Our lives have changed dramatically in the past 3 decades as the Internet has grown to almost all corners of the world. The “Digital Age” is here, allowing massive amounts of data to be stored in relatively small spaces. The early phases of the Internet allowed individuals to receive data from Web sites. This evolved to Web sites that could interact with their users. Some people began keeping journals of their thoughts on various subjects online and “blogs” became commonplace in the latter half of the 1990s. All of this led to the explosion of social media during the 2000s with the founding of LinkedIn in 2002, MySpace in 2003, Facebook in 2004, YouTube in 2005, and Twitter in 2006. Social media has revolutionized the manner in which humans interact and communicate. The dominant method of obtaining information is now the Internet.1 As of September 2013, 70% of Americans had high-speed broadband Internet access at home.2 Social media has become the most used Internet activity and continues to increase with an average user engaged more than 6 hours per week.3 The implications for practicing surgeons are not yet fully known, and this article hopes to serve as a launching point for orthopaedic trauma surgeons who use social media in their personal and professional lives.
THE ONLINE REPUTATION
Almost every person has an online reputation, including orthopaedic surgeons. Knowing and managing the information about yourself and your practice on the Internet is critical for surgeons. The first step is assessing what is currently online.4,5 Put your name in Google or other search engines and see what appears. Pay careful attention to the first and second pages as only 15% of web users look beyond the second page of results.6 Although everyone hopes to find positive things, negative information or reviews may be present. Surveys of web users have shown that 75% of people searching for health-related information fail to verify the information discovered.6
So, how can surgeons create a positive online reputation? Surgeons need to be online and create a digital presence.4–6 Negative posts or comments about a physician can be posted online by a named person or anonymously. Web sites are not criminally liable for content posted by a third party per federal law and multiple cases have upheld this protection.7 Lawsuits can be used to try and obtain the identity of an anonymous poster or to remove defamatory content. However, success depends on the specifics of the case, and lawsuits are generally costly, timely, and frustrating,7 and should only be used as a last resort.4 The best way to combat negative comments and reviews is to dilute them with your own Web sites and profiles on other social media sites.6 Encourage satisfied patients to post positive reviews online.4,5 Search engine optimization has become a field unto itself and you or your practice can take various steps or seek assistance from a professional to bring positive search results forward.4 Monitoring your online reputation can be time consuming, but simple steps can be taken, including creating Google Alerts that will provide a daily update of online activity.4,6
Damage to an online reputation can also be self-inflicted. Personal social media accounts should be separated from professional accounts per the American Medical Association (AMA), Federation of State Medical Boards (FSMB), and the American Academy of Orthopaedic Surgeons (AAOS).8 Everyone needs to understand that posts on social media sites, blogs, or Twitter can last forever, and every physician should assume that online posts are permanent.9 Offensive content, as defined by others, on a personal account, can affect personal reputation and reflect on your professionalism.8 Screen captures can make deleted posts exist forever. CeeLo Green tweeted “women who have really been raped REMEMBER!!!” and then promptly deleted the tweet in August of 201410; however, screen captures of the image were made and circulated, and can be easily found on multiple search engines. More than 80% of residency coordinators surveyed believed personal social media information reflects on an individual's ability to be a physician and more than 60% thought it reasonable to include these accounts in their evaluation of the candidate.11 Seventy-eight percent of recruiters now check search engines on potential employees and 63% check social media accounts.12
Password security and privacy settings on personal and professional online accounts must be excellent.9 A simple Google search for “Hack Facebook Account13” (Fig. 1) returned 33,900,000 results. A hacked account of any kind can allow access to private or embarrassing information and/or photos or allow offensive material to be posted under your online identity.
The Health care Information Portability and Accountability Act (HIPAA) of 1996 created penalties for improperly disclosed protected health information (PHI).14 A physician should not share PHI, even once deidentified, on personal social media sites. When e-mail and text messaging are used to communicate PHI, it must be done through secure and encrypted services.6
Physicians must be extremely careful as PHI can be inadvertently shared. Almost all smartphones double as an excellent camera and clinical photographs of wounds, surgeries, and x-rays can be taken and easily transmitted among providers for communication and education. Smartphone applications can allow automatic uploading of all photographs to the cloud, and providers must ensure that photographs are deidentified and securely protected. If photographs are uploaded to Facebook, their policy states you have granted “nonexclusive, transferable, sublicensable, royalty-free, worldwide license” to use the content until you delete “your IP content or your account, unless your content has been shared with others and they have not deleted it.”15 Clinical photographs or videos should never be uploaded to a social media site, as retrieval of all copies is not feasible.15
Photographs can also be taken and shared between provider and patient. Photographs of postoperative incisions where the patient has concern for infection may be shared through secure e-mail or secure text message, substituting for an office visit.6 Images generated during a patient's treatment should be protected as a part of the medical record.15 The issue of consent for clinical photographs is unclear. If a patient can be clearly identified by his face or identifying marks likes tattoos or scars, informed consent is required; when no identifying features are present, the issue of consent is unclear.15 However, providers taking photographs for medical or research reasons should ask for and document the patient's informed consent.15
Listservs are offered by many professional societies to serve as online discussion boards. The Orthopaedic Trauma Association (OTA) provides a listserv that is open to any subscriber but is geared for orthopaedic trauma surgeons.16 It allows for dissemination of information regarding education, meetings, and information of interest to subscribers. The listserv also allows physicians to post HIPAA compliant cases to discuss with other practicing orthopaedic trauma surgeons. Some professional societies, such as the American Society for Surgery of the Hand, exclusively allow society members to use the listserv.7 Many other platforms, including OrthoMind, Medscape, and Sermo, exist for case discussions with variable amounts of subscribers and use.17 VuMedi was started in 2008 and many consider it a “YouTube for surgeons,” where procedural videos can be posted and later viewed when a site-user signs in.7 Users can comment and post questions regarding the techniques shown; however, these comments are still in the public domain and must be carefully considered.7
Professional social networking sites are designed to separate professional from personal social media accounts. LinkedIn is a Web site for all professions and allows contact with recruiters, other physicians, and industry personnel. The Web site can also assist with job searches and keeps all of this activity private. Doximity was launched in 2010 and allows doctors to communicate to find appropriate specialists and to share patient data with HIPAA compliant practices and claims to have 30% of the physicians in the United States in its network.18
Ethical and privacy concerns have likely slowed the use of social media in marketing individual or group practices. Establishing a strong digital presence and online reputation helps build practices, can be a strong source of new patients, and should become even more important in the future. Howard Luks emphasizes that providers “must be where (their) potential patients choose to be” and believes that he receives 10 new patient inquiries everyday due to a strong online presence.6
Twitter, an instantaneous microblog, has changed information exchange and is the most widely used microblogging platform.8,19 Up to 40% of patients in an orthopaedic hand practice were using social media as of 2010,20 and this percentage has likely grown in all orthopaedic subspecialties since. However, less than 1% of board certified orthopaedic surgeons use Twitter for professional reasons.19 TweetChats allows opportunities for collaboration among parties with similar interest.8 The AAOS has a Twitter profile (@AAOS1) that is followed by thousands of subscribers, which demonstrates a public interest in musculoskeletal medicine.19 Although a large portion of a trauma practice is generated through emergency room call, “cold trauma” referrals and patient base can be built through a strong online presence and this opportunity awaits as technology continues to advance.
The utility of social media for research is largely unknown. An institutional review board or ethics committee must approve patient contact through social media for research purposes. As human interaction moves into the digital space, social media will likely provide the best contact point for patients in the coming decades. The landline, mobile phone numbers, and addresses of yesterday are likely to be the Facebook accounts, Twitter profiles, and yet to be created social media sites of the future.
One group used YouTube videos of ankle fractures to determine whether the Lauge-Hansen classification system correlated with actual injury mechanisms.21 This novel idea resulted in a podium presentation at the 2009 annual meeting of the OTA and was published in the Journal of Orthopaedic Trauma.
The Digital Age is here and will not be going away. Physicians should engage now to maximize opportunities for their practice and professional development. Several resources are available for novices to social media. The “Social Media in Health care: A Primer for Orthopaedic Surgeons” published by the AAOS Practice Management Committee in 2012 is an excellent place to learn more.
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