Current Concept Review

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#PediPodsOnline: Social Media Use in Pediatric Orthopaedic Surgery

Philip Nowicki, MD, FAAOS¹; Craig Louer Jr., MD²; Corinna Franklin, MD³; Carter Clement, MD, MBA⁴; POSNA Public Education and Media Relations Committee*

¹Helen DeVos Children’s Hospital, Grand Rapids, MI; ²Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN; ³Shriner’s Hospitals for Children, Philadelphia, PA; ⁴Children’s Hospital New Orleans, New Orleans, LA

Correspondence: Philip Nowicki, MD, FAAOS, Helen DeVos Children’s Hospital, 35 Michigan St., Suite 4150, Grand Rapids, MI 45903. E-mail: [email protected]

Received: March 12, 2022; Accepted: March 14, 2022; Published: May 1, 2022

DOI: 10.55275/JPOSNA-2022-0023

Volume 4, Number 2, May 2022

Abstract:

This paper from the Public Education and Media Relations Committee of the Pediatric Orthopaedic Society of North America (POSNA) provides a primer for pediatric orthopaedists on the use of social media in practice. It is an adjunct to the recently produced podcast focused on the same subject. Social media has proven to be a useful means for physicians to educate patients and colleagues, collaborate with peers, and promote causes and organizations to optimize overall orthopaedic patient care. In this manuscript, social media ambassador members from POSNA discuss ways to get started, use, and stay out of trouble when navigating the social media arena.

Key Concepts:

• Social media use is an emerging trend in medicine that allows interested physicians to keep current with healthcare news and studies, engage with peers worldwide, advocate for social causes, and humanize themselves by sharing personal interests.
• Failure for physicians to become involved in social media sacrifices opportunities in communication, advocacy, and education.
• Individual surgeon “micro-influencers” can often have greater public impact than medical societies alone.
• Social media allows for the wide dissemination of personal research and academic citation.
• Physicians should always offer social media posts professionally, with respect, kindness, and humility.

Introduction

Social media has become an everyday part of our lives. It has evolved from a way to reconnect with old friends, digitally acquaint with new people, and find new areas of interest into a tool to effect social change and individually integrate with the larger world. It has become publicly ubiquitous, with 72 percent of U.S. adults having at least one social media account and 90 percent of teenagers utilizing some form of it.^1,2 Healthcare has developed a niche within social media and physician utilization continues to grow, with 90 percent of physicians using social media for personal use and 67 percent using it for professional use.³ Social media offers the potential for physicians, specifically pediatric orthopaedic surgeons, to reach and interact with the public through a menagerie of ways. Yet, physicians must be aware of the uses and potential pitfalls unique to its use. This paper shares guidance and wisdom from social media ambassador members of the Pediatric Orthopaedic Society of North America (POSNA) (Figure 1) regarding the use of social media in pediatric orthopaedics. It is an accompaniment to the recently produced podcast episode from Peds Ortho: https://podcasts.apple.com/us/podcast/social-media-pearls-pitfalls/id1464797241?i=1000553455228.

Getting Started

To begin, a brief overview of social media and the various platforms used by physicians is warranted. Social media (#SM) refers to web services and applications where users can create personal profiles, post content, and interact with other users they share a common connection with.² The most popular platforms include Facebook, Twitter, Instagram, TikTok, and YouTube.

Facebook (FB): Founded by Mark Zuckerberg, FB was initially used to link college students to one another. It is now a giant social networking site that allows anyone to share photos, comments, and videos online. Users may interact with one another or with groups, businesses, and celebrities by following them. FB makes money through advertising and a digital retail space; lately, the company has faced protracted controversy over privacy concerns.

Twitter: Created by Jack Dorsey, Noah Glass, Biz Stone, and Evan Williams, Twitter is a social networking micro-blogging service where users can post and interact with messages called “tweets.” Initially, all messages were limited to 140 characters in length, but currently up to 280 characters are allowed. It allows for grouping of posts by topic using a hashtag (“#”) that can be subsequently referenced, and users can identify themselves via unique “handles” that begin with “@” before their chosen name.

Instagram (IG): Founded by Kevin Systrom and Mike Krieger, IG is a photo and video sharing social networking application currently owned by Facebook. Users can upload media and edit with filters as well as organize by hashtags and tag other users. Besides singular uploads, IG also offers a “story” feature that provides a sequential feed to share media.

TikTok: Owned by a Chinese company, TikTok allows users to create and view short videos (15 seconds up to 3 minutes) ranging across a multitude of genres such as pranks, trends, dances, and entertainment. TikTok is very popular among young users (<25 years of age) and like IG, is heavily used by “influencers” who can sell branded merchandise to the public.

YouTube: Founded by Steve Chen, Chad Hurley, and Jawed Karim, YouTube provides video content and uploads by users and is currently owned by Google. Users can make or follow pre-established “channels” that span every possible genre. Popular “YouTubers” can grow their channels into multi-million-dollar franchises. Videos can be short or full length, with the ability to publish full-length presentations for public viewing.

Getting introduced to #SM seems daunting at first: there is a learning curve to climb, we have busy schedules, privacy concerns have emerged, and you may worry about the self-image you will convey, among other barriers. However, physicians need to be involved in the overall #SM conversation. A recent AAOS Now article outlined tips for physicians getting started, including defining an objective for #SM use, defining an individual persona, having a realistic view on gaining followers, and engaging one’s audience.^4,5 Once your goals are established, stick with them and be genuine in your content.⁶ Beginning through simple observation is a straightforward way to obtain a feel for the posts people make, especially when using IG or Twitter.⁷ Once comfortable with the chosen platform(s), move on to posting content.

Following like-minded colleagues helps to obtain an assessment for appropriate posts. From here, establish your persona. Do you want your posts to be strictly personal focusing on family pictures and events, do you want to share medical articles and links to articles or groups you have an interest in, or do you prefer a hybridized content collection? Begin to engage your audience by providing content, keeping in mind to remain respectful, kind and humble, and conduct yourself in a professional fashion.⁶ Social media can become an addictive behavior, so set rules for use such as a daily time limit or timeframe to engage. Make sure to spend time on other things like research, sleep, eating well, and spending time with friends and family.⁶ Dr. Schmitz shares, “We have a rule that you don’t do it at the dinner table when we’re having dinner.”

Social Media Use

Patients are utilizing #SM, and physicians need to do the same, as avoiding #SM can sacrifice opportunities for communication, education, and advocacy.² Physicians need to know that #SM is a strong tool to bridge the gap to the public. According to national surveys, the main goals of physicians using #SM include personal use (60 percent), keeping up with healthcare news (40 percent), engaging in peer discussion (33 percent), and marketing their practices (20 percent).⁸ Another wonderful use is sharing patient stories and accomplishments.

Personal use is an obvious utility for #SM, as it is what made #SM so popular to begin with. The #SM ambassadors agree that FB and IG are most effective for personal use, including sharing family pictures, exploring and posting news stories, and sharing spontaneous thoughts. Users can engage with other connected people, catch up with old friends, or network with new ones. IG offers a unique way of sharing, providing a storied format to interact with. #SM is a useful tool for personal catharsis. Twitter is an optimal option for this given its truncated post format. Dr. Weiss explains how this practice shares the “human” side of physicians: “It’s the humanity that’s fun. It’s important not just for up-and-coming medical professionals to see but patients too. I think humanizing physicians in this day and age is really important because there’s just so much angst and anxiety surrounding medical care.”

 

Social media aids busy surgeons in keeping up to date with health news. #SM platforms utilize algorithms that display content based upon previous user interaction such as searches and follows. News organizations can provide links to stories, some free and others requiring payment or a subscription. Twitter allows individuals to adopt unique “handles” to identify themselves and provides a way to share brief thoughts or share news and journal articles with followers. With the shortened format (≤ 280 characters per post), a user can readily screen what they feel is important. They can access and share a link to a story or article at large, adding personal commentary and opening a discussion for others. Utilizing the hashtag (“#”) system, users can link their own content to a topic and access broader content to that subject. This enables crosstalk between platforms. This is especially useful when promoting a research article. The major orthopaedic groups, including AAOS and POSNA, have active social media capabilities that can publish informatics linked to recent articles for users to peruse. Social media ambassadors are useful in this arena as they can actively disseminate information to a wider public than the specialty society alone. This will be discussed more later.

Social media connects people with similar interests by tagging other users or seeing the tags of followers, making it a strong tool for equity and change.⁶ By connecting with surgeons from around the world, #SM is a great avenue to share difficult cases for discussion. For surgeons in the developed world, it is a great way to give back and help educate surgeons in less developed countries.⁷ For Dr. Bennett, this started in fellowship as he had a family at the time. He says, “[I] was not really able to do a bunch of overseas stuff, but I liked the idea of being able to contribute a little bit to the care of people who were not in a resource-rich environment.” Social media has also led to interaction between people of all levels in the healthcare industry. This is what has been referred to as “flattening the hierarchy” where every person in medicine is given an equal voice.² This is especially important for minority physicians, giving them a stage to empower their voices to be heard on topics such as equal pay and racial justice.

Social media is an easy and low-cost way to promote one’s practice.^7–9 The exposure can increase traffic to a practice website, important for those in private practice. The accomplishments of practice partners can be amplified by garnering attention from a wider audience. Conversely, many physicians may be uncomfortable with explicit self-promotion and instead prefer to focus their #SM activities on education, connecting with peers, etc. Social media can also be utilized to promote and share the mission of groups a user is involved with. It allows the development of “supportive disease subcultures” that can make a small disease/condition larger and educate a broader audience about them.²

 

For pediatric orthopaedic surgeons, our patient success stories make us proud, not only for the personal virtue of a job well done, but in being advocates for our patients to share how they overcame the adversity of their underlying condition. Dr. Schmitz reflects, “Coming home after a day of clinic and seeing that you have new followers and recognizing that they’re your patients … it’s fun to see their perspective in things.” Patient consent for picture use is necessary and is discussed in more detail later in this paper. Surgeons can be advocates for their patients by allowing the patient to post their stories and x-rays on #SM. Dr. Bennett explains, “My hospital has gotten involved in trying to use social media to share stories with families so that they know at least they have the resources in our area. … I started telling families from the beginning of my practice that they can take a picture of their own x-ray. I don’t specifically tell them to post anything online, but most of them do anyway.” Dr. Chambers shares, “I think it’s great when patients post their accomplishments. One of my transverse myelitis patients is currently on the U.S. paralympic tennis team and is a professional tennis player. She posts her pictures at Wimbledon, the French Open, and the Australian Open on our page which really encourages other kids and families that anything is possible.” Parents can share their stories through POSNA’s OrthoKids.org website under the “Community” tab. A general photo/video release is provided for patients to grant permission to share their stories.¹⁰

Social Media Use for POSNA

The POSNA #SM ambassadors are in a distinct position to offer insight and advice for putting #SM to work for POSNA and pediatric orthopaedic surgeons stemming from their experience with other orthopaedic organizations.

The one #SM platform that has not received much attention to this point is TikTok and it is an area where POSNA can improve in reaching patients. Dr. Weiss explains the importance of TikTok: “If we want to educate patients, we have to go where they are, and TikTok is where patients are living now.” TikTok would be opportune for sharing basic information on pediatric orthopaedic conditions since it allows for posting of short videos. Dr. Bennett adds, “[TikTok] could be utilized more for the orthopaedic surgeon to give a brief summary of different pathologies and the way they are treated. I’ve seen some people do that pretty effectively and they are getting thousands of interactions.” Such content can be used as a parent reassurance tool to utilize as an adjunct tool in the office.

POSNA already does an excellent job in promoting the work of their members but should continue to reach out and share members’ posts to add to a greater audience. Dr. Weiss describes how the subspecialty societies alone have a relatively small audience, and it is the individual physician members who act as micro influencers and who are ideal for sharing messages and information because they can reach more individuals. By engaging with its members, POSNA can secondarily reach a greater patient audience.

By the very nature of the patients it represents, POSNA can amplify patient stories and set itself further apart from other orthopaedic societies. Dr. Weiss opines, “Where we [POSNA] can make even more of a difference than our sister societies is in reaching out to children to support them through [their condition], whether it’s in amplifying better care for them or it’s just supporting their differences. Getting their stories out there for them to feel like they’re not alone, I think that’s a really powerful piece of social media.” POSNA can also promote group causes for conditions that pediatric orthopaedists treat, specifically smaller groups that might not otherwise receive a lot of exposure.

One way POSNA (specifically JPOSNA^®, POSNA’s journal) and other medical specialty societies can improve the promotion of research is using Altmetric scores. Altmetrics are a way to measure online attention and engagement and are geared towards research. An Altmetric score assesses posts on #SM platforms as well as online activity to measure the impact an article is registering. It is the modern way to track influence in the digital world, assessing impact broader than the secluded scholarly community.¹¹ Dr. Schmitz explains, “[T]here are journals looking at Altmetrics scores based on how many retweets and news articles reference [a] paper, with early data suggesting it may correlate with citations. I think that there is a role for physicians to get out their science message by Instagram or tweeting bits of their articles or links to their articles. I think that’s one thing we’ll potentially see in the future that journals and societies will be more proactive in getting out research.”

Staying Out of Trouble

Social media is useful in medical practice, but there are numerous examples of public officials, celebrities, and even physicians getting into trouble with unpremeditated and impromptu replies or posts. For physicians, specific areas of concern include patient confidentiality, imprudent medical advice, and inappropriate self-disclosure.²

As physicians and surgeons, we want to share our patient stories, successful and challenging. We desire to empower our patients and their healthcare journey as well as ourselves in knowing we helped someone to recovery or sharing our confounding cases to improve our knowledge and skills. This can be achieved using #SM but it needs to be performed appropriately, beginning with patient confidentiality. The Health Insurance Portability and Accountability Act (HIPAA) is a crucial tool to keep our patients safe. HIPAA clearly outlines what protected health information (PHI) is and who can see and use this data. When posting online, it can be easy to take and share a spontaneous picture of a patient or an x-ray without knowing the repercussions behind it. Doing so injudiciously can carry hefty penalties for a hospital system and a surgeon, including fines, termination, and loss of license.¹²

To obviate this, most medical specialty societies, including the American Medical Association (AMA), the American Academy of Pediatrics (AAP), and the American Academy of Orthopaedic Surgeons (AAOS), have published best practices and requirements regarding patient confidentiality and HIPAA compliance.^2,12,13 These can be accessed through the links provided in the reference section. The #SM ambassadors offer specific advice related to confidentiality and HIPAA compliance. Dr. Weiss recommends obtaining a second set of eyes for posts: “Anytime I’m going to put up a tweet or Instagram or anything that involves a picture, I get a second set of eyes to make sure that I haven’t included anything in that picture that could identify them.” Surgeons should always obtain patient consent for anything that they consider posting on #SM.¹⁴ Dr. Bennett adds, “[My] hospital has a five-page consent form, and it has all the social media platforms that are commonly used. The family has to consent to all of those things, and the consent is scanned into the chart.” Dr. Weiss further advises, “If you’re going to post something about a patient, first get their consent, but then mask the post by never posting near the time you are seeing the patient as another layer of patient confidentiality.”

Physicians need to be careful about offering unsolicited medical advice on #SM given the possibility of forming a legal patient-physician relationship, just as can occur during casual conversation.² It is okay to respond to general medical questions, but physicians should be careful about giving explicit medical advice to individuals through specific posts or direct messaging.^2,6,14 As physicians, we want and need to educate the public, as it is part of our creed. A straightforward way to protect ourselves for the medical advice we provide is to offer a disclaimer.⁹ This alerts other users that all opinions on a page or platform are our own and do not imply specific medical advice. Instead of providing advice, physicians can direct the public to websites such as OrthoInfo, POSNAcademy, or OrthoKids to offer patients a portal for present and future information.¹⁴ Another way to add protection is to open and maintain separate accounts on the #SM platforms for personal and professional use.¹⁴ This allows physicians to monitor traffic and content and prevent posts that may contradict their mission as well as prevent becoming a victim of catfishing.¹⁴

Inappropriate self disclosure² is an essential tenet to mind when engaging with #SM. This pertains to personal posts and opinionated tweets that can come back to haunt a physician. Everyone on the internet can potentially see a post, even in ways to work around private settings. It is wise to pose the “what if my grandma sees this?” question, but reframe it as “what if my patients see this?”⁶ The AMA Code of Ethics warns that “physicians must recognize that actions online and content posted may negatively affect their reputations among patients and colleagues, may have consequences for their medical careers, and can undermine public trust in the medical profession.”¹³ Even though #SM posts can be cathartic, “anonymity can breed disinhibition.”² For physicians to protect themselves, Dr. Weiss advises, “If you work for an organization or if you are in an organization, you need to understand what their rules are. There may be rules that you are not allowed to be on social media during the day, in which case you cannot post while you are at work. It may be that they do not want you out there representing them at all. So, you have to know what your home organization believes. Dr. Bennett adds, “Anything I worry about or think twice about, I just delete it.”

Along these same lines, as the AMA Code of Ethics outlines, physicians have a responsibility to bring attention to any unprofessional content that their colleagues are posting online to that colleague.¹³ Dr. Weiss shares an anecdote on the podcast about a post she made during the pandemic regarding vaccines and a colleague who acquired Covid-19 after being vaccinated. The vaccine regulator at her institution discussed the matter privately with her to bring to her attention what such a post could do to fuel the anti-vaccine fervor at the time. As Dr. Weiss ends her story, “I think we have to be unafraid to pull [a post] and unafraid to apologize if it’s something we shouldn’t have put out there in the first place. And that’s what I did.” Listen to the accompanying podcast to hear the story in its entirety.

Finally, avoid the temptation to get into “virtual fights.” Be wary of trolls that opine simply to create a reaction. Dr. Bennett explains, “[I]t is easy to get dragged into a fight with trolls. … It is easy to strike back, especially if they say something that is clearly incorrect. One of the better ways to deal with it is just to mute or block that person.”

Pearls

For this closing section, the POSNA #SM ambassadors share pearls of wisdom regarding navigation of the #SM world that can be useful to those just starting out or seasoned veterans looking to expand their outreach.

Dr. Chambers recommends surgeons keep their #SM content informational, allowing their content to function as a supplement of resources for patients during a busy clinic visit. For him, this includes posting an instructional video for his patients on applying for Section 8 housing, insurance funding, and how to obtain guardianship/conservatorship of young adult children. He also recommends educating patients on local and national events that could directly influence or affect their medical care. He suggests that physicians be vigilant in monitoring their #SM accounts to assess if people are advertising inappropriate content on them such as stem cell injections, hyperbaric oxygen treatments, etc. When you find these posts, he suggests having a plan for dealing with them. The easiest way is simply blocking them from your sites.

Dr. Weiss recommends that when using social media, you should pair with a like-minded friend or “buddy” to assist with promoting one another. Partnering with a user that already has a large following can improve exposure for a surgeon, especially as they are beginning their #SM presence.

Dr. Schmitz recommends dipping one’s toe in the social media water. He encourages picking a platform, following friends, and seeing where it leads over a trial run. Start small by searching and following users who are interesting and then build up by adding posts and more elaborate content. If one does not find it attractive, it can be turned off.

Dr. Bennett recommends securing any #SM accounts in one’s name. This prevents co-opting of an individual’s name or handle (catfishing) and ensures that one’s online presence stays pure with the user. He recommends opening social media accounts even if you are not going to be an active participant and securing them with a strong password to ensure other users cannot hijack a name and cause harm by posting unacceptable posts.

Conclusion

Social media and its beneficial applications continue to grow. By having a social media presence, pediatric orthopaedic surgeons can continue to reach current and future patients, share mission and values directly with them, and provide an educational platform of up-to-date information for them. Social media provides the ability to collaborate more fully with peers both regionally and globally. By understanding best practices for social media use, pediatric orthopaedic surgeons can continue to develop and share the enrichment that patients bring to their everyday life.

*POSNA Public Education and Media Relations Committee: John W. Anderson, MD; Jennifer Beck, MD; Laura Bellaire, MD; David Michael Bennett, MD; Robert Hyun Cho, MD; Carter Clement, MD, MBA; Corinna Franklin, MD; Jonathan Harley Koenig, MD; Alexander L. Kuzma, MD; Craig Lauer Jr., MD; Alex Lopyan, MD, MS; John P. Lubicky, MD; Erin Meisel, MD; M. Siobhan Murphy-Zane, MD; Philip Nowicki, MD, FAAOS; Selina Poon, MD; Stephanie Stopka Pearce, MD; B. Stephens Richards III, MD; Christen Marie Russo, MD; Jeffrey R. Sawyer, MD; Susan A. Scherl, MD; Alison Schiffern, MD; Matthew Robert Schmitz, MD; Timothy Skalak, MD; Bryan Tompkins, MD; Jennifer M. Weiss, MD; Klane K. White, MD; Marcella Woiczik, MD.

Disclaimer

P. Nowicki: Editorial board for Orthopedics, paid consultant for Orthopediatrics. The remaining authors have no conflicts of interest to disclose.

References

1. Pew Research Center. Social Media Fact Sheet. Available at https://www.pewresearch.org/internet/fact-sheet/social-media. Accessed February 7, 2022.
2. Macauley R, Elster N, Fanaroff JM. Ethical considerations in pediatricians’ use of social media. Pediatrics. 2021;147:e2020049685.
3. Educational Commission for Foreign Medical Graduates. Ask the experts: physicians and appropriate use of social media. Available at https://ecfmg.org/echo/experts-social-media.html. Accessed February 13, 2022.
4. Schafer MF, Pearson LL. Social media for orthopaedic surgeons. October 1, 2010. Available at https://www.aaos.org/aaosnow/2010/oct/youraaos/youraaos11/. Accessed February 7, 2022.
5. Mazza JS, Shim JH. Building and managing your online presence. December 1st, 2016. Available at https://aaos.org/aaosnow/2016/dec/youraaos/youraaos9/. Accessed February 7, 2022.
6. Gabrielli AS, Mehran N. Watch out for common social media pitfalls. December 1st, 2020. Available at https://www.aaos.org/aaosnow/2020/dec/managing/managing03/. Accessed February 7, 2022.
7. Schuett DJ. Your patients and colleagues are on social media, and you should be too. September 1, 2020. Available at Your Patients and Colleagues Are on Social Media, and You Should Be Too (aaos.org) https://www.aaos.org/aaosnow/2020/sep/managing/managing02/. Accessed February 7, 2022.
8. Hilibrand AS. The value of social media for orthopaedic surgeons. November 1st, 2015. Available at https://www.aaos.org/aaosnow/2015/nov/youraaos/youraaos3/. Accessed February 7, 2022.
9. Jildeh TR, Okoroha KR, Guthrie ST, Parsons III TW. Social media use for orthopaedic surgeons. JBJS Rev. 2019;7(3):e7.
10. POSNA Photo/Video consent. Available at https://form.jotform.com/203234850062042. Accessed February 17, 2022.
11. Zhang D, Earp BE. Correlation between social media posts and academic citations of orthopaedic research. J Am Acad Orthop Surg Glob Res Rev. 2020;4(9):e20.00151.
12. Ihekweazu UN. Do not forget about HIPAA when posting on social media. November 1st, 2020. Available at https://www.aaos.org/aaosnow/2020/nov/managing/managing01/. Accessed February 7, 2022.
13. American Medical Association. Code of Medical Ethics Opinion 2.3.2: Professionalism in the Use of Social Media. Available at https://www.ama-assn.org/delivering-care/ethics/professionalism-use-social-media. Accessed December 29, 2021.
14. Mercurio AM, Sutton KM. Five best practices for the social media-inclined orthopaedic surgeon. January 1st, 2021. Available at https://www.aaos.org/aaosnow/2021/jan/managing/managing02/. Accessed February 7, 2022.