Approved by Council: June 2022

Companion Resources: Advice to the Profession

Definitions

Social media¹: Online platforms, technologies, and practices that people use to share content, opinions, insights, experiences, and perspectives. Examples of social media include, but are not limited to, Twitter, Facebook, YouTube, Instagram, LinkedIn, and discussion forums.

Disruptive behaviour: Inappropriate words, actions, or inactions by a physician that interfere with (or may interfere with) the physician’s ability to collaborate, the delivery of quality health care, or the safety or perceived safety of others. Disruptive behaviour may be demonstrated through a single act, but will more commonly be identified through a pattern of events. Disruptive behaviour may include, for example, bullying, attacking, or harassing others and making discriminatory comments.² An example of behaviour that is not likely to be considered disruptive behaviour includes constructive criticism offered in good faith with the intention of improving patient care or the health-care system.³

Policy

This policy sets out expectations to help physicians navigate the online environment and prevent conduct that could harm the public’s trust in individual physicians and the profession as a whole. The focus of this policy is on a physician’s professional use of social media, but it can also apply to personal use depending on several factors, for example, the connection between the physician’s conduct and their professional role.⁴

The College recognises that physicians have rights and freedoms under the Canadian Charter of Rights and Freedoms, including the freedom of expression, subject to reasonable limits. Physicians hold a respected position in society. Professional conduct and communication are important to preserve the reputation of the profession, foster a culture of respect, not adversely impact patient care, and avoid harm to the public while using social media.

1. Physicians must comply with the expectations set out in this policy, other College policies,⁵ and other relevant legislative and regulatory requirements⁶ when using social media.

Professionalism

2. Physicians must uphold the standards of medical professionalism, conduct themselves in a professional manner, and not engage in disruptive behaviour while using social media.
3. Physicians must consider the potential impact of their conduct on the reputation of the profession and the public trust.
4. Advocacy for patients and for an improved health care system is an important component of the physician’s role. While advocacy may sometimes lead to disagreement or conflict with others, physicians must continue to conduct themselves in a professional manner while using social media for advocacy.

Health-related information and clinical advice

5. When disseminating general health information on social media for educational or information-sharing purposes, physicians must:
   1. disseminate information that is:
      1. verifiable and supported by available evidence and science, if making statistical, scientific, or clinical claims; and
      2. not false, misleading, or deceptive.
   2. be aware of and transparent about the limits of their knowledge and expertise; and
   3. not misrepresent their qualifications.
6. When disseminating information on social media, physicians must be mindful of the risks of creating a physician-patient relationship or creating the reasonable perception that a physician-patient relationship exists.⁷
   1. Physicians must not provide specific clinical advice to others on social media unless they are able and willing to meet the professional obligations that apply to a physician-patient relationship and the requirements in the Virtual Care policy and the Personal Health Information Protection Act, 2004 (PHIPA).⁸

Professional Relationships and Boundaries

7. Physicians must maintain professional and respectful relationships and boundaries with patients, persons closely associated with patients, and medical students and/or postgraduate trainees over whom they have responsibilities while using social media.⁹
8. While using social media, physicians must consider the impact on and must not exploit the power imbalance inherent in:
   1. the physician-patient relationship when engaging with a patient or persons closely associated with them; and
   2. any relationship with a medical student and/or postgraduate trainee while responsible for mentoring, teaching, supervising or evaluating a medical student and/or trainee.¹⁰

Privacy and Confidentiality

9. Physicians must comply with the requirements set out in PHIPA and its regulations and the expectations set out in the College’s Protecting Personal Health Information policy while using social media.

Posting patient health information

10. If a physician is posting original content on social media containing health information about a patient, physicians must:
    1. de-identify the patient information;¹¹ and/or
    2. obtain and document express and valid consent from the patient or substitute decision-maker (SDM) for the publication of the content on social media, including when there is any doubt that the anonymity of a patient can be maintained.¹²
11. In fulfilling the requirement to obtain express and valid consent from the patient or SDM, physicians must:
    1. show them the content to be published;
    2. inform them that consent to publication can be withdrawn at any point;
    3. inform them about the risks of publication of the content (for example, that once posted on social media it may be unable to be completely withdrawn);
    4. engage in a dialogue with them about the publication of the content, such as the purposes of posting the content, where it will be posted, and any other relevant information, regardless of whether supporting documents (such as consent forms, patient education materials or pamphlets) are used; and
    5. consider how the power imbalance inherent in the physician-patient relationship could cause patients to feel pressured to consent and take reasonable steps to mitigate this potential effect (for example, by informing the patient that if they do not consent, it will not impact their care).

Seeking out patient health information

12. Physicians must refrain from seeking out a patient’s health information online¹³ without a patient’s consent unless:
    1. the information is necessary for providing health care;
    2. there is an appropriate clinical rationale related to safety concerns;¹⁴
    3. the information cannot be obtained from the patient and relied on as accurate and complete, or cannot be obtained from the patient in a timely manner;
    4. they have considered whether it is appropriate to ask the patient for consent to seek out the information online; and
    5. they have considered how the search may impact the physician-patient relationship (for example, whether it would lead to a breakdown in trust).
13. Physicians must document the rationale for conducting the search, the limitations (if any) on the accuracy, completeness or up-to-date character of the information, and any other relevant information (for example, search findings and the nature of search) in the patient’s record.
14. Physicians relying on patient health information found online for clinical decision-making must:
    1. take reasonable steps to confirm the information is accurate, complete, and up-to-date, as is necessary for its purposes, prior to using the information; and
    2. if it is safe and appropriate to do so, disclose to the patient the source of the information, the clinical rationale for obtaining the information, and any other relevant information.

Endnotes

^1. For the purposes of this policy, the term “social media” may also refer to other electronic or digital communications such as email, websites, and text messaging, depending on the context in which it is used and its impact. For more information, see the Advice to the Profession.

^2. Discriminatory comments can take various forms, but may involve the expression of negative attitudes, stereotypes, and biases on the basis of protected grounds in the Ontario Human Rights Code (e.g., race, ethnic origin, creed, ancestry, colour, sexual orientation, gender identity, sex, disability, etc.) as well as other categories (e.g. socioeconomic status, education, weight, etc.).

^3. For more information on disruptive behaviour see the Advice to the Profession. The Physician Behavior in the Professional Environment policy and the Guidebook for Managing Disruptive Physician Behaviour contain further information on disruptive behaviour in the workplace environment.

^4. For more information, see the Advice to the Profession.

^5. Including Advertising, Boundary Violations, Physician Behaviour in the Professional Environment, Professional Obligations and Human Rights, Protecting Personal Health Information, Virtual Care, and Physicians’ Relationships With Industry: Practice, Education and Research.

^6. Including the Personal Health Information Protection Act, 2004, S.O. 2004, the Medicine Act, 1991, the Libel and Slander Act, R.S.O. 1990, the Copyright Act, and the Criminal Code (e.g., hatred offences under sections 318 – 320.1), and their regulations.

^7. For example, by providing information in a manner that would lead a reasonable person to rely on it as clinical advice. If asked a medical question, physicians can direct individuals to the appropriate channels to obtain care. See the Advice to the Profession for more information.

^8. The provision of clinical advice through information and communication technologies is considered providing virtual care. Physicians must continue to meet the standard of care, which can include performing a comprehensive assessment, considering risks and benefits of treatment options, obtaining consent, etc.

^9. Boundaries can be sexual, financial/business, social, or other. For the definition of a “patient”, see the Boundary Violations policy. For more information on maintaining appropriate boundaries, see the Advice.

^10. For more information on professional relationships with students and trainees, see the Professional Responsibilities in Medical Education policy.

^11. A privacy breach can occur if the sum of the information available is sufficient for the patient to be identified, even if only by themselves. For more information on de-identification see the Advice to the Profession.

^12. If relying on consent, physicians must only post a patient’s personal health information, to the best of their knowledge, for a lawful purpose (in accordance with s.29(a) of PHIPA). For content posted for the purposes of advertising, physicians must comply with the General Regulation under the Medicine Act, 1991, S.O. 1991 and the Advertising policy.

^13. This excludes authorized use of electronic health tools, such as patient databases, for the delivery of health care.

^14. For more information on what may be considered a clinical rationale related to safety concerns, see the Advice to the Profession.