Expert Opinion

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The members of the AACAP Ethics Committee have considerable expertise in a wide range of issues relevant to the practice of child and adolescent psychiatry in the clinical, administrative and scholarly activity arenas. They are happy to provide information and perspectives on the various ethical issues that occur in child and adolescent psychiatric practice. Click here to e-mail the committee with a brief overview of the information being requested and contact information. In addition to an individual response, the question and response will be summarized and provided on the AACAP Ethics Website in an anonymous fashion.


Member Question
While I would never consider being a Facebook friend with a patient, what are the thoughts about LinkedIn?

Ethics Committee Responses
Treatment Issues

Patient
While communication with patients is a vital aspect of care, communication outside the time and space of the treatment session risks boundary blurring and loss of the therapeutic frame. Why is the patient seeking this kind of connection? Patients may not anticipate the level of exposure and loss of confidentiality that the Linked In connection might ultimately lead to. And once information is out on the Internet, it is largely permanent.

Provider
This type of connection seems to leave the psychiatrist vulnerable and exposed regarding his or her own privacy. In addition to allowing patients' access to additional information about the physician, being connected could potentially link the patient to the psychiatrist's colleagues, friends and family who had not agreed to the relationship or to the sharing of their information with patients.

General Discussion
There may be some valid examples how LinkedIn might be helpful and used safely and successfully by certain clinicians in particular communities and practice settings. It is not as black and white or clear-cut an issue as being a Facebook friend. (Most would agree that there are many ethical issues with befriending current and former patients on Facebook). It is easy to say, "Don't do this." The fact is to not participate in social media almost requires not having any presence on the Internet. That isn't realistic, and it also isn't good for understanding patients. In some ways, it is similar to the issues that doctors and other health professionals, not just mental health professionals, deal with in small towns, rural communities, where everyone knows everyone. When there are only 50-60 people in your church, and two of those are patients, it is a very different situation than in a large city where the chances of this occurring are much smaller. The Internet has brought us closer together, creating both new risks and new opportunities.

How can we, as clinicians, understand the dangers - and potential supports - available to our patients if we never go online? This is an important part of many of our patients' lives. We need to be familiar with it and understand it; otherwise we run the risk of being like the parents of our patients who know far less about computers and the Internet than their children (our patients). For better or worse, the Internet is an integral part of the complexities of the modern patient-physician relationship. Websites such as Angie's list, the numerous physician rating websites, and even web-content belonging to people with the same name, all distract patients from the professional information we want them to have and that they are seeking. Patients are hungry to know about their physicians and they are searching the Internet for information. It's our choice to participate and our responsibility to know and manage what patients find.

What is publicly available in the context of these and other websites, whether free or for pay, is considerable. If one is on the Internet, there is a lot of information out there already. Sort of like the phone directory, only much more extensive. Some of this is readily available to anyone, such as faculty profiles that many universities offer. Some of it is less readily available, such as information on Facebook or LinkedIn where one may have "some" degree of control over who sees it. And some may only be available for a fee, such as services that search for individuals using the Internet. Also, businesses and other organizations may have Facebook pages or create other online communities that you may be part of, and your information may be accessible via those routes.

Clinicians should learn about and understand the potential perils of submitting profiles to these professional online networks, especially the fact that they include individuals outside of psychiatry and medicine who may be patients, and who have the ability to pass along to unidentified others information that could be inappropriate to have in the general, public domain. A practical approach regarding online professional networking might be, "What kind of information is appropriate and ethical for child and adolescent psychiatrists to share online if and when they decide to use services such as LinkedIn?" For example, one could place information on LinkedIn which is professional data (e.g. professional biography, credentials) and already available on the Internet. Physicians have used blogs, twitter accounts, and LinkedIn accounts to promote their professional identity and work. However, it is essential to consider and protect the exposure of personal social networking activities by utilizing privacy settings and choosing selected connections.

Social networking and Internet communication, as they become pervasive, are developing a status for much of the public with standards that have different perspectives from previous ones on communication and sharing. Many individuals do not have the same expectations, or even conceptions, of secrecy, privacy, and confidentiality that previously existed. In many ways, this is a realistic response to a world in which secrecy is largely non-existent. We should not abandon confidentiality or privilege in our professional practice; but we need to reconsider what these things now constitute both in practice and in the lives of our patients.

There are a number of guidelines and recent articles now about electronic communication and use of Internet based services. Each decision about use has to weigh the costs and benefits. The constant expansion or media and formats make hard and fast rules unworkable. There are some references listed below and a diagram that can guide thinking through the complexities of media options.

Expert Opinion Chart

S Koh, G Cattell, D Cochran, A Krasner, F Langheim, D Sasso, Toward guidelines for psychiatrists' use of electronic communication and social media, in submission to Journal of Psychiatric Practice.

AADPRT has a curriculum posted on their website with great resources and bibliography.
http://www.aadprt.org/vtodocs/professionalism_and_the_internet/AADPRT_Professionalism_and_the_Internet_Curriculum.pdf

DeJong SM, Benjamin S, Anzia JM et al. Professionalism and the Internet: What to teach and how to teach it. Academic Psychiatry 2012; 36:356-362.

Draper B, Winfield S, Luscombe G. "The Senior Psychiatrist Survey I: age and psychiatric practice." Aust N Z J Psychiatry. 1999 Oct;33(5):701-8.

Eysenbach, G. (2000). "Towards ethical guidelines for dealing with unsolicited patient emails and giving teleadvice in the absence of a pre-existing patient-physician relationship systematic review and expert survey." J Med Internet Res 2(1): E1.

Federation of State Medical Boards. Model Policy Guidelines for the Appropriate use of Social Media and Social Networking in Medical Practice.
www.fsmb.org/pdf/pub-social-media-guidelines.pdf

Frankish K, Ryan C, Harris A. Psychiatry and online social media: potential, pitfalls and ethical guidelines for psychiatrists and trainees. Australas Psychiatry. 2012 Jun;20(3):181-7.

Gabbard GO, Kassaw KA, Perez-Garcia G. "Professional boundaries in the era of the Internet." Acad Psychiatry. 2011 May-Jun;35(3):168-74.

Gabbard GO et al. Professionalism and Boundaries in Cyberspace. In: Gabbard GO, Roberts LW, Crisp-Han J,et al.,ed. Professionalism in Psychiatry. Washington, DC: American Psychiatric Publishing; 2012:59-73.

Guseh, J. S., 2nd, R. W. Brendel, et al. (2009). "Medical professionalism in the age of online social networking." J Med Ethics 35(9): 584-6.

Internet Ethics Issues (research focused, but illustrates the issues/challenges):
http://internetresearchethics.org/

Jain (2009), "Practicing Medicine in the Age of Facebook," NEJM 361(7):649-51.

Lagu T, Greysen SR (2011). "Physician, monitor thyself: professionalism and accountability in the use of social media." J Clin Ethics 22(2):187-90.

Landman M, Shelton J, Kauffmann R, Dattilo J (2010). "Guidelines for Maintaining a Professional Compass in the Era of Social Networking," J Surg Educ 67(6):381-6. Epub 2010 Nov 5.

Professional Risk Management Services, Inc. Risks Associated with Specific Internet Activities - A Guide for Psychiatrists. 2010. Available at:
TheProgram@prms.com.

Shore R, Halsey J, Shah K, Crigger BJ, Douglas SP: AMA Council on Ethical and Judicial Affairs (2011). "Report of the AMA Council on Ethical and Judicial Affairs: professionalism in the use of social media." J Clin Ethics 22(2):165-72.

Spielberg, A. R. (1999). "Online without a net: physician-patient communication by electronic mail." Am J Law Med 25(2-3): 267-95.

Thompson, L.A., K. Dawson, et al. (2008), "The Intersection of Online Social Networking with Medical Professionalism," J Gen Intern Med 23(7): 954-7.