Many physicians use social media to interact with others, share content with a broad audience, and seek out medical information online. Social media can present important opportunities to enhance education and facilitate discourse and knowledge translation. The use of social media, which is highly accessible, informal, fast-paced, and constantly evolving, raises questions about how physicians can uphold their professional obligations. This companion Advice document provides further guidance around how the expectations in the Social Media policy can be met.

General

Do these professional expectations apply to my personal use of social media?

The focus of the policy is on a physician’s professional use of social media, but it can also apply to personal use. Several factors impact whether personal use of social media may be considered unprofessional, including, but not limited to, the nature and seriousness of the conduct and/or communication itself, whether or not the physician was known to be, could reasonably be known to be, or represented themselves as a member of the profession, and the connection between the conduct and/or communication and the physician’s role and/or the profession.

Physicians may decide to use professional and personal accounts, but it is important to keep in mind that the professional and personal are not always easily separated. Even when posting in a personal capacity, others may know of your status as a physician, or physicians may sometimes share personal details on professional accounts. As such, it is important that physicians act professionally in both contexts.

Does the policy apply to other forms of electronic communications such as emails, text messaging, video conferencing, and messaging applications?

Depending on the purposes and contexts for which they are used, electronic communications that are not traditionally considered social media can have a broad impact and involve interaction with others in a manner similar to that of social media. In these circumstances, the policy is more likely to be applicable to a physician’s conduct. For instance, responding to an email list or sending out an email newsletter can reach a wide network of people online, similar to posting on a discussion forum or a group page on a social media platform.

Professionalism

What is considered disruptive behaviour?

Although the term “disruptive” may have different meanings in other contexts, in this policy disruptive behaviour is demonstrated when inappropriate conduct interferes with, or has the potential to interfere with, quality health care delivery, the physician’s ability to collaborate, or the safety or perceived safety of others.

Disruptive behaviour poses a threat to patients and outcomes by inhibiting the collegiality and collaboration essential to teamwork, impeding communication, undermining morale, and inhibiting compliance with and implementation of new practices. Whether behaviour is truly disruptive depends on its nature, the context in which it arises, and the consequences flowing from it. Some examples which are not likely to be considered disruptive behaviour include constructive criticism offered in good faith with the intention of improving patient care or facilities or good faith patient advocacy.

Sometimes inappropriate conduct may occur concurrently with other problems, for example, health issues, or may be influenced by different stressors and/or physician burnout. A list of resources and supports is available on the CPSO’s website for physicians if they have concerns about their health and well-being.

What does the CPSO mean by “professionalism” and “reputation of the profession” when using social media?

Professionalism is a fluid and contextual concept. It can require physicians to navigate and balance their duties towards individual patients, the public, the health care system, colleagues, and themselves. CPSO’s commitment to integrating equity, diversity, and inclusion is also relevant to how we may conceptualize professionalism, given that traditional concepts of professionalism have often centred around the identities and cultural norms of dominant groups.

In general, what is considered professional behaviour will be informed and guided by College resources, including policies, and other professional resources, such as the Canadian Medical Association’s Code of Ethics and Professionalism and the Royal College of Physicians and Surgeons of Canada’s CanMEDS Framework.

Maintaining trust is an important aspect of medical professionalism. Physician conduct can impact the reputation of the profession when it undermines public trust and confidence in the profession. This in turn can adversely impact patient access to health care and patient care itself. The evaluation of the potential impact of a physician’s conduct and/or communication on the reputation of the profession will be based on an analysis of the facts and circumstances. In addition to communicating in accordance with the tenets of professionalism as outlined above, upholding the reputation of the profession includes:

• acting in accordance with the law
• participating in professional regulation
• adhering to clinical standards and demonstrating professional competence
• maintaining the same standard of professional conduct in an online environment as expected elsewhere

What do I have to consider when engaging in health advocacy on social media?

CPSO, as well as the Royal College of Physicians and Surgeons of Canada’s CanMEDS framework, recognizes that advocacy is a key component of a physician’s role.

If you practise in an institutional setting, you may be subject to their policies or guidelines around social media use. Some institutions may require express permission before engaging in advocacy activities on social media that could be interpreted as directly involving them. You may also wish to consider whether it is appropriate to notify your institution’s administration and/or members of the care team prior to engaging in advocacy online, even if no policies or guidelines require it.

On occasion, while engaged in advocacy intended for the betterment of patients, an institution, or the health-care system, physicians may find themselves in conflict with others, including colleagues or the administration of the institution where they work. In such cases, it may be necessary to consider the impact of the physician’s conduct on their ability to deliver quality health care, their ability to collaborate, or the safety of others. When these are impaired by a physician’s advocacy, it is important to consider whether the advocacy efforts are in fact in the best interests of patients and the public.

The College recognizes that, unfortunately, physicians may find themselves experiencing personal attacks or harassment online with respect to their advocacy. Physicians can familiarize themselves with and use privacy controls and reporting mechanisms to help address this conduct. The College also recognizes that these interactions can be harmful and distressing to physicians. A list of health and wellness resources for physicians can be found on the CPSO’s website.

How can I support equity, diversity, and inclusion goals through my social media use?

There is a growing commitment to integrating cultural humility and cultural safety within the health-care system and the medical profession. Cultural humility is a perspective that involves exercising self-reflection and acknowledging oneself as a learner when it comes to understanding another’s experience. Cultural safety is an outcome that recognizes and strives to address power imbalances inherent in the health care system. The goal is an environment free of racism and other forms of discrimination, where people feel safe when receiving and accessing health care, and where providers feel safe and respected providing health care.

With these goals in mind, CPSO supports physicians striving to foster an environment that is inclusive. It is also important for physicians to be aware that their conduct on social media (including liking, sharing, or commenting on other content) may be visible to others and that unprofessional comments and behaviour (which can be overt, or more subtle, like microaggressions) have the potential to make others feel marginalized and impact their feelings of safety and trust, and potentially impact patients’ willingness to access care. For more information, please visit CMPA’s guidance related to cultural safety and CPSO’s Equity, Diversity, and Inclusion resources.

What do I do if an individual reaches out to me on social media with a medical question?

Physicians are permitted to share health information that is intended for general education and not patient-specific. For example, information on a physician’s blog on diabetic self‐care or information on a business page that encourages patients to get a seasonal flu shot are not intended as a substitute for a physician’s clinical advice. Clinical advice refers to individualized advice given to a specific patient for a particular health concern.

You can respond to questions without providing clinical advice. For instance, you can inform the individual that you do not provide advice on social media and direct them to make an appointment through appropriate channels, or you can provide information for emergency or urgent care services, if applicable.

Physicians interacting with patients online must meet privacy and confidentiality obligations, as outlined in the Protecting Personal Health Information policy. Physicians who provide clinical advice to patients online must comply with the Virtual Care policy and other relevant College policies.

What should I consider when sharing general health information that involves statistical, scientific, or clinical claims?

The policy requires that physicians disseminate information that is verifiable and supported by available evidence and science if making statistical, scientific, or clinical claims. It is important for physicians to also consider the potential associated risks of sharing such information.

When physicians share information online, it is likely to be given significant weight or value by many, especially when that information makes statistical, scientific, or clinical claims. Sharing information without strong scientific evidence can introduce risks, including that patients and members of the public will act on this information in a way that could jeopardize their health.

For instance, if a physician shares information about a potential new or unconventional drug or treatment, the risks of sharing this could include influencing members of the public to seek that drug when it may be inappropriate for them and when it may have unexpected negative consequences (e.g., side-effects). As when making treatment decisions for patients, generally speaking, the higher the potential risk, the higher the level of evidence required.

Keeping in mind the relationship between risks associated with specific claims and the strength of evidence appropriate to support those claims, the Advice to the Profession: Complementary and Alternative Medicine document may be informative. It provides additional information regarding how to evaluate the strength of evidence and various factors to consider.

What kind of information would be considered misleading or deceptive?

Sharing false information would be a breach of the expectations in the policy. What is considered “misleading or deceptive” is broader than this. Physicians can avoid being misleading or deceptive by thinking carefully about whether the wording of posts includes content that may lead the reader to an incorrect conclusion, create a false impression, or that leaves out key information or context.

In some circumstances, such as during a public health crisis, information may change and evolve rapidly, and information that may have been shared at one time may subsequently be inaccurate or no longer applicable. The policy is not intended to capture such instances where physicians share what was the best available information at the time.

The policy is also not intended to prevent reasonable debate and/or exploration of new developments in medicine. However, physicians who make statements that contradict scientific consensus, including in the context of a public health crisis, can create confusion, increase mistrust, and impact overall public health and safety. As a physician, it is important to keep in mind that your statements, particularly those containing statistical, scientific, or clinical claims, can be very influential and be perceived as more credible, regardless of whether you are speaking about an issue within your expertise or not.

Professional Relationships and Boundaries

How can I maintain appropriate boundaries with patients on social media?

As a physician, there is an increased risk associated with managing a dual relationship with a patient, including the potential for compromised professional judgment and/or unreasonable patient expectations. Personal information is more readily accessible on social media and connecting online can lead to inappropriate self-disclosure by patients and/or physicians.

The College recognizes that, especially in smaller communities, physicians and patients may interact within the same social network. What entails maintaining appropriate boundaries may therefore differ depending on the circumstances. Maintaining appropriate boundaries may mean refraining from connecting with patients and persons closely associated with them on social media. Patients may feel pressured into accepting an invitation from their physician due to the inherent power imbalance in the physician-patient relationship. If a patient or a person closely associated with them requests to connect on social media, you must consider the potential impact on the physician-patient relationship. Relevant factors include the type of clinical care provided, the length and intensity of the relationship, and the vulnerability of the patient. When declining an invitation, you can discuss with the patient the reasons for doing so to prevent harm to the physician-patient relationship. Since personal content is generally limited on a professional social media account, using one can also help you connect with patients without compromising the therapeutic relationship.

Physicians must also comply with the expectations in the Boundary Violations policy when engaging with patients and persons closely associated with them.

Privacy and Confidentiality

How do I de-identify information if I want to post about a patient on social media?

To de-identify the personal health information of an individual means to remove any circumstances that it could be utilized, either alone or with other information, to identify the individual.

An unnamed patient may still be identified through a range of information, such as a description of their clinical condition, or date, time, and/or location. When posting photographs, even if a patient is not directly pictured, other details such as the timestamp or location (which may be found in a photograph’s metadata), can be used to reveal information about an individual. Even if only the patient can identify themselves from the information, that may be deemed a breach of confidentiality.

Given the increased risks of identification and the highly accessible and permanent nature of the internet, protection of patient privacy is paramount and physicians may wish to consider obtaining consent for posting even de-identified information whenever possible. Physicians must obtain and document consent before publishing patient information where there is any doubt that the patient can be kept anonymous (for example, posting a photograph with an identifiable part of a patient’s body).

Why must I refrain from seeking out patient health information if it is publicly available?

The policy aligns with the requirements in the Personal Health Information Protection Act, 2004 (PHIPA), which only permits indirect collection of personal health information without consent in limited circumstances. In addition, physicians preserve patient trust and protect the physician-patient relationship by refraining from seeking out patient health information online without consent. Many patients hold a reasonable expectation of privacy that their physicians will not search for their information online. Patients may perceive this to be a boundary violation, a lack of trust, or a lack of respect for their autonomy, which may lead to a breakdown in the physician-patient relationship.

What are appropriate clinical rationales related to safety concerns for seeking out patient health information online?

Situations where there is a risk of serious bodily harm to a patient or to others and danger is imminent would most clearly establish an appropriate clinical rationale related to safety concerns, for instance, where there are concerns about the risk of suicide or serious harm to a patient. There are also circumstances which, in the physician’s professional judgment, may include urgent or emergent factors and it may be reasonable to search for information about them online in order to deliver appropriate care to the patient. For instance, this may occur when a patient presents to the emergency room unresponsive or otherwise unable to provide critical information.

What can I do to protect my privacy while using social media?

It is important to keep in mind that privacy can never be fully guaranteed online, even when posting in a closed forum. Posts can be shared more widely than originally intended (for example, screenshots of posts and messages can be shared on other platforms) and can be hard to remove once online. Resources from the Office of the Privacy Commissioner of Canada below provide useful guidance on how physicians can customize account privacy settings to better maintain control over and limit access to their personal information when posting online.

Resources

Canadian Medical Protective Association

• Social media: The opportunities, the realities
• Top 10 tips for using social media in professional practice
• Good Practices Guide: Social Media
• Protecting patient privacy when delivering care virtually
• Participating in health advocacy
• Advocacy for change: An important role to undertake with care

Office of the Privacy Commissioner of Canada

• Staying safe on social media
• Privacy and social media in the workplace
• Tips for using privacy settings

Office of the Information and Privacy Commissioner of Ontario

• De-identification
• Privacy and Security Considerations for Virtual Health Care Visits
• Frequently Asked Questions: Personal Health Information Protection Act