General practice consultations frequently present ethical challenges.1 However, short appointments and full clinics leave little opportunity for ethical discussion and reflection. Relative professional isolation, time pressures, and the lack of formal structures for ethics advice found in secondary care also make support difficult for GPs to access.2 Consequently, GPs may rely on informal online sources for advice on ethical dilemmas. GP groups on social media forums (SMFs), originally established to provide a platform for GPs to discuss clinical queries and for professional networking, increasingly include discussion of ethical problems.3,4 The General Medical Council (GMC)5 and Royal College of General Practitioners (RCGP)6 have published specific guidance regarding the use of social media by doctors, including the importance of considering potential ethical challenges such as confidentiality, and professionalism. However, although these provide extensive advice regarding online discussions between doctors and their patients, they fail to provide guidance relating to the use of professional groups on SMFs, and therefore do not focus on potential issues that might arise for doctors using these.
Here we review how GPs currently use SMFs for discussion of such issues and suggest that it could be useful for GPs and other ‘office-based’ primary care clinicians to reflect on two questions: what might GPs discuss in online forums, and are there any ethical issues connected to the use of SMFs themselves?
WHAT ETHICAL ISSUES DO GPs DISCUSS ON ONLINE FORUMS?
There is a lack of empirical research regarding what ethical issues GPs discuss online. Discussion with users of SMFs dedicated to medical ethics suggests that major concerns revolve around professional ethics pertaining to workplace appraisal or strikes, or responses to existential issues like ‘post-birth abortion’.7 Examination of posts on general medical SMFs suggests that ethical issues discussed predominantly focus on in-practice issues such as confidentiality and end-of-life care, as well as issues triggered by a change in general attitudes, the media, and the law, such as assisted suicide.8
ADVANTAGES OF SMFS FOR ETHICS SUPPORT
SMFs are increasingly used in undergraduate medical education as they are perceived to offer a convenient, educationally valuable, and positively viewed format for peer-supported learning.9,10 Although their use in ethics education has not yet been evaluated, it is likely that similar benefits may be found. Furthermore, using SMFs for discussion of ethical dilemmas may not only benefit the GP experiencing the dilemma, but also those participating in or observing discussions, resulting in shared moral learning and a wider impact on practice.
Taking into consideration time pressures experienced by GPs, SMFs appear to offer a possible safe space to reflect on cases outside of ‘real time’, without referring formally to a medicolegal defence organisation. They offer potential access to a diverse, experienced peer support network,6 potentially including colleagues with formal ethics or legal training. Some single SMFs have over 6000 GP members, representing a considerable reach of around 15% of the GP workforce in England.
CONCERNS ABOUT DISCUSSION OF CASES ON SMFS
Perhaps the most obvious concern pertaining to SMFs surrounds confidentiality, with breaches of confidentiality and use of identifiable patient information taking place despite clear professional guidelines.10 Professional guidelines5,6 highlight the fact that even limited individual pieces of information about a patient may be put together with information about the person writing the post to make the patient identifiable. Forum users need to be aware that what makes a case ethically interesting or problematic may also make it identifiable.11 Even closed forums should be treated as being potentially public.
The unofficial and often anonymous nature of SMFs means that the quality of clinical or ethical advice given may be open to question. Advice given on SMFs may be purely anecdotal or inaccurate, but evidence suggests that doctors are often reluctant to challenge the accuracy or appropriateness of online material.12 Although ultimate clinical responsibility lies with the treating clinician, the medicolegal standing of advice given on SMFs remains unclear.4 The RCGP advises that GPs should ‘engage with the public but be cautious of giving personal advice’ 6 on SMFs, but guidance does not consider professional advice that might be given to other clinicians. The GMC states that ‘the standards expected of doctors do not change because they are communicating through social media’ ,5 but there is yet to be formal application of such standards to a potential case and so it is yet to be determined how this might apply in practice. The recent case of Dr Bawa-Garba, regardless of how her reflections were used, has highlighted the potential for inclusion of online reflections and statements in medicolegal proceedings; uncertainty remains around the use of discussions made online, which would include contribution to SMFs.13 Although the lack of official record within departmental, practice, or patient notes may be attractive to clinicians, it also represents a deficiency in audit trail around such conversations.
SMFs have been described as ‘echo chambers’, susceptible to in-group bias among individuals with similar beliefs, reinforcing particular viewpoints while dismissing contradictory information, that is, amplifying confirmation bias. One study demonstrated the more active a SMF community was (measured through metrics such as ‘likes’ and ‘shares’), the more self-segregated and polarised it was towards news sources of a narrower range of standpoints, despite a much wider array of available online information.14 This selective exposure to a limited scope of narratives is problematic when considering ethical issues that, by their nature, often require evaluation of conflicting perspectives. Furthermore, such reinforced in-group favouritism may lead to hostility and prejudice towards out-group members such as patients or allied health professionals. The GMC5 and RCGP6 highlight the importance of treating colleagues with respect, and recognise the complexities in communicating with colleagues through social media, particularly where there might be a disagreement of views or criticism of decisions or political viewpoints.
Other issues of professionalism may emerge on SMFs, particularly where discussion arises because of a perceived fault on behalf of the patient or carer. Posts may contain disparaging comments about patients, colleagues, or wastage of resources,10 setting a poor example to GPs and trainees, and violating principles of accepted ethical and professional conduct. Despite physicians considering discussing a patient disrespectfully online to be unethical (even where the patient is non-identifiable),4 this practice continues.10 Anonymity associated with SMFs contributes to such behaviour, which may be less likely to occur in an offline environment.
The RCGP advises doctors that it may be necessary to ‘intervene’ if they witness a colleague behaving inappropriately,6 suggesting an obligation for healthcare professionals to take action should they witness unprofessional conduct of colleagues online. This might involve posting a comment asking the originator to modify or remove the offending item, ideally with reasons, and/or reporting it to the moderator. Many SMFs have options to report both offensive posts and ‘posters’.
THE FUTURE OF SMFs
The 2018/2019 mandate for the NHS document published by the government has a significant emphasis on primary care harnessing technological solutions and the adoption of electronic platforms, not only for advice and guidance but also for patient consultations.15 SMFs represent a potentially useful avenue for support and reflection on ethical issues for GPs, transcending the relative professional isolation imposed by the GP workday. However, they may themselves be ethically problematic if those moderating and using such forums are not aware of their responsibilities. There is a need for further consideration of how existing online forums are used, and whether it is time for organisations such as the BMA or the royal colleges to offer closed forums moderated by colleagues with relevant knowledge of practice, ethical analysis, and/or medical regulation. Facebook, for example, is exploring ways of providing fact-checking to posts to ensure legitimacy and accuracy. To be well used and used well, such forums may need to be clearly for educational rather than summative purposes.
PRACTICAL TIPS FOR SAFE AND ETHICAL USE OF SMFS
Always ensure patient confidentiality is maintained, remembering that even limited pieces of information about a patient case might make it identifiable, particularly once associated with your profile/location.
Consider all SMFs to be public, even if ‘closed’. Although there are often procedures that attempt to ensure professional exclusivity, these are not foolproof, and discussions on ‘closed’ SMFs have previously made it into the public domain and media.
Be wary of acting solely based on clinical advice given on SMFs — discuss such advice with colleagues in your practice.
Be aware of inappropriate/unprofessional behaviour of colleagues on SMFs and take appropriate action.
Notes
Funding
Selena Knight is an Academic Clinical Fellow supported by the NIHR. Benedict Hayhoe is supported by the Imperial NIHR Biomedical Research Centre and the NIHR CLAHRC for NW London. The views expressed are those of the author and not those of the NIHR.
Provenance
Freely submitted; externally peer reviewed.
Competing interests
The authors have declared no competing interests.
- © British Journal of General Practice 2019