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Dynamic Chiropractic – July 1, 2013, Vol. 31, Issue 13
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dynamicchiropractic.com >> Marketing / Office / Staff

Maintaining Professional Boundaries in a Facebook World: Social Media Guidelines for DCs

By Mark Sanna, DC, ACRB Level II, FICC

A few months ago, I received an unexpected message on my Facebook account: "Hi Doc, do you remember me? I'm so happy to find you here on Facebook. It's been years since I have seen you and I'm glad to reconnect with you.

I'm hoping you will keep in touch." I was caught off guard by this "friend request" from one of my former patients. It made me consider the challenges that chiropractic professionals confront every day concerning social media etiquette.

"Friending" Your Patients

A health care provider's relationship with their patients must be professional at all times. When you accept a "friend request" from a current or former patient, it crosses professional boundaries and can be damaging to the therapeutic relationship. When tackling the ethical and professional challenges related to online social networking with patients, your practice must have a policy on Internet use (including e-mails from patients) specifically addressing online clinician and patient interactions.

But before you close your Facebook or other social networking accounts, or if you are considering opening one, you may want to keep in mind the following advantages and disadvantages of using online social networking sites. Social media allows you to disseminate information quickly and to a large population for no cost. When your practice participates in social media, it sends an implied message to your patients that your practice is on the technological cutting-edge. Social media can also serve as an online bulletin board for your practice where you can post information about upcoming events such as health-related seminars and community activities.

Manage the Benefits and Risks of Social Media

social media - Copyright – Stock Photo / Register Mark The lack of filtering systems in social networking sites is a major disadvantage. Some people post images or messages that have indelicate content. Although users can enable different privacy settings, restricting some of the privileges on the Web site will defeat the purpose of online social networking.

Let's go back to my case scenario of being contacted by a former patient. I replied politely and respectfully that I was happy to hear from him and that it would be best for us to keep in touch through other venues, rather than via Facebook. He replied that he "understood" and we took the conversation offline where it belongs.

When interacting on social media, use common sense and keep the following considerations in mind:

  • Does the content have the potential to damage a career or impair working relationships?
  • Will the content breach your patients' trust or be detrimental to your practice?
  • In general, carefully consider the potential for harm to others as well as yourself.

Understanding Social Media Terminology

On social media, a "friend request" is not exactly what it sounds like. Friends on social networks like Facebook are not the same thing as who we typically think of as friends. In a savvy marketing move, the social media site MySpace popularized the terminology to describe any contact – be it a stranger, spammer, friend, enemy, or family member – who asks to allow them to add you to their list (or "address book," using old-school terminology).

Because Facebook makes no differentiation as to what a "friend" actually constitutes, these people are more accurately described as contacts (a term which is decidedly far less marketing-friendly). So,, if someone has 10,000 Facebook "friends," that really means next to nothing, since nothing is qualified.

What's a Professional to Do?

When you get a friend request on Facebook, what you're really getting is a simple request to form a network connection between your profile and their profile. This connection implies some sort of two-way relationship, but often says little about what that relationship actually is (some social networking websites such as Facebook and LinkedIn do a better job of helping us identify the type and closeness of these relationships). An important point to consider when "friending" someone on social media is that other people on both your network of "friends" as well as their network can see this connection.

When a chiropractor receives a friend request from a professional colleague, they typically accept it if they know (or know of) the person. But when they receive a similar request from a patient or former patient, many are left scratching their heads. The same is true when they receive an e-mail from a patient or former patient. If the professional hasn't set clear guidelines or expectations up-front, it leaves the door open to such questions.

Internet and E-mail Policy

The key, then, is to clearly define the boundaries of the relationship not only offline, but online, too. This means putting together an "Internet & E-mail Policy" you can give to patients during their first visit and recommend they read and understand it. A part of your policy should describe whether you accept patient e-mail, and if so, under what circumstances (appointment changes? health issues?). Part of what should be included in your professional online policy is what a lot of practitioners miss – what to do about social networks. A friend request isn't an e-mail, so it's not really covered by an e-mail policy. The answer is to specifically address social networks and "friend requests" in your online policy.

Consistency is important in setting clear boundaries in all professional relationships, including those involving social media. If you make an exception for a patient in one circumstance, the patient may unfortunately interpret that differently than you intended. Patients are not a professional's "friend" (although a friendship may develop over time). When a friendship between doctor and patient develops, the publication of such information, whether a patient realizes it or not, may result in a violation of the patient's health care privacy.

While they may think such a "friend connection" is harmless fun, it may be used by future employers to pass judgment or draw conclusions that are detrimental to the patient. Worse yet, the patient may never know or realize that such information may be harming them (since social networks don't tell you who has viewed what information of yours once you make someone a "friend").

The Safest Approach

For now, it is best to keep doctor-patient boundaries clear and consistent online: Patients should not send social networking "friend requests" to professionals and professionals should avoid accepting them or sending such requests to their patients or former patients. This policy should be made clear to a new patient at the initiation of care to minimize future misunderstanding.

Social networking is a powerful tool, but it is also a tool that can be misused and sometimes even abused. People are not always clear or aware of what information is available to the public or their "friends" list, and what information is private. And people may not always understand the long-term ramifications and implications of sharing such information with others.

Privacy Concerns

Sharing information on social networking sites is easy – too easy! Health care is one of the most regulated professions in the United States. When using social media, always adhere to Health Insurance Portability and Accountability Act (HIPAA) regulations and maintain professional boundaries of the doctor-patient relationship.

Most social networking sites offer tools that let you control how you share your information and communications; options include sharing with everyone and sharing with friends only. Sharing with friends only is recommended as the default – yet making it your default doesn't guarantee your posts will stay between friends.

For example, suppose you post something witty about a challenging patient, while withholding names and identifying remarks. Your friends find your comments amusing and repost it on their Facebook, where friends of their friends see it and repost it on their own sites. Now your friends-only message has gone viral and is circulating around the social-media universe – and potentially can get back to the patient and/or their employer.

Defamation Law and Social Media

Nurses have been terminated for posting even seemingly harmless statements, such as "My job is boring." Five California nurses lost their jobs and are facing disciplinary action for discussing a patient on Facebook, even though their posts included no names, photos or identifying information.

When posting on social media, it is important to understand the risks. Assume anything you post will be read by everyone, especially those you don't want reading it. Tell your patients that if there's something they don't want their employer to read or to know about them, don't post it. A good rule of thumb is not to post anything you wouldn't want your spouse, child, parent or employer to read.

Termination by Posting

Most employers can legally terminate employees for making disparaging comments about their employer, co-workers or patients. Posting defamatory remarks on the Internet can lead to civil lawsuits alleging defamation or slander. What's more, postings to social media sites generally are considered permanent, even if you delete them.

Several years ago, a group of doctors and nurses were suspended for taking part in the "The Lying Down Game," an Internet craze in which participants took pictures of themselves lying face down in unusual places and uploaded them onto Facebook. The group was reported to hospital management after pictures of them lying on resuscitation carts, ward floors and the ambulance helipad were spotted on the site.

The National Labor Relations Board recently published a new Social Media Regulation. It states that employees have the right to communicate with one another with the aim of improving wages, benefits or working conditions.However, employees still need to be careful about what they post. Those releasing confidential information, or who are ranting and raving about their employers, will receive a rude awakening if they believe their "free speech" will be defended.

You Are a Professional 24/7

Social networking is a great tool you can use to expand your professional network, connect with colleagues and increase your knowledge. But using it carelessly can imperil your job and livelihood. Let common sense and discretion guide you online. Maintain appropriate boundaries and privacy, and adhere to your practice's code of professional conduct and social networking policies. Remember, you're a professional, 24/7.


Dr. Mark Sanna, a 1987 graduate of New York Chiropractic College, is a member of the ACA Governor's Advisory Board and a member of the President's Circle of NYCC and Parker College of Chiropractic. He is the president and CEO of Breakthrough Coaching (www.mybreakthrough.com).

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