Ethical Use of Public Networks and Social Media in Surgical Innovation

Introduction

Surgeons are increasingly using social media in the professional domain, experiencing the benefits of rapid communication for advertising, professional development, advocacy, and innovation. ¹ These platforms have revolutionized professional and personal interaction by overcoming geographical, logistical, and hierarchal barriers.^1,2 However, along with this expanded access come challenges managing information dissemination and ensuing perceptions, the risk of biased patient/research participant recruitment, the potential for overlap between personal and professional lives, and the precarious nature of self-interest in professional social media use.^1–6

As any student of surgical history knows, inventiveness in the operating room has led to innumerable innovative approaches now taken for granted. Despite our strict regulatory clinical research environment, many surgical innovations and subsequent evolution in practice arise not out of empiric clinical trials but rather a longitudinal surgical culture of trial and error that happens every day.^7,8 Improvisation and innovation are expected of surgeons who believe that an individualized approach to the case may require novelty in the pursuit of the best interests of the patient.

Distinguishing innovative surgical practice, clinical research, and quality improvement remains challenging. ⁹ The classic definition of research is that its goal is the creation of new generalizable knowledge. As every practicing surgeon knows, improvisation and innovation in the operating room are inherent to individual practice, and quality improvement initiatives require that we review outcomes data to ensure that standards of care are met. This process can look and feel like research as new techniques emerge and data are published supporting their effectiveness. Regulating this activity has challenges. ⁹ How social media platforms impact recruitment and dissemination of these nascent findings and outcomes remains understudied.

The ethics of surgical innovation in the context of social media has not been extensively discussed. The nature of social media favors attention grabbing, sensationalized content.^10,11 Innovation is inherently sensational and demands attention. The alignment of these intrinsic characteristics forms a basis for its appeal and contagion on social media. The use of social media in surgical innovation thus requires a more robust ethical analysis.

Embracing Innovation

Historically, new ideas are not always good ideas. When put into the context of social media, innovative techniques can spread rapidly and become popular with little-to-no peer review or even informal professional vetting.^1,2 Never before has information been able to spread as widely within a short amount of time. Sharing information on social media platforms is cheap, efficient, and produces value. ¹ Access is worldwide, despite geographic location or type of device used. Social media provides tools such as hashtags that boost the involvement of those within a specialty to communicate about innovative techniques or research. ¹¹ Barriers to attending research conferences are overcome with immediate updates happening throughout a conference. Patients can find other patients suffering from similar conditions and form groups that share innovative procedures they have found to be successful. ⁵

However, true innovation carries unknown risk. We may fully understand the risks of a well-established operation, but we cannot confidently know the true risks of the new surgical technique at the outset. We know that obtaining adequate informed consent for research involving innovative surgical procedures is a significant challenge. ⁷ Needless to say, an era in which the most influential information is tweeted with a character limit will hamper any reasonable attempt to provide comprehensive information and to convey nuance. Attention to the conclusions a patient may have about an operation from the limited context of social media is paramount. Assessment of patient understanding is necessary to offer innovative techniques through social media.

Due to the expansive use of social media by almost all subgroups of the population, it can function in crowdsourcing patients/participants. While it is intriguing to utilize such a platform to recruit potential participants or new patients, this can be problematic. There may be coercion in disenfranchised populations to participate in research concerning new surgical techniques. ⁵ Some argue that social media access differs across user groups, and results in biased patient exposure and participant recruitment. ¹² Also, there is a potential to disproportionately recruit heavy social media users, which may include individuals who distrust conventional sources of valid information and may be more accepting of innovation, and thereby vulnerable. Conversely, those without electronic devices can be deprived of the opportunity to participate. Others contend that participant loss as a result of limited access to resources and transient lifestyles decreases participant retention and leads to attrition bias. ⁵ This attrition bias may be resolved using social media to locate, track, and communicate with study participants who are at risk of being lost since social media use transcends the barriers of socioeconomic status. ⁵ As a result, social media can both increase and decrease bias in research.

However, social media also plays a legitimate role in enhancing the management of innovative research. Academic journals encourage authors to tweet “check out my new publication” with a link to the online article as soon as it is published. Academic conferences designate a specific hashtag for attendees to use to promote the conference and its research presentation highlights. The improved dissemination of innovative research using social media cannot be denied but requires a higher level of caution to avoid certain pitfalls.

Privacy

Privacy concerns have been the major issue in social media over the past several years.^3,4,11 Users willingly upload unbelievable amounts of personal information, which is then available not only to other users but is also shared with third parties. While users sign privacy agreements that legally facilitate this kind of data exchange, few appreciate the magnitude and potential consequences. ¹³

Users may willingly or inadvertently share details of what medical professionals and regulators consider protected health information (PHI). PHI includes information that is individually identifiable, and surgeons readily understand that a photograph of a face or a patient's birthday or social security number is something that should not be shared on social media without explicit consent from the patient. However, an intraoperative video depicting an innovative approach to a rare condition may share enough elements that a patient could be identified. While the regulatory climate is complex, the overriding ethical principle at stake is respect for persons.

It has become routine for plastic surgeons sharing before and after photographs of patients on social media to obtain consent for using their patients' photographs. However, it is less clear how prevalent a patient's consent is obtained to use their computed tomography or magnetic resonance imaging images, photographs of a specimen, or videos recorded on the laparoscope on social media. Most consent forms have a clause referring to use for educational purposes; however, the line between education and entertainment is blurred on social media. Some authors have highlighted the complex relationship between imaging and the body that may call for increased use of consent forms in all instances of sharing imaging on social media.^14,15

Innovative procedures are perfect subjects for posting on social media, though the effect of the post may be different given the intent and the context. For example, posting photographs or videos of an intraoperative improvisation due to aberrant or complicated anatomy to a closed group of surgeons might facilitate discussions among experts who face similar challenges, and can add to an overall body of knowledge and discourse around improving approaches to similar cases. Posting the same video to a patient and family group may have a completely different outcome. Particularly for surgeons who operate on rare conditions, there may even be a moral imperative to utilize social media to communicate innovations as they evolve to capitalize on the combined experience of many specialists. Unfortunately, the intention of the surgeon is only one component of this equation, as the intended audience and the actual audience may differ—allowing for a range of contextual features to determine the meaning and use of patient images. ⁴ Discussing with the patient what parts of an innovative operation are acceptable for broadcast on social media demonstrates the utmost respect for persons and respect for an individual's autonomy over what information about their body is made available for public consumption.

The online era has also blurred distinctions between professional and personal relationships, and when to apply public versus medical privacy regulations. ¹⁶ For example, historically, a patient could not reach out directly to a surgeon before an initial consultation. But now, a simple tweet can pair a surgeon to a potential patient, and it may be unclear to both parties when such exchanges morph into a clinical encounter. Distinguishing when patient privacy rules and state regulation of medical practice would take effect in an online encounter can be difficult to discern. ¹⁷ In addition, the specific IT platform and structure impact privacy controls. For example, patient support groups are common on Facebook, with some open, closed (must ask permission to join), and secret (unsearchable and by invitation only). ¹⁸ The degree of privacy of support groups should influence the actions of surgeons participating in these support groups. Eberlin et al. have described principles to guide these interactions. ¹⁷

Surgeons As Advertisers

Since engagement with social media is unavoidable for many, surgeons require concrete guidance regarding the professional use of social media in daily practice and innovation. ² The importance of professionalism in unregulated innovation cannot be understated. ¹⁹ The process of becoming a surgeon instills a greater sense of self-regulation, a higher standard of ethics, and a central focus on altruism. ³ In the context of social media, professionalism must survive among increased patient–provider contact as the motivation to share online is not intrinsically altruistic. ² When sharing information online, someone commonly hopes for one of three things: (1) the information will be rewarded with valuable information in return, (2) to gain recognition, and (3) to make a difference or gain a sense of community. ² For patients, the motivation is often to be rewarded with valuable information or to gain a sense of community. For surgeons, the motivation could be to make a difference or to gain recognition. A starting point in avoiding the pitfalls of self-interest in social media use can begin with the sole desire to make a difference in patients' best interests.

The objective assessment of an innovative procedure can be influenced by competing factors. These factors include the time, money, and effort a surgeon puts into learning a new technique; the pressure from the hospital/department to offer innovative techniques; and patient exposure to new and improved techniques on the Internet. ¹⁹ Investment in any endeavor predisposes one to champion that course of action. This self-interest is common in innovative surgical techniques and becomes a larger issue in the context of social media. Quite often, physicians already have an online presence in the form of reviews on different medical forums offered to the public. ¹¹ Brand building on social media can be a powerful tool for a surgeon to influence their online presence. Invariably, this brand building can lead to self-promotion, which is enhanced when offering innovative procedures. In addition, a social media account can be viewed as free advertising. The idea that a professional social media account can act as advertisement is not new, but when the account includes photographs and videos of patients, it can be difficult to avoid “medutainment” or the use of using the patient–physician relationship as a source of entertainment by which to increase notoriety or attract patients.^4,20

A surgeon utilizing innovative techniques must consider different aspects of this concept to utilize social media appropriately for medical use. When “advertising” an innovative technique on social media, it is best to strive for a clear presentation of the innovative technique to enhance patient understanding. Access to more in-depth information by linking a website with broader material regarding the innovative procedure is best due to the abbreviated nature of most social media forums.

Patients gravitate online to surgeons with influence, which commonly translates into having more followers. ²⁰ Social media users with large amounts of innovation generate more followers. The influence these users have develops a community centered on them as experts in a subject. This expertise may make patients more willing to schedule a surgical consultation after researching a surgeon online and finding a sufficient social media presence and branding. ⁴ The setting of social media is distinct from comprehensive websites with general information. Websites can be viewed as static informational tools while social media involves interaction with the surgeon and other patients, making the viewer feel like the information is more up to date and valid. Of course, measuring and assessing quality of surgical care are difficult from every vantage, not just online.

Surgeons may not necessarily be at the forefront of this process. Patient and family groups on Facebook inform each other of surgical innovations. For example, many patients who have traveled from across the country to the University of Michigan for a chance to receive an innovative three-dimensional-printed tracheal splint for severe tracheal and bronchiomalacia learned about the procedure through social media. Some patients may not be candidates for treatment but arrive with the expectation of receiving the innovative procedure. Surgeons must be wary of pressure to use expanded indications in this setting.

Recommendations

It seems inevitable that surgeons will become more and more involved in the realm of social media, especially if they desire an ability to curate their own identity as a surgeon online. For this reason, it may be in their best interest to accept the opportunity to be involved in social media. However, taking the time to understand and apply the recommendations above should occur before diving into this complex environment.

Conclusion

Social media allows for unprecedented speed in dissemination of ideas, including novel and innovative surgical techniques and approaches. It democratizes medical information by putting it directly in the hands of colleagues, patients, and the public, and facilitates direct-to-consumer marketing of surgical procedures at virtually no cost. Discourse among surgeons using social media allows for collaboration and consultation on cases that may be difficult or uncommon, drawing on the collective wisdom of a worldwide virtual community but also bypassing traditional privacy protections and other regulatory firewalls. Thus, inherent pitfalls include potential overlap between the personal and the professional, management of disseminated information and unproven novel approaches, biased research recruitment, and the unchecked pursuit of self-interest. Part of our duty is to recognize and avoid these pitfalls, both individually and as a profession.