April 2019, Volume 69, Issue 4

Special Communication

Social Media and Ethos of Medical Practice

Muhammad Fayyaz  ( Army Medical Corps, Alumnus of Centre of Biomedical Ethics and Culture (CBEC), SIUT Karachi, Pakistan )


Social media is an undeniable reality in our lives. The professional use of social media is increasing with every passing day. It has provided new avenues of service delivery in individual and hospital practices. But the operational structure of most social media platforms can create problems for its professional use in healthcare, as the controls that exists in physical environment under regulatory frameworks, aren't available there. Indeed, it's a daunting task to maintain, for example, confidentiality and ownership of health data, which once shared staysforever in cyberspace. Healthcare providers especially Physicians and all other stakeholders should focus on this changing face of healthcare and try to develop guidelines which can lessen fears, promote optimal use, and can help maintain ethos of practice of medicine on social media.
Keywords: Social Media, Healthcare, Ethos, Ethics, Pakistan


In January 2011, four nursing students of Johnson County Community College in Kansas city were dismissed from the programme, on a photograph of them with 'Human Placenta' which landed on Facebook.1 In England, a privacy campaigner company 'Big Brother Watch' revealed 806 incidences of health data breaches by health care providers in three years. Most of them involved postings of unsolicited patient images or inappropriate comments on them. 2 Throughout the known human existence, the flow of information has never been that fast and multi-layered as it is today. The different forms of human interaction that exists today are unprecedented. Many of these platforms are unbelievably complex, where every individual is not only a consumer, but a creator of content as well. If we look back, with-in a century, 'Television' as a media is getting irrelevant after its invention in 1927. The Human Civilization saw the first digital computer in 1946, having a spread of 167 square meters and 50 tons in weight. 3 It merely took 46 years to turn into an amazing combo of cellular power with computin g in the form of 'Smartphone'. 4 Smartphone not only transformed itselfinto more powerful, robust and complete machine by harnessing the power of wireless internet but changed the world around it. In 2018, internet users in the world will cross 4 billion mark. Though existence of internet technology predates the advent of smartphone, but 73% of current internet consumption is on smartphones, making them primary devices of communication and entertainment. Around 66% individuals in 52 leading nations of the world own a smartphone. 5  Though smartphone penetration in Pakistan clocks at 34% now, but, by the year 2020, it will increase to 51% of the population.6 The most common use of a smartphone involves social media in our personal and professional lives; hence, we need to understand what social media is and what is its impact on healthcare?

What Constitutes Social Media?

There is no single definition of social media. According to Merriam-Webster dictionary, Social Media constitutes' forms of electronic communication (such as websites for social networking and microblogging) through which users create online communities to share information, ideas, personal messages, and other content (such as videos)'.7 Darrel Berry, a photographer and researcher coined this term in 1994, however, the first recognizable social media site was created in 1997 with the name of 'Six Degrees'.8 In the 21st century, with the advent of modern machines, the media has got so powerful that all kinds of real interactions not only started flowing through it, but started happening on it independent of any physicality. Until recently, social media had no governess except some basic rules by the founders. The uncharted waters of social media started off as an enter tainment avenue, mushroomed into business ventures, communication hubs and touched every sphere of life. That's why online privacy issues are now seriously debated, and only recently, online privacy and data safety has been added to the mix of booming social media industry. If we look at these platforms, Facebook and WhatsApp are on the top. Facebook Inc. was founded in 2004. It is the largest social media giant in the world, with 40 Billion dollars annual revenue and 2.13 Billion active users in 2018.9 WhatsApp is a cross-platform which took off as a smartphone application in 2009 as messaging service  over the internet while anchoring in Subscriber IdentityModule (SIM) numbers. Till December 2017, it had impressive penetration to 1.5 Billion people worldwide, after expanding to personal computers, documents sharing and free audio-visual calling over the internet which transcends the international boundaries. In addition to these two platforms, there exists plethora of social media platforms, having different models of work and their numbers are rising. \

Physician-Patient relationship on Social Media

Practice of medicine is an art and science which serves ailing humanity. Though data privacy and safety in social media culture is something very new, but in practice of medicine the idea of privacy and confidentiality is deep and matured over time as a basic condition. At the core of practice of medicine is communication, which brings many sensitive aspects of a person into the knowledge of a physician. The physician-patient relationship is one of the most sacred interaction in human history, which is an aspect of healing in-itself. Healing requires a trusted interaction without any fear, anxiety and loss at any stage. As modern practice of medicine is in a constant struggle to remain relevant and provide better, faster and cost-effective services; social media is one of the tool which can help healthcare providers on many fronts in public health, personalized care, patient education and feedback. Now, clinical interactions have started happening online in real-time. From clinical histories to lab reports, prescriptions and complete health files etc. are shared either by patient themselves or by healthcare providers for variety of purposes. This practice sans international boundaries, logistical needs and people are resorting more and more towards getting prescription without leaving their homes. But, it's a risky practice and doubleedge weapon. On one end, it strengthens patient autonomy and service delivery, but on another, physicians resort to marketing their institution or their own practice. On one end, with a click, a health advisory is sharable by anyone which can affect thousands of people in realtime, but on another, missing judgment on authenticity. 10 For example, Twitter Hashtag Ebola Alert successfully spread information regarding Ebola epidemic in Nigeria, with the support of UNICEF and WHO and thousands of people got benefited with-in short span of time. But on 8th August 2014, Nigerian Newspaper 'Vanguard News' reported that 2 Nigerians lost their lives and 20 got admitted in hospitals, based on twitter message – which went viral in matter of hours across Nigeria, despite governmental effort to control- that drinking salt water protects from Ebola. 11Therefore, when we have mediums with strong power of both positives and negatives, it gets really important to define broad parameters for safe and effective use, conforming to the values of standard medical practice, and, Do No Harm is one such standard.

Health Data Ownership on Social Media

Whatever is written or uploaded generates data. Today, an average person's one day data consumption is more than a lifetime of a 15th Century individual. The volume of healthcare activities over social media is so high that a company called 'Symplur' has emerged. Their only  business is healthcare social media analysis. For example,#hcsmR is Symplur collaboration with Stanford Medicine X to promote research in healthcare social media. Projects like Symplur are exciting and powerful ventures but structured on business and profit generating values which many of the users are unclear. Likewise, 'Twitterdoctors.net' is another venture which comprise of more than 1,000 physicians. The only disclosure available is that they are the best people around, sharing health information. 12 In both cases, disclosures are incomplete without any mention of conflict of interest. Data mining ventures are thriving on causally written tweets/posts, playing in a vacuum of unclear rules. One of those unclear rules is: who owns this health data? This fast paced and changing landscape essentially mandates that 'Medical Ethics' should catch-up on them in the larger interest of humanity, by raising the questions, for example, about data ownerships and incomplete disclosures etc.

Personal vs Professional Use of Social Media

Use of social media is a tightrope for professionals. Most health professionals are clear about boundaries of personal and professional lives in physical environment but really unclear about them on social media. 13 For example, a primary care physician asks for an advice on antihypertensive agent from a group of internists on social media. It is highly unlikely that the recommender's conflict of interest regarding recommended product will be known to advise seeker. Pharmaceutical companies are also pushing their agendas on physicians and patients on social media platforms and getting positive response in terms of sale volumes. 14 Despite this, about 90% physicians in the world use social media and 67% of them use it professionally. While in Pakistan, 44% physicians and medical students were found using Facebook platform for professional purposes. 15 The task of controlling flow and content to prevent breach of privacy and unethical practices, is really a difficult task. 16 In Pakistan, PMDC has neither issued any guidelines in code of ethics 17 nor any broad parameters for social media use. International institutions18 like American Medical Association (AMA), International Committee of Medical Journal Editors (ICMJE), Institute of Medicine (IOM) and British medical Association (BMA)19 have provided broad frameworks to maintain professional boundaries in online interactions. Despite a general acceptability of social media platforms for professional use in different countries by regulatory bodies, there are voices of dissent. They claim that the structures of these platforms are based on peer to peer interactions which are not professionally aligned. Befriending with patients by physicians or vice versa will give undue access to personal lives of physicians, patients, families, and peer groups. This unnecessary access may compromise trust and patient care as we have seen in a case in Pakistan. 20 Because of this, a time-shifted risk of misuse will remain forever. 21 Additionally, unprofessional happenings are a common-place. Prescriptions on half baked information, medically and sexually explicit materials, discriminations, and insensitive use of language is common that easily spills over into so-called 'professional interactions'. Of ten Physicians get themselves, unknowingly, involved in 'medutainment', sharing things out of patient-physician relationship on the name of public education, but, to attract and get hold of potential patients- a complete disregard to fiduciary relationship. 22 On social media, once something is shared, the control is lost permanently. The contents can be downloaded and used anyway possible. Despite delete functions, the footprints remain permanent in the cyber world.23

The Way Forward

The reductionist view of human body as a mere collection of organs and tissues-in-trouble, has increasingly taken roots in our hospitals and clinics. The same view is spilling over into social media clinical interactions where treatments are going-on but healing is missing.The question is why should we need to understand this? As it appears, social media will be getting a centre stage in patient care soon, and by default, missing the 'healing touch' of physician, in addition to prevailing reductionist view. Recently Mark Zuckerberg, founder and CEO of Facebook Inc., regretted in front of US congressional committee in a data breach case, of his big mistake by not taking the 'broad enough view" of his responsibility and not doing due diligence to prevent harmful use of his platform.24 His statement, though focused on Facebook, but represents the abysmal situation of safety of social media platforms. This strengthens the view that healthcare providers at all tiers need to contemplate deeply, in collaboration with patients, lawyers, governments, regulators, pharmaceuticals and IT industries, in order to up-hold the ethos of practice of medicine while engaging social media. To keep the trust reposed in them as healers, physicians are expected of higher standard of conduct and professionalism. In order to do that, following are some of the broad guidelines, which can be useful as ready reckoner:

1. Maintain strict control on privacy settings of platform in use.

2. Thoroughly understand 'Terms of Use' for professional accounts on social media.

3. Maintain professional and personal accounts separately.

4. Apply same standards of physician-patient interactions on social media as it happens in physical encounters.

5. Maintain confidentiality of health data to the utmost unless extremely necessary, where a direct patient benefit or harm is clearly involved. Apply discretion on sharing identifiers unless extremely necessary.

6. Disclose Conflict of Interest in 'about' or 'profile' section or whichever way it gets easy visibility.

7. Complete disclosure of intent and extent of sharing i n formation followed by written consent.

8. No sharing of data including images and visuals of patients on any social media platform for branding or practice promotion.


Social media is full of risks for professionals. General population especially young adults, are particularly at risk of illusion of knowledge, with limited capacity to interpret patient visuals and images. Adherence to above mentioned and professional guidelines, may not remove completely, but will limit to a greater extend, the possibility of misuse of most social media platforms.

Disclaimer: None.
Conflict of Interest: None.
Source of Funding: None.


1. Nursing Students Expelled For Posting Photo of a Placenta on Facebook. [Online] [Cited 2018 Apr 28]. Available from: URL: http://newsfeed.time.com/2011/01/04/nursing-students-expelledfor- posting-photo-of-a-placenta-on-facebook/
2. Trusts reveal staff abuse of social media. Healthcare Professionals Network. The Guardian [Online] [Cited 2018 Apr 28]. Available from: URL: https://www.theguardian.com/healthcare-network/2011/nov/ 0 9 / trusts- r eve a l - s t a f f - a b u s e - o f - s o c i a l -me di a - facebook
3. When was the first computer invented? [Online] [Cited 2018 Apr 28]. Available from: URL: https://www.computerhope.com/issues/ ch000984.htm
4. December 1994. Reviews, Simonizing the PDA. [Online] 1999 [Cited 2018 Apr 28]. Available from: URL: http://web.archive.org/web/ 1 9 9 9 0 2 2 1 1 7 4 8 5 6 / b y t e . c o m / a r t / 9 4 1 2 / s e c 1 1 / a r t 3 . h t m
5. Smartphone penetration to reach 66% in 2018. [Online] 2017 [Cited 2018 Apr 28]. Available from: URL: https://www.zenithmedia.com/ smartphone-penetration-reach-66-2018/
6. Smartphone penetration in Pakistan 2014-2020. Statistic. [Online] [Cited 2018 Apr 28]. Available from: URL: https://www.statista.com/ statistics/ 671542 /smart phone-penetration-as-share – of connections- in-pakistan/ 7. Social Media. Definition of Social Media by Merriam-Webster.
[On l i n e ] [ C i te d 20 1 8 A p r 2 8 ] . Av a i l a b l e f r om: U R L : https://www.merriam-webster.com/dictionary/social%20medi 
8. The Complete History of Social Media: Then And Now - Small Business Trends [Online] [Cited 2018 Apr 28]. Available from: URL: https://smallbiztrends.com/2013/05/the-complete-history-ofsocial-  media-infographic.html
9. Top 20 Facebook Statistics - Updated April 2018 [Online] [Cited 2018 Apr 28]. Available from: URL: https://zephoria.com/top 15-  valuable-facebook-statistics/
10. Smailhodzic E, Hooijsma W, Boonstra A, Langley DJ. Social media use in healthcare: A systematic review of effects on patients and on their relationship with healthcare professionals. BMC Health Serv Res 2016; 16: 442.
11. News ABC. Nigerian Ebola Hoax Results in Two Deaths [Online] 2014 [Cited 2018 Apr 28]. Available from: URL: http://abcnews. go.com/Health/nigerian-ebola-hoax-results-deaths/story? id=25842191
12. Twitter Doctors | The #1 Directory For Twitter Doctors! [Online] [Cited 2018 Apr 28]. Available from: URL:
13. Pirraglia PA, Kravitz RL. Social Media: New Opportunities, New Ethic al Conce rns. J G en Inter n Med 2013; 28: 165-6 .
14. Akhtar N, Kanpurwala M, Arshad R, Sharafatullah T. Perception and Impact of Social Media in Pharmaceutical Marketing and Promotion in Pakistan. Scholars Academic Journal of Pharmacy 2015; 4: 54.
15. Jafarey A, Shekhani S, Azam ME, Gill R, Shirazi B, Hassan M, et al. Physicians in Cyberspace: Finding Boundaries. Asian Bioeth Rev 2016; 8: 272-89.
16. Rehman M, Irem K, Ilyas M. Social Media: A Prospective or a Dilemma: The case of Pakistan. Int J Manag Res Emerg Sci 2014; 4: 47-68.
17. Pakistan Medical & Dental Council; Code of Ethics. [Online] [Cited 2018 Apr 28]. Available from: URL: http://www.pmdc.org.pk/Ethics/ tabid/101/Default.aspx
18. DeCamp M. Physicians, Social Media, and Conflict of Interest. J Gen Intern Med 2013 ; 28: 299-303.
19. BMA - Social media guidance for doctors. [Online] [Cited 2018 Apr 28]. Available from: URL: https://www.bma.org.uk/advice/ employment/eth ic s /s oc ia l-me di a- gui dan ce -for- doc tor s
20. Shekhani AJS. Pakistani medical codes weren't violated in sending friend request to Sharmeen's sister - and that's a
problem [Online]/
2 0 1 7 [ c i t e d 2 0 1 8 A p r 2 9 ] . A v a i l a b l e f r o m : U R L : https://www.dawn.com/news/1367064
21. Krowchuk HV, Lane SH, Twaddell JW. Should Social Media be Used to Communicate With Patients? Am J Maternal Child Nurs 2010; 35: 6-7.
22. Bennett KG, Vercler CJ. When Is Posting about Patients on Social Media Unethical "Medutainment"? AMA J Ethics 2018; 20: 328-35.
23. Potts DC, Hohler AD. Neurologists and technology. Neurol Clin Pract 2013; 3: 149-54.
24. Mark Zuckerberg's testimony to Congress [Online] [cited 2018 Apr 28]. Available from: URL: https://www.cnbc.com/2018/04/09/ congress-released-mark-zuckerbergs-prepared-testimony-aheadof- wednesdays-hearing.html.

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