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Asiodu, I. V., Waters, C. M., Dailey, D. E., Lee, K. A., & Lyndon, A. (2015). Breastfeeding and
Use of Social Media Among First‐time African American Mothers. Journal of Obstetric,
Gynecologic
&
Neonatal
Nursing, 44(2),
268-278.
Retrieved
from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4359664/
This article is written by three highly respected college professors from the University of
California and two affiliated authors from the Department of Women, Children, and Family
Health Science at the University of Illinois. They effectively discuss African- American
first- time mothers who are breastfeeding. The participants are breastfeeding mothers, they
are first time mothers, and they are African- Americans. This article demonstrates that this
population is continuously using the internet and social media to find more information on
parenting. They also use mobile apps to find information about infant development. The
high usage of social media, the internet, and mobile apps to get information on parenting
and infant development, as well as infant feeding, means that social media plays a vital role
in finding information on parenting issues. Thus, this article is relevant to my research
because it shows how social media is helpful to learn information on maternity care and
parenting. The authors interview not only pregnant and nursing women, but also the
individuals who offer women support, which makes the research findings more accurate.
Apart from interviewing participants, they also used other journals to get more information
on the topic, thereby increasing the quality and accuracy of the study.
Azu, M., Lilley, E., & Kolli, A. (2012). Social Media, Surgeons, and The Internet: An Era or an
Error? The American Surgeon, 78(5), 555–558. Retrieved from
http://search.proquest.com/docview/1018553334/
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In this article, the authors at the Cancer Institute of New Jersey, discuss surgeons'
information found on the internet, and then explain how it affects patients and physicians.
They draw evidence from the National Research Corporation to support their argument.
Many patients go online to find information on the doctors before meeting them, and any
negative information they find builds doubts and mistrust. Therefore, the authors discuss
the importance of clinicians having a presence on the internet and monitoring the
information available about them. This article focuses on examining rating sites and how
they negatively and positively affect a physician. Also, to reduce some of the conflicts that
may arising, it is crucial to separate their personal and professional accounts. They need to
avoid sharing information on the wrong channel/website such as Yelp. While
acknowledging that it is hard to deal with negative information on rating sites, these authors
provide ways to mitigate such occurrences. This article is relevant to my research. The
authors also use resources other than their own experiences and ideologies, which makes
the article well- researched and a great reference for my research.
Benetoli, A., Chen, T., & Aslani, P. (2018). How Patients’ Use of Social Media Impacts Their
Interactions with Healthcare Professionals. Patient Education and Counseling, 101(3),
439–444. Retrieved from https://doi.org/10.1016/j.pec.2017.08.015.
In this article, the authors focus on groups with chronic conditions and their research as
corresponding authors of the Department of Pharmaceutical Sciences at the State
University of Ponta Grossa. They discuss how acquiring information on social media
affects the patients’ interactions with physicians. They explore how patients use social
media to help make decisions regarding their health, and the attitude patients and HCPs
have towards the use of social media for healthcare research. Patients are empowering
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themselves by looking for health-related information on the internet and this results in
better communication with doctors. Patients never interact with HCPs on social media, but
their interactions with peers and discussions on health-related issues help them gain
sufficient knowledge about various health conditions. Also, the interactions help them
prepare questions, which they eventually ask their HCP about. These interactions also
provide them with an understanding of the decision-making process. Its exploration of the
attitude of HCPs towards the use of SM made the study more relevant since it looked at
how SM affects both parties (patients and HCPs). Therefore, this article is reliable, and it
provides an overview of how social media is relevant in their healthcare, which is the area
of focus for my research.
Breland, J., Quintiliani, L., Schneider, K., May, C., & Pagoto, S. (2017). Social Media as a Tool
to Increase the Impact of Public Health Research. American Journal of Public
Health, 107(12), 1890–1891. Retrieved from https://doi.org/10.2105/AJPH.2017.304098.
This article is written by four highly respected college professors at the Center for
Innovation to Implementation. They approach the traditional methods of communication
and how social media has influenced communication in public health. Social media came
in as a platform for individuals to interact and make “friends,” but, over the years, it has
turned out to be one of the most crucial communication technologies. Most of the
population is on a social network, and this has made organizations reconsider their views
about social media. Professional institutions, like the health sector, have adopted social
media as the primary channel to distribute information to the public. The author relies on
information from certified doctors and other researchers on these platforms who are dishing
out credible and accurate information to people searching for health empowerment.
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Additionally, practitioners have the chance to connect and forge relationships that help
them grow professionally. This article is relevant to my research because it is published
under the American Journal of Public Health. It proves that, other than assisting people in
connecting, communicating, or being conversant with current happenings in the world, it
also helps them in conducting health research and being informed on health issues. It also
shows how scientists and policymakers in healthcare can use social media platforms to
their advantage.
Denecke, K. (2014). Ethical Aspects of Using Medical Social Media in Healthcare
Applications. Studies in Health Technology and Informatics, 198, 55–62. Retrieved from
https://primo.alfred.edu/discovery/fulldisplay?docid=medline24825685&context=PC&vi
d=01SUNY_AUA:01SUNY_AUA&search_scope=MyInst_and_CI&tab=Everything&la
ng=en.
In this article, the author, who is affiliated with the Innovation Center Computer Assisted
Surgery in Leipzig University, carry out their research with their experience in social
media. Denecke also analyze various literature reviews to support their argument on the
ethical issues of social media usage in healthcare. There are ethical issues that physicians
have to consider when interacting with patients through social media. A physician
researching this site must find a few things, such as issues of privacy and confidentiality.
The article also has illustrations on the increased usage of social media in healthcare. For
example, the recruitment of individuals for research on the internet raises some ethical
issues. It is no secret that many adolescents under the age of 18 are active on social media
and are quick to jump to volunteer for survey and research without the consent of their
parents. This article is relevant for my research because physicians and researchers need to
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know how to conduct themselves when using social media. Patients also need to understand
what to do to protect their privacy when using social media to seek information about
specific conditions. So, until there are well-stipulated frameworks to function with, ethical
concerns will always be an issue.
He, Z. (2019). Understanding and Bridging the Language and Terminology Gap Between Health
Professionals and Consumers Using Social Media. Social Web and Health Research,
103–121. doi: 10.1007/978-3-030-14714-3_6.
The author of this article, He, is an assistant professor at Florida State University in the
School of Information. The author conducts his research on technology advancements and
their influence on the health professionals. He outlines various advancements, especially
social media, and how they have influenced the public. He argues that there is a need to
understand the existing gap between language and terminology. This article describes
eHealth literacy and various methods of harnessing social media to lead to the
understanding of the existing gap between professionals and consumers. The author relies
on his own research that the advancements on technology have led to various effects on
healthcare. According to the author, there is room for development for health applications
for the consumers, as they need to ensure that they are more adaptive to health literacy.
People often seek health information online and seek social support. This article is vital for
my research as it outlines the importance of social media in healthcare.
Househ, M., Borycki, E., & Kushniruk, A. (2014). Empowering Patients Through Social Media:
The
Benefits
and
Challenges. Health
10.1177/1460458213476969.
Informatics
Journal, 20(1),
50–58.
doi:
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In this article, the authors are as a professor in the College of Public Health and Health
Informatics. They support his argument through a study of various literature, as well as his
research as a public health professional. The authors note that the involved parties in the
health sector use social media for different purposes. The organizations use it for reaching
out to the customers, fundraising, provision of information, and advertising. The doctors
and other professionals handle it for both professional and personal purposes. Interestingly,
he states that physicians rarely use social media to communicate with the patients in
observance of the AMA guidelines on the patient-physician relationship. Finally, this
article touches on how the patients use social media to acquire information and educate
themselves on health matters. This article also points out challenges facing the integration
of this technology and ethical crossroads. Therefore, I will use this article to show the
negative effects of social media on healthcare, and I will outline the various uses of social
media and how they positively impact healthcare professionals.
Nadel, S. (2017). Healthcare Professionals Encounter Hurdles When Faced with Negative
Reviews on Social Media. The Health Lawyer, 30(2), 30–36. Retrieved from
http://search.proquest.com/docview/2089335383/
According to this article, Nadel is an Executive Director of American Council for an
Energy-Efficient Economy (ACEEE) organization. Nadel highlights the challenges health
practitioners meet when they get negative reviews online and discusses how to deal with
such instances. As a qualified psychologist, Nadel draws information from legal entities to
complete this study. Online consumer reviews present a significant impact on medical care
professionals, and in this article, Nadel argues that there is no guaranteed legal leverage for
negative ratings and reviews on the internet. So, physicians should choose other ways to
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counter negative comments. The author provides numerous ways to handle this issue, and
they range from reaching out to the patient to suing for violation of confidentiality. One of
the standout methods is encouraging loyal patients to write positive reviews to outweigh
the negative ones, which makes them look like isolated cases. Being a lawyer representing
health practitioners makes Nadel resourceful, and the information he gives in his article is
beneficial to clinicians who might find themselves in a critical situation. I found this article
is relevant because it shows how reviews on social media sites negatively affect physicians,
and Nadel suggests actions that can be taken to combat such issues.
Pentescu, A., Cetină, I., & Orzan, G. (2015). Social Media’s Impact on Healthcare
Services. Procedia Economics and Finance, 27(C), 646–651. Retrieved from
https://doi.org/10.1016/S2212-5671(15)01044-8.
According to this article, the researchers at the Faculty of Economic Sciences in Lucian
Blaga University, and the Faculty of Marketing in Bucharest University of Economic
Studies acknowledge the vital role that social media plays in the healthcare sector. This
article also recognizes the latest technological advancements that make it easy to share
information. This article reveals that social media does benefit not only the patients but
also health care professionals. As much as social media has been helpful, there are
significant concerns about its relevance in the healthcare sector. The authors examine these
concerns and try to see whether they apply to the healthcare system of Romania.
Accordingly, this article is of good quality because it specifies its target audience. The
authors do not target a general reader, but specifically those from Romania. I found this
article to be reliable and credible to my research because it evaluates the concerns that both
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healthcare professionals and patients have toward the use of social media. One of the
concerns includes misinformation, as people can share wrong information on social media.
Price, A. M., Devis, K., LeMoine, G., Crouch, S., South, N., & Hossain, R. (2018). First Year
Nursing Students Use of Social Media Within Education: Results of a Survey. Nurse
education
today, 61,
70-76.
Retrieved
from
https://www.sciencedirect.com/science/article/abs/pii/S0260691717302538.
In this article, all the authors are affiliated with the Canterbury Christ Church University,
and they are all in the university’s School of Nursing, except Hossain. The purpose of the
study is to evaluate the use of social media by student nurses before and after starting the
pre-registration program. In total, there were 121 participants. Most of the students who
participated in the survey said that the use of social media was beneficial. They said that it
provided them with a platform where they participated in discussions and shared
information. Through these platforms, they were able to increase awareness of nursing
issues in their course. This article also uses tables and other illustrations, which make the
results of the study easy for the reader to understand. This article is relevant to my research
because it takes a different angle from other studies by looking at nursing students and how
social media is relevant to them.
Read, C. (2014). The Growing Influence of Social Media in Healthcare. Nursing Times, S2–S3.
Retrieved from http://search.proquest.com/docview/1535384388/
In this article, Read draws information from different documentaries that focus on the
nature of communication over the decades. He also does his research as a qualified
journalist to illustrate the growing influence of social media in healthcare. The article
focuses on the enormous growth of the online social networks over decades and their
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impact on healthcare. Today, a Tweet by health personnel can reach millions of people in
a single click without someone having to write press releases, which only reach a few
people. Moreover, health practitioners have platforms like We Nurses, where they can
connect and exchange ideas regardless of their geographical locations or institutional
affiliations. Social media also provides individuals with the same ailments to come together
and share concerns, which creates awareness about where people can get treatment and
assistance. That said, the piece does not point out any downsides of online networks, but it
is clear that a single misleading message can cause damage. This article is published in a
reputable Nursing Journal, Nursing Times, which means it is reliable. Also, it covers all
the essential areas needed in my research, making it relevant to my topic.
Ventola C. L. (2014). Social Media and Healthcare Professionals: Benefits, Risks, and Best
Practices. P & T : A peer-reviewed journal for formulary management, 39(7), 491–520.
Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4103576/
In this article, Ventola is a consultant medical author in New Jersey, relies on information
from various sources such as blogs and wikis, to support his argument about social media
practices. Ventola explains that healthcare professionals are using social media for multiple
purposes such as professional networking and development, patient care and education,
and many others. There are some sites like Doximity, Doc2Doc, and QuantiaMD that
exclusively deal with healthcare professionals and also provide a stage to share
experiences, ideas, and other things affecting the sector. Apart from these benefits, social
media has its negative aspects such as dissemination of imperfect information, which lacks
credibility and reliability. Ventola points out that when professionals get too close to
patients on the internet, the boundary lines become blurry, and it becomes easy to violate
Phyu 10
the ethical code. That said, social networks provide a great avenue to enhance the
healthcare field, and the possibilities will only keep growing. This article is relevant to my
research because I need to understand the benefits, risks, and best practices HCPs should
be aware of before using social media.
SOURCE #1
How patients’ use of social media impacts
their interactions with healthcare
professionals
Author links open overlay panelA.BenetoliabT.F.ChenaP.Aslania
Show more
https://doi.org/10.1016/j.pec.2017.08.015Get rights and content
Highlights
•
Patients were empowered by using social media for health-related purposes.
•
Patients could participate more actively in the treatment decision-making
processes.
•
The use of social media by patients improved their relationship with their
healthcare professionals.
•
However overt or tacit opposition from healthcare professionals was reported.
Abstract
Introduction
Patients are increasingly accessing online health information and have become more
participatory in their engagement with the advent of social media (SM). This study
explored how patients’ use of SM impacted their interactions with healthcare
professionals (HCPs).
Methods
Focus groups (n = 5) were conducted with 36 patients with chronic conditions and on
medication who used SM for health-related purposes. The discussions lasted 60–
90 min, were audio-recorded, transcribed verbatim, and thematically analysed.
Results
Participants did not interact with HCPs on SM and were not expecting to do so as they
used SM exclusively for peer interactions. Most reported improvement in the patientHCP relationship due to increased knowledge, better communication,
and empowerment. Participants supplemented HCP-provided information with peer
interactions on SM, and prepared themselves for consultations. They shared online
health information with HCPs, during consultations, to validate it and to actively
participate in the decision-making. Although some participants reported HCP support
for their online activities, most perceived overt or tacit opposition.
Conclusion
Participants perceived that their SM use positively impacted relationships with HCPs.
They felt empowered and were more assertive in participating in decision-making.
Practice implications
HCPs should be aware of patients’ activities and expectations, and support them in
their online activities.
•
•
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Keywords
Social media
Patients
Chronic conditions
Decision-making
Empowerment
Healthcare professionals
1. Introduction
The Internet has increased access to a range of health-related information, and its
evolution to Web 2.0 has provided a more participatory environment where users
develop and disseminate online content. Web 2.0 has provided the technological
foundation for the appearance of social media platforms [1]. Web 2.0 has allowed the
development of easy-to-use and interactive platforms where individuals and
communities share, co-create, discuss, and modify user-generated content (e.g. texts,
images, audios, videos, games) employing mobile and web-based technologies [2].
Social media (SM), dubbed the “participative Internet” [3], has therefore been enabled
through the evolution of Web 2.0. Putting it simply, SM consists of a wide range of
websites and applications whose content is created by Internet users [1]. It has
provided a new venue for public communication, including health communication [4].
As a result, SM has turned out to be not only an emerging trend for patients seeking
health information [5], but also a venue for them to interact with one another. Online
communities of patients with a shared health problem have become common [6].
Popular topics discussed include disease symptoms, prognosis, examinations and
procedures, and treatments [7]. Besides getting additional useful information directly
from peers [8], online patients have also obtained social support for self-management
of their chronic conditions [9].
It has been argued that patients’ access to online health information can impact their
relationship with healthcare professionals (HCPs) [10]. As Web 2.0 and SM are
dynamic communication technologies with increasing penetration in people’s daily
lives, it is vital to keep abreast of changes in its use by patients. Additionally, it is
important to fully comprehend how patients are accessing health services and
interacting with their HCPs after engaging with peers on social media. Findings from
the literature have revealed that patient participation in health-related discussions on
SM and other online forums could have an impact on the patient-HCP relationship.
Patients have felt empowered and confident with the knowledge and support obtained
online [11], [12] and consequently have asked more relevant questions and
communicated better with HCPs [11], [13], [14], [15], [16]. However, on the flip side,
it has been claimed that patients’ active participation in online health activities with
peers could threaten HCP expertise in some cases [17] leading them to negatively
react to patients’ online autonomous health activities. This in turn could have a
disempowering effect on patients [18]. Patients have ended up looking for other health
providers in response to a physician’s negative attitude or due to the recommendation
of “good doctors” from peers [15].
Chiu and Hsieh [13] investigated how cancer patients wrote (and read) blogs about
their condition and the impact of such activity on their illness experience. Cancer
patients reconstructed their life story in the blog, articulated their expected end of life
and how they wished to be remembered after death [13]. Using in-person and virtual
focus groups, Rupert et al. [18] found that patients used online health communities or
support groups to obtain information not provided by HCPs and discussed information
obtained online with their clinicians, positively impacting the patient-HCP
relationship [11], [18]. An Australian study [17] employing interviews explored the
use of online support groups by men with prostate cancer. It showed that the online
environment allowed patients to share private information without the constraints
imposed by face-to-face social interactions. However, medical specialists perceived
this behaviour as a threat to their expert status and control over decision-making
processes [17].
A recent review by Smailhodzic et al. [19] about the use of SM in healthcare
incorporated studies dealing with patients’ use of SM and its influence on their
relationship with HCPs. While recognizing the limited number of studies on this topic,
the authors proposed that SM use by patients increased their empowerment leading to
a more equalized power balance between patients and HCPs. Considering the relative
novelty and relevance of the topic, further research is deemed necessary. A
comprehensive understanding of patients’ use, perceptions, and opinions about the use
of SM for health-related purposes is important in order to design services that meet
their needs and expectations. Moreover, further research is necessary in order to better
understand SM’s potential for supporting patient-HCP relationships [20]. Therefore,
the aim of this research was to explore patients’ experiences, opinions and perceptions
about their use of SM for health-related purposes. Specifically, the study objectives,
reported here, were to determine the impact of these online activities on patients’ inperson healthcare services use and health decision-making behaviour; and its effect on
patient-HCP relationships.
2. Methods
2.1. Focus groups
A qualitative approach was used to allow participants to articulate their experiences,
and help elicit in-depth information from them [21]. Focus groups were chosen
because they are an efficient way of gathering the views of several individuals
simultaneously [22], uncovering important constructs that may not be tapped through
individual interviews [23]. A focus group guide (Appendix 1 in Supplementary
materials) was developed to address the broad research aims. Findings pertaining to
the questions on impact of SM on healthcare services use and healthcare professional
interactions have been reported here.
2.2. Participants and recruitment
2.2.1. Inclusion criteria
Participant inclusion criteria were: 1) adults with a chronic disease, 2) taking a
medication for that disease, 3) had used SM for health-related purposes in the last 12
months, and 4) able to participate in the study without the assistance of a translator.
2.2.2. Recruitment
All participants were recruited from the Sydney metropolitan area by a market
research company. They received detailed verbal and written information about the
study. Forty participants were recruited and thirty-six participated in the discussions.
Each participant was reimbursed AUD$80 for their time and travel expenses.
2.3. Data collection
Five focus groups were conducted in three separate dedicated venues in Sydney,
Australia. All participants provided written consent and completed a demographics
questionnaire. Discussions lasted 60–90 min and were facilitated by PA, a female
pharmacist and academic experienced in conducting focus groups. The discussions
were guided by the focus group questions (Appendix 1 in Supplementary materials)
and audio-recorded. Focus groups were conducted until data saturation [24], which
was at the conclusion of the fourth focus group. One additional focus group was
conducted for validation purposes.
2.4. Data analysis
Note taking during discussions and debriefing immediately after ensured that
important information was not ignored and constituted a preliminary analysis [23].
Therefore the data analysis started during and in parallel with data collection [25]. All
audio-recordings were transcribed verbatim and thematically analysed [26]. Thematic
analysis was chosen as it is not aligned with a particular epistemological,
philosophical, or theoretical approach and is a flexible tool to generate themes in
qualitative research [26]. Repeated reading of notes and transcriptions afforded
familiarity with the data. Transcriptions were then coded line-by-line, by AB, with the
assistance of NVivo 11® (QSR International), and discussed with PA. Coding was
open, not restricted by theoretical assumptions and was dynamic and iteratively
developed throughout the analysis. An inductive approach [27] assured a data-driven
analysis. Codes with a repeated pattern across the data were collated together and
grouped into sub-themes and later assembled into overarching themes.
3. Results
A total of 36 participants (Table 1) took part in the focus groups (n = 5). A wide range
of chronic disease states (e.g. hypertension, depression, anxiety, cancer, arthritis,
Crohn’s disease) was represented among the participants.
Table 1. Participants’ demographics.
Characteristic
Participants (n = 36)
Sex
Female
17 (47%)
Characteristic
Participants (n = 36)
Male
19 (53%)
Age
Range
27–71
Mean ± SD
47.3 ± 10.2
Country of birth
Australia
26 (72%)
England
2 (5.5%)
New Zealand
2 (5.5%)
Other
6 (17%)
Education
Less than High School
3 (8%)
High School
11 (30%)
College or Technical Education (TAFE)a
6 (17%)
Undergraduate
12 (33%)
Postgraduate
2 (6%)
Data missing
2 (6%)
Employment status
Full-time
18 (50%)
Part-time
9 (25%)
Home duties
3 (8%)
Retired
2 (6%)
Unemployed
4 (11%)
Self-reported health status
Excellent/very good
14 (39%)
Fair
17 (47%)
Poor/very poor
5 (14%)
Three overarching themes related to the impact of SM in patients’ interactions with
HCPs and health care services emerged from the analysis. Table 2 provides a sample
of quotations illustrating such themes.
Table 2. Overarching themes and respective quotation sample.
Themes
Illustrative quotations
“I think, if you know the language and you're familiar with concepts and closer to a level
that a doctor understands or operates in, it’s a little bit easier, the interaction” [Focus group
(FG)2, female participant (f)10]
SM use and its
impact on
interactions with
HCPs
“I think if you prepare yourself for a session with the doctor, you know what exactly you
want to ask; they can answer” [FG5, f31]
“I think they [HCPs] probably take you a bit more seriously when you know your stuff,
because they can’t fool you around, because they know that you have the answers” [FG2,
f12]
“I have questions mentally prepared, questions which I think are going to be pragmatic for
me and kind of get the information directly from a professional” [FG5, m35]
“I’ve gone to my doctor with the information. So, I don’t just take it literally until I get
further into it and then I’ll decide or speak to the doctor about it” [FG4, f27]
“I was like pretty helpless … other times just gets really confusing if I tell them my stuff and
then they tell me other stuff” [FG3, m19]
Decision-making
process
“I was on a discussion group on polycystic ovaries. And there was this talk about metformin.
Well, that’s for diabetes. Where’s the connection? But some doctors had discovered that
metformin worked really well for polycystic ovaries because are insulin resistant. So I went
to my doctor with that and he gave me puzzled look. He said ‘give me a week and I’ll read
up’. And within that week I went back and he immediately put me on it” [FG1, f8]
“I was having a problem with a high blood pressure tablet. I was getting dizzy, sick. And I
said to the doctor ‘there's something wrong with me’. He said ‘just give it some time’. So I
went on to the forum and people had the same problem. They said ‘tell your doctor he’s
wrong and get off that, and tell him you want to try Drug XX or something else’ … then I
went back to the doctor and I told him and he changed the medication. Perfect. But if I
stayed with the doctor’s advice and never checked it myself, I’d feel sick all the time” [FG2,
m13]
“I go to my doctor once a fortnight. I skipped the last two meetings. I was getting more
online than I was in the office” [FG3, m20]
SM use and its
impact on
healthcare services
usage
“I have one [GP], but then … I would do research and come to idea that I have some
problem … I would ask and insist on certain tests and then if she refused … I found few
other doctors that are completely okay with that” [FG3, f16]
“Maybe it saves you the trip to the doctor… because you're informed and can go to the
pharmacist” [FG5, m35]
“I used SM to figure out who are the good doctors and who are the bad doctors” [FG5, m35]
3.1. SM use and its impact on interactions with HCPs
No participant reported interacting with HCPs via SM. Only digital communication
technology predating SM (e.g. chatroom) was used for communicating with HCPs.
For example, non-government organisations like BeyondBlue (beyondblue.org.au)
and Black Dog Institute (blackdoginstitute.org.au) were cited as useful online
resources where psychologists and psychiatrists could be accessed for live chats.
Participants received private counseling and referral to other services if needed. A
private service named “Ask the Doctor” (askthedoctor.com), where patients could ask
health-related questions, was also mentioned. No other online interactions with HCPs
were reported.
Most participants did not expect to interact with HCPs on any SM platforms they were
using. In fact, they thought it would be strange if a HCP participated in online
communities: “I probably would be quite dubious if somebody sort of popped up and
messaged saying ‘hi, I’m a professor or I’m a brain surgeon’ … I would be wary”
[FG1, f3]. However, some did expect that “undercover” HCP researchers could be
among virtual community users. Interestingly, it was mentioned that not only HCPs’
credentials, but also the advice provided in these circumstances would be questionable
since this service would be dissociated from a HCP’s regular workload and
employment.
Even though not interacting with HCPs on SM, participants reported that being active
online improved their face-to-face relationship with HCPs. This effect was perceived
to be due to their empowerment, manifested as improved health literacy and better
communication. Participants stated that interactions with online peers helped them to
better prepare and to articulate questions during consultations: “I think it helps also to
ask your doctor the right questions because you understand your conditions better”
[FG2, f12]. Some participants even hypothesised that HCPs would have a higher
regard for well-informed patients; consequently providing better services for them.
This improved interaction was perceived to facilitate participants to obtain more
useful information from their doctors: “to make use of your time with your specialist,
to ask the right questions … you're going in armed with information so you can
engage and get as much information” [FG2, f10]. They believed that improved
communication and being better prepared for consultations meant more efficient
consultations, especially as they are often short. Moreover, participants believed that
HCPs, particularly specialists, did not have to spend time explaining basic information
about the disease, prognosis, and treatment options because they were better informed.
3.1.1. Sharing information obtained online with HCPs
Most participants tended to discuss the information obtained online with their HCPs,
especially with their doctors. It was pointed out that verifying the validity of the
information found online was an important activity performed by HCPs: “I read, take
note, compare … then when I go see the doctor, I ask to get more clarity” [FG1, m1].
Similarly, pharmacists were mentioned as HCPs who could be accessed for doublechecking online health information: “I tend to ask the professionals … I was with the
pharmacist at the hospital, and I asked him about something. I talk to my chemist too”
[FG1, f5]. However talking to pharmacists was problematic due to lack of privacy in
the community pharmacy setting: “I tend to prefer my doctor because my pharmacist
has a thousand people around with no privacy” [FG1, f3].
3.1.2. Participants’ experiences and perceptions of HCPs reactions to their use of SM
Some participants reported on their HCPs’ reactions when they visited them with
health-related information found online or discussed in SM groups.
The majority felt that HCPs did not appreciate that their patients were accessing
online health information. In fact, some participants reported that some HCPs overtly
expressed opposition: “I went to a sports injury physio, and when she talked about
something she knows I want to check online, watch YouTube, then she tells me ‘don’t
go to websites … don’t trust websites”' [FG3, f17]. They believed that this opposition
may be because HCPs were concerned about patients being more inquisitive: “maybe
they feel that because we know what they’re going to talk about, we may ask more
questions. I find doctor doesn’t really like you to ask questions” [FG3, f17]. In some
cases, participants experienced hostility: “he rolls his eyes and goes ‘another one’s
been to the Internet again”' [FG2, m9]. Indifferent reactions were also reported.
In general, several participants had the impression that HCPs do not support patients’
autonomous search for health information and participation in online forums and SM:
“doctors don’t even like SM. I know one that hates it” [FG5, m36], “I think the
[healthcare] professional people are very against it [SM]” [FG3, f17].
On the other hand, there were some participants who reported that HCPs were
receptive to their online health-related activities. Patients’ increased knowledge about
their condition and treatment options not only led them to be more assertive when
interacting with HCPs but also sometimes changed the way HCPs approached them,
i.e. HCPs were more interested in their comments and opinions. A few participants
reported strong support from physicians for their online activities: “my doctor tells me
to get whatever information I can and if I’m not sure about it, just give him a call”
[FG3, m21]. With a few even reporting that doctors would recommend patients to go
online to find ways of helping themselves, particularly when no actual treatment or
procedure was indicated. This helped to establish a respectful and collaborative
patient-HCP relationship.
3.2. Decision-making process
SM had a significant role in fostering decision-making: “listen to another people’s
thoughts if they’ve had the same experience … help me to make a decision” [FG3,
f17]. Online engagement increased participants’ willingness to be actively engaged in
therapeutic decision-making: “if you’ve got knowledge, then you can negotiate,
suggest, and talk about it more successfully rather than just being told ‘this is what
you're going to take”' [FG1, f5].
Several participants highlighted that decision-making was an agreement between the
HCP and themselves and for most, discussing the information obtained online with
HCPs before acting on it was the rule. However, a few expressed a firm resolve to
follow what they themselves believed was right, regardless of HCPs’ opinions.
Participants bringing and discussing online treatment information during
consultations, influenced medication selection and initiation. A few participants
reported that their doctors could be persuaded to change their treatment even though
acknowledgment of the patient’s contribution was not always explicit: “they might
change it [treatment] but they won’t tell you they’re changing it for that reason
[information brought by patient]” [FG4, m23].
Suggestions to discontinue or change medications due to side-effects were also
common after participants had discussed these matters with online peers. Participants
felt they could better discuss treatment options with their doctors and treatments could
be modified as they would suggest new treatments according to what they had learnt
on SM.
Being knowledgeable about health, however, did not change participants’ reliance on
HCPs. Most articulated that HCPs were the most trusted and well-trained people: “I
want to be able to read and look, research, have all this knowledge. But you still got to
go take it to people who do all that training” [FG1, f8].
Despite most participants acknowledging that their online activities empowered them
for the decision making process, some participants felt frustrated in the decisionmaking process when doctors did not acknowledge their contribution by disregarding
the information they were presenting. Moreover, the negative impact on patients’
ability to participate in the decision-making process was strongly felt when HCPs
expressed hostility towards their online activities: “disempowers you pretty quickly”
[FG1, m9].
3.3. SM use and its impact on healthcare services usage
The use of SM for health-related purposes seemed to influence the frequency with
which healthcare services were accessed by the participants, though a clear trend was
not established in this study. On the one hand, a few participants accessed fewer
healthcare services since some of their health needs were met by the virtual peer
interactions and the information obtained. But on the other hand, there were
participants who increased their healthcare services use due to improved health
knowledge. One participant even identified HCPs inclined to accept suggestions
obtained from online sources.
Accessing other health services was also mentioned. For example, a few participants
reported that with the information obtained on SM they could get their health needs
addressed by their community pharmacist rather than their doctor.
It is important to note that the selection of health services, in particular HCPs, was
influenced by online peer interactions as patients were seeking recommendations.
While some participants preferred to obtain a HCP recommendation from strangers
within large online forums or SM groups, others believed that recommendations from
close friends on social networking sites were more appropriate and trustworthy:
“sometimes I put out a message on my page saying, ‘I’m looking for a practitioner,
has anyone got some good referrals?”' [FG2, m11].
SM was used as a platform to post complaints about health services and the health
system: “I use it for venting quite a lot about frustrations to do with access to services,
stigma when it comes to using those services” [FG3, m21].
4. Discussion and conclusions
This study has demonstrated an overall positive impact on the patient-HCP
relationship due to patients’ use of SM as clearly articulated by the participants, and
has provided new insights into the specific aspects of patient-HCP relationship. This
study also corroborated previous research indicating that patients’ use of SM for
health-related purposes positively influenced their relationship with
HCPs [11], [14], [18], [28].
Whilst previous research found that patients did not disclose their Internet activity
during clinical visits [29], this current study demonstrated that they did. Participants
stated being open about their online sources when interacting with HCPs. Therefore it
can be hypothesised that SM use by patients can increase their openness about online
activity compared to other types of Internet sources. Furthermore, it is also possible
that the increased use of the Internet for information, in general, and for health,
specifically, has shifted the “societal norm” to patients being more likely to report
seeking and finding health-related information on-line (Internet and SM).
The findings presented here are in line with previous research that has shown that
patients’ access to online health information tended to diminish the paternalistic
approach to care experienced since patients were more prepared and able to
participate and take more responsibility for their health outcomes [10]. The interactive
environment provided by SM can help not only to consolidate knowledge that could
have been acquired from traditional sources and websites, but also provides a more
informal and user-friendly mechanism for information transmission, expanding the
chances of obtaining further knowledge. Such improvements in patients’ knowledge
and empowerment are therefore reflected in a new patient-HCP relationship.
Therefore, it is possible that SM is providing more opportunities for patients to learn,
especially to gain first-hand experiences and opinions from peers, which can also
support better engagement with HCPs. Additionally, the study has shown that patients
were not only resorting to online peer interactions to supplement information from
HCPs as shown in the literature [18], but also they were preparing themselves prior to
clinical consultations. For this reason, the findings substantiate a prediction made in
2003 that one of the key features of the future patient would be to bring a list of
questions to consultations [30].
Irrespective of how and when patients were seeking health-related information on SM
platforms, the availability of SM and their online activities have transformed their
health-related behaviour as demonstrated in this study. Online peer interactions
increase patients’ health-related knowledge [15] because patients share both relevant
health information and their own experiential stories [31]. Such increased knowledge
has been conducive to patient empowerment [11], [12], [32], which is then reflected in
patients’ ability to better articulate doubts and concerns [33] and to actively
participate in the decision-making process, particularly treatment choices. The
findings corroborate previous studies that have reported improved patient-HCP
communication when patients actively participate in online
discussions [11], [32], [33]. This study also revealed that patients believed the
improvements in patient-HCP relationship were due to patient empowerment and the
higher regard from HCPs towards informed patients. This study, however, did not
investigate if patients with a relatively good relationship with their HCPs would be the
ones to perceive the most improvement. Therefore future studies should address this
point.
This study highlighted that despite the health information accessed online and the
increasing online discussions among patients about health-related matters, HCPs
remained a trusted source to validate information. This is in line with studies reporting
that most patients or carers relay the information found online with their doctors [34].
Such approach seems to be an important component of the improved communication
previously discussed and a vital element for patients’ participation in decisionmaking. It has been found that peer-to-peer online discussions provide patients with
useful quality information [35] and by discussing this information with their clinicians
patients were asserting themselves during consultations and influencing treatment
decisions. Although this active role in imparting their own information can be
interpreted as a sign of patients’ concern that HCPs may not be aware of the latest
treatment breakthroughs [33], it is most probable that patients are increasingly taking
responsibility for their own health.
Interestingly, participants’ perceptions of improved relationships with HCPs
contrasted with most of them reporting overt or tacit HCP opposition to their online
health-related activities. HCPs negatively reacting to patients presenting online
information during consultations have been reported previously [29]. There may be
several reasons explaining this behaviour. For example, it is known that HCPs
struggle between paternalism and patient autonomy as they see their expertise and
judgment undermined by online informed patients [36]. HCPs who may feel
threatened in their expertise may react negatively during consultations with patients
who bring online content [17], [18]. Other reasons that may lead HCPs to express
opposition include concern about misleading health information, improper use of
health services (e.g. delayed visits), incorrect disease self-management [37], and
limited time [38]. Regardless of the underlying reasons, HCPs’ resistance to patients’
use of SM for health-related purposes was found to disempower patients, as also
reported by other researchers [18]. Additionally, HCPs should be mindful that their
opposition can lead to patients not only getting a second opinion, but even to change
their healthcare provider [15], [18]. As SM use might represent an important element
in the evolving nature of the patient-HCP relationship [39], it is thus suggested that
HCPs should move to information exchange (dialogue) rather than transfer [40],
favouring a patient-centred interaction involving collaboration in obtaining and
analysing the information [41]. As a result, patients’ contribution would be
acknowledged strengthening their relationship with their HCP.
Lastly, patients’ use of SM may impact healthcare services usage. This finding
contrasts with a previous research reporting that Internet use by patients had no
impact on healthcare services usage [42]. One explanation for this difference could be
due to the interactive nature of SM having a more pronounced effect on patients than
the use of regular websites and emails. Nevertheless, it is important to emphasize that
the findings presented here prevent the establishment of a trend as it pointed to both
directions: increased and decreased use of healthcare services. While some
participants reported decreasing use of health services, others reported that peer
interaction and more knowledge led them to demand more health procedures (e.g.
laboratory tests).
There are some study limitations. Firstly, all participants were recruited from the
Sydney metropolitan area, restricting the transferability of findings to other
populations. Secondly, group heterogeneity in demographic factors (e.g. age) and
diseases states might have impacted the way experiences and usage were discussed.
Thirdly, although our focus was on SM platforms, some participants occasionally
reported on their online activities on websites. Finally, as all findings were selfreported, they may have been influenced by recollection bias, social desirability and
focus group dynamic.
4.1. Conclusions
SM can assist in empowering patients primarily through increased knowledge, leading
to a more engaged patient during HCP consultations, willing to participate in health
and treatment decision-making processes. Despite reporting that better
communication improved the patient-HCP relationship, patients still experienced HCP
opposition to their online health-related activities. Nevertheless, HCPs were trusted to
ultimately validate health information obtained online.
4.2. Practice implications
Peer interactions on SM are already shaping how patients experience healthcare
services and its impact may increase as more and more people start to use SM for
health-related purposes. HCPs should be prepared for the new SM savvy patient.
Although genuine concerns exist regarding patients’ use of SM for health-related
purposes, HCPs cannot alienate themselves from this increasing activity and should
consider information brought to them during consultations.
Conflicts of interest
None.
I confirm that all participants’ personal identifiers have been removed or disguised so
the persons described are not identifiable and cannot be identified through the details
of the narrative.
Acknowledgements
The authors would like to thank all patients who participated in this study providing
their valuable experiences and opinions.
This study was partially funded by a grant awarded to Arcelio Benetoli for
Professional Innovation offered by the Young Pharmacist Group (YPG) –
International Pharmaceutical Federation (FIP) and FIP Foundation for Education and
Research at the 75th FIP World Congress of Pharmacy and Pharmaceutical Sciences.
Dusseldorf, Germany 29 September – 3 October 2015.
Arcelio also holds a scholarship from the Brazilian Government/National Council for
Scientific and Technological Development (CNPq) “Science Without Borders”
Program.
Appendix A. Supplementary data
The following are Supplementary data to this article: Download Word document
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https://doi.org/10.1016/j.pec.2017.08.015
SOURCE #2
Social Media as a Tool to Increase the Impact of Public
Health Research
Abstract
Translate
Roughly 69% of US adults use at least one kind of social media, with similar rates across racial and
ethnic groups and rates near 90% for adults younger than 30 years.1 Professional organizations,
public health agencies (e.g., the Centers for Disease Control and Prevention [CDC] and the World
Health Organization), and hospitals routinely use social media for science and health messaging.
Disseminate Public Health Research Posting links to scientific articles or media pieces on social
media can expand readership to a wider audience; for example, three tweets about a Cochrane
review increased hits to its webpage threefold, and readers linking to the Web page via Twitter spent
threefold more time on the page than those arriving from other sources.3 Another study comparing
views of two journal articles and a blog post summarizing the articles showed that the blog post was
viewed approximately 30 000 times, which equated to more than 10 times as many views as either
journal article.4 Although these findings are impressive, the reach of work shared on social media
will depend on the size of the sharer's audience (i.e., number of followers). Influence Policy Social
media provides a way to share evidence for or against health policies with the public, policymakers,
and other key stakeholders. Because politicians are motivated to please their constituents, using
social media to educate constituents about proposed policies and encouraging them to contact
political representatives to voice opinions can affect politicians' actions. Aid Public Health Research
Social media can be used for numerous research purposes, including surveillance activities and
behavioral interventions.6,7 Given social media's ubiquitous use, lack of geographic barriers, and
equal representation of traditionally underserved populations, study recruitment through social media
has the potential to produce more representative study samples.
Less
Full Text
Translate
The traditional methods that public health researchers use to communicate their work, including
conference presentations and journal articles, have limited reach. Professional conferences are not
attended by the public, and few scientific papers receive mass media attention. Furthermore, not all
presentations and journal articles will be of interest to the media, and, among those that are, some
control over the message can be lost depending on how journalists frame the work. Social media, by
contrast, allows public health researchers to both shape messages and disseminate their work to
any audience they choose to build. Social media posts can also complement media coverage by
assisting in the dissemination of press releases and providing forums for discussion. To the extent
that public health researchers effectively and efficiently leverage social media, it provides an
unprecedented opportunity to directly reach the public, shape public discourse, and affect policy.
Social media refers to online platforms that allow users to generate content, exchange information,
and communicate with one another. Popular platforms include Twitter, Facebook, Instagram,
Snapchat, and YouTube. Blogs, which allow for longer-form content, are another form of social
media. Roughly 69% of US adults use at least one kind of social media, with similar rates across
racial and ethnic groups and rates near 90% for adults younger than 30 years.1 Professional
organizations, public health agencies (e.g., the Centers for Disease Control and Prevention [CDC]
and the World Health Organization), and hospitals routinely use social media for science and health
messaging. All major news outlets and many local news outlets also use social media, providing
additional dissemination portals and ways to combine news and events with the capabilities of
smartphones. The US President and almost all members of Congress use social media, presenting
opportunities to interface with legislators.
Researchers have been slower to adopt social media for professional use. One study revealed that
just 47% of US scientists surveyed had ever used social media to discuss their work.2 Although
further research is needed to explore how public health researchers use social media and to
determine the extent to which it is used to engage the public versus professionals, public health
researchers have much to gain from disseminating their work on social media. Here we describe five
such benefits. We also developed a primer to guide public health researchers in the use of popular
social media platforms (see the appendix, available as a supplement to the online version ofthis
article at http://www.ajph.org).
BENEFITS OF A SOCIAL MEDIA PRESENCE
The benefits described subsequently are not an exhaustive list, but do represent the breadth of
areas in which social media can increase the impact of public health research.
Disseminate Public Health Research
Posting links to scientific articles or media pieces on social media can expand readership to a wider
audience; for example, three tweets about a Cochrane review increased hits to its webpage
threefold, and readers linking to the Web page via Twitter spent threefold more time on the page
than those arriving from other sources.3 Another study comparing views oftwo journal articles and a
blog post summarizing the articles showed that the blog post was viewed approximately 30 000
times, which equated to more than 10 times as many views as either journal article.4 Although these
findings are impressive, the reach of work shared on social media will depend on the size of the
sharer's audience (i.e., number of followers). If few people follow a social media account, reach may
be limited. However, once a follower shares information, that follower's audience can share it with
others, expanding reach exponentially. Building an audience takes some work (see the appendix)
but can pay big dividends.
Combat Misinformation
More than 70% of Internet users say that they look for health information online5; unfortunately, such
searches often result in misinformation. Dr. Oz, lauded as "America's doctor," has millions of Twitter
followers despite being widely criticized for making unsubstantiated health claims. Similarly, Dr.
Mercola, another physician, has more than a million followers on Facebook despite being accused of
false claims by the US Food and Drug Administration and the Federal Trade Commission. An
increased presence of public health experts on social media could increase the availability of
accurate online health information, which might offset the impact of individuals making false claims
and support fact checking efforts (e.g., @factcheckdotorg).
Influence Poiicy
Social media provides a way to share evidence for or against health policies with the public,
policymakers, and other key stakeholders. Because politicians are motivated to please their
constituents, using social media to educate constituents about proposed policies and encouraging
them to contact political representatives to voice opinions can affect politicians' actions. The
president's enormous Twitter following and use of Twitter to communicate directly with the public
suggest that social media is increasingly relevant to discussions of policy and politics both in the
United States and abroad.
Aid Public Health Research
Social media can be used for numerous research purposes, including surveillance activities and
behavioral interventions.6,7 Given social media's ubiquitous use, lack of geographic barriers, and
equal representation of traditionally underserved populations, study recruitment through social media
has the potential to produce more representative study samples. Furthermore, patients increasingly
use social media to connect with each other in public and private forums. Conversations in these
online patient communities often center on health behaviors and probably provide more nuanced
and realistic information about health-related attitudes and beliefs than traditional survey measures.
Enhance Professional Development
The increasing presence of academics, clinicians, industry professionals, public health departments,
and health care systems on social media provides many opportunities for professional connection
outside traditional settings. Several public health chats on Twitter allow public health researchers to
engage with the public, including CDC chats and #hcsm (health care social media; see the
appendix). In addition, social media-based metrics are becoming part of professional evaluations at
many institutions, including the Mayo Clinic. Tools are available to evaluate social media impact,
including Altmetric, which measures a study's total mentions in media, social media, and blogs.
Similarly, ImpactStory.org compiles information for a researcher's total body of work. These tools are
likely to become important features of promotion materials in the future.
CAUTIONS REGARDING SOCIAL MEDIA USE
Social media posts are generally public and create searchable records, so transgressed boundaries
can have serious consequences, including termination of employment. Separating professional and
private social media accounts, treating online interactions the same as other public interactions, and
being informed about institutional policies (e.g., the Hatch Act forfederal employees) can prevent
complications. Many institutions have media or public affairs offices that can also provide advice.
Even with highly professional feeds, the public nature of social media means that users may receive
unwanted comments. In such cases, it can be helpful to disengage and use platform features to
block or report inappropriate users or comments. A final consideration is time management:
checking Twitter once a day is a nominal time commitment, but hosting a blog or managing multiple
feeds may require professional training and assistance (see the appendix for additional information
on time management).
CONCLUSIONS
Social media can be an important tool for public health researchers to disseminate their work, affect
policy, conduct research, and engage in professional networking. Although social media use is not
yet ubiquitous among public health researchers, it is among the general public and therefore
provides an enormous opportunity for science communication. Developing a social media presence
requires some time investment; however, the investment is likely to benefit the user, the field of
public health, and the public at large. Â1PIİ
Jessica Y. Breland, PhD
Lisa M. Quintiliani, PhD
Kristin L. Schneider, PhD
Christine N. May, PhD
Sherry Pagoto, PhD
CONTRIBUTORS
J. Y. Breland, L. M. Quintiliani, K. L. Schneider, and S. Pagoto contributed to the conceptualization,
writing, and editing of the editorial. C. N. May contributed to the writing and editing of the editorial.
ACKNOWLEDGMENTS
Jessica Y. Breland is supported by a Department of Veterans Affairs Health Services Research &
Development Career Development Award (CDA 15-257) at the VA Palo Alto. Sherry Pagoto is
supported by grant K24HL124366 from the National Heart, Lung, and Blood Institute. At the time of
writing, Christine N. May was supported by grant R25CA172009 from the National Cancer Institute.
We thank Jazmin Reyes-Portillo and Vivian Yeh for their feedback and Elon Hailu for her help in
editing the editorial.
Note. The views expressed herein are those of the authors and do not necessarily represent the
views of the Department ofVeterans Affairs or the United States government.
Sidebar
Correspondence should be sent to Jessica Y. Breland, Center for Innovation to Implementation, VA
Palo Alto Health Care System, 795 Willow Rd (MPD-152), Menlo Park, CA 94025 (email:jessica.breland@va.gov). Reprints can be ordered at http://www.ajph.org by clicking the
"Reprints" link.
This editorial was accepted August 16, 2017.
doi: 10.2105/AJPH.2017.304098
References
REFERENCES
1. Pew Research Center. Social media fact sheet. Available at: http://www. pewinternet.org/factsheet/social-media. Accessed September 8, 2017.
2. Rainie L, Funk C, Anderson M. How scientists engage the public. Available at:
http://www.pewinternet.org/2015/02/ 15/how-scientists-engage-public. Accessed September 8, 2017.
3. Jayaram M, Moran L, Adams C. Twittering on about mental health: is it worth the effort? Evid
Based Ment Health. 2017;20(1):1-3.
4. Hoang JK, McCall J, Dixon AF, Fitzgerald RT, Gaillard F. Using social media to share your
radiology research: how effective is a blog post? J Am Coll Radiol. 2015;12(7):760-765.
5. Fox S, Duggan M. Health online 2013. Available at: http://www.pewinternet.
org/2013/01/15/health-online-2013. Accessed September 8, 2017.
6. NaslundJA, Kim SJ, Aschbrenner KA, et al. Systematic review of social media interventions for
smoking cessation. Addict Behav. 2017;73:81-93.
7. Sinnenberg L, Buttenheim AM, Padrez K, Mancheno C, Ungar L, Merchant RM. Twitter as a tool
for health research: a systematic review. AmJPublicHealth. 2017; 107(1):e1 -e8.
Word count: 1610
Copyright American Public Health Association Dec 2017
APA
Breland, J., Quintiliani, L., Schneider, K., May, C., & Pagoto, S. (2017). Social Media as a Tool to
Increase the Impact of Public Health Research. American Journal of Public Health, 107(12),
1890–1891. https://doi.org/10.2105/AJPH.2017.304098
SOURCE #3
Social Media, Surgeons, and the Internet: An Era or an
Error?
Abstract
Translate
According to the National Research Corporation, 1 in 5 Americans use social media sites to obtain
healthcare information. Patients can easily access information on medical conditions and medical
professionals; however physicians may not be aware of the nature and impact of this information. All
physicians must learn to use the Internet to their advantage and be acutely aware of the
disadvantages. Surgeons are in a unique position because, unlike in the primary care setting, less
time is spent developing a long-term relationship with the patient. In this literature review, we discuss
the impact of the Internet, social networking websites, and physician rating websites and make
recommendations for surgeons about managing digital identity and maintaining professionalism.
[PUBLICATION ABSTRACT]
Full Text
Translate
Headnote
According to the National Research Corporation, 1 in 5 Americans use social media sites to obtain
healthcare information. Patients can easily access information on medical conditions and medical
professionals; however physicians may not be aware of the nature and impact of this information. All
physicians must learn to use the Internet to their advantage and be acutely aware of the
disadvantages. Surgeons are in a unique position because, unlike in the primary care setting, less
time is spent developing a long-term relationship with the patient. In this literature review, we discuss
the impact of the Internet, social networking websites, and physician rating websites and make
recommendations for surgeons about managing digital identity and maintaining professionalism.
PATIENTS USE THE INTERNET to ''Google'' a physician with the same ease one ''Googles'' a local
eatery. In fact, according to National Research Corporation, 1 in 5 Americans use social media sites
to obtain healthcare information.1 Most physicians accept the fact that patients search them online
before committing to an initial visit, but do physicians know what information their patients' searches
reveal? Information on education, training, board certification, publications, disciplinary actions, and
malpractice claims are frequently available online.2, 3 Personal information, such as address,
mortgage, marriage records, court filings, and social networking profiles can also be obtained online,
which may have obvious professional ramifications when it comes to maintaining a reputable
practice.4-6 In an era where social media and the Internet are king, physicians must learn to use the
Internet to their advantage and be acutely aware of the disadvantages.
The question regarding extent of professional information to share is not a new issue, nor is it unique
to social media or the Internet. The first bill supporting the public's demand for more information on
health care providers was introduced in response to 1993 legislation by the Massachusetts Teachers
Association's insistence that the Massachusetts Rate Setting Commission obtain detailed facts
about physicians, and make it accessible to the public. The Massachusetts Medical Society, in
collaboration with the Board of Registration in Medicine, fiercely lobbied for changes regarding the
extent of information the public should be allowed to view. The bill addressing physician profiles was
subsequently passed in 1996. This was quickly followed by similar laws in other states, and in 2000,
guidelines from a special committee of the Federation of State Medical Boards were published
detailing what is acceptable to include in a publicly accessible state medical board physician profile.7
Now, 15 years later, the debate over personal versus pertinent data appropriate for public review
remains relevant to physicians, but the issue has spiraled from a state-wide level right into
cyberspace. Multiple studies have examined issues surrounding the availability of personal and
private information on the Internet in relationship to a physician's professional integrity, but more
research is needed to address reasonable guidelines for physician Internet presence and
appropriate social media discourse.
In 2010, Mostaghmim and colleagues6 randomly selected 250 internal medicine physicians from the
Massachusetts Board of Registration in Medicine and performed Google searches to characterize
professional and personal information that is available on the Internet. They found that 93.6 per cent
had professional information and 32.4 per cent had personal information searchable online. Rating
sites existed for 86.4 per cent of the providers and three providers had five or more reviews on a
single site. The most commonly encountered personal information included social networking sites,
hobbies, charitable and political donations, and family information. They concluded that physicians
should monitor the content that is available online, because much of the personal information is not
typically considered appropriate to share with patients (i.e., religion, sexual orientation, political
views) and may undermine the doctor-patient relationship.
Although there are inherent concerns with professional boundaries surrounding physicians' presence
in cyber social circles, a lack of Internet presence should perhaps be of equal concern. Failure to
have an easily accessible ''digital identity'' may pose a problem largely due to the public's
expectation of ''digital connectedness''. In a 2008 article, Gorrindo and Groves4 recommend creating
web pages with contact information, hours of operation, services, etc. By having factual, neutral, or
positive data easily accessible, patients may be less likely to search further and find negative or
private information. The authors further recommend using privacy settings for social networking
sites, responding to defamatory comments, monitoring digital identity, and addressing concerns with
patients searching for personal information. Additionally, many authors advise physicians to take a
proactive approach to fostering their Internet images by creating an interactive website with
professional background information highlighting credentials, practice philosophy, and patient
testimonial.4, 8-11
Physician rating websites are increasingly common and comprise a sizeable share of a physician's
digital presence, providing patient-initiated appraisals of a physician and/or practice. Patients use
these websites for various reasons that include learning more about other patients' experiences,
making decisions to establish or continue a relationship with a particular physician, or to make
comments regarding their interaction with a physician; however, the accuracy of statements on these
websites is unverified. Furthermore, patient ratings are not a measure of clinical skill or good medical
practice and patients' assessments, based mostly on interpersonal interaction and/or perceived
physician ability, may not reflect quality of care, clinical knowledge, or clinical judgment.12, 13 Even
a glowing comment may mislead a patient into overestimating a physician's expertise or skill.
Although comments of praise are not expected to negatively impact one's practice, they may provide
patients with an unfounded sense of security regarding skill sets most patients are not qualified to
evaluate. In 2010, Reimann and Strech13 conducted a study evaluating the use of 13
comprehensively identified patient experience and satisfaction elements in American and German
physician rating websites. The authors found only five to six of 13 elements were evaluated in the
three most commonly used American physician rating websites. Unfortunately, physician rating
websites are presently ungoverned; however they are an unquestionably powerful means by which
patients can communicate about their experience. In fact, extremely unfavorable comments written
in such sites have the great potential to damage a physician's practice indefinitely.
Although it is important for patients to have a voice, and their satisfaction with physicians assessed,
posting anonymous comments to an unregulated website does not offer a patient any means of
constructive recourse, or an opportunity for proper investigation of their claim. Physicians with
negligent patient care practices should not be shielded from disciplinary action, but physicians, like
anyone else, deserve to have appropriately sanctioned organizations decide if a claim is justified. In
2007, one author described her experience with a bad rating after a patient used a rating website to
find her office location, and found a vehemently negative review.14 The patient had transferred from
her previous practice and told her, ''If I didn't know you, I might have cancelled my appointment.''
The doctor e-mailed the site administrators, asking for a retraction. They edited the reviewer's
comments, but the numerical ratings were not changed. Anonymous ratings may be based on a
single visit, are subjective, and may not be representative of a physician's practice.15 Physicians
have little ability to respond to complaints due to privacy issues. Additionally, it would be difficult to
create a strong legal case for defamation, and in an effort to defend one's reputation the lawsuit may
result in further tarnishing. Although the majority of ratings are favorable,many physicians are
concerned and frustrated by negative ratings because they have little control or recourse.16 The
United States Supreme Court protects anonymous comments posted online as free speech. Legal
action against the websites is also challenging due to Section 230 of the Communications Decency
Act of 1996,17 which protects a website operator from being held responsible for publishing content
written by someone else, even if that content is defamatory. If individuals can be identified, they may
be liable for posting comments with intent to harass or defame, however many cases fail to meet the
legal standard for libel15, 16, 18, 19 although repeated postings by an individual may constitute
harassment or stalking via an electronic medium.16, 17 Interestingly, Canadian law is different, and
a Canadian physician may have cause for a libel lawsuit against both the reviewer and the
publishing website.16, 20 The law regarding defamatory libel in the Criminal Code of Canada holds
the publisher of comments responsible for their content.19
Fortunately, the American Medical Association (AMA) has taken an interest in anonymous Internet
evaluations of physicians and has written recommendations regarding the issue.21 They oppose the
publication of inaccurate, unreliable, or meaningless healthcare data, and advocate that physicians
be allowed to review any information before its online publication. The AMA also encourages such
websites to establish safeguards against false or defamatory statements. However, because such
safeguards are not presently in place, various strategies can be used to manage negative web
content. One option is to request removal of negative comments by the website administrator, but
such a request may not be honored. Even if the website removes the comment, the damage may
already be done given the indelible footprint Internet content is designed to leave. Another option is
to hire legal counsel, but options for recourse may be limited. A third option is to use companies
dedicated to helping professionals build or enhance a favorable online reputation, like Reputation
Defender.8 A fourth option is responding directly to negative postings on a physician rating website.
However, it is difficult to know if responding to comments using such websites as one's vehicle to do
so is valuable, as it may only lend credibility to websites that allow the posting of subjective, and
possibly inaccurate information; the harm is potentially misleading earnest patients seeking valid
information about their physicians. In their 2010 article, Santry and colleagues11 raise interesting
points regarding use of social media specifically in the surgical practice. They comment that e-mail
and texting patients may improve compliance and help maintain relationships, but raises questions
of liability, compensation, and lack of interaction. For example, intraoperative ''Tweeting'' can keep a
patients' family updated in real time, but can be distracting and may violate patient privacy.
Researchers from Vanderbilt University Medical Center's Department of Surgery investigated use of
Facebook by residents and faculty.22 They found that 64 per cent of their 88 residents (n456) and
22 per cent of 127 faculty members (n428) had Facebook pages. Of those with profiles, 50 per cent
were accessible to the public. Of the 50 per cent publicly accessible pages, 31 per cent had
comments related to work and 14 per cent referenced specific patient encounters or care
information. The authors caution that use of social media websites must be done with care to uphold
professional integrity and maintain patient privacy. Physicians must consider the benefits and
potential harms of self-disclosure using online forums and social-networking sites.23-26 Use of
social-networking sites and blogs is more commonplace with younger physicians who are still in the
nascent phases of carving out a professional identity. In this regard, it is not surprising that the AMA
Resident and Fellow Section and the American College of Surgeons Resident and Associate Society
have been principal forces directing their respective organizations' attention to the issue. More
established clinicians frequently take the role of mentor and ethical compass in navigating rules of
professionalism, however their own inexperience with Internet-based social forums may pose
additional challenges to the less established physician seeking guidance in establishing a 21st
century professional career.4, 24
Although most agree that not everything read on the web should be internalized as gospel truth, it is
human nature to be curious. This curiosity also extends to the patients' desire to learn about their
conditions as well as their clinicians. Like a sommelier with an educated palate, physicians are
trained to read with a skeptical eye and recognize evidence-based research against a background of
myth, anecdote, and opinion. The patient of the past approached the initial encounter seeking both
medical command and technical competence. Today's ''Web 2.0'' savvy patient enters the exam
room armed with questions and answers gleaned from ''surfing the net,'' but lacking the ability to
discern what is valid. Thus, surgeons find themselves entering a novel physician-patient relationship.
Although the Internet can be an excellent educational tool for both surgeons and patients, some
information may be unreliable, outdated, or open to misinterpretation. Reflecting on this point, Santry
et al. pose a pertinent question, ''What is the surgeon's role for patients who rely more on the
Internet than on professional experience and judgment to dictate care?''11
Surgeons are in a unique position because, unlike in the primary care setting, less time is spent
developing a long-term relationship with the patient. In fact, surgical patients often take a leap of
faith when urgent or emergent surgery is needed. In a setting where trust is established in an
expedited manner so may be a patient's interest in using social media and the Internet to discuss
their dissatisfaction with a surgeon with whom a weak rapport has been established. Surgeons need
to actively participate in building their Internet presence to have some control over the media content
displayed when an Internet search is performed using their name or practice. Although it is difficult to
prevent negative media content, it is possible to promote and initiate positive media content about
one's practice. Benefits of the Internet include a wide audience and an inexpensive mode of
advertisement; however, great care must be taken to avoid blurring the professional relationship
between a patient and surgeon. Although voluntarily posting personal information on the Internet and
social networking sites seems contrary to the historical notion of ''professional distance,'' for younger
surgeons attempting to establish a bustling practice, no Internet presence may be as detrimental as
a negative review. Patients can shop for a doctor based on ratings and Internet marketing, pushing
surgeons to monitor their online images and create websites to attract new clients.11 Experienced
surgeons often rely on referrals from established primary care physicians in the community, but less
well-known surgeons may have to rely more on establishing credibility using the Internet.
Concepts regarding integrating social media into surgical patient care were discussed at the 96th
Annual Clinical Congress of the ACS in a workshop forum so the topic is certainly recognized as
important. In a 2011 research study, Chretien et al.27 examined the Twitter pages of 260 users who
self-identified as physicians. Of the 191 subjects (73.5%) who identified their specialty, surgeons
were the most represented group, accounting for 20.4 per cent (n 4 39). As more surgeons explore
web-based venues for connecting with patients and colleagues, the ACS may need to define new
rules for ethical behavior online. Unfortunately, for now, the right balance between traditional, officebased patient-surgeon communication and the burgeoning need to compete with Internet technology
to maintain a viable surgical practice remains a pressing, unanswered question.
Ultimately, groups like the AMA, the ACS, and others need to continue to address acceptable means
of integrating cyber technology into one's practice. Healthcare has changed dramatically over the
years with patients not only becoming more informed about their needs but who is a qualified
provider. In a patient's journey as healthcare consumer, the Internet is often used to obtain more
information about their condition as well as the physicians who are candidates to serve as their
provider. Unfortunately, the quantity of publicly searchable information may be far greater than some
surgeons realize. Worthy of equal concern is the abundance of physician rating websites and the
trust many patients place in the largely subjective, and certainly unsubstantiated content found within
them. Almost 20 years ago, the Massachusetts Medical Society recognized the need to determine
the impact of impending legislative changes on its members. By their proactive approach, physicians
gained a voice in resolving the balance of physician privacy, professional integrity, and public
demand for more access to physician profile detail. Faced with the new challenges posed by
technological evolution, medical societies must again assume a presiding role in this new
discussion. In addition to increasing physician awareness about monitoring and maintaining a
credible Internet presence, lobbying for regulations of physician rating websites is paramount.
References
REFERENCES
1. National Research Corporation. 1 in 5 Americans use social media for health care information.
Lincoln, NE. Available at: http://hcmg.nationalresearch.com/public/News.aspx?ID49. Accessed
February 21, 2011.
2. Guglielmo WJ. Shaping your profile on the web. Med Econ 2001;78:28-30, 35-6.
3. Hallam K. Physicians caught in the web. Mod Healthc 2000; 30:30-2.
4. Gorrindo T, Groves JE. Web searching for information about physicians. JAMA 2008;300:213-5.
5. Thompson LA, Dawson K, Ferdig R, et al. The intersection of online social networking with
medical professionalism. J Gen Intern Med 2008;23:954-7.
6. Mostaghmim A, Crotty BH, Landon BE. The availability and nature of physician information on the
internet. J Gen Intern Med 2010;25:1152-6.
7. Federation of State Medical Boards. Report of the Special Committee on Physician Profiling.
Available at: http://www.fsmb.org/ pdf/2000_grpol_Physician_Profiling.pdf. Accessed May 21, 2011.
8. Aungst H. Patients say the darnedest things: you can't stop online ratings, but you can stop
fretting about them. Med Econ 2008;85:27-9.
9. Pasternak A, Scherger JE. Online reviews of physicians: what are your patients posting about
you? Fam Pract Manag 2009;16: 9-11.
10. Peregrin T. Time to tweet: social networking for surgeons. Bull Am Coll Surg 2011;96:46-8.
11. Santry HP, Dehmer JJ, Nelson JS, Raman SR. Modern surgical communication and the practice
of surgery. Bull Am Coll Surg 2010;95:33-9.
12. Cassel C. No stars for satisfaction ratings. Mod Healthc 2008;38:22.
13. Reimann S, Strech D. The representation of patient experience and satisfaction in physician
rating sites. A criteria-based analysis of English- and German-language sites. BMC Health Serv Res
2010;10:332.
14. Meyer C. My web rating: oh no! Med Econ 2007;84:51-2, 55.
15. Rice B. Trashed on the web? Now what? Med Econ 2007; 84:32-4, 36-7.
16. MacKay B. RateMDs.com nets ire of Canadian physicians. CMAJ 2007;176:754.
17. Federal Communications Commission. Title V Telecommunications Act 47 U.S.C. § 230.
Washington, D.C. Available at: http://transition.fcc.gov/telecom.html. Accessed May 21, 2011.
18. Segal J. The role of the internet in doctor performance rating. Pain Physician 2009;12:659-64.
19. Segal J, Sacopulos MJ, Rivera DJ. Legal remedies for online defamation of physicians. J Leg
Med 2009;30:349-88.
20. Minister of Justice of Canada. Criminal code of Canada R.S.C. 1985, c. C-46: Part VIII offences
against the person and reputation, defamatory libel. Available at: http://laws-lois.justice. gc.ca.
Accessed May 1, 2011.
21. American Medical Association. Resolution 822, I-09: anonymous cyberspace evaluations of
physicians. Annual Meeting of the Board of Trustees 2010;91-9.
22. Landman MP, Shelton J, Kauffmann RM, Dattilo JB. Guidelines for maintaining a professional
compass in the era of social networking. J Surg Educ 2010;67:381-6.
23. Chin JJ. Medical professionalism in the internet age. Annals Academy of Medicine 2010;39:3457.
24. Guseh JS, Brendel RW, Brendel DJ. Medical professionalism in the age of online social
networking. J Med Ethics 2009;35:584-6.
25. Jain SH. Practicing medicine in the age of Facebook. N Engl J Med 2009;361:649-51.
26. Jain S. Googling ourselves - what physicians can learn from online rating sites. N Engl J Med
2010;362:6-7.
27. Chretien KC, Azar J, Kind T. Research letter: physicians on twitter. JAMA 2011;305:566-8.
AuthorAffiliation
MICHELLE C. AZU, M.D.,*[dagger] ELIZABETH J. LILLEY, M.P.H.,[dagger] APARNA H. KOLLI,
M.D., M.S.*[dagger]
From the *Cancer Institute of New Jersey, New Brunswick, New Jersey and the [dagger]University of
Medicine and Dentistry of New Jersey, New Brunswick, New Jersey
Address correspondence and reprint requests to Michelle Azu, M.D., Cancer Institute of New Jersey,
195 Little Albany Street, New Brunswick, NJ 08903. E-mail: azumc@umdnj.edu.
Word count: 3236
Copyright Southeastern Surgical Congress May 2012
APA
Azu, M., Lilley, E., & Kolli, A. (2012). Social Media, Surgeons, and the Internet: An Era or an
Error? The American Surgeon, 78(5), 555–558. Retrieved from
http://search.proquest.com/docview/1018553334/
SOURCE #4
HEALTHCARE PROFESSIONALS ENCOUNTER
HURDLES WHEN FACED WITH NEGATIVE
REVIEWS ON SOCIAL MEDIA
Abstract
Translate
[...]through nothing more than the use of this process, the aforementioned client was able to restore
her rating back to five stars. Positive reviews further serve the purpose of making a negative review
seem like an isolated incident or simply the product of an unreasonable patient, rather than evidence
of a practitioner's substandard care. Because healthcare services can be of a more sensitive and
personal nature than those of restaurants or auto mechanics, special care should be taken in
encouraging patients to leave reviews. By way of example, a fertility clinic in California required its
patients to sign a contract stating that the patient would not leave negative reviews regarding the
practice.30 Despite being located in California, the clinic provided nationwide egg donation services,
and the validity of the contract clause was challenged by the state of New Jersey, which deemed the
clause to be in violation of the New Jersey Consumer Fraud Act and thus unenforceable.31 In a
separate case, a dentist attempted a different and more novel approach to the issue by requiring her
patients to sign an agreement prior to treatment stating that they would refrain from publishing
commentary related to the dentist's practice and, if they did choose to publish such commentary, that
the intellectual property rights and copyrights to the published content would belong to the dentist.32
A lawsuit ensued when one of the dentist's patients posted negative reviews in spite of the
agreement, and the agreement was struck down by the court, which cited a misuse of copyright law
and a violation of dentists' ethics among the reasons why the agreement was legally invalid.33
Further undermining any attempt to limit negative reviews through contract, President Obama
subsequently signed into law the Consumer Review Fairness Act, which imposed a blanket invalidity
to all contractual terms going forward that seek to suppress the posting of negative reviews on the
internet.34 Finally, clinicians should be extremely wary of "reputation management firms," as such
firms will often take it upon themselves to violate the terms of service of internet review sites by
submitting fake reviews. [...]there is no guarantee that a demand letter will be effective.
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