Doctors and the use of social media and electronic communication systems: The new FNOMCeO recommendations

A document entitled “Recommendations for the use of social media, email, and instant messaging in the medical profession and in doctor-patient communication” (“Recommendations”) was published by the Italian Federation of the Orders of Surgeons and Dentists (“FNOMCeO”)—ICT working group— on July 21, 2023.

This initial set of guidelines for Italian doctors using these new communication systems runs along the lines of similar initiatives by various associations and scientific bodies in other countries^[1]. In the intention of FNOMCeO, the content of the Recommendations should be used in the future to amend and supplement the sections in the current Code of Medical Deontology on computerization and healthcare innovation and healthcare communication and advertising activities by doctors.

The Recommendations are intended to prevent and limit potential negative repercussions for patients and healthcare professionals resulting from improper use of these tools, especially due to doctors sharing health information and content on social networks and using electronic communications systems (email, instant messaging, and the like) in their interactions with patients. Today, partly due to the pandemic, doctors use these channels increasingly frequently. Moreover, critical issues emerged during the pandemic, namely the dissemination of a large amount of information—much of it false and misleading—on the web (known as an infodemic). This had the potential to foster behavior harmful to the health of citizens/patients and, more generally, generate mistrust toward the national health system and the professionals who work in it.

The use of social media in health communication and doctor/patient interactions

The FNOMCeO begins by proposing recommendations for “appropriate and ethical” use of social media by doctors. It takes the guidelines already adopted by major international scientific bodies and adapts them to the Italian context.

Key points include:

• Separation of private/professional activity: a doctor who is active on social media should create two separate profiles, one private and one for professional purposes, in order not to compromise patient trust and also to guard against patients having access to personal content that a doctor might share (e.g., “political” content). For these reasons, recommendations for doctors include creating private personal profiles accessible only after acceptance of a “friend request” and being extremely cautious when accepting friend requests from patients, to avoid undermining patient trust.^[2]
• Scientific accuracy of published content and other cautions: regardless of the type of social profile doctors use (private or professional), they should only share content with proven scientific accuracy, avoid offering individual medical advice, and always clarify that they are speaking on their own behalf and not as representatives of the facilities where they work. According to the FNOMCeO, a doctor should help to disseminate scientific culture and health information on the web by “writing about health” and “not about medicine and cures” in order to foster citizen empowerment. Furthermore, as a general rule, a physician should always bear in mind that any content, once published on the web, is beyond the control of its author and could be accessed by an indefinite number of subjects for an equally indefinite period of time.
• Protection of patient privacy and the reputations of others: on social networks, a doctor must protect the privacy of their patients by not publishing posts that contain personal health data and by ensuring anonymity and non-recognizability when publicly discussing a clinical case. Furthermore, a professional is required to use extreme caution when expressing judgement, comments, and opinions and should always consider how the public may perceive the posted content.
• Conflicts of interest: without prejudice to the prohibition on doctors promoting healthcare products directly, it is recommended that doctors make explicit in their social content the possible presence of potential conflicts of interest by including an electronic “tag,” e.g., #COI or #NOCOI (which stand for “conflict of interest” and “no conflict of interest”)^[3] or by providing a link to a disclosure form (examples include a doctor’s scientific contribution to a certain treatment or a financial contribution from the company producing the treatment).

Social networks and health advertising

Social networks can be (and indeed increasingly are) used by healthcare professionals as a promotional tool, to publicize their activities and services. Law No. 145/2018^[4] allows “members of the registers of the orders of health professions” to carry out healthcare advertising as long as (i) it only contains information on their qualifications and specializations, the types of services offered, and the related costs; and (ii) the messages safeguard the right to correct health information, without any elements of an attractive or suggestive nature, including communications containing offers, discounts, and promotions that could lead to the improper use of health treatments. The reference to offers, discounts, and promotions is the result of a recent legislative change implemented by the legislature in an attempt to clarify the ban on communications designed to attract patients by leveraging prices^[5].

Furthermore, in relation to drugs and medical devices, the law^[6] and the Italian Ministry of Health guidelines^[7] prohibit health professionals from offering testimonials recommending the use of specific products to the public.

Finally, in accordance with the Code of Medical Ethics, Art. 56, a doctor may not offer patronage to advertising promoting the marketing of products, whether medical or not, of third-party companies.

Therefore, healthcare professionals may only use social networks for promotional purposes—whether their own or those of third parties—to a limited extent. Such communication should be closely monitored.

The use of email systems in doctor/patient communication

A second set of proposals concern the use of email for doctor/patient communication. Email can be very useful to a physician, for example, in managing follow-up after medical appointments. It can be used to create an ongoing relationship between physician and patient, and the patient may receive assistance from the professional, including through the sharing of links and in-depth materials. The recommendations developed by the FNOMCeO are a reworking of the indications of the American Medical Association and can be broken down into those dealing with patient privacy protection and those concerning practical management of email, as follows:

• Protection of privacy: a doctor may use email only with patients they know and after receiving patients’ informed consent for use of these tools; if parties other than the doctor are expected to have access to patients’ personal information, patients must be informed of that. Message encryption systems for email are recommended. Web-based platforms that enable a better protected and more secure digital environment by integrating communication with medical record/healthcare management systems are also recommended when sensitive data is communicated.

• Email management: it is recommended that doctors implement automatic response systems to indicate receipt of messages and establish days and times when they are available to answer questions by email, including establishing a maximum response time. It is also advisable for doctors to create a standard message format to facilitate communication, to archive such exchanges in the medical records, and to use data backup systems to avoid losing important conversations.

Doctor-patient communication via instant messaging

Instant messaging systems—chief among them the well-known WhatsApp platform—now see widespread use among physicians in interactions with both colleagues and with patients. No doubt the immediacy and effectiveness of such interactions has merit, and documents in various formats can also be exchanged on these systems. However, they do give rise to critical issues. Doctors may find their workloads increasing to unsustainable levels as requests for interaction from patients increase, and the security of shared data raises data management issues.

Since there are no comprehensive guidelines on the subject as of yet, the FNOMCeO takes no position on this issue and instead urges authorities and operators to draw up recommendations for the use of instant messaging systems by doctors. It suggests taking a close look at technical, organizational, and ethical aspects of their use, as well as data confidentiality and privacy, and also recommends involving the Data Protection Authority.

[1] British Medical Association (BMA), American Medical Association (AMA), American College of Physicians (ACP), Canadian Medical Association (CMA), Australian Medical Association.

[2] In contrast to the FNOMCeO, the British Medical Association recommends outright rejecting friend requests from patients.

[3] This is in line with Article 2 of the Digital Chart Regulation of the Istituto di Autodisciplina Pubblicitaria (IAP)—as well as AGCM’s indications—which requires the inclusion of hashtags such as #adv in the posts of celebrities, influencers, and similar figures with a promotional purpose.

[4] Art. 1, para. 525.

[5] Decree-Law No. 69 of June 13, 2023 (Art. 6).

[6] Article 117(1)(f) of Legislative Decree No. 219 of April 24, 2006, also applicable to medical devices according to settled case law.

[7] Ministry of Health Guidelines of September 27, 2017 “Use of testimonials in the advertising of medical devices, in vitro diagnostic medical devices, and medical-surgical devices.”