In 1975, the Federal Trade Commission declared that a professional society’s ban on advertising restrained trade and was therefore illegal.1 However, professional societies were slow to embrace marketing, despite its legal protection. This resistance was repeated when the first websites came out, particularly with the posting of before-and-after photographs. Even after professional societies themselves embraced the use of websites, social media have now become the target of criticism.2,3 However, social media are a different beast. Their power lies in unprecedented flow of information in the form of video, pictures, and text, along with an open communication channel between viewer and poster.
The impact of social media on American culture is evident in the number of Facebook users (2 billion monthly users), Instagram users (800 million monthly users), and Twitter users (330 million monthly users).4–7 In contrast to the previous generation of media outlets such as radio, television, and newspapers, social media allow interactive communication through features such as “likes,” “comments,” and “reposts/retweets.” Because there is no editor, publisher, producer, or curator controlling content, the user can post any content, regardless of its validity. Therefore, although social media are a powerful and versatile tool, the plastic surgeon should first learn their nuances and risks, and then proceed with caution.
Since the introduction of social media, the plastic surgery community has embraced them as a tool for marketing, education, and communication.8,9–12 Despite their popularity, there are minimal guidelines and information for young plastic surgeons and trainees regarding how to use social media. Currently, 65 percent of adults and 90 percent of young adults use social media, and many trainees are likely already using one or more platforms.13 However, trainees should be aware of unique considerations regarding use not covered in professional articles, which are generally aimed at board-certified plastic surgeons. In this study, we will discuss the current literature, trends, and ethics on social media use by plastic surgeons and make recommendations for young plastic surgeons.
SOCIAL MEDIA AND PLASTIC SURGERY
Historically, plastic surgeons have been innovators and early technology adopters. Although some plastic surgeons embrace social media, others regard them with apprehension, as evidenced by a survey of the American Society of Plastic Surgeons in 2013, which showed that approximately 50.4 percent of plastic surgeons use social media in their practice, whereas 49.6 percent do not.8 In contrast, plastic surgeons in the United Kingdom were more likely to incorporate social media, accounting for 82 percent of the British Association of Plastic, Reconstructive and Aesthetic Surgeons.10
Although some plastic surgeons feel social media have impacted them positively, others feel that impact has been negative. According to a study by Vardanian et al.,8 many plastic surgeons believe social media are an effective marketing tool (52.1 percent), a platform for patient education (49 percent), a good networking tool (27.8 percent), and a good apparatus for new patient referrals (24.3 percent).14 However, others refrain from social media over concerns of professionalism (54.1 percent), patient confidentiality (48.8 percent), and becoming too accessible (45.9 percent).8 Similarly, in another survey, respondents felt that Facebook increased their practice exposure, resulted in positive patient feedback, and provided an opportunity for low-cost advertising, although it allowed unwanted solicitations, was too much time-consuming, and compromised the patient’s privacy.15
ETHICS AND SAFETY
I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know.
The major drawback of social media is possible breach of patient privacy and confidentiality, putting patients at risk and physicians in possible violation of the Health Insurance Portability and Accountability Act of 1996 law. Snapchat, Instagram, and Facebook allow users to record, post, and broadcast live videos. Several plastic surgeons have posted videos featuring clinical procedures ranging from botulinum toxin injections to buttock augmentations. Although the videos can be educational to patients, concerns have been raised regarding videos that violate established ethical standards regarding respect for the patient out of concern for plastic surgery patients and the professional standards of its members. Examples include performing a dance next to an anesthetized patient and displaying excised abdominal tissue in a comical manner.16
Because of concerns regarding possible ethical violations, the American Society of Plastic Surgeons formed the Social Media Taskforce and concluded that the existing American Society of Plastic Surgeons Code of Ethics is sufficient for current social media use.17,18 Currently, the American Society of Plastic Surgeons code of ethics states that the member may be subject to disciplinary action if the member uses, participates in, or promotes the use of any public communication or private communication containing photographs, images, or facsimiles of persons (1) who have received the services advertised, but who have experienced results that are not typical of the results obtained by the average patient, without clearly and noticeably disclosing that fact; (2) before and after receiving services, which use different light, poses, or photographic techniques to misrepresent the results achieved by the individual; and (3) that falsely or deceptively portray a physical or medical condition, injury, disease, including obesity, or recovery of relief therefrom. Adhering to these principles is critical because it is very easy to post the before-and-after photographs on social media for the sole purpose of recruiting patients, which can lead plastic surgeons to be susceptible to overadvertising, overminimizing risks, using different photographic techniques, and possibly falsely presenting results.
Currently, review of ethics of social media in plastic surgery is limited to only one study. Dorfman et al. analyzed social media use against the four principles of medical ethics, including respect for patient autonomy, beneficence, nonmaleficence, and justice.16 Their recommendations for ethical practice of video sharing included not only asking patients for video consent, but also informing them that they have a right to refuse, and that their images can be used by other social media users. To facilitate filming without loss of operative time, they also recommended hiring a trained videographer.14,19,20
CURRENT LITERATURE ON SOCIAL MEDIA USE BY YOUNG PLASTIC SURGEONS
As social media incorporate augmented reality and virtual reality, we can anticipate that they will continue to evolve and improve, and applications for professional education and public communication will continue to grow. We believe that residents who embrace social media early in their career will be better prepared to take advantage of all that the media have to offer while posting in a safe and ethical way.
To evaluate the current literature on social media use and recommendations for young plastic surgeons, we have performed a computerized search of the MEDLINE database by means of Ovid using the following search terms: “Plastic Surgery” or “Aesthetic Surgery” and “Facebook,” “Instagram,” “Twitter,” “Snapchat,” or “Social media.” The only limit that was applied for each search term was that it had to be published in English.
The computerized search was performed in November of 2017. A total of 348 articles were identified from the initial search. The abstracts of each article were reviewed and repeated articles were removed; 35 articles of potential relevance remained. All studies were reviewed by one of the authors (M.J.C.).
The literature review demonstrated a paucity of high-level literature on social media use by plastic surgeons. Of the 35 studies, 24 studies were published between 2010 and 2015, and the remaining 11 studies were published after 2015. The majority of articles were categorized as low-level literature such as tutorials (20 percent), viewpoints (17.1 percent), surveys (14.3 percent), quantitative analyses (14.3 percent), editorials (8.6 percent), letters (5.7 percent), cross-sectional studies (5.7 percent), commentaries (5.7 percent), one case report (2.9 percent), one abstract (2.9 percent), and one review (2.9 percent) (Fig. 1). There were no randomized trials, cohort trials, or systematic reviews of Level I studies.
As expected, the majority of audience and subjects of articles were for unspecified “plastic surgeons” (60 percent), followed by “board-certified plastic surgeons” (31.4 percent), “board-certified and board-eligible” (2.9 percent), and “residents” (5.7 percent). Of the 35 studies, only two studies discussed social media use by residents: (1) “The Plastic and Reconstructive Surgery Facebook Page: Newfound Treasure”; and (2) “Connect with Plastic Surgery: Social Media for Good.” Both articles recommended that residents use Plastic Reconstructive Surgery Facebook for articles and videos published by the Journal.14,21 However, they did not make further recommendations for residents and young plastic surgeons regarding (1) guidelines for posting plastic surgery topics, (2) choosing a platform, (3) determining the type of content to post, and (4) effective use of hashtags.
RECOMMENDATIONS FOR YOUNG PLASTIC SURGEONS ON THE USE OF SOCIAL MEDIA
Guidelines for Posting Plastic Surgery Topics
Most residents likely have at least one social media account. During residency, they may begin developing a professional online persona. To separate communication with friends and family from plastic surgery topics, we recommend opening separate accounts for personal and professional use.22 In fact, as of 2013, 75.1 percent of the American Society of Plastic Surgeons members had done so.8 The two accounts allow the user to customize the contents toward each account to minimize mixing posts about one’s personal life with those concerning one’s professional practice.23,24
Choosing a Platform
Of the many platforms available, including Facebook, Instagram, Twitter, Snapchat, RealSelf, YouTube, and LinkedIn, each has its advantages and disadvantages. Managing more than two accounts can be overwhelming, so we recommend choosing one or two networks that allow sharing of posts. Currently, Instagram and Facebook have the most active users, and each platform has its own advantages.
Most residents likely already have a Facebook account that they established during high school or college, and have maintained it as a means of sharing their personal life with their friends. Because personal content is made for friends and family, we recommend opening a separate Facebook business account for professional use. A business page measures “friends” as page “likes,” and there are a number of options not available on personal accounts, including pages for a virtual tour, reviews, events, services, and a form to request an appointment. Facebook can be a useful way for a physician to announce his or her practice after graduation.
Both Instagram and Snapchat allow photograph and video sharing directly from one’s phone. Because plastic surgery is a visual field, photographs and video clips can have a powerful impact on creating one’s professional image.
Twitter now categorizes itself as a news app rather than a social networking app in the iOS App Store. Favored by journalists, celebrities, and politicians, it is more useful for posting education materials than it is for promoting one’s practice.7 Like Instagram, Facebook, and YouTube, Twitter allows the use of hashtags (#).
Whatever platform you choose, spend time watching other users’ feeds to learn the culture before posting. Then, experiment to see the response you get. If nobody likes or shares a particular type of post, do something different.
Determining the Type of Content to Post
According to the study by Sorice et al., patients wish to see a variety of content on a plastic surgeon’s social media feed, including information about the practice, before-and-after photographs, casual photographs, videos of actual treatments, and the doctor’s blog.11 What to post depends on your audience and your own prowess. A resident interested in completing a hand fellowship should consider including information of interest to hand patients, whereas the resident pursuing aesthetic surgery will have very different content. Be creative. For example, hand patients may appreciate photographs of Rodin hand sculptures. If you are a writer, consider starting a blog. Develop your own voice and let your personality shine through. Photographs of resident get-togethers, conferences, family, or your latest marathon can personalize your feed while maintaining professionalism.
Sorice et al. found that 79 percent of patients were not interested in posts with a link to a plastic surgery article available for a fee. Even lay press articles and scientific articles available for a fee were less popular than other posts. In contrast, the doctor’s blog and videos about treatments were popular. Thus, although it may seem that patients are not interested in education, they are in fact very interested, but only when the information is easily understood and designed specifically for them. Consequently, shooting a video or writing a blog to accompany a scientific article you have just written may be the most effective way to educate the public about your work.11 In addition, interactive education sessions on Plastic and Reconstructive Surgery (PRS) Grand Rounds by means of Facebook Live and PRS Journal Club at Facebook Q&A (Figs. 2 and 3) provide an exceptional opportunity for residents to learn from experts and post questions during the live feed.
Although posting clinical photographs of consenting patients can be a valuable tool to educate the public and attract patients, we recommend that trainees refrain from posting patient-related photographs or videos. Although the attending physician may choose to post patient images, which the resident can like or share, creating original posts with those same images may be legally problematic for trainees.25,26 For example, an inadequate patient consent may constitute a breach of the Health Insurance Portability and Accountability Act of 1996, and can lead to serious consequences, which can jeopardize the resident’s career. Even if an image appears to contain no identifying features, the image’s metadata may reveal the patient’s identity. To be acceptable within the Health Insurance Portability and Accountability Act of 1996, the resident needs to “deidentify” or obtain the patient’s consent to include the patient’s protected health information on social media27,28 in addition to saving the image and all images contained within a video with a file name that contains no trace of the patient’s identity. In addition, he or she needs to check and follow their institutional policy regarding the protected health information. However, a quick video clip related to plastic surgery without protected health information is acceptable. (See Video, Supplemental Digital Content 1, which shows a video demonstration of setting up the surgical table for rhinoplasty, http://links.lww.com/PRS/D447.)
Effective Use of Hashtags
The hashtag is used for three broad purposes: (1) to organize and categorize content, (2) to identify trending topics, and (3) for branding purposes. Hashtags are searchable within an application, bringing up other posts that contain the searched hashtag.
According to Branford et al., the majority of “plastic surgery” material posted in social media is by the public (70.6 percent), and only 6 percent of the postings are by plastic surgeons.29 This finding indicates a broad interest in the topic among the public, but it indicates that the use of #PlasticSurgery can facilitate public education and the promulgation of articles, videos, and blog posts about evidence-based plastic surgery. Consequently, we recommend using this hashtag when posting any educational materials on plastic surgery.19
Other hashtags related to plastic surgery include #rhinoplasty, #breastreconstruction, #microsurgery, #breastlift, #breastaugmentation, #mastopexy, #facelift, #cosmeticsurgery, #ilooklikeasurgeon, and #PRSJournal. An example of the use of a hashtag for the purpose of branding includes the use of #DoYourHomework, which is used by the American Society of Plastic Surgeons and its members to educate the public on what board certification means and how to choose a plastic surgeon. Examples of trending hashtags not related to plastic surgery include #BostonStrong and #MeToo.
Although it can be fun, creative, and novel to make your own hashtag to brand yourself and make it easier for patients to find you, hashtags are only useful for the latter purpose if people think about them when they run a search. In contrast, your own hashtag can be an effective branding tool, especially if it conveys a positive theme or emotion. Examples of this are #LoveMyJob, #GivingBack, and #LivingTheDream.
Like many new technological innovations, social media are a powerful tool that should be used with caution. In our study, we reviewed current literature on social media use by residents, and there is a paucity of literature on how residents should approach social media. Because residents risk jeopardizing their career through inadvertent oversights, they should be particularly selective about the content they post. In addition to maintaining professionalism, trainees should avoid posting patient images and be aware of all the ways in which it is possible to violate a patient’s privacy. By learning about professional use and establishing a brand during residency, the plastic surgeon can become familiar, versatile, and comfortable with social media and use these media for future professional development and practice growth.
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