Etiquette for doctors on social media



    Are tolerance, understanding and humility in short supply in social media? The internet is helping to shape who we are, but as doctors we should also help to shape the online communities that we are a part of.

    Social media is used by hundreds of millions of people every day, and has become an integral part of everyday life for many. Online social networks have made the world a more accessible and smaller place than ever before, and have given us an unprecedented opportunity to contact a large group of people about work-related and private issues, unencumbered by distance and time delays. The diversity in public discourse has flourished, and anyone with a computer and internet access can potentially get their message out to the whole world in next to no time.

    The medical profession has also embraced the digital era, and the scope of remote teaching, apps, online forums and networking opportunities is seeing rapid growth. Where we were previously at the mercy of cluttered and dusty encyclopaedias – usually on a shelf in a far-off office – we now have the world's accumulated medical knowledge at our fingertips, just a few taps away. Clinical advice and discussions are no longer limited to the morning meeting and small talk over a sandwich at lunchtime, they can now take place anywhere – even with colleagues on the other side of the globe.

    Despite the possibilities, we are still novices when it comes to understanding how these media impact on us and how the nature of our interactions differs on digital platforms. We have had thousands of years to cultivate social conventions and perfect the art of face-to-face conversation, but our experience with digital communication only stretches back a few decades. The pen is said to be mightier than the sword, but perhaps we have replaced this sword with an automatic rifle in the form of a keyboard and the internet. Are we really able to handle communication via a chat function, or have we taken on something whose consequences cannot entirely be foreseen?

    Why do we use social media at all?

    Why do we use social media at all?

    The human race is a social species, and even if we disregard the effects of self-isolation during the pandemic, we have a great need for social interaction. Affirmation, a sense of belonging, self-assertion and voicing conflicting opinions are just some of the social needs that can be met in part via digital platforms. Participation in online social networks has been shown to have a number of positive effects: teenagers get a boost to their self-esteem and well-being when they receive positive feedback on their profile and posts (1). Those who have a low level of satisfaction with life have also been shown to experience positive social effects from online social networks (2). However, multiple studies have linked the use of social media to an increased incidence of anxiety and depression, and the effects of social media on our mental health are still a matter for debate (3).

    The online debating community

    The online debating community

    Personal experiences as both a participant and a spectator in a number of different online forums have shown that exchanges of opinion and debates can escalate and come to a head faster than during face-to-face encounters. The relative importance of the topic appears to be almost irrelevant. Uncompromising stances and harsh personal attacks are just as likely to occur in forums about wine or gardening as about international politics or religion. Background and education also do not seem to make much difference, and doctors and lawyers in free flow in the comments field are no less prominent than other occupational groups when it comes to offensive statements and generally distasteful behaviour.

    We have had thousands of years to cultivate social conventions and perfect the art of face-to-face conversation, but our experience with digital communication only stretches back a few decades

    The Council for Medical Ethics has dealt with several complaints about comments by doctors and how they present themselves in online newspapers and social media. Closed online forums for doctors have been an arena for heated debate where the moderators often have a difficult time trying to keep the discussions on a professional footing. Outside these closed groups, another factor also comes into play: when speaking publicly, we as doctors are inextricably linked to our clinical title. This could be seen as a paradox at a time when many young doctors wish to make a distinction between their role as a doctor and as a private individual. Nevertheless, when we post comments online and give the writer within us free rein, we will continue to be perceived as representatives of the medical profession – and our conduct and the views we express will therefore also impact on other people.

    Given that the internet offers almost infinite opportunities for valuable exchanges of views, learning and cooperation, how is it that arrogance, polarisation, personal attacks and conflict so easily take over?

    Algorithms, echo chambers and emotions

    Algorithms, echo chambers and emotions

    In the article 'Teaching Humility in an Age of Arrogance', philosophy professor Michael Patrick Lynch writes about how humility is increasingly giving way to arrogance in public discourse (4). The polarisation and escalation of the discourse we often see in social media is partly driven by the way that online media platforms work. The algorithms driving the internet are designed not only to give us access to vast amounts of information, but also to ensure that we receive more of precisely the kind of information that we want – and even the information that we did not know we wanted. With ever better precision and efficiency, we are served up advertisements, news items, suggestions for sites to follow, and political views that primarily reflect our own. The result is that we help to define our own echo chambers, in which we are fed more and more of what we already believe, and are encouraged to regard everyone who doesn't agree with us as misinformed and stupid. This scenario represents a breeding ground for arrogance and condescension, and solid doses of both self-reflection and self-confidence may be required to prevent us from being 'guided into' our own opinions and the voicing of them.

    The format of online debates and social media means that input is made up of brief, pointed statements with emotive content. A study by Brady et al. (2017) showed that posts with moral-emotional words were shared on social media far more than other posts. In their study, each moral or emotional word in a post on Twitter increased the probability of the tweet being shared by 20 % (5).

    In the vast stream of online information, posts that require more than a few seconds of users' attention are unlikely to capture their interest – which leaves little room for reflection and nuance. In other words, if you want to be seen and get a response, you need to shout loudly, keep it short and preferably pull at the heart strings.

    The more faceless and impersonal our interaction is, the easier it is to act without compassion or regard for the other party

    A post that directly attacks the health authorities' priorities or lambasts someone for their opinion on who should get priority for COVID-19 vaccines, probably gets shared far more widely and attracts a greater number of comments than a more balanced post. Why spend time and energy on ethical considerations and well-considered input when it will disappear and be quickly forgotten in the stream of emotive, sharply worded and populist posts?



    Our encounters with others on social media are inherently impersonal as we cannot see their body language or hear their tone of voice. This lack of direct feedback on our behaviour can be a major communication challenge, since we are used to continuously adapting our message and form of delivery based on the response we get. The more faceless and impersonal our interaction is, the easier it is to act without compassion or regard for the other party. When we attach a face, a story or a relationship to the person we are talking to, it is both easier and more natural to be empathetic – or respectful at the very least. The more GPs that a surgeon has as personal friends, the more difficult it is to tar them all with the same brush.

    On top of this, self-esteem that is temporarily bolstered as a result of the echo chamber effect has been shown to have a negative impact on behaviour and self-control (6). The sum of these effects produces an explosive SoMe cocktail, almost designed to escalate emotive discourse and conflict.

    Medical truths in social media

    Medical truths in social media

    Democratisation and the capability to rapidly disseminate information make it more difficult to figure out what is true. Healthcare professionals and patients have access to a vast amount of medical and scientific information online, and the individual's ability to critically assess the sources largely dictates the extent to which inaccurate information on medical issues is shared.

    In a study that investigated the differences in the diffusion of true and false news stories distributed on Twitter from 2006 to 2017, false news was interpreted by readers as more novel than true news, and was consequently shared more (7). The internet's algorithms do not differentiate between health information campaigns by the World Health Organization, World Diabetes Day, anti-vaccine movements or alternative medicine for cancer, and the evaluation of what is true is left to us.

    During the COVID-19 pandemic, we have seen a rapid acceleration in the dissemination of medical information via digital platforms, and the discourse on scientific truths in social media has been intense. Many people use social media as an important source of news (8, 9), and since few of us have a doctorate in epidemiology or in critically assessing sources, it has proved challenging even for well-educated clinicians to truly understand what we know and do not know at any given time. In February 2020, the World Health Organization warned that the massive 'infodemic' during the pandemic made it very challenging for the general population to find reliable sources and credible information (10). Nevertheless, self-appointed epidemiologists and experts have not been slow to come forward in both social and more traditional media to argue with great conviction that their truth is the truth.

    Intellectual humility

    Intellectual humility

    In light of this, one may ask whether moderation, humility and uncertainty have a place in social media – and whether they have the power to penetrate the arrogance, prejudices and challenging language. Can we trust those who loudly proclaim that they own the whole truth, or is the truth something we find together, through curiosity, discussion and a willingness to see other perspectives?

    We can also ask ourselves whether it is basically laziness that is to blame for the framework that social media create for discussion? Shouldn't we be able to have a civilised, inspired and mutually respectful conversation even if the platforms are facilitating something different?

    Shouldn't we be able to have a civilised, inspired and mutually respectful conversation even if the platforms are facilitating something different?

    Emily Chamlee-Wright, president of the Institute for Humane Studies at George Mason University in the United States, describes intellectual humility as the most fundamental ingredient of a good conversation. The world is a very complicated place, where no one can possess the whole and full truth, so our unique starting point is therefore both valuable and limiting. We bring with us our own insight by virtue of who we are and where we are from, but this defined starting point also means that we cannot embrace all of the knowledge that lies in the alternative perspectives of millions of other people. This limitation in our own knowledge of the world means that we should enter into any conversation or discussion with a large dose of humility. We need others to fill our knowledge gaps, and they need us (11).

    The possibilities

    The possibilities

    Social media is a potential treasure trove of fruitful discussion, learning and exchanges of opinions that transcend geographical and cultural divides. Today's doctors have a whole world of clinical experience, research results, health policy diversity and alternative perspectives available at their fingertips at all times. However, how we exploit the potential of these new arenas is ultimately up to us.

    Extensive advice and multiple guidelines have been written on good debate culture, including by Arne Næss (12) and the Storting (13). Of more concrete benefit to the medical profession is the Danish Medical Association's 'Good advice for doctors on social media' (14) (Box 1).

    Box 1 Good advice for doctors on social media

    Remember that you are still a doctor on social media

    Maintain a professional distance to your patients

    Remember your duty of confidentiality – even when inviting professional sparring on social media

    Maintain a good tone and communicate with respect

    Be aware of copyright and consent when sharing photos

    Be cautious with marketing and advertising

    Understand the rules for deleting personal data (GDPR)

    We can probably not expect everyone to agree on what constitutes a factual and constructive exchange of opinions online. Neither is it acceptable to cover up real disagreements and differences of opinion in the attempt to establish a more 'educated' debate, and we cannot moderate away everything that violates more or less accepted norms. Nevertheless, I would argue that most opinions and counter opinions can be expressed in a respectful manner. A perhaps somewhat utopian wish would be for those reading this text to internalise the following two considerations before writing their next post:

    1. Everyone (yes, absolutely everyone) is more than what you see.

    2. Everyone has knowledge and experience that you do not.

    Keeping these affirmations foremost in our mind may help prevent us from treating others disrespectfully. This also comes with a positive side effect: the odds of being listened to and treated in the same way increase considerably. With a little luck, we may even learn something from each other.

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