- Email: [email protected]
Social Media and Online Communication: Clinical Urology Practice in the 21st Century
Business of Urology urologypracticejournal.com
Social Media and Online Communication: Clinical Urology Practice in the 21st Century Michael J. Ehlert*,y From the Department of Urology, William Beaumont Hospital, Royal Oak, Michigan
Abstract Introduction: Social media use by urologists is common with more than 66% reporting an active account. Most of this is for personal use or at urological conferences, although it can be a powerful tool for patient education and engagement. Patients and care givers are increasingly using online materials to search for health information, although how social media is used is still unclear. For the practicing urologist this review provides an introduction to the use, platforms and risks of social media and other online communication. Methods: Available social media platforms and their use are reviewed. The unique challenges associated with digital communication are outlined along with suggested ways to post information responsibly. Results: Users should have clear goals when engaging patients online. These may include disease education, practice updates or patient information. Social media accounts should regularly be screened for misuse or harmful comments. Patient confidentiality and professionalism should always be maintained. The widespread sharing and posting of digital content pose unique challenges and advantages for health care professionals. Maintaining the urologist reputation and that of the practice requires all content to be assumed public, even if posted on personal accounts. Conclusions: Overall the popularity of social media and online communication is increasing. The role in the physician-patient relationship is still evolving. Patient education, disease awareness and expanding the reach of a urologist practice are all possible online and with social media. Key Words: urology, social media, practice management, Internet, public relations
Attendees of any major urology meeting in the last 2 years have undoubtedly noted the explosion of social media in medicine. It is now commonplace for meeting planners to hold TweetÒ-ups, post TwitterÒ hashtags, tout pre-event abstract promotion and even maintain a social media lounge, as during the recent 2014 AUA (American Urological Association) meeting. Social media use among urologists and urology residents remains high with more than 66% and 86%, respectively, reporting some type of account.1 Aside from peer-to-peer connections and use at meetings there remains the question of how a urology practice can best use social media and online communication for patient care,
Submitted for publication July 7, 2014. * Correspondence: Medical Office Building, William Beaumont Health System, 3535 West 13 Mile Rd., Suite 438, Royal Oak, Michigan 48073 (telephone: 248-551-0803; FAX: 248-551-8107; e-mail address: michael. [email protected]). y Financial interest and/or other relationship with Michigan State Medical Society Board of Directors. 2352-0779/15/21-2/0 UROLOGY PRACTICE Ó 2015 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
clinical outreach and education. As part of the Internet and American Life Project a recent Pew Research Center poll of 3,014 adults showed that 35% had searched online for information on a health condition.2 The most common reason for seeking information was a specific disease or medical problem, followed by medical treatments or procedures (see table). Furthermore, 20% of survey respondents had consulted online heath care reviews or rankings, mostly for drugs and treatments (18%) or physicians (17%). A survey of more than 3,000 practicing physicians showed that a third recommended a smartphone or tablet app to a patient and 47% used a smartphone to show a patient photos or a video during a clinical encounter.3 Caregivers are increasingly younger and well educated, and a urology practice must provide timely, accurate digital communication to survive in a competitive environment. More importantly social medial use has eclipsed email as the number 1 online activity.4 One of 5 individuals who are 18 to 24 years old now follow at least 1 health care provider on social media,5 which emphasizes the need for urologists to maintain a presence in this digital landscape.
RESEARCH, INC.
http://dx.doi.org/10.1016/j.urpr.2014.08.005 Vol. 2, 2-6, January 2015 Published by Elsevier
Social Media and Online Communication
Most commonly searched online health topics2 Topic
% Adults
Specific disease or medical problem Certain medical treatment or procedure How to lose wt or how to control your wt Health insurance, including private insurance, Medicare or Medicaid Food safety or recalls Drug safety or recalls A drug you saw advertised Medical test results Caring for aging relative or friend Pregnancy þ childbirth How to reduce your health care costs Any other health issue
55 43 27 25 19 16 16 15 14 12 11 20
This article aims to clarify the types of social media and online communications available to the practicing urologist, act as a resource for starting out in this digital space, suggest potential uses for the online presence of your practice and outline the risks and challenges in maintaining your social media accounts. How Social Media Works Social media differs from static web pages and other digital content. It is meant to be directed by the user and not the content provider, shared among friends and others in a network, allow for rapid posting and commenting, and generally have a theme or topic that enables users to search for related material. Users design their digital experience through preferences, likes and those whom they connect with online. Mobile technology and cell phones have further expanded the reach of social media through apps. These content specific programs allow users to avoid searching or loading full web pages. Benefits to the urologist practice could be to provide a dynamic link to the practice or to disease specific content to bring in new patients. Social media may also allow you to share your expertise far beyond your local community. Whatever your goals are for entering this digital area, it is essential to know about the different online platforms and unique pitfalls of these mediums. How to Use Social Media Several social media platforms are available that enable users to connect and share information (Appendix 1). The main differences in platforms are content length and the methods of sharing or searching for information. Unlike website content social media searches are performed in each program through key words, hashtags (Twitter), groups (FacebookÒ) or topics (PinterestÒ). Patients and users may follow you after finding your profile if the content is relevant and provides information that they find helpful. The goal is to have them repost, like, share or recommend your postings to their contacts.
3
Tagging your posts with key words, much like MeSHÒ terms in the peer reviewed literature, allows patients to find your posts when searching for a disease, treatment or test. A good example is Twitter, which uses hashtags to classify Tweet topics, eg #prostatecancer or #kidneystone. Twitter also allows you to tag someone in your Tweet using their handle, eg @mikeehlert (MJE). Followers of that user will then see the Tweet even if they do not follow your account. Pinterest uses a search system that captures the name of your board, which is a self-chosen topic for a group of postings, as well as words that you type in the pins (photos or links to articles). While this may be confusing for the new user, in practice it is quite simple. Think of boards as a physical corkboard in the hospital with notices, photos and memos pinned to it. Facebook uses pages dedicated to a user or group of users organized around social causes, interests or even diseases. The act of liking a page allows the user to see posts, upcoming events and updates in the ongoing news feed. Practices or individual providers may chose to host a Facebook page. For a more in-depth primer various user guides exist for physicians considering starting off in social media (http://www. aafp.org/about-site/about/contact/updates/social-media.html and http://www.auanet.org/education/videos-webcasts.cfm). Basic user guides are also available on the user site of each platform. However, simply opening an account and posting will not guarantee that anyone will read your content. You must drive traffic from your website, clinic signs and business cards, and through relevant tags, topics and posts. Liking other similar content, reposting other material and engaging users in conversations and comments will also promote traffic to your accounts. The most common use in urology remains personal and educational pursuits. Sharing content before, during and after large meetings continues to expand. Between meetings the Twitter based international journal club @iurojc is hosted. More than 1,600 Tweets have been sent since the inception in November 2012. Many large health centers and urology departments also host twitter feeds, including The James Buchanan Brady Urological Institute, New York University, Tower Urology in Los Angeles and others. Facebook is home to more private and local practices, although several large urological periodicals also host pages. Chronic disease and pain support groups are also common on Facebook, acting as repositories for referrals, education and communities for those with the condition. Applications such as Pinterest and TumblrÒ seem to host mostly urology humor posting at this time. A urologist or practice can engage patients through these platforms by posting disease specific content, practice service updates, provider and subspecialist promotions, and general urological news. Blogs Blogs are a unique form of sharable content because of the length of articles that can be posted. They can be seen as a middle ground of sorts in social media. Longer and more
4
Social Media and Online Communication
detailed than the common mobile apps, blogs are set up to allow for searches based on topics, user names and the bloggers who are most read. Readers have the option of adding comments or questions, which can be filtered before you allow them to appear. This provides more control over who or what is added to your blog page. After you start a blog it must be maintained and kept informative for your target audience. If you try to share general urological information or advocate for disease awareness, avoid overly technical terms, provide key steps for diagnosis and followup, and post links to videos and more information. Some bloggers choose to blog daily or weekly but intermittent posts are also reasonable. Most hosting sites allow you to build blog archives sorted by date or topic thread. If you are part of a larger practice, your web developer may be able to build in a blog function to your website. While this still allows comments and archiving, it would not be searchable in the larger blog hosting sites or mobile apps. To increase readership you may post a link to your newest blog entries on your other accounts, such as Facebook or Twitter. Videos Minimally invasive technology has made digital video sources a growing presence in urology. YouTubeÔ is the most recognized and visited video site. It allows for dedicated channels in your account, searchable topics and trends, and suggests other videos based on your postings. You can link to your YouTube channel from your blog, website, Facebook page and any other social media platform. Videos can also be cross posted to other social media platforms. Presenting drawings, showing procedure animations and explaining complex issues verbally not only informs patients but gives the viewer a glimpse into your bedside manner. Speaking clearly and using visual aids can convey a complex medical message quickly but this requires some careful planning. Good production, sound and editing are critical to driving good traffic to the posts. With modern cameras, free editing software and some thoughtful scripting this can easily be achieved by the practicing urologist. Murphy et al recently posted a well informed review on how to create impactful clinical videos.6 Certainly any patient testimonials or procedures videos should only be posted after written consent is obtained. In a survey by the AUA Residents Committee of practicing urologists and urology residents 22% had posted surgical videos online and only 5% consulted a practice manager, hospital attorney or supervisor before doing so.7 Web Pages Most urologists currently host a website with basic information such as practice location, physician names and types of treatments offered. Because sharing and recommending content are the cornerstones of social media, enabling site visitors to share the content of your site must be built in. Your web developer should include links to your social media accounts in a clearly visible area of the page, usually the upper right corner. If you host a blog, a link to the most recent topic is
helpful. If visitors view your website on a mobile device, consider building a mobile version to allow for fast loading and navigation. Optimization for mobile devices limits the format to a single scrolling column and active links for the user to make a call, view locations on a default map program or directly access social media content in a platform loaded on their device. This ease of use has led to the explosion of social media. A slowly loading or poorly navigable site is the main reason for clicking away.8 Common Risks and Challenges The 2-way communication, rapid post sharing and unfiltered comments in social media expose your practice to a set of unique liabilities (Appendix 2). Current thinking supports that there is no effective way to separate private and professional lives in a digital world where nothing can be deleted.9 Offhand comments or posts may be interpreted wrongly as offensive or be generally unprofessional. Even maintaining separate professional and personal accounts does not eliminate your exposure to these risks. This is especially worrisome when 62% of urologists report using social media for personal reasons only.1 Online activity has also been cited by state medical boards in disciplinary action.10 Any breach of PHI (protected health information) or enough identifying information risks professional and financial liability. While HIPAA (Health Insurance Portability and Accountability Act) protects health information generally contained in the medical or billing record, a general breach of patient confidentially carries civil liability for physicians. Posting about a patient or case that day from your personal online account may be viewed by family members or patients. The same context and risk apply to surgical videos. Furthermore, social media has been described as a context collapse on which material posted can be viewed by an almost infinite audience. When interacting face to face with patients, you adjust your tone and attitude based on the context of the social situation. This is not possible with posted and social media, which can lead to inadvertent consequences. Your optimism and upbeat tone on robotic surgery may not be well received by someone who experienced a recent complication. Also, as social media use continues to expand at urological meetings some posting may become more personal and contain direct comments about other urologists. Only post and save things that you are willing to share publicly with your patients. The AUA and EAU (European Association of Urology) recently endorsed social media best practices.11,12 Further risks exist when patients solicit inappropriate relationships with physicians. In a survey of practicing providers 35% received friend requests from patients or their families,13 which is consistent with the urology experience.7 Current or potential patients may request specific medical advice, which should be avoided in all cases. However, not all questions should be viewed as soliciting medical advice. Online communication still allows for a reasonable forum and discussion of diseases and treatment options. Include a disclaimer on blogs and websites clearly stating that posted material does
Social Media and Online Communication
not represent medical advice and is not a substitute for physical examination and diagnosis at the clinic. Finally, those employed by a large practice or institution should first check with the social media policy before embarking on these activities. If you are not posting as the official representative of the practice, many employers require you to state that all material represents your opinion and not that of the institution. You must avoid misconstruing your activity as those of the larger employer. Putting It All Together Setting your practice goals before you begin will prevent wasting time and money on social media. A recent GallupÒ poll showed that 62% of the 18,000 polled reported that social media had “no influence at all” on purchasing decisions.14 While health care is not traditionally considered a purchase and social media use is not paid advertising, the question remains whether this mode of communication has any real benefit to the practicing urologist. Social media for patient education on diseases, treatments and testing complements currently available material, such as that on the NIH (National Institutes of Health, http://kidney.niddk.nih.gov/) and Urology Care FoundationÒ (http://www.urologyhealth.org/urology/) websites. At least 1 study revealed that online urological information on common diseases was quite poor with only 12% scoring excellent by DISCERN criteria,15,16 leaving much room to add quality content. Having social media accounts listed under your practice or name enables users to search for you in the respective applications. This may draw potential patients to your practice, although there is only anecdotal evidence to support this. Users can also post questions or reach out to your office,
5
although this requires active monitoring of the accounts and times of responses. How much content you post also depends on the manpower and resources needed in your geographic area. In relatively saturated markets this may be a competitive advantage. However, for rural or regionally dominant urology groups patient education and access may be more appropriate goals. A survey of plastic and reconstructive surgeons showed that half were regular users of social media.17 While 52% of respondents thought that this was an effective marketing (65%) and patient education (49%) tool, 65% believed that it ultimately had no impact on their practice. Only 1.5% of respondents thought that it had a negative impact on their practice. Conclusions Social media and online communication are a large part of online activity and they are increasing steadily. Physicians continue to be active in this digital space personally and professionally. Urologists are most active at meetings and conferences, although opportunities exist to extend the use to patient education and engagement. Social media use is not without risks and challenges and this may be an unwarranted use of urologist time and resources. For those seeking to use social media for their practice several platforms exist, each with certain strengths and weaknesses. Thorough knowledge of each account as well as strict professional behavior is critical. Expanding the digital footprint of your practice is possible with all forms of online communication but this requires clear goals and adequate resources to be successful. Many practices may only need a simple website with contact information while others may seek to act as a resource for patients seeking treatment, education and disease advocacy.
Appendix 1. Social media platforms Platform
URL
Potential Benefits
Potential Limitations
Twitter
www.twitter.com/
Quick posting and sharing of posts (tweets) Links to webpages and other sites can be tweeted Large number of followers can be reached quickly Tweets can be labeled and sorted by topic (# hashtags)
Limit on tweets is 140 character Users must click on links to access more information Negative tweets by others cannot be edited or deleted Needs constant monitoring to stay current
Facebook
www.facebook.com/
By far the most used social media platform Easy to post and update profile Negative posts can be deleted Followers can like, comment and share posts with their friends Photos and videos are easily uploaded Robust mobile app
Postings do not show on all follower news feeds Some patients may avoid medical topics on personal accounts Risk of being solicited for medical advice in posts Negative press on privacy settings
YouTube
www.youtube.com/
Easy to upload and create channel Longer and more complicated material can be presented Excellent for visual items (procedures, anatomy) Your personality and bedside manner is conveyed
Searches can be overwhelmed by competing topics (legal advertisement) Poor production and editing can leave negative impression Requires time and resources to build good material (continued on next page )
6
Social Media and Online Communication
Appendix 1. (continued ) Platform
URL
Potential Benefits
Potential Limitations
Pinterest
www.pinterest.com/
Videos, website and blogs can be pinned to your board Entire boards are shared and followed Updates appear to those following you/your boards Topics are easily searched and repinned to user boards Content favors visual media and photos
Users may unfollow your boards after time Limited window to grab attention among other searched boards No specific tags to drive searches
Blog
Multiple platforms available
Longer informational postings Followers can share and link to your blog Creates archive of prior post and topics Can include links to helpful information in posts Comments can be screened before posting
Requires web traffic to be linked to your blog Does not develop true social network Multiple blog site and platforms are confusing It is time intensive to write robust quality material Limited mobile apps available
Appendix 2. Potential risks of using social media Risks of Using Social Media
Proposed Best Practices
Patients request medical advice Protected health information (PHI) shared Inappropriate physician comments or photos shared Angry patients post negative comments and reviews Misunderstood context of postings Web bot spam postings to your account Account hacked and spammed Patients seeking inappropriate relationships with physicians Institutional or employer reputation at risk Legal questions of posting surgical videos without consent
Refer them to office appointment and use disclaimer Never post about surgery or patient you saw Assume all posts are public and edit before sharing, including personal accounts Avoid being defensive or engaging in online arguments Be clear and factual, avoid judgmental comments Monitor accounts regularly Use 2-step login and keep passwords current Maintain professional behavior at all times, including personal accounts First check with employer rules on social media Post only with written consent of patient and de-identify all information
References 1. Loeb S, Bayne CE, Frey C et al: Use of social media in urology: data from the American Urological Association (AUA). BJU Int 2014; 113: 993. 2. Fox S and Duggan M: Health Online 2013. Pew Research Center’s Internet and American Life ProjectWashington, D.C.: Pew Research Center 2013. 3. Manhattan Research: Taking the PulseÒ U.S. Available at: http://www. manhattanresearch.com/ttp. Accessed July 2, 2014. 4. ComscoreÒ: It’s a Social World, December 21, 2011. Available at http:// www.comscore.com/Insights/Presentations-and-Whitepapers/2011/it_is_a_ social_world_top_10_need-to-knows_about_social_networking. Accessed July 2, 2012. 5. One in Five Millennials Follow a Healthcare Provider on Social MediaMinneapolis: Russell Herder 2012. 6. Murphy DG, Everaerts W and Loeb S: The Big Data Challenge: Amplify Your Content Using Video and Maximise Your Impact. BJUI International, June 6, 2014. 7. Ehlert M, Fox J, Loshley D et al: Social media use among urology residents and fellows. Presented at meeting of American Urological Association North Central Section, Naples, Florida, 2013. 8. Lohr S: For Impatient Web Users, an Eye Blink is Just Too Long to Wait. New York Times, February 29, 2012. 9. DeCamp M, Koenig TW and Chisolm MS: Social media and physicians’ online identity crisis. JAMA 2013; 310: 581.
10. Greysen SR, Chretien KC, Kind T et al: Physician violations of online professionalism and disciplinary actions: a national survey of state medical boards. JAMA 2012; 307: 1141. 11. Roupret M, Morgan TM, Bostrom PJ et al: European Association of Urology (@Uroweb) recommendations on the appropriate use of social media. Eur Urol 2014; 66: 628. 12. American Urological Association: Social Media Best Practices. Available at http://www.auanet.org/press-media/social-media-bp.cfm. Accessed August 7, 2014. 13. Bosslet GT, Torke AM, Hickman SE et al: The patient-doctor relationship and online social networks: results of a national survey. J Gen Intern Med 2011; 26: 1168. 14. Elder J: Social Media Fail to Live Up to Early Marketing Hype. Wall Street Journal, June 23, 2014. 15. Rivera S and Elder JS: The quality of treatment information for common urologic conditions on the web. Presented at meeting of American Urological Association Western Section, Monterey, California, November 3-7, 2013, poster 143-03-04. 16. Charnock D, Shepperd S, Needham G et al: DISCERN: an instrument for judging the quality of written consumer health information on treatment choices. J Epidemiol Community Health 1999; 53: 105. 17. Vardanian AJ, Kusnezov N, Im DD et al: Social media use and impact on plastic surgery practice. Plast Reconstr Surg 2013; 131: 1184.
Social Media and Online Communication: Clinical Urology Practice in the 21st Century Michael J. Ehlert*,y From the Department of Urology, William Beaumont Hospital, Royal Oak, Michigan
Abstract Introduction: Social media use by urologists is common with more than 66% reporting an active account. Most of this is for personal use or at urological conferences, although it can be a powerful tool for patient education and engagement. Patients and care givers are increasingly using online materials to search for health information, although how social media is used is still unclear. For the practicing urologist this review provides an introduction to the use, platforms and risks of social media and other online communication. Methods: Available social media platforms and their use are reviewed. The unique challenges associated with digital communication are outlined along with suggested ways to post information responsibly. Results: Users should have clear goals when engaging patients online. These may include disease education, practice updates or patient information. Social media accounts should regularly be screened for misuse or harmful comments. Patient confidentiality and professionalism should always be maintained. The widespread sharing and posting of digital content pose unique challenges and advantages for health care professionals. Maintaining the urologist reputation and that of the practice requires all content to be assumed public, even if posted on personal accounts. Conclusions: Overall the popularity of social media and online communication is increasing. The role in the physician-patient relationship is still evolving. Patient education, disease awareness and expanding the reach of a urologist practice are all possible online and with social media. Key Words: urology, social media, practice management, Internet, public relations
Attendees of any major urology meeting in the last 2 years have undoubtedly noted the explosion of social media in medicine. It is now commonplace for meeting planners to hold TweetÒ-ups, post TwitterÒ hashtags, tout pre-event abstract promotion and even maintain a social media lounge, as during the recent 2014 AUA (American Urological Association) meeting. Social media use among urologists and urology residents remains high with more than 66% and 86%, respectively, reporting some type of account.1 Aside from peer-to-peer connections and use at meetings there remains the question of how a urology practice can best use social media and online communication for patient care,
Submitted for publication July 7, 2014. * Correspondence: Medical Office Building, William Beaumont Health System, 3535 West 13 Mile Rd., Suite 438, Royal Oak, Michigan 48073 (telephone: 248-551-0803; FAX: 248-551-8107; e-mail address: michael. [email protected]). y Financial interest and/or other relationship with Michigan State Medical Society Board of Directors. 2352-0779/15/21-2/0 UROLOGY PRACTICE Ó 2015 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
clinical outreach and education. As part of the Internet and American Life Project a recent Pew Research Center poll of 3,014 adults showed that 35% had searched online for information on a health condition.2 The most common reason for seeking information was a specific disease or medical problem, followed by medical treatments or procedures (see table). Furthermore, 20% of survey respondents had consulted online heath care reviews or rankings, mostly for drugs and treatments (18%) or physicians (17%). A survey of more than 3,000 practicing physicians showed that a third recommended a smartphone or tablet app to a patient and 47% used a smartphone to show a patient photos or a video during a clinical encounter.3 Caregivers are increasingly younger and well educated, and a urology practice must provide timely, accurate digital communication to survive in a competitive environment. More importantly social medial use has eclipsed email as the number 1 online activity.4 One of 5 individuals who are 18 to 24 years old now follow at least 1 health care provider on social media,5 which emphasizes the need for urologists to maintain a presence in this digital landscape.
RESEARCH, INC.
http://dx.doi.org/10.1016/j.urpr.2014.08.005 Vol. 2, 2-6, January 2015 Published by Elsevier
Social Media and Online Communication
Most commonly searched online health topics2 Topic
% Adults
Specific disease or medical problem Certain medical treatment or procedure How to lose wt or how to control your wt Health insurance, including private insurance, Medicare or Medicaid Food safety or recalls Drug safety or recalls A drug you saw advertised Medical test results Caring for aging relative or friend Pregnancy þ childbirth How to reduce your health care costs Any other health issue
55 43 27 25 19 16 16 15 14 12 11 20
This article aims to clarify the types of social media and online communications available to the practicing urologist, act as a resource for starting out in this digital space, suggest potential uses for the online presence of your practice and outline the risks and challenges in maintaining your social media accounts. How Social Media Works Social media differs from static web pages and other digital content. It is meant to be directed by the user and not the content provider, shared among friends and others in a network, allow for rapid posting and commenting, and generally have a theme or topic that enables users to search for related material. Users design their digital experience through preferences, likes and those whom they connect with online. Mobile technology and cell phones have further expanded the reach of social media through apps. These content specific programs allow users to avoid searching or loading full web pages. Benefits to the urologist practice could be to provide a dynamic link to the practice or to disease specific content to bring in new patients. Social media may also allow you to share your expertise far beyond your local community. Whatever your goals are for entering this digital area, it is essential to know about the different online platforms and unique pitfalls of these mediums. How to Use Social Media Several social media platforms are available that enable users to connect and share information (Appendix 1). The main differences in platforms are content length and the methods of sharing or searching for information. Unlike website content social media searches are performed in each program through key words, hashtags (Twitter), groups (FacebookÒ) or topics (PinterestÒ). Patients and users may follow you after finding your profile if the content is relevant and provides information that they find helpful. The goal is to have them repost, like, share or recommend your postings to their contacts.
3
Tagging your posts with key words, much like MeSHÒ terms in the peer reviewed literature, allows patients to find your posts when searching for a disease, treatment or test. A good example is Twitter, which uses hashtags to classify Tweet topics, eg #prostatecancer or #kidneystone. Twitter also allows you to tag someone in your Tweet using their handle, eg @mikeehlert (MJE). Followers of that user will then see the Tweet even if they do not follow your account. Pinterest uses a search system that captures the name of your board, which is a self-chosen topic for a group of postings, as well as words that you type in the pins (photos or links to articles). While this may be confusing for the new user, in practice it is quite simple. Think of boards as a physical corkboard in the hospital with notices, photos and memos pinned to it. Facebook uses pages dedicated to a user or group of users organized around social causes, interests or even diseases. The act of liking a page allows the user to see posts, upcoming events and updates in the ongoing news feed. Practices or individual providers may chose to host a Facebook page. For a more in-depth primer various user guides exist for physicians considering starting off in social media (http://www. aafp.org/about-site/about/contact/updates/social-media.html and http://www.auanet.org/education/videos-webcasts.cfm). Basic user guides are also available on the user site of each platform. However, simply opening an account and posting will not guarantee that anyone will read your content. You must drive traffic from your website, clinic signs and business cards, and through relevant tags, topics and posts. Liking other similar content, reposting other material and engaging users in conversations and comments will also promote traffic to your accounts. The most common use in urology remains personal and educational pursuits. Sharing content before, during and after large meetings continues to expand. Between meetings the Twitter based international journal club @iurojc is hosted. More than 1,600 Tweets have been sent since the inception in November 2012. Many large health centers and urology departments also host twitter feeds, including The James Buchanan Brady Urological Institute, New York University, Tower Urology in Los Angeles and others. Facebook is home to more private and local practices, although several large urological periodicals also host pages. Chronic disease and pain support groups are also common on Facebook, acting as repositories for referrals, education and communities for those with the condition. Applications such as Pinterest and TumblrÒ seem to host mostly urology humor posting at this time. A urologist or practice can engage patients through these platforms by posting disease specific content, practice service updates, provider and subspecialist promotions, and general urological news. Blogs Blogs are a unique form of sharable content because of the length of articles that can be posted. They can be seen as a middle ground of sorts in social media. Longer and more
4
Social Media and Online Communication
detailed than the common mobile apps, blogs are set up to allow for searches based on topics, user names and the bloggers who are most read. Readers have the option of adding comments or questions, which can be filtered before you allow them to appear. This provides more control over who or what is added to your blog page. After you start a blog it must be maintained and kept informative for your target audience. If you try to share general urological information or advocate for disease awareness, avoid overly technical terms, provide key steps for diagnosis and followup, and post links to videos and more information. Some bloggers choose to blog daily or weekly but intermittent posts are also reasonable. Most hosting sites allow you to build blog archives sorted by date or topic thread. If you are part of a larger practice, your web developer may be able to build in a blog function to your website. While this still allows comments and archiving, it would not be searchable in the larger blog hosting sites or mobile apps. To increase readership you may post a link to your newest blog entries on your other accounts, such as Facebook or Twitter. Videos Minimally invasive technology has made digital video sources a growing presence in urology. YouTubeÔ is the most recognized and visited video site. It allows for dedicated channels in your account, searchable topics and trends, and suggests other videos based on your postings. You can link to your YouTube channel from your blog, website, Facebook page and any other social media platform. Videos can also be cross posted to other social media platforms. Presenting drawings, showing procedure animations and explaining complex issues verbally not only informs patients but gives the viewer a glimpse into your bedside manner. Speaking clearly and using visual aids can convey a complex medical message quickly but this requires some careful planning. Good production, sound and editing are critical to driving good traffic to the posts. With modern cameras, free editing software and some thoughtful scripting this can easily be achieved by the practicing urologist. Murphy et al recently posted a well informed review on how to create impactful clinical videos.6 Certainly any patient testimonials or procedures videos should only be posted after written consent is obtained. In a survey by the AUA Residents Committee of practicing urologists and urology residents 22% had posted surgical videos online and only 5% consulted a practice manager, hospital attorney or supervisor before doing so.7 Web Pages Most urologists currently host a website with basic information such as practice location, physician names and types of treatments offered. Because sharing and recommending content are the cornerstones of social media, enabling site visitors to share the content of your site must be built in. Your web developer should include links to your social media accounts in a clearly visible area of the page, usually the upper right corner. If you host a blog, a link to the most recent topic is
helpful. If visitors view your website on a mobile device, consider building a mobile version to allow for fast loading and navigation. Optimization for mobile devices limits the format to a single scrolling column and active links for the user to make a call, view locations on a default map program or directly access social media content in a platform loaded on their device. This ease of use has led to the explosion of social media. A slowly loading or poorly navigable site is the main reason for clicking away.8 Common Risks and Challenges The 2-way communication, rapid post sharing and unfiltered comments in social media expose your practice to a set of unique liabilities (Appendix 2). Current thinking supports that there is no effective way to separate private and professional lives in a digital world where nothing can be deleted.9 Offhand comments or posts may be interpreted wrongly as offensive or be generally unprofessional. Even maintaining separate professional and personal accounts does not eliminate your exposure to these risks. This is especially worrisome when 62% of urologists report using social media for personal reasons only.1 Online activity has also been cited by state medical boards in disciplinary action.10 Any breach of PHI (protected health information) or enough identifying information risks professional and financial liability. While HIPAA (Health Insurance Portability and Accountability Act) protects health information generally contained in the medical or billing record, a general breach of patient confidentially carries civil liability for physicians. Posting about a patient or case that day from your personal online account may be viewed by family members or patients. The same context and risk apply to surgical videos. Furthermore, social media has been described as a context collapse on which material posted can be viewed by an almost infinite audience. When interacting face to face with patients, you adjust your tone and attitude based on the context of the social situation. This is not possible with posted and social media, which can lead to inadvertent consequences. Your optimism and upbeat tone on robotic surgery may not be well received by someone who experienced a recent complication. Also, as social media use continues to expand at urological meetings some posting may become more personal and contain direct comments about other urologists. Only post and save things that you are willing to share publicly with your patients. The AUA and EAU (European Association of Urology) recently endorsed social media best practices.11,12 Further risks exist when patients solicit inappropriate relationships with physicians. In a survey of practicing providers 35% received friend requests from patients or their families,13 which is consistent with the urology experience.7 Current or potential patients may request specific medical advice, which should be avoided in all cases. However, not all questions should be viewed as soliciting medical advice. Online communication still allows for a reasonable forum and discussion of diseases and treatment options. Include a disclaimer on blogs and websites clearly stating that posted material does
Social Media and Online Communication
not represent medical advice and is not a substitute for physical examination and diagnosis at the clinic. Finally, those employed by a large practice or institution should first check with the social media policy before embarking on these activities. If you are not posting as the official representative of the practice, many employers require you to state that all material represents your opinion and not that of the institution. You must avoid misconstruing your activity as those of the larger employer. Putting It All Together Setting your practice goals before you begin will prevent wasting time and money on social media. A recent GallupÒ poll showed that 62% of the 18,000 polled reported that social media had “no influence at all” on purchasing decisions.14 While health care is not traditionally considered a purchase and social media use is not paid advertising, the question remains whether this mode of communication has any real benefit to the practicing urologist. Social media for patient education on diseases, treatments and testing complements currently available material, such as that on the NIH (National Institutes of Health, http://kidney.niddk.nih.gov/) and Urology Care FoundationÒ (http://www.urologyhealth.org/urology/) websites. At least 1 study revealed that online urological information on common diseases was quite poor with only 12% scoring excellent by DISCERN criteria,15,16 leaving much room to add quality content. Having social media accounts listed under your practice or name enables users to search for you in the respective applications. This may draw potential patients to your practice, although there is only anecdotal evidence to support this. Users can also post questions or reach out to your office,
5
although this requires active monitoring of the accounts and times of responses. How much content you post also depends on the manpower and resources needed in your geographic area. In relatively saturated markets this may be a competitive advantage. However, for rural or regionally dominant urology groups patient education and access may be more appropriate goals. A survey of plastic and reconstructive surgeons showed that half were regular users of social media.17 While 52% of respondents thought that this was an effective marketing (65%) and patient education (49%) tool, 65% believed that it ultimately had no impact on their practice. Only 1.5% of respondents thought that it had a negative impact on their practice. Conclusions Social media and online communication are a large part of online activity and they are increasing steadily. Physicians continue to be active in this digital space personally and professionally. Urologists are most active at meetings and conferences, although opportunities exist to extend the use to patient education and engagement. Social media use is not without risks and challenges and this may be an unwarranted use of urologist time and resources. For those seeking to use social media for their practice several platforms exist, each with certain strengths and weaknesses. Thorough knowledge of each account as well as strict professional behavior is critical. Expanding the digital footprint of your practice is possible with all forms of online communication but this requires clear goals and adequate resources to be successful. Many practices may only need a simple website with contact information while others may seek to act as a resource for patients seeking treatment, education and disease advocacy.
Appendix 1. Social media platforms Platform
URL
Potential Benefits
Potential Limitations
www.twitter.com/
Quick posting and sharing of posts (tweets) Links to webpages and other sites can be tweeted Large number of followers can be reached quickly Tweets can be labeled and sorted by topic (# hashtags)
Limit on tweets is 140 character Users must click on links to access more information Negative tweets by others cannot be edited or deleted Needs constant monitoring to stay current
www.facebook.com/
By far the most used social media platform Easy to post and update profile Negative posts can be deleted Followers can like, comment and share posts with their friends Photos and videos are easily uploaded Robust mobile app
Postings do not show on all follower news feeds Some patients may avoid medical topics on personal accounts Risk of being solicited for medical advice in posts Negative press on privacy settings
YouTube
www.youtube.com/
Easy to upload and create channel Longer and more complicated material can be presented Excellent for visual items (procedures, anatomy) Your personality and bedside manner is conveyed
Searches can be overwhelmed by competing topics (legal advertisement) Poor production and editing can leave negative impression Requires time and resources to build good material (continued on next page )
6
Social Media and Online Communication
Appendix 1. (continued ) Platform
URL
Potential Benefits
Potential Limitations
www.pinterest.com/
Videos, website and blogs can be pinned to your board Entire boards are shared and followed Updates appear to those following you/your boards Topics are easily searched and repinned to user boards Content favors visual media and photos
Users may unfollow your boards after time Limited window to grab attention among other searched boards No specific tags to drive searches
Blog
Multiple platforms available
Longer informational postings Followers can share and link to your blog Creates archive of prior post and topics Can include links to helpful information in posts Comments can be screened before posting
Requires web traffic to be linked to your blog Does not develop true social network Multiple blog site and platforms are confusing It is time intensive to write robust quality material Limited mobile apps available
Appendix 2. Potential risks of using social media Risks of Using Social Media
Proposed Best Practices
Patients request medical advice Protected health information (PHI) shared Inappropriate physician comments or photos shared Angry patients post negative comments and reviews Misunderstood context of postings Web bot spam postings to your account Account hacked and spammed Patients seeking inappropriate relationships with physicians Institutional or employer reputation at risk Legal questions of posting surgical videos without consent
Refer them to office appointment and use disclaimer Never post about surgery or patient you saw Assume all posts are public and edit before sharing, including personal accounts Avoid being defensive or engaging in online arguments Be clear and factual, avoid judgmental comments Monitor accounts regularly Use 2-step login and keep passwords current Maintain professional behavior at all times, including personal accounts First check with employer rules on social media Post only with written consent of patient and de-identify all information
References 1. Loeb S, Bayne CE, Frey C et al: Use of social media in urology: data from the American Urological Association (AUA). BJU Int 2014; 113: 993. 2. Fox S and Duggan M: Health Online 2013. Pew Research Center’s Internet and American Life ProjectWashington, D.C.: Pew Research Center 2013. 3. Manhattan Research: Taking the PulseÒ U.S. Available at: http://www. manhattanresearch.com/ttp. Accessed July 2, 2014. 4. ComscoreÒ: It’s a Social World, December 21, 2011. Available at http:// www.comscore.com/Insights/Presentations-and-Whitepapers/2011/it_is_a_ social_world_top_10_need-to-knows_about_social_networking. Accessed July 2, 2012. 5. One in Five Millennials Follow a Healthcare Provider on Social MediaMinneapolis: Russell Herder 2012. 6. Murphy DG, Everaerts W and Loeb S: The Big Data Challenge: Amplify Your Content Using Video and Maximise Your Impact. BJUI International, June 6, 2014. 7. Ehlert M, Fox J, Loshley D et al: Social media use among urology residents and fellows. Presented at meeting of American Urological Association North Central Section, Naples, Florida, 2013. 8. Lohr S: For Impatient Web Users, an Eye Blink is Just Too Long to Wait. New York Times, February 29, 2012. 9. DeCamp M, Koenig TW and Chisolm MS: Social media and physicians’ online identity crisis. JAMA 2013; 310: 581.
10. Greysen SR, Chretien KC, Kind T et al: Physician violations of online professionalism and disciplinary actions: a national survey of state medical boards. JAMA 2012; 307: 1141. 11. Roupret M, Morgan TM, Bostrom PJ et al: European Association of Urology (@Uroweb) recommendations on the appropriate use of social media. Eur Urol 2014; 66: 628. 12. American Urological Association: Social Media Best Practices. Available at http://www.auanet.org/press-media/social-media-bp.cfm. Accessed August 7, 2014. 13. Bosslet GT, Torke AM, Hickman SE et al: The patient-doctor relationship and online social networks: results of a national survey. J Gen Intern Med 2011; 26: 1168. 14. Elder J: Social Media Fail to Live Up to Early Marketing Hype. Wall Street Journal, June 23, 2014. 15. Rivera S and Elder JS: The quality of treatment information for common urologic conditions on the web. Presented at meeting of American Urological Association Western Section, Monterey, California, November 3-7, 2013, poster 143-03-04. 16. Charnock D, Shepperd S, Needham G et al: DISCERN: an instrument for judging the quality of written consumer health information on treatment choices. J Epidemiol Community Health 1999; 53: 105. 17. Vardanian AJ, Kusnezov N, Im DD et al: Social media use and impact on plastic surgery practice. Plast Reconstr Surg 2013; 131: 1184.