Think before you Tweet: ACS social media guidelines aim to prevent Internet regret


Think before you tweet. That’s what surgeons should remember before they express themselves on social media.

Anger and frustration can prompt ill-advised social media postings that have a big potential for blowback, Heather J. Logghe, MD, FACS, and her colleagues wrote in the Journal of the American College of Surgeons. But so can enthusiasm about posting about a new device or procedure, a fascination with a difficult case, the sense of relief that a patient made it though a harrowing period, or even just the simple joy of tossing back a beer or two with pals at the local watering hole (J Am Coll Surg. 2017. doi: 10.1016/j.jamcollsurg.2017.11.022 ).

The effects of an unguarded post can be profound and long-lasting, wrote Dr. Logghe and her colleagues from the Resident and Associate Society of the American College of Surgeons.

“In a survey of 48 state medical boards, 44 (92%) reported online-related misbehavior with serious disciplinary consequences leading to license restriction, suspension, or revocation. A 2011 study of ‘Physicians on Twitter’ revealed that 10% of the physicians sampled had tweeted potential patient privacy violations. A 2014 study of publicly available Facebook profiles of 319 Midwest residents found 14% had ‘potentially unprofessional content’ and 12.2% had ‘clearly unprofessional’ content, the latter including references to binge drinking, sexually suggestive photos, and HIPAA violations.”

Dr. Logghe , of Thomas Jefferson University, Philadelphia, is a member of the American College of Surgeons’ (ACS’s) social media committee tasked with creating practice recommendations for clinicians’ use of social media. Conducting a literature review was the first step to creating a surgeon-specific document, and the team found seven online behavior guidelines directed at physicians. Groups authoring these papers included the American Medical Association, the Federation of State Medical Boards, the American Congress of Obstetricians and Gynecologists, and several international groups.

Dr. Logghe and her colleagues reviewed each one, synthesized the information, and created a practice recommendation statement specific to the ACS. While not encoded in any professional ethics requirements, “Best Practices for Surgeons’ Social Media Use: Statement of the Resident and Associate Society of the American College of Surgeons” does lay out some common, potentially problematic scenarios and offers some suggestions about how to avoid Internet regret.

Everything discussed in the paper revolves around maintaining a decorous public persona. Professionalism on and off the clock is a key tenet of the recommendations. Definitions of key terms like “professionalism” are an important basis for any practice guideline, but sometimes concepts are not easy to define, the team wrote. “Perhaps the limitation most difficult to address in any formalized guideline is the necessary subjectivity in interpreting what is ‘appropriate’ or ‘professional’ online – or in any other setting,” the authors wrote. The ACS Code of Professional Conduct does not explicitly define either of those terms or discuss the appearance of unprofessional behavior.

In the absence of a plain-and-simple definition, the authors attempted to couch the social media recommendations in terms of ACS’s commitment to maintaining the patient trust. It urges surgeons to “avoid even the appearance of impropriety.”

The practice recommendations touch on a number of areas that are potentially problematic for surgeons, including confidentiality, financial conflicts, collegial support, and general social responsibility.


Maintaining privacy is more than a courtesy to patients: It’s a federally mandated law with serious punitive repercussions if violated. Blogs, YouTube, Twitter, and Facebook offer a vast potential for sharing information with and educating the public, but postings can also easily violate HIPPA standards, the team wrote.

“In general, most social media platforms are not HIPPA-compliant,” no matter how the privacy settings are adjusted. These modes of communication are never appropriate for patient-physician communication: They can’t be archived in an electronic health record, and it is ill advised to give any medical advice by using these channels.

Discussing a particular case online, even with the usual defining details omitted, can be a bad idea.“Simply de-identifying patient information may not be sufficient. When posting information online, one must be cognizant of the context of other information available online. Such information includes the poster’s place of employment, news media, and publicly available vital statistics. Therefore even when posting general comments about hospital events, surgical cases, or patients under one’s care, it is essential to consider the sum of information available to the reader, rather than simply the information shared in the isolated post.”


Most employers have social media guidelines and don’t take kindly to violations – which can affect both current and future job postings. “A strong social media presence can be of benefit to one’s employer, [but] content that portrays a surgeon in an unprofessional or controversial light can be detrimental and even career-damaging.”

This reaches beyond professional communications online and deep into a surgeon’s personal life, the team noted, so exercise caution when “friending.”

“While this practice is inevitable, surgeons should be aware of potential conflicts. Connecting with or accepting friend requests from some but not all coworkers or coresidents could be interpreted as favoritism and may create a problematic work relationship. … Surgeons should consider primarily connecting with coworkers on professional websites if they have little contact with them outside the workplace.”

As for friending patients – just don’t, for both your sake and theirs. “Accepting a patient’s Facebook friend request may allow them access to events, details, and commentary not traditionally appropriate for the patient-physician relationship. Accepting such requests is strongly discouraged. If concerned about appearing rude or rejecting a patient’s request to be Facebook friends, the patient can be referred to society guidelines or best practices such as these.” One helpful alternative to such a request may be to invite patients to follow a practice website or other professional page.

Conflicts of interest

Online friends might not require disclosures when a surgeon posts about an exciting procedure or piece of equipment, such as whether there is a financial interest in doing so, but it’s important to be proactive. “As always, it is the physician’s responsibility to avoid even the appearance of impropriety. If it is not feasible to include a relevant conflict of interest within a post, the post should not be made.”


Irritated about a colleague? Keep it to yourself – especially if you’ve had a beer. “It is never appropriate to post derogatory comments about patients or colleagues. Surgeons should be careful not to post in anger or under the influence of any substance. Statements about a colleague’s abilities, experience, or outcomes intended in jest may be appropriate for the surgeon’s lounge, yet entirely inappropriate for public consumption. Again, the ‘pause-before-posting’ practice is likely to prevent regretful posts in this vein.”

Privacy and Permanence

The Internet goes everywhere and lasts forever. A snappy quote that’s funny at 2 a.m. might not seem so hilarious in the light of day – or even in the light of a day 5 years yet to come.

The delete key is a false friend, and that clever pseudonym you dreamed up is probably as crackable as the classic “Pa55word” password. “One should presume that all content posted online will remain there forever and may be seen by anyone. Again, ‘pause-before-posting’ is a recommended practice.”

Privacy settings should be viewed as an illusion, the team noted. In this era of face recognition and tagging, images carry just as much risk as words.

Collegial support

Maybe your mother was right when she said, “This is for your own good.” If a colleague’s postings are getting out of hand, a tactful heart-to-heart might be the best course of action. “As coined by Dr. Sarah Mansfield, ‘Looking after colleagues is an integral element of professional conduct.’ Surgeons who notice colleagues posting unprofessional content that could be damaging to both the colleague and the public’s trust in the profession should discreetly express their concern to the individual, who should then take any appropriate corrective actions. … If the action is in violation of the law or medical board regulations, it should be reported to the appropriate governing bodies.”

Physician, Google Thyself

The team acknowledged that an online presence is virtually a must for professional development. And even if you don’t create a web page, chances are your university or hospital has done it for you. The media is interested in your life, too, and may make mention of your activities – both positive or negative.

“To better understand and control this publicly accessible information, surgeons are encouraged to periodically self-audit themselves online and taking measures to ensure that the information present is accurate and professional.” Some professional service websites are more trustworthy than others. The team encouraged physicians to participate in the ACS professional pages, LinkedIn, Doximity, and ResearchGate.

Not rules – just recommendations

The team stressed that their recommendations aren’t meant to stifle personal expression. Instead, their aim is to prompt a more conscious use of what can be a very powerful tool for both self-expression and professional development.

“The authors recommend no punitive action based on a perceived ‘violation’ of these recommendations alone. While they refer to other guidelines, including laws such as HIPAA, that must be appropriately enforced, these best practices are intended to guide the practicing surgeon in the use of social media rather than act as regulations or encourage reprimand. Rather than encouraging a social media landscape as sterile as the operating theater, the authors hope these recommendations lead to conscious consideration of online behavior, to avoidance of preventable harm, and to recognition of others’ views of their posts.”

None of the authors reported any financial disclosures.

SOURCE: Logghe HJ et al. J Am Coll Surg. 2017. doi: 10.1016/j.jamcollsurg.2017.11.022 .