April 20, 2012

All rights reserved Overview: This document is based on a simple premise: medical students should engage with social networking tools, such as Twitter, Facebook, and blogging to name a few. Moreover, these tools so benefit an authentic pursuit of the knowledge and skills of the medical profession that their engagement should be encouraged and guided by medical schools. While the premise is simple, the execution is challenging because, as symbolized by their white coats, medical students behavior in the online space entails similar expectations as does their behavior in physical space. Therefore, even though medical students may be familiar with social media before entering medical school, it is appropriate to develop a robust framework of guiding principles. The purpose of this document is to develop such a framework in three parts. The first part is directed toward the student as an abbreviated list of opportunities that social media affords various aspects of medical training. The second part addresses the unique risks of unstructured activity on social networking sites, expanding well beyond the contents of traditional social media policies, with specific sections on managing risks to students, to institutions, and to patients from a legal, ethical, and professional perspective. The third section briefly outlines a stepwise process for introducing a student to social media as a physician in training. This document cannot be considered definitive since new social media platforms, devices, and software are continually developed and old versions abandoned. However, as the specific instances change, hopefully the themes in this document will endure, and if nothing else, serve as useful experiences for future guidelines. The only way to stay up to date is to engage, and this document aims to provide the support to engage carefully and effectively.

Social Media for the Medical Student by Aaron Stupple

Part I: Social Media Strategy for Medical Students

Introduction: Budding physicians are coming to recognize the power of a few good apps. Consider the following situation: your patient with right upper quadrant pain and abdominal distension needs a paracentesis today. Your senior resident is familiar with the procedure, but wont be by to supervise the intern for a few minutes, during which time the intern is asked to prepare the patient for the procedure. The intern is almost as unfamiliar with the procedure as you are. Typically, you would witness the ongoing display of feigned competence, nursing frustration, and patient agitation. Later, during some down time or at home, you would reference paracentesis on the web so that you would be spared the embarrassment you had witnessed. Or, you could use an app. Medscape is a mobile app designed for doctors that has a little known featurea procedures tab that includes, among others, paracentesis. There, it describes the indications, preparation, technique, and interpretation of results, all supported with references. More substantive than Wikipedia, more available and too-the-point than UpToDate, you could soon be telling your intern how to prepare,

assuring the nursing staff why the procedure is necessary, and explaining to the patient what he can expect when the procedure is finished. Staying ahead of the information curve is a growing challenge. While medical school trains students to stay current with developments in the clinical and basic sciences, little attention is devoted to the latest point-of-care smartphone, tablet, and web applications. Until medical school curricula effectively modernize from its early 20th century roots, it is unlikely that they will provide guidance for staying abreast of the latest apps. Until that time, your best source will be social networking sites like Twitter, Facebook, blogs, Google+, and any other of the rapidly emerging two-way communication platforms. A particularly effective method to stay up-to-date on these helpful new tools that are rarely incorporated into traditional medical education is to use Twitter. As of this writing, a useful source is @iMedicalApps, the Twitter feed for the website iMedicalApps.com. In the form of once or twice daily short messages, or tweets, that include a web link, @iMedicalApps offers continual brief updates that are easy to peruse or search. The @iMedicalApps Twitter feed consists of very brief descriptions with a link, like this:

The top 20 free iPhone apps for medical professionals: http://bit.ly/fcGDLe.

On Twitter, @iMedicalApps is just one of many great resources. The best sources are often an individual physician from a students area of interest who can comment on an apps value from the perspective of an experienced clinician. What sounds like a time-consuming process is actually more efficient than traditional use of web surfing or email to stay current. Several time-saving features bear mentioning. 1- The content is pushed to one place, your Twitter feed, obviating the need to regularly check in on websites and scan through irrelevant material. 2- Since the service is social, particularly useful tweets get highlighted by people in your network who share your interests. If you are interested in primary care, your attention is appropriately drawn when a prominent family physician recommends an interesting patient management app. 3- As a social service, it is also quick and easy to communicate directly with information sources. 4- Unlike email, tweets dont demand your attention. Instead, theyre simply available for use if you want them. The purpose of this document is to introduce the value of social media in medicine, particularly for medical students. Contrary to perception, appropriate use of social media supports several requirements of genuine, sound medicine. By adopting tools like Twitter, Facebook, blogging, and a whole host of other interfaces, a medical student can advance their studies and understanding of central aspects of the medical profession. The following are several strategic areas for applying social media tools. Staying up to date: People whose career interests match your own and are active in social media tend to share relevant news and updates. By tuning in, you can save yourself much of the effort required to actively hunt up this information. Instead, you can create your own network of interesting sources. Topics can span the massive diversity of relevant medical topics, from basic and clinical developments to changes in policy or technology, only a few of which are genuinely supported by medical curricula. With the accelerating pace of innovation, the sheer volume of new stuff can be efficiently filtered with social media.

Example: The Institute of Medicines updated its vitamin D recommendations in late 2010. While these guidelines would take months or years to reach medical curricula, social media tools can easily catch these updates on the day they were released. More than that, the social nature allows access to the developing controversy about what the guidelines mean, a controversy and discussion that grows stale with time. Mentoring and Advice: Social media services offer a simple way to connect with people who share your interests, to network, and to gain advice. By sharing what others post and commenting on their content, students have a method to casually develop relationships. Example: The process of students meeting mentors, and ultimately collaborators and letter writers, has already begun with Twitter. On scenario began with the offer of guest lecturing after the would-be mentor noticed his tweets were being shared by an engaged medical student. Networking: Social media is a powerful tool to stay in touch with old colleagues. While email exchanges can become burdensome, they often trail off when people separate. Facebook and Twitter offer quick contact with minimal time obligations. Professionalism: Being a member of a profession, rather than simply an independent service provider, means engaging with the broader issues of healthcare, both as an individual and as a member of a physicians organization. Example: There are a number of physician-commentators who maintain blogs and post their writings on Twitter. By finding a few compelling voices, one can both keep tabs on developments like healthcare legislation and new provider models, as well as offer comments and share opinions. Business of Medicine: Medical schools and residency programs are notorious for releasing their trainees with little preparation for the business realities of managing a practice. Social media offers a way to gain insight into these realities in the absence of classroom content. Example: New and innovative care models, like direct primary care, do not find their way into medical curricula until they are sufficiently established. However, such cutting-edge techniques often access social media channels to publicize their progress. By gaining exposure to these ideas long before residency, fellowship, and practice, savvy students can have a better idea of opportunities early on in their career planning. Teaching: Tools like Facebook or Yammer are excellent resources with which to ask and answer the vast number of questions arising in medical education. Rather than requiring a faculty member to answer individual questions repeatedly by email, open groups enable such answers to be visible to everyone logging in. Such interactive tools both improve feedback and leverage student answers, promoting active learning.

Example: The use of a Facebook group is very well received in a first-year basic science course at SUNY Upstate. Clinical Applications (in the future): Although this is largely uncharted territory, there are several examples of doctors who use patient relationships over social media tools to improve scheduling and to affect behavior change. By getting involved earlier, students can establish an understanding of social media tools so that they may become pioneers of these developments.

Part II: Social Media Policy for Medical Students

Introduction: Medical students represent a unique user of social networking tools like Facebook and Twitter, among others. In brief, we describe five reasons: 1) The information that medical students steward is particularly sensitive, the privacy of which is protected by federal legislation (HIPAA). 2) Sharing patient information is central to both the practice and culture of medicine. 3) Medical students have a lot to lose, both in terms of resources invested and future career ramifications, if found in violation of privacy rules. 4) Having matured entirely in the internet age, most todays medical students have deeply ingrained information sharing habits that are incommensurate with the traditions of their profession. 5) There is a growing body of MDs, healthcare workers, pharmaceutical representatives, information technology firms, and others, many with unclear motivation, who encourage medical students to engage with social media without adequately preparing them to be responsible. In hopes of addressing these risks, this document discusses separately the means to protect students themselves, their patients, and their home institutions (medical schools, hospitals, and clinics), organized into 46 distinct points that deserve a thorough inspection and understanding. Protecting Patients: While upholding the legal responsibilities of patient information is of primary importance, students must understand that they have ethical and professional obligations above and beyond the requirements of HIPAA legislation. These three areas are addressed separately. Legal Obligations: 1- Students may not share any individually identifiable health information that relates to the individuals past, present or future physical or mental health or condition for which there is a reasonable basis to believe it can be used to identify the individual.1 (Appendix A) 2- In addition, any shared information must be expunged of 18 identifiers, the most common of which are the following: (See appendix A for complete list) - Name - Location: All subdivisions smaller than state (street, city, county, zip code, etc.) - Date: Birth dates, admission/discharge dates, encounter dates, surgery dates, etc. - Images: Full face photographic images and any comparable images - Age if Above 90 Years

3- Since the specifics of a case are protected, general comments about the uniqueness or other interesting features of a presentation are unacceptable. Examples: I saw my first case of Guillain-Barre syndrome today. I got to assist in the repair of a total anomalous pulmonary venous return! This lady had a birthmark that looked like China. I saw a guy with a tattoo of Gandhi. 4- Since location is protected, no information about patients may be shared on services that are location-aware, such as a Facebook profile that includes the students city, or tweets that are geo- tagged. 5- Since dates are protected, no postings may be referred to by time, including use of the word today, as in, I participated in my first birth today! 6- Pictures, even if not including faces or any other identifying information, are unacceptable if they relate to unique features. 7- Since age above 90 is protected, one must describe encountering a 92 year-old as a patient over 90 years old.

Ethical Obligations: Even if the patient information has been de-identified and is therefore lawful to share, it may still be unethical or unprofessional. A student should have an adequate grasp of the special ethical issues surrounding patient care before engaging in any online discussion of experiences. The following guidelines are addressed for each major ethical principle.2 Dignity- Student doctors should empathize with patients as individuals capable of making choices based on their particular values. Patients are vulnerable by definition, and especially vulnerable when being discussed in public without the ability to represent themselves. 8- Display empathy with shared feelings rather than pronouncing judgments. 9- Dont objectify patients as disease states; use patient with diabetes rather than diabetic. Be especially careful to avoid derisive terminology, for example cabbage patch, a term sometimes used in the cardiac critical care unit. 10- Dont demean choices that patients make or the values that drive those choices. For example, never judge the cause of a patients obesity or motivations for smoking. Compassion- Student doctors should demonstrate sympathy for suffering and misfortune and efforts to provide relief, without prejudice. Casually discussing experiences in the day-to-day jargon common among physicians demonstrates a lack of compassion to those patients and their families, to others suffering with those same conditions, and to all those in the caring community who empathize.

11- Dont trivialize suffering by speaking casually about a patient experience. Comments about an operation being cool or showing excitement at seeing an exotic condition are inappropriate in public. 12- Even if de-identified, publicly sharing the gory details of a case, including pictures, show a lack of concern for suffering. 13- Avoid including unnecessary details (demographics, ethnicity, etc.) in support of stereotypes of certain conditions. Confidentiality- Although confidentiality is protected by law, doctors must still pro-actively assure patients of this. A student doctor maintaining an online presence gives cause for doubt, which may discourage patients from seeking treatment and from being open about sensitive details. Therefore, such practitioners should take the extra effort to assure that their online behavior cant be perceived as violating confidentiality. 14- Dont make jokes or other comments that may be misinterpreted as a lapse in confidentiality. 15- Only share powerful, intimate experiences to make a powerful point for an upright cause. 16- Be extra careful to identify when you have been given permission to share information. Honesty- Doctors are knowledge workers, and their service to society depends on trust. It is important to maintain a consistent message in the office and in public, including online. 17- Never write something that you are not confident is true. Do not promote anything that you do not truly support. Do not publish partial truths that may mislead. Do not make promises you cannot keep. When possible, offer references. Act in the Best Interest of Patients. 18- Dont be selfish- Online content about patients should only be shared for their ultimate benefit. As in all walks of medical life, you should always ask yourself if and how this serves patient interests before posting. 19- Dont post details in order to impress, to achieve credibility or gravitas, to entertain, to shock, or to ridicule. 20- Be open about conflicts of interest. 21- Competence- Only offer services that you can safely and effectively provide. Do not try to offer interventions online if you lack the means to competently follow through. 22- Do not attempt to establish a therapeutic relationship online. Instead, wait until guidelines for best practices are established.

23- A special note on friending- There is no reason, at least for a student doctor, to establish a close relationship with select patients (i.e. friending on Facebook), unless you previously know the person in a personal context outside of patient care. If so, you should not discuss that patients care in any way. Professional Obligations: Unlike other industries, doctors have a contract with society wherein they agree to provide services in their patients best interests, superseding doctors own gains, financial or otherwise. Doctors have a fiduciary responsibility not only to provide care at the bedside, but to advocate for patients in the public space on social justice issues like access to care and fairness of distribution and allocation of healthcare resources. This translates to several obligations in the online space. 24- Social Justice: Student doctors must develop an understanding of healthcare issues and work toward becoming comfortable in advocating for their position. Online comments about public policy should be restricted until this comfort has been reached, lest impulsive opinions both mar the discourse and come back to haunt the student later in their career. 25- Discipline: Just as society relies on the medical profession to regulate itself, student doctors should take action when they see others behave inappropriately online. When doing so, students should be mindful to communicate only with those directly involved, in private, and with great discretion. Additionally, students must recognize that they may be taking online content out of context and should therefore approach their colleagues delicately. Protecting Institutions: Medical schools and hospitals have special relationships with their communities, forged on years of intense experience, sacrifice, dedication, volunteerism, and shared community identity. As a member of such an institution, a medical student represents a variety of groups, some obvious and others less so. Since perception is reality online, students may easily find themselves unintentionally speaking on behalf of groups in inappropriate ways. Referent Groups that student doctors implicitly represent: Medical School: Students class, entire student body, faculty and staff, administration, and alumni. Hospital: Patientsboth current and past, staff, volunteers, administration, and donors. Community: All community members who identify with the hospital and medical school as part of the place wherein they live. The future: Since online text never dies, your comments also represent the future members of each of these groupsfuture students, faculty, community members, etc.for untold years and amid shifting contexts. 26- Be familiar with your institutions online presence and refer comments with direct links to those sources (homepage, Facebook page, etc.). 27- Check with the marketing department before conducting online activities for a group within the institution. Make sure that the presentation is in-line with the institutions public face.

28- Refrain from any comments that you are not entirely comfortable making on behalf of the referent groups listed above. 29- Be particularly respectful when referencing your institutions. Since you are speaking in a mixed audience on behalf of a mixed audience, always reflect on how each group that you represent could interpret your comments. 30- Be polite. Address people formally, avoid casual and inappropriate language, especially when offering disagreement. 31- Be serious. Avoid spam or other off-topic content. 32- Be supportive. Avoid self-promotion for its own sake. Avoid cynicism. Be aware of your institutions values and standards. 33- Be responsible. Avoid posting private material about any group members, including pictures or stories. Complaining about members of your provider team on Facebook is a particularly common transgression. 34- Be accurate. Make sure your statements are in accordance with actual facts and refrain from speculation. If you are not particularly knowledgeable, do not comment. If you make a mistake, address it quickly, honestly, and openly. 35- Offer content that is high quality and unique to your particular area of experience or expertise. 36- Be clear. Explicitly state that you speak only for yourself, as in opinions are my own. If you do weigh in on a topic related to the institution, state your role and relationship with that institution. Do use your institutions email address for within-group correspondence so your identity is clear. Otherwise, use your personal email address. 37- If dissatisfied with an institutions policy or action, discuss it first only with the people or representatives responsible. Protecting Students Themselves: All content posted online must be considered permanent, searchable, and traceable. Additionally, comments on third party services like Twitter and Facebook must be considered someone elses intellectual property, and they are free to distribute it or otherwise utilize it as they please. 38- First and foremost, to protect yourself and your reputation, you must adhere to the above recommendations, particularly patient privacy. 39- Establishing a robust, quality online presence can create a visibility buffer, where positive content about you rises to the top of search results. 40- Do not offer medical advice, or anything that could be interpreted as medical advice.

42- Do not solicit, or interact in a way that could be interpreted as soliciting, protected health information. 43- Reflect before you post. Think about the different ways your content may be misconstrued. One mistake may be sufficient to terminate an entire career. 44- As a future physician, impulsive and uninformed comments made during training may be considered to represent you at any point later in your career. 45- Comments on topics unrelated to medicine may be considered reflective of your medical judgment and trustworthiness.

46- Comments left on other peoples content, such as blog posts, may be attached to the sentiment of those posts, even if you are expressing disagreement.

Part III: A plan for safe, gradual engagement.

Introduction: If medical schools are going to encourage students to engage social media, students should do so gradually and at a pace that poses minimal risk to themselves, the patients they serve, and their home institution. The Levels of Engagement are designed to offer a stepwise introduction that starts from the most removed, and therefore safest, level of engagement, and progresses toward increasing involvement. Since most, but not all, medical students enter training with some social media experience (Facebook and reading/writing blog entries), several of these levels may seem unnecessary. However, as noted above, incoming students are not yet familiar with the differences between casual social media use and that of a physician in training. Therefore, an effective system offers recommendations accessible to members at any stage of social media facility. Table 1. Levels of Engagement
1. Anonymous Private Consumer Establishes accounts that are anonymous (not identifiable as that student) and private (only viewable by those the student allows). Consumes information only, does not contribute any content.

Description

Level

2. Anonymous Private Sharer

The safest way get a feel for how that particular online service works, who sees what content. Notice what is and is not effective and appropriate. Recommended only until comfortable with how process works.

3: Anonymous Public Sharer As before, but As before, but also shares now increases others material, ones presence so usually in the that anyone may form of links, that receive shared has already been content. Might created. comment on content already produced, but not produce any. Sharing what Enables some others say is still networking, relatively whereby sharing passive. Take others content in care to share a public way only appropriate brings notice to material. common interests.

4: Identifiable 5: Public Content Public Sharer Creator Ones screen As As before, but now name identifies actively engages the user and is topics, offers an publicly opinion, and might available. Might contribute longer c comment on form commentary. content already produced, but not produce any. Total networking enabled. Ideally all students would reach this level of use. Should only be engaged after significant experience with previous levels, a deep grasp of professional expectations, and a significant fund of knowledge and insight.

Please forward any recommendations to the author at astupple@gmail.com. References: 1. US Department of Health and Human Services. Health Information Privacy. http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/index.html 2. Bernard Lo. Resolving Ethical Dilemmas. Lippincott Williams & Wilkins; Third edition 2005

Purpose

Appendix A
Protected health information(PHI) is individually identifiable health information, including demographic information, collected from an individual, and is created or received by a health care provider, health plan, employer, or health care clearinghouse; and relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual; and that identifies the individual; or with respect to which there is a reasonable basis to believe the information can be used to identify the individual. PHI may be transmitted in any medium, electronic or otherwise. Health information that is de-identified is no longer protected, and may be shared. De-identified health information does not identify an individual and with respect to which there is no reasonable basis to believe that the information can be used to identify an individual. Health information is de-identified only if a statistician determines that the risk for identification is very small that the information could be used, alone or in combination with other reasonably available information, by an anticipated recipient to identify an individual who is subject of the information; or If the following 18 identifiers of the individual or of relatives, employers, or household members of the individual, are removed: (A) Names; (B) All geographic subdivisions smaller than a State, including street address, city, county, precinct, zip code, and their equivalent geocodes, except for the initial three digits of a zip code if, according to the current publicly available data from the Census Bureau: (1) The geographic unit formed by combining all zip codes with the same three initial digits contains more than 20,000 people; and (2) The initial three digits of a zip code for all such geographic units containing 20,000 or fewer people is changed to 000. (C) All elements of dates (except year) for dates directly related to an individual, including birth date, admission date,, discharge date, date of death; and all ages over 89 and all elements of dates (including year) indicative of such age, except that such ages and elements may be aggregated into a single category of age 90 or older; (D) Telephone numbers; (E) Fax numbers; (F) Electronic mail addresses; (G) Social security numbers; (H) Medical record numbers; (I) Health plan beneficiary numbers; (J) Account numbers; (K) Certificate/license numbers; (L) Vehicle identifiers and serial numbers, including license plate numbers; (M) Device identifiers and serial numbers; (N) Web Universal Resource Locators (URLs); (O) Internet Protocol (IP) address numbers; (P) Biometric identifiers, including finger and voice prints; (Q) Full face photographic images and any comparable images; and (R) Any other unique identifying number, characteristic, or coded.

Source: Summary of HIPAA Privacy Rule www.hhs.gov/ocr/privacy/hipaa/understanding/summary/index.html