Caroline Mercer | Toronto | May 7, 2018
More doctors are posting about patients online, raising serious ethical concerns.
Four years ago, Toronto plastic surgeon Dr. Jamil Ahmad joined the social media platform Instagram to share pictures of a trip to the Middle East. More than 10 000 followers later, the account has become a powerful professional tool. He regularly posts before-and-after photos of patients, alongside family snapshots and gym selfies.
Ahmad said patients are “dramatically more informed” about surgery because of accounts like his. Many plastic surgeons and dermatologists have amassed large social media followings in recent years. South of the border, cosmetic dermatologist Dr. Simon Ourian has more than two million followers on Instagram, rivaling some of his celebrity clients, while plastic surgeon Dr. Sheila Nazarian has experimented with live-streaming procedures.
But as more doctors are showcasing their work on social media, others are questioning the ethics of posting about patients in such a public and informal space. At minimum, the rules for publishing patients’ information in journals, textbooks and educational presentations should also apply to social media, said Dr. Alireza Jalali, head of anatomy at the University of Ottawa’s Department of Innovation in Medical Education. “There are clear guidelines that people need to follow, and that’s, unfortunately, sometimes not done very well.”
“I always tell people, Twitter is new, but publication is not,” he explained. “If I want to submit a photo of a patient, or imagery of patient to a journal, I need consent.”
Being respectful to patients is just as important online as it is offline, Jalali added. “You’re a doctor 24/7. It doesn’t matter that you were on Twitter. You said something wrong; it’s going to affect your career.”
Ahmad said he uses the same consent process for social media that he does for conferences or journal articles. He said many of his patients are “very happy” to allow him to share their photos to help others. “A lot of patients know that I have Instagram and they’ve actually been on there and looked at everything.”
For people thinking about surgery, seeing before-and-after photos or videos of surgeons interacting with patients gives them a sense “not only about what the potential results can be, but what the process is,” Ahmad said.
However, some experts worry that the usual consent processes don’t address the new ethical challenges posed by social media. By design, social media blurs the lines between personal, professional, educational and promotional content. Many posts cross the line into unethical self-promotion and “medutainment,” but it’s hard to tell where that line is drawn, said Dr. Christian Vercler, a plastic surgeon and assistant professor at the University of Michigan.
Even when a patient gives consent, “it is critical to recognize that using the patient–physician relationship as a source of entertainment by which to increase notoriety or attract patients utterly demeans the surgeon’s protective duty toward the patient,” Vercler argued in a recent commentary.
Doctors should be careful to understand patients’ motivations for giving consent, he told CMAJ. “If you’re already saying yes to an operation, it seems like a much smaller thing by comparison to say yes to the use of your images on social media,” he said. “People may not know what they’re getting themselves into.”
In his commentary, Vercler cited the case of a patient who consented to her surgeon sharing images of her breast reduction on social media. After the operation, she was shocked to see a Snapchat video of the surgeon holding up her excess tissue to show viewers “how much extra breast tissue you might be carrying around.” Fighting back tears during a postoperative visit, she told the surgeon, “I assumed you’d treat my experience with respect.” In such situations, the original post can be taken down, but countless copies may continue to circulate online.
It’s important to consider who might see a post, especially on platforms that are popular with young people, Vercler said. Some surgeons are “placing naked patient images into a context where your audience is underage.”
Context matters, he explained. Images that may be appropriate to publish in a medical journal for an audience of professionals may not be appropriate to publish on Snapchat “where there are lot of sensational images being posted by the majority of users.” Posting about patients in that context is questionable “because the observer is expecting something that’s mostly going to be entertainment.”
Photo credit: alvarez/iStock
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