Social Media Guidelines and Best Practices: Recommendations from the Council of Residency Directors Social Media Task Force

Social media has become a staple of everyday life among over one billion people worldwide. A social networking presence has become a hallmark of vibrant and transparent communications. It has quickly become the preferred method of communication and information sharing. It offers the ability for various entities, especially residency programs, to create an attractive internet presence and "brand" the program. Social media, while having significant potential for communication and knowledge transfer, carries with it legal, ethical, personal, and professional risks. Implementation of a social networking presence must be deliberate, transparent, and optimize potential benefits while minimizing risks. This is especially true with residency programs. The power of social media as a communication, education, and recruiting tool is undeniable. Yet the pitfalls of misuse can be disastrous, including violations in patient confidentiality, violations of privacy, and recruiting misconduct. These guidelines were developed to provide emergency medicine residency programs leadership with guidance and best practices in the appropriate use and regulation of social media, but are applicable to all residency programs that wish to establish a social media presence. [West J Emerg Med. 2014;15(1):26-30.]

# Introduction
The term "social media" encompasses a wide variety of Internet-based resources to share content among users. This term includes social networking sites, video-or picturesharing sites, forums, blogs, and other tools. Information

## Pillow et al
Social Media Guidelines and Best Practices medicine (EM), "...use of social media among emergency physicians is unusually strong... emergency physicians have embraced the healthcare side of social media in a way not seen among other specialists."In addition to the various EM blogs and sites covering daily practice issues, there has even been a call for integrating social media into emergencypreparedness efforts. [bib_ref] Integrating Social Media Into Emergency-Preparedness Efforts, Merchant [/bib_ref] Social media has now become a preferred method of communication and information sharing. It offers the ability for various entities, especially residency programs, to create an attractive Internet presence and "brand" the program.Social media, while having significant potential for communication and knowledge transfer, carries with it legal, ethical, personal, and professional risks. [bib_ref] Revisiting Social Network Utilization by Physicians-in-Training, Black [/bib_ref] [bib_ref] Health professions students' use of social media, Giordano [/bib_ref] [bib_ref] Medical professionalism in the age of online social networking, Guseh [/bib_ref] [bib_ref] professionalism and Facebook: a dilemma for young doctors, Macdonald [/bib_ref] [bib_ref] The Intersection of Online Social Networking with Medical Professionalism, Thompson [/bib_ref] [bib_ref] Professionalism in the digital age, Mostaghimi [/bib_ref] [bib_ref] Online professionalism: social media, social contracts, trust, and medicine, Snyder [/bib_ref] The negative side of social media is highlighted in multiple publications, which illustrate problems including disclosure of private information and lapses in professionalism. [bib_ref] Online Posting of Unprofessional Content by Medical Students, Chretien [/bib_ref] [bib_ref] It's your own risk: Medical students' views on online posting, Chretien [/bib_ref] [bib_ref] Physician, monitor thyself: professionalism and accountability in the use of social media, Lagu [/bib_ref] [bib_ref] professionalism and Facebook: a dilemma for young doctors, Macdonald [/bib_ref] [bib_ref] Facebook activity of residents and fellows and its impact on the doctor-patient..., Moubarak [/bib_ref] [bib_ref] How facebook almost ended my career with a single click, Strausburg [/bib_ref] Due to the unique climate of social media, even simple actions like "friending" (a function of social media platform Facebook  , whereby one user can request to be a "friend") can be misinterpreted as violations of professional or personal boundaries. Despite the dangers, social media offer tremendous benefits for recruiting, communication, and education. [bib_ref] How facebook saved our day!, Ben-Yakov [/bib_ref] [bib_ref] Twitter: an essential tool for every physician leader, Bottles [/bib_ref] [bib_ref] Twittering healthcare: social media and medicine, Terry [/bib_ref] Implementation of a social networking presence must be deliberate, transparent, and optimize potential benefits while minimizing risks.
These guidelines are designed to provide guidance to EM residency programs not only for the development and use of a program-specific social media presence, but also for the education of residents in potentially problematic use of social media that may impact professional functions in their private life. They are designed to complement and do not supersede any institutional guidelines or local, state or federal laws. The social media guidelines outlined in this paper constitute an expert consensus opinion for best practices and are approved by the Council of Emergency Medicine Residency Directors (CORD) Board of Directors as of November 2012.

# Methodology
Several hundred EM residency directors and other academic faculty members attended a lecture on the issues of social media in resident selection at the March 2011 CORD Academic Assembly. Following that session, a Social Media Task Force was assembled consisting of 14 geographically diverse educational leaders. The group met regularly over the next 14 months to review available literature and policies.
Policies from the institutions represented on the task force were reviewed when they existed (including Mayo Clinic,Regions Hospital,University of Michigan,Baylor University,Eastern Carolina University, and Carolinas Medical Center. In addition, policies from national organizations were obtained and reviewed including those from Society of Academic Emergency Medicine (SAEM),American Medical Association (AMA),and Indiana State Bar Association (ISBA).A literature search was performed for additional resources using search terms of social media, education, graduate medical education and professionalism.
There was considerable variation among these institutions as to the presence and content of a social media policy. While many universities and professional organizations had social media policies designed to restrict employee activity to protect the institution, few if any encouraged social media use. None addressed the unique needs of residents and residency leadership. Much of the literature reports residents unintentionally or unknowingly violating institutional policies and suffering professional consequences.
After review of the literature and existing institutional and organizational guidelines, the task force developed a graduate medial education (GME)-specific set of recommendations. These were then independently reviewed by Tobi Tanzer, J.D., vice president of integrity and compliance for Health Partners-Regions Hospital. The guidelines were then submitted to the CORD Board of Directors for review and endorsement.

## Recommendations
It is our strong recommendation that each residency program develop a social media policy and education effort. [bib_ref] Social media policies at US medical schools, Kind [/bib_ref] [bib_ref] Social media in medical school education, Wells [/bib_ref] Institutional officials should be involved in the development of these materials. The initial discussions should be held with the designated institutional officer (DIO), public affairs, legal or privacy officer, and information technology (IT) departments for consideration of any existing policies and procedures, as well as subtleties of law relevant to public versus private institutions.

## Content management
When a program initiates a sponsored social media site, it should designate a content manager (moderator) who is a permanent employee (i.e. not a trainee) who will assume responsibility for the maintenance and monitoring of posted content. That content manager needs to be proficient in the operation of the chosen platform as it pertains to administrative issues regarding posting, access, and privacy. That person also needs to ensure routine updating and monitoring of the site. In addition, plans for transfer of content management should be made in advance to facilitate a smooth transition. Areas of responsibility for the content manager include: Site management is an evolving realm with unforeseen risks. Content managers may be responsible or liable per individual institutional requirements, for all content posted on the sites. [bib_ref] A legal primer for social media, Burke [/bib_ref] [bib_ref] Online Professional Networks for Physicians: Risk Management, Hyman [/bib_ref] It is recommended that content managers frequently communicate with the institution regarding site content and any questions be vetted by the institution before posting. It is important to note that once content is placed on an institutionally sponsored site, it is then owned by the institution and not the posting individual or the content manager. [bib_ref] A legal primer for social media, Burke [/bib_ref] 

## Communication plan
A program should have a communications plan/policy that proactively addresses the use of social media and potential issues. This should encompass: - Plans to deal with adverse events, including spam, negative comments, complaints, and unprofessional behavior.

## Residency program-specific issues education
Residency programs should provide guidance and education to residents, fellows, faculty, and other personnel under their supervision regarding appropriate social media use. Particular attention should be paid to professionalism issues, including personal reputation and medical privacy.Direct policing of individual resident or personnel activities on the Internet (aside from on the department-sponsored social media site) is discouraged as it represents a significant intrusion into resident privacy and is beyond the capability and purview of a residency program. However, should an issue involving a personal site be brought to the attention of a program, it is the responsibility of the program to take appropriate action to protect privacy and professionalism standards.

## Professionalism and privacy
Professionalism and privacy issues are accentuated on social media. The same standards of professionalism and privacy are required online as in person, but normal standards may not be sufficient to avoid misperceptions or legal issues. Residents should familiarize themselves with the American Medial Associations' Professionalism in the Use of Social Media guidelines. [bib_ref] Report of the AMA Council on Ethical and Judicial Affairs: professionalism in..., Shore [/bib_ref] Posted content must be assumed to be permanent, public, and even if deleted may still exist in an archive, database, or download formats. Information may prove to be damaging to an individual's reputation among colleagues and patients, and may affect future relationships and employment.Privacy settings are relatively easy to circumvent and should not be relied upon to protect postings from public disclosure. Respect for patient confidentiality is essential as federal and state confidentiality laws apply to social media sites. [bib_ref] A legal primer for social media, Burke [/bib_ref] [bib_ref] Patient privacy and social media, Hader [/bib_ref] [bib_ref] The decision to access patient information from a social media site: what..., Jent [/bib_ref] Even de-identified discussion of patients and specific medical cases on social media sites should be avoided.

## Recruitment & educational relationships
A program should recognize the potential for inequitable relationships to exist through social media. Institutional guidelines with regard to harassment and appropriate relationships should be applied to interactions on social media as in other venues. It is our strong recommendation that people in a position of power/authority not initiate a personal online relationship with an individual in a subordinate position. Exceptions may be made for situations where it is appropriate for monitoring a remediation/probationary circumstance or for primarily educational group experience, such as with an online journal club hosted on a social media platform.
A program director or other individuals in positions of authority (e.g. chief resident) should apply a consistent action to requests for a social media relationships to avoid favoritism or perception of such. It is recommended that individuals in a position of authority maintain a separate public presence that may be used for residency purposes such as facilitating online educational interactions (e.g. Facebook  journal club) or monitoring a trainee for remediation purposes, including monitoring of professionalism if previous issues have existed.
Significant controversy exists with regard to whether a program should search for online information about prospective residents. [bib_ref] Protected health information on social networking sites: ethical and legal considerations, Thompson [/bib_ref] Each program should individually decide whether and how they will use online information and consistently apply the same standard to all applicants. This decision should encompass consideration of:

# Conclusion
Every residency program should develop a social media policy and educational effort for learners with early involvement of institutional personnel. The program should designate a content manager who is responsible for the site, including compliance with institutional regulations. The program should also have a communications plan that addresses the use of social media in an anticipatory manner. Proper use of social media is a key professionalism issue, and it is the responsibility of the program to provide education to residents, fellows, faculty, and other staff under their supervision. Although social media can be a powerful tool, programs should recognize that the potential for inequitable relationships exist. Individuals in a position of authority, in general, should not initiate an online relationship with an individual in a subordinate position.
These guidelines were developed to assist residency program leadership with appropriate use of social media platforms. Additional resources are being made available online through CORD to assist with educational efforts. These will be found at http://cord.sharepointsite.net/default.aspx.
[fig] : Target audience Purpose of the site, including educational objectives and explicit consideration of the function of the site such as degrees of access and interactivity planned Level of privacy and security required Issues of medical advice and redirection of patients to appropriate venues [/fig]