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Dear Dr. Mossman:
A patient has invited me to “friend” her on Facebook. I’m uncomfortable with this request, but I don’t want her to feel rejected. How should I respond?—Submitted by “Dr. V”

Among the many cultural developments that characterize the Internet era, few have had the impact of the social networking Web site Facebook. Because of Facebook, “friend” has become a transitive verb, and “like,” “wall,” “poke,” and “post” have acquired meanings that reflect new modes of communication and interpersonal connection. As of early 2012, Facebook had >800 million users.¹ If you’re like most medical students, residents, and junior faculty members,² you have a Facebook page.

The ubiquity of Facebook has added new dimensions to defining, teaching, and modeling professionalism in medicine.^3,4 Facebook can be used to rapidly disseminate medical information through status updates and medical support groups.⁵ Professionals can create profiles, post their curricula vitae, and “like” professional journals—including Current Psychiatry.

But social media such as Facebook also present clinicians with new ethical and professional challenges.⁶ If you use Facebook personally or professionally, you need to decide how you will separate your personal and professional identities in a forum that rapidly distributes information across the Web for all to see. Sound, responsible decisions about your online profile can let you and your employing institutions prosper from the many benefits that accrue to savvy Facebook users—while avoiding potential embarrassments and liability.

Before you create a profile or “post” your next “status update” on your “wall,” you should:

understand potential boundary violations
know how to activate your security and privacy settings
remember that you represent not only yourself but your profession.

Boundary crossings, violations

Feelings of online closeness and informality make receiving “friend” requests from patients far from uncommon.⁷ The Internet lets individuals quickly check out people and learn personal information (eg, where they live and what their homes cost) that was hard to discover 15 years ago. But the information on a person’s Facebook page usually is much more personal than what Internet searches reveal—and often much less dignified.

A quick Internet search of the phrase “professional boundaries” will show that concern about maintaining proper relationships between professionals and service recipients is not restricted to psychiatry. Yet the special, intensely personal nature of mental health care—especially psychotherapy—traditionally has made psychiatrists place special constraints on their relationships with patients.

Because psychiatrists recognize that even brief comments about ourselves can affect how patients feel, we refrain from forms of self-disclosure that non-psychiatric colleagues view as innocent.⁸ Psychiatrists also do not freely socialize with patients or provide care to persons we know well. We avoid blurring therapeutic and other types of relationships because such “boundary crossings” can cause problems and because “crossings” can be precursors to serious “boundary violations”—eg, sexual contact with patients.

Clinical Point

Information on a person’s Facebook page usually is much more personal than Internet searches reveal and often much less dignified

Most doctors decline “friend” requests from patients because friending them could adversely affect the treatment relationship and could lead to new relationships that might interfere with patient care.⁹ The American Medical Association’s social media guidelines do not forbid friending patients, but physicians are advised to “consider separating personal and professional content online” and “maintain appropriate boundaries” with patients.¹⁰ The British Medical Association simply tells physicians to “politely refuse” patients’ friend requests.¹¹

Privacy problems

Psychiatrists who friend patients need to be aware of potential privacy breeches among Facebook users. Individuals whose presence among a psychiatrist’s friends becomes known (eg, via a wall post) are revealing their connection to the psychiatrist, and other friends may surmise that an individual is a patient.

Also, Facebook’s “find friends” feature ostensibly lets Facebook locate individuals who are common to pairs of people and who can then be suggested as potential friends to others, but “find friends” imports members’ entire e-mail address books. If doctors who are on Facebook have patients in their webmail address books and have allowed “find friends,” then Facebook will import e-mail addresses, potentially disclosing associations between patients and their doctors.¹²

Facebook has tools that let users block their profiles from public view, but these privacy settings can be difficult to access and understand. Although social networking among medical trainees and new graduates is common in the culture of emerging professionals, most Facebook users allow anyone to view their profile—the default privacy setting.^2,13 Even if you don’t friend patients, failing to privatize your account leaves your Facebook information readily available to the public, including your patients.

Professionalism in cyberspace

Under some circumstances, medical advice given in casual, outside-the-office contexts can establish a doctor-patient relationship, with all its accompanying obligations and liability risks. This is true of Facebook communications. If you communicate medical information or advice to someone in a form specific enough to be relied upon, you may be establishing a doctor-patient relationship. If harm comes to a person who relied upon your information, a negligence lawsuit could result—even though you never saw or spoke to the “patient.”¹⁴

Clinical Point

Psychiatrists should use Facebook with greater caution than most persons, including physicians in other specialties

Medical training programs have found that medical students and residents have posted work-related comments on Facebook that directly referenced specific patient situations or other patient care matters. Such actions can breach the Health Insurance Portability and Accountability Act of 1996 and can jeopardize careers.¹⁵ Medical professionals also have posted uncouth, inappropriate, and embarrassing content—profanity, frankly discriminatory language, tales of intoxication, and sexually explicit information. In a recent survey of 78 medical schools, 60% responded that their students had posted unprofessional online content.¹⁶ In 45 cases, schools reported such incidents and responded to follow-up questions about disciplinary actions; 30 schools gave informal warnings, and 2 schools reported student dismissals.

Using Facebook

Should psychiatrists stay off Facebook? Of course not. Many prominent American psychiatrists are on Facebook because, like everyone else, they enjoy keeping in contact with friends and family.¹⁷ Thousands of professional groups (eg, the American Psychiatric Association) and physician practices have Facebook pages. Institutions, schools, and agencies use social media to promote their curricula, notify students and staff of course changes, or organize meetings. Professionals join groups or “like” groups associated with their specialty to affiliate with each other, and they use Facebook to promote their practices, disseminate information, and network with colleagues.

Psychiatrists need not shy away from establishing an account on Facebook,¹⁸ but they should do so with greater circumspection than most persons, including physicians in other specialties. Table 1 lists several examples of Facebook behavior that all physicians should avoid.^{2,13,16,19,20}

What about using Facebook to learn about your patients? Medical reports about checking Facebook to resolve emergencies have appeared,²⁰ and forensic psychiatrists can use Facebook and other Internet resources to learn about evaluees.²¹ But if doctors search for information about a patient’s out-of-office behavior or statements, it may be like “driving down a patient’s street to see what he or she is up to,” which, although legal, seems inappropriate in a professional relationship.²²

Clinical Point

Psychiatrists should not ‘friend’ patients and should not accept ‘friend’ requests from patients

Recent experience suggests that medical schools and residencies should include “e-professionalism” in their curricula, emphasizing instruction and guidance on where personal and professional identities may intersect and where they should be kept separate. Table 2 lists several responses to the new challenges to medical professionalism posed by Facebook and other social media.^5,6

Table 1

Facebook errors: What to avoid

Category	Pitfalls
Information	Relationships, religious views, home address, and telephone number all may be readily viewable to the general public and patients if privacy settings are not properly configured
Photos	Intoxication, sexually explicit material, risk-taking behavior
“Wall posts”	Blatant comments about patients, disgruntlement with institution or supervisors
Security settings	Lack of privacy restrictions
“Friends”	Friending patients and supervisors
“Like”	“Liking” groups that contain pornographic material or other controversial topics
Source: References 2,13,16,19,20

Table 2

Promoting e-professionalism

Understand and activate all relevant privacy and security settings on social networking sites
Recognize the need to teach e-professionalism in the curricula of medical schools and residency training programs
Combine instruction on professional use of Facebook with teaching about relevant legal regulations in medicine (eg, HIPAA)
Guidance in online professionalism should come from faculty supervisors or program directors
Faculty should model appropriate Facebook behaviors for employees, medical students, and residents
Users of social media are well-advised to conduct Web searches on themselves and modify their pages to conform with professional standards
Politely decline patients’ “friend” requests
Discussions of medical professionalism, involving students, faculty, and employers, can help identify issues and define responses
Institutions should establish and enforce guidelines for Facebook professionalism
HIPAA: Health Insurance Portability and Accountability Act of 1996 Source: References 5,6

Responding to Dr. V

Psychiatrists should not “friend” patients. If you receive a “friend” request, you should proceed in 1 of the following ways:¹⁷

Simply ignore the request. If your patient asks why you didn’t respond, explain that you use Facebook only for personal matters
Ignore the request, and at the patient’s next appointment, mention the request and politely explain that you do not “friend” patients
Ignore the request, but ask the patient about it at your next meeting. This is especially important for a patient whose treatment examines the doctor-patient relationship (eg, psychodynamic therapy), but may be valuable even in medication-focused care.

Related Resources

Facebook. www.facebook.com.
Foreman J. Think before you click. Boston Globe. April 12, 2010.

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

Facebook: Social networking meets professional duty