What should doctors do if patients friend them on Facebook? That's one of the latest questions that medical professionals are struggling with as social media finds its way into the doctors' offices and hospitals, bringing with it new challenges and opportunities.

Healthcare providers say platforms, such as YouTube, Twitter, and blogs, let them reach the public on a much greater scale than is possible one to one and is far less expensive than TV and radio. Social media also lets providers connect with niche audiences that have rare conditions. However, there are concerns: Providers need to be sure to keep patient information confidential, which can be tricky. And providers struggle with new ethical issues, such as: If you're a medical school instructor, should you friend your students on Facebook? Should doctors friend their patients?

For the University of California San Francisco Medical Center, its incoming students are bringing the challenges of social media with them. Students entering medical school are typically 22 years old, they've grown up with Facebook and earlier social media, said Russ Cucina, associate medical director of information technology. "Our students are expecting the ability to be able to interact on Facebook," he said.

"I've already started to receive friend requests from some of our trainees, even though I'm not their friend, I'm an instructor," Cucina said. "My default reaction is that, while I might have a warm professional relationship with them, I am not their friend. But that may be because I'm 37 and they're 22."

Cucina said he separates his personal relationships on Facebook and professional relationships on LinkedIn. When he gets a friend request on Facebook from a professional colleague, he usually responds with a connection request from LinkedIn instead.

"I've yet to be friended by a patient," said Cucina, who is an M.D. "I'm sure the day will come when I am friended by a patient, and clinicians will have to decide what to do if they are in that situation." When he is friended by a patient, he said he'll turn that request down.

"Hypochondriac Feed Of The Day"

While social media are largely used for individual communications at UCSF, they're a form of mass communication for the Mayo Clinic. The clinic launched its social media efforts with a podcast in September 2005, as a way to get additional leverage from existing radio segments that it provided to stations, said Lee Aase, Mayo Clinic's manager of syndication and social media. Apple highlighted the Mayo Clinic podcast on the front page of the iTunes site, which boosted downloads from 900 per month to 74,000. The Mayo Clinic later expanded its initial 60-second podcast--"the hypochondriac feed of the day," Aase called it--to longer podcasts (iTunes link) on subjects including cancer and heart disease.

The clinic also maintains blogs, where it posts audio and video files as well as text entries, and started a Facebook fan page as soon as those became available, updating the fan page with articles from its blogs and video content. The page has about 8,300 fans. The clinic uses its Twitter page as a means of tying everything together and notifying the public when new content is available, Aase said. The clinic's major focus is on blogs, Facebook, Twitter, and YouTube. "We just mix and match those platforms; it's kind of like your four basic food groups, you blend them in different ways," he said.

Mayo sees social media as an extension of word of mouth. "Word of mouth has been a crucial part of building Mayo's brand for more than a hundred years," Aase said. "People come here, have a good experience, go home and tell about it. We see social media as the 21st Century version of word of mouth. We're talking to the whole world, potentially."

Social media lets doctors help people in much greater numbers than in-person treatments. "We can talk to one doctor on a video camera for 10 minutes, and put out information that helps thousands," Aase said.

For example, the clinic's most popular video is a 22-minute interview with a doctor on the subject of Postural Orthostatic Tachycardia Syndrome, a condition primarily affecting teenage girls frequently misdiagnosed as simple depression or fakery. "For those patients that are really craving this information, it's the kind of information they couldn't get otherwise," Aase said. "We couldn't get 22 minutes on the air from something like that--nobody would let us buy it."

Ethical Concerns

Companies in the healthcare industry looking to use social media face a range of regulatory and ethical issues.

HIPAA compliance is the main concern for the Mayo Clinic. Patients are legally entitled to post information on their own conditions, but the clinic needs to get a consent form for interviews with patients about their stories. The middle ground is when a private individual posts a message about another person's condition. In that case, the Mayo Clinic removes identifying details so the information doesn't point back to a specific person.

"I wouldn't say we had huge obstacles, we just needed some soaking time, to work it through and make the case," Aase said.

As the social-media savvy students now in medical school grow to become doctors, administrators, and instructors themselves, the medical profession will have to develop rules for using tools like Facebook. But Cucina says he's confident that will happen.

"We had these same conversations 10 or 15 years ago about the Internet. As the Internet became ubiquitous, people wrote articles about whether medical groups should have Web sites, and whether doctors should have e-mail. Now, it's taken for granted they should," Cucina said. "We understand boundaries," when to use encryption and greater security to manage privacy, and that diagnoses and difficult conversations shouldn't be communicated through e-mail. The same understandings will develop for social media.

Cucina is in the forefront of developing those rules—he's teaching a class, called, "Blogs, Tweets, and Facebook: What the Hospital and Medical Administrator Needs To Know," in October in San Francisco as part of a continuing education program that doctors are required to take to keep their licenses.

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