Online behaviors need ethical clarification

Consequences vary for violations

There is low consensus among state medical boards as to whether derogatory speech toward patients, showing alcohol use without intoxication, and providing clinical narratives without violation of confidentiality constitute a violation of online professionalism, according to a recent study.1 Researchers found moderate consensus on whether depicting alcohol intoxication, violating patient confidentiality, and using discriminatory speech are violations, and high consensus that citing misleading information about clinical outcomes, using patient images without consent, misrepresenting credentials, and inappropriately contacting patients are violations.

Areas of high consensus suggest that these are online behaviors that physicians should never engage in, and increased awareness of these specific behaviors might reduce investigations and improve online professionalism for physicians, the researchers concluded. “In the pre-survey interviews with key informants in the licensure community, we encountered a lot of concern about these online behaviors. We were expecting boards to demonstrate high consensus around the most egregious behaviors,” says S. Ryan Greysen, MD, MHS, MA, assistant professor in the Division of Hospital Medicine at University of California, San Francisco.

“What was most interesting was learning more about the thought process of boards and the importance of contextual elements for the vignettes in ‘gray areas,’ such as alcohol use,” says Greysen. The boards are clearly not interested in “policing” doctors who post pictures of themselves drinking online, he explains, but if the online pictures suggest problematic use of alcohol, or if the doctor in question has a history of problematic use, then this can become an important piece of the overall picture.

“The overwhelming message here is to apply the same principles of professionalism to online and offline actions,” says Greysen. “Sometimes, doctors feel that what they do online has no bearing on their professional obligations. On the contrary, boards clearly view public actions — online or not — as part of the physician’s duty to maintain professionalism.”

Clarity is needed

While some online behaviors are clearly unethical — for example, posting information identifying a patient without consent — “others are becoming clear, such as the idea that providers should not post anonymously,” says Matthew DeCamp, MD, PhD, a post-doctoral fellow in bioethics and health policy at the Johns Hopkins Berman Institute of Bioethics and Division of General Internal Medicine in Baltimore, MD. “For those areas where clarity is lacking, providers should proceed cautiously, keeping in mind that information spreads rapidly, can be beyond one’s control, and is essentially permanent.”

Almost half (49%) of 180 first-year medical students reviewed or changed their online presence immediately after attending a two-hour session on online professionalism.2 “This reflects the urgency experienced by our students to build their professional online presence early in their training,” says Desiree Lie, MD, MSED, clinical professor of family medicine and course director for the Professionalism and the Practice of Medicine course at the Keck School of Medicine of the University of Southern California in Los Angeles.

“Their responses reinforce to educators that we should introduce this curriculum early in medical school training,” argues Lie. “We were impressed by the thoughtfulness of students’ reflections about their developing professional identities and about the responsibilities inherent in the transition from student to physician.”

Current providers who have been educated in a less digitally connected age are likely to be surprised by the attention paid to professional and personal online presence by their younger new practice partners, adds Lie. “They may see a rise in the use of social media for the marketing of professional services — a practice that will certainly be subjected to greater public scrutiny in future,” she says.

Major role for bioethicists

Bioethicists can engage with physicians in helping them to think critically about their online activities, says Amy DeBaets, PhD, an assistant professor in the Department of Bioethics at Kansas City (MO) University of Medicine and Biosciences — for instance, they can point out that physicians should assume that anything they write in an online format, including “private” networks like Facebook and Twitter, can be made public.

“All it takes is one friend to make it known to the world. So don’t talk about your patients online, even when you think it’s private,” she says. “Likewise, don’t use the Internet as a sounding board for complaints you may have about colleagues or those who work for you.”

Bioethicists have already been helping to sort out some of these issues, such as helping institutions understand and navigate the ethical challenges of recruiting and conducting clinical research via social media and social networks, says DeCamp, but also have a major role to play in clarifying some of the gray areas. For example, bioethicists can help determine whether providers should separate personal and professional identities online, or if this is even possible.

Bioethicists can help by working with hospitals and health care systems to develop and implement guidelines for online activity and public statements made by physicians, adds DeBaets. “We can work with existing professional codes, expand them to include the utilization of new technologies, and give guidance on specific questions as they arise,” she says.

Bioethicists are already helping hospitals and health systems to think through some challenging issues, says DeCamp. For example, a health system might have its providers post expert content about diseases or treatments on its social media sites. “How can that health system ensure meaningful disclosure and management of providers’ potential conflicts of interest, such as commercial funding and industry relationships, given the brevity and format of most social media content?” asks DeCamp. “Bioethicists are actively engaged in brainstorming ways to accomplish this, to ensure the veracity of online information.”


  1. Greysen SR, Johnson D, Kind T, et al. Online professionalism investigations by state medical boards: First, do no harm. Ann Intern Med 2013;158(2):124-130.
  2. Lie D, Trial J, Schaff P, et al. Being the best we can be: Medical students’ reflections on physician responsibility in the social media era. Acad Med. 2013;88(2):240-245.


  • Amy DeBaets, PhD, Assistant Professor, Department of Bioethics, Kansas City (MO) University of Medicine and Biosciences. Phone: (816) 654-7234. E-mail:
  • Matthew DeCamp, MD, PhD, Post-Doctoral Fellow in Bioethics and Health Policy, Johns Hopkins Berman Institute of Bioethics and Division of General Internal Medicine, Baltimore, MD. Phone: (410) 583-2926. E-mail:
  • S. Ryan Greysen, MD, MHS, MA, Assistant Professor, Division of Hospital Medicine, University of California, San Francisco. Phone: (415) 476-5924. E-mail:
  • Desiree Lie, MD, Clinical Professor, Keck School of Medicine, University of Southern California. Phone: (626) 457-4074. E-mail: