I have never looked up a story a patient has told me if they were talking about a family member who was in the news or something like that.

Caplan: I have a question that could bring our show to an immediate halt: Is worrying about social media something that only old people like me are concerned about but younger physicians and younger patients don't care about because they grew up with it?

Bhargava: That is a great question. Twenty years ago, would our profession look at doctors who had websites and brand that in a negative way? Perhaps. Now, it seems run-of-the-mill. A lot of great doctors have personal websites. I use mine as a platform for good public health messaging. I do believe that things are shifting and I wonder—and this is why this is such a great topic—does the shift include products and politics? Is that okay or not? Twenty years from now, will we look like old fogies because we may be naysayers? What is that shift going to look like?

Caplan: Let's go there for a second. Jessi, we've talked about using social media, having a presence there, using it as a megaphone, using it for public health education. When I introduced the program, I said there was a Glamour magazine site with med students endorsing the eye care products they like. What do you think about that, Jessi? Should we be telling the world, "I'm no dermatologist; I'm actually a cardiologist. But here is the eye cream I like"?

Gold: That's a very interesting question. I saw that Glamour article and posted it on Twitter, and it probably received among the most comments of anything I have ever posted, from other doctors reacting. It was two camps. One camp said absolutely not. This is ridiculous. First of all, what do doctors know about eye creams? Second of all, if they're endorsing it, does it mean it's a physician endorsing it? Even if they're only med students, does it add extra clout to the endorsement?

The other side is that med students are in debt and they're not making money. We're not giving them good loans or good sources of money. How can we blame them for wanting extra money? They're not endorsing medical products, for the most part. You will see Instagram influencers who are med students or nurses, and they're endorsing scrubs and stethoscopes. At what point does that cross over?

Eye cream is a little weird, because if you're not a dermatologist, it maybe doesn't fall into your specialty. But maybe eye cream doesn't seem like medicine. They asked doctors to endorse cigarettes in the past. The companies know what they're doing.

Caplan: True. They did a lot of advertising. "I smoke Camels; it's the safest cigarette" kind of stuff. Endorsing an eye cream is fine. But I'm not sure there's any evidence that eye creams do anything. There's that whole oddball world where the cosmetic companies make claims about wrinkle removal or whatever, age spot treatments, and claim some science. Aren't the medical students pushing the frontier where they ought not, if they're not in dermatology or some related area, and they're in with a product that's iffy?

Bhargava: I would agree with that. You really have to be careful about what you endorse. Ultimately, we are scientists. We have to use data and science to back up what we're saying. I know Jessi talks a lot about advocacy efforts in certain arenas. Both of us, and all people who have a social media platform—at least most of the physicians I follow—tend to use data to substantiate what they're saying.

Caplan: They get uncomfortable if they wander too far from what they read in the literature.

Bhargava: Exactly. I believe that speaks to the integrity of the profession. Once you wander away from that, how are you different from Joe Smith walking down the street who's saying, "I like these headphones"?

Caplan: Do you buy that, Jessi?

Gold: I do. One of the hard things about it is that there's a line between a med student in training or a nursing student, and becoming an attending and having the clout of what it means to be a doctor.

Caplan: I have to interrupt and say that I'm not sure anybody within medicine cares what a medical student thinks about anything. But go ahead.

Gold: That's a product of hierarchy. We can get into that another time. I do think med students may not realize exactly what they're doing. In my institution, I know there are no rules for endorsements by medical students, but there are for residents. You fill out disclosure and conflict-of-interest forms. They're not asking the med students to do that. If a lot of students start endorsing products or the profession wants to make a statement about it, then the institutions are going to have to start teaching it. Institutions are going to have to start talking about it.

Caplan: That's a great point. Did anyone mentor you, or teach you, or say anything about the rules or the limits of what it would mean to endorse things or give opinions?

Gold: Social media was on the rise when I was in college and then in training. I think people were using it, but not to the same extent they're using now. I learned Twitter by being on Twitter more than anything else, and having a high bar for feeling comfortable about saying something. Maybe over time, I've become more comfortable expressing myself within certain limits. But no one really role-modeled that for me.

One of my mentors from medical school uses Twitter and Instagram, but mostly privately and about things like running. He wasn't necessarily teaching me how to use it for medicine.

Bhargava: I had no social media mentoring in medical school or residency. Certainly, when I went into practice and especially as I met people through the AAP or other doctors, such as Dr Gold, I received some peer mentoring, in that they had established themselves. Certain doctors I knew had websites and were actually leaders in social media for a decade or so. Of course, people like that, who are science-based and use it for the public health good, are great mentors, but certainly I had no formal training.

Caplan: We've said that one rule for someone who's thinking about doing this is to stay connected to the evidence; try to limit your opinions to things that are grounded in science or the role of the physician that you are. What about politics? Do you ever offer your political opinions about the glories of Donald Trump, the wonders of Bernie Sanders, or whoever it might be? Do you go there?

Bhargava: I personally stay away from politics. It gets very muddy very fast, so I prefer, again, to stick to the professionalism and to the science. Have I talked about policies or topics that might be looked at as political? Sure, I have—gun violence being one of them, and also gender equity.

Caplan: Those topics generate controversy, we know.

Bhargava: Absolutely. Even gender equity generates controversy. I'm not sure why, but it does.

Caplan: Would you go some distance, for example, if the president says, "I want to cut Medicare and Medicaid or put work requirements into eligibility"? Would you get into that down the road?

Bhargava: If it affects the health of the patient, such as healthcare reform, then yes. There was an issue around children's health a couple of years back. Those are the things I will advocate for the patient. Those definitely are science-based. I have written blogs about this. It's not political; it's about health. Yes to that.

Caplan: What about you, Jessi? Would you go down the road of endorsing a candidate or worrying about Missouri policy on contraceptive availability or the attempts to restrict abortion?

Gold: I always talk about the issue, not the person. I try hard not to say, "This is because of so-and-so president" or "This is because of so-and-so legislator." Saying something like that could mean that someone who believes in that person would never be able to see me as a provider. It doesn't necessarily mean the same thing for other specialties, and I have seen people who have a very big Twitter presence talk about politics. It works for them, they like it, and it's comfortable for them. It has made a brand for them and it works. But I've never gone there.

I definitely advocate for things too, like gender equity and preventing gun violence . I will talk about mental health. If any policy comes out that affects mental health, I will discuss it. I will also look to the American Psychiatric Association (APA) and other professional organizations to see what they're talking about. If the APA made a statement on the mental health of the children at the border, I might then say something, but I might not say it otherwise.

Caplan: That is another interesting guardrail, as the professional association that you're in takes a position.

Here is a different question: What event, posting, or phenomenon that you were involved in do you regret? Do you have a tweet you wish you had never sent, or something you wrote? What has been something that you at least hesitated over, if not regretted?

Bhargava: I shouldn't say I have no regrets, because I would have to look through all of my posts to truly answer that question. Generally speaking, I do use our professional organizations in science as guardrails. I have nothing that comes to my mind. I'm not saying that I don't use social media as a platform for public health; I absolutely do. But I cannot remember anything bad like that.

Caplan: Jessi, have you ever had a blunder or something you wish you could retract?

Gold: A couple of things come to mind. The first is that tone is missing from social media, or any kinds of posts. Sometimes you say things and think that they sound sarcastic, like a joke, but you miss the intersectionality of the post, and you can offend people pretty easily. I cannot think of an example of that, but I'm sure that I've done that multiple times.

I've also been unprepared for the blowback related to some things. I wrote a piece when I was in residency about in-patient psychiatry—advocating for it—and about the myths that have been perpetrated about in-patient psychiatry being scary, and let's make all of the Halloween movies about it. I wrote that it's not that scary. I understand why it can feel scary, but it's not.

I got so many messages. I didn't expect that. It was probably naive of me, because there are definitely antipsychiatry movements. I just didn't really think about it. That was surprising. Whereas I wrote about gun violence, and I wrote about a bunch of my friends who are abortion providers who have coat hanger tattoos. I expected blowback on those, and I actually got less than I got about the psychiatry post.

Caplan: How do you cope with it? Do you just say that that's the price of being out there?

Gold: Kind of. I try to be thoughtful about what I write. I try not to alienate people. When I did the tattoo story, it was about the people doing the work, not necessarily about abortion. I am not trying to alienate patients despite my own personal beliefs.

You cope by just getting a tough skin. You don't want to poke the trolls. You're not going to get anywhere by replying and trying to defend what you've written. "But you don't understand. Read this piece of evidence, and you'll totally believe me." That doesn't work. Some social media–personality doctors do reply to trolls and use that to create more conflict and conversation. It's never been something I'm good at, nor do I want to do that.

Caplan: I'm pretty sure you would both agree that if you're getting paid for your opinion online, whether about a product, eat blueberries, or whatever, that ought to be a part of a disclosure.

Bhargava: Absolutely. That should be a part of a disclosure. As Jessi pointed out, perhaps medical students should also be held to that standard. It would be a good lesson for them to learn, because truly, it's about digital citizenship. At the end of the day, they might not know that they're going to be signing disclosures left and right for every speaking opportunity they have or anything they do. I do believe they should be taught about that.

Gold: I think it should be disclosed. It's hard, because there are definitely things you endorse by yourself that don't seem to be connected to your university, yet all the time you are connected to your university. I can post in my profile that "these views are my own," but someone can still google me and see where I work. You have to be really careful about that.

I agree with Hansa that med students should be included in the conversation. When it comes to whether you tell your patient what you're doing, I think that depends on the activity and how it could affect patient care.

I don't know if it matters if you are endorsing an eye cream and it's just an eye cream, or it's just makeup and it has nothing to do with anything you're involved in at work. As a psychiatrist, do I need to say, "Just so you know, I also endorse this eye cream"?

Caplan: What do you make of celebrities who come out and endorse healthcare products online? "I'm going to get this artificial knee. It's the best one for me." There are plenty of drug endorsements out there. These people are using their authority, if you will, and celebrity. Does that bother you, Hansa?

Bhargava: It doesn't really matter whether it bothers me. It's happening. Frankly, they're not trained with the rigor that we are. They are held to a different standard than we are, I think. What do you think about that, Jessi?

Gold: I think they're using their platform for money and not necessarily for good. It's hard; they've been offered an endorsement deal. They liked it. They maybe used the product once. It's their job to make money. I get it. But they do cross the line a lot of times. There are definitely celebrity healthcare lines and products that are dangerous.

Caplan: I chase Goop around. There are a lot of products that seem to me to not be grounded in much of anything or that could be dangerous. Do you guys ever spend time chasing that celebrity stuff and trying to debunk it as unscientific?

Bhargava: There is one issue that I will chase around, and that is the vaccine issue. I don't like it when celebrities advocate against vaccines. In fact, on talks we've done on Reddit, some antivaxxers have come on and debated me. I'm happy to debate that with factual evidence. It's something that is going to affect not just the patient but society, and all of us at some point, as we're seeing with all of the outbreaks. Yes, I will chase certain issues down for sure.

Caplan: Jessi, have you tried to be sheriff?

Gold: I don't know that I have the authority to be sheriff in all forms of medicine. I don't go after anyone unless I believe it affects mental health, similarly to Hansa in choosing vaccines as her advocacy issue. I will support people who go after Goop, though. There's a very prominent gynecologist who talks a lot about it, and she's really funny and entertaining to follow; she's very smart and does it very well.

Caplan: I think that's Jen Gunter. I know her, yes.

Gold: I will comment on or repost what she's saying. Someone needs to be doing it, and I'm really glad she is.

Caplan: I'm going to end by asking each of you to talk to me. I'm a medical student. I like talking to the public. Part of the reason I got into healthcare was not just to see patients, but also to advocate for health promotion and to advocate for a science-based lifestyle. Should I do it? What should I worry about? You weren't mentored; mentor me, Hansa.

Bhargava: Sure. I would say that it's important to stick to the science when you talk about products, policy, or patient health. That's what we have been taught. It also speaks to your integrity and the trust that patients and the profession have in you. I would say, stick to the science as much as possible, and always be clear and transparent about what you do. You may decide sometime in your career to be a part of a food company or an eye cream company, but try to make that decision looking through the lens of science, and always be transparent about who you are.

Caplan: What would you say, Jessi?

Gold: I would say do it, but do it thoughtfully. I teach a class on media advocacy and literacy that's an elective to med students. We have a social media class, and we had a long conversation about this. One thing that came up was that, over time, when you're not a resident or you're not in a hierarchical position where you feel that you don't know enough to talk, you get more and more comfortable about talking. It's okay to not jump to being the forefront advocate for something as a med student or a resident. It's okay to tiptoe into social media and see what other people are doing or to ask someone for help. I do believe that it may end up being a necessity in the field.

I just submitted a journal article. They asked for my Twitter handle. My sister is a researcher. She's about 8 years older than me, and she only does research. She's never used social media. But they told her she needed a Twitter account. I have been teaching her how to use Twitter. I believe there will be only very rare occasions where they're not going to want you to be doing this. You will have to learn.

Caplan: Thanks to Jessica Gold and Hansa Bhargava for enlightening me and our audience on the ins and outs of social media. I'm laughing to myself, because I think one thing we have established is that the old-school view, that you keep your opinions to yourself, is so dead as to be rotting. We're not going back there. Whatever the basis was for that position, it's gone. The presence of social media has undermined it completely.

If you want to influence public opinion and stand for the dissemination of good health and science, it's probably going to be through these social media outlets. At the same time, we need more training. We need more mentoring. It would be good to have more policies established, even demanding transparency about who pays us. There's more to be done, but it certainly has become very clear that we're not going back.

I'm Art Caplan for Both Sides Now. Thank you for watching.

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