The term ‘‘social media’’ refers to computer-mediated technologies that enable individuals and communities to gather, communicate, network, and share information (1). The use of social media in medicine is widespread and continues to grow among healthcare providers and trainees (2). Social media is a valuable tool for marketing and patient inter- action (3, 4). In addition, patients use social media to elicit help and support in navigating the medical system (5, 6). Women >18 years of age spend the most time online of all demographic groups and are more likely to use social networking and health-related websites than men (7). Infertile women and couples often use web-based information when selecting a medical practice (7) and will seek information online as a complement to guidance from a healthcare provider (8). Thus, for providers in the area of reproductive medicine, the use of social media presents unique opportunities; however, challenges also exist, specifically concerning online etiquette and outreach, ethics, and patient privacy (9). 

WHAT SOCIAL MEDIA PLATFORMS ARE RELEVANT TO PRACTITIONERS?

Available services in social media can be grouped into general categories based on their primary purpose. Although not an exhaustive list of categories and platforms, the types of social media most relevant to healthcare providers include (10):

1. Social networks such as Facebook, Twitter, and LinkedIn, that connect people, brands, and businesses online.
2. Networks that allow media-sharing of photos, videos, and audio, such as Instagram, Snapchat, and YouTube.
3. Networks that provide reviews of products, businesses, and brands by consumers, such as Yelp, Health- grades, Google, and ZocDoc.
4. Discussion forums that share news and opinions, such as Disqus, Reddit, Quora, and SREI community chat.
5. Sites that share visual content, such as Pinterest.
6. Sites that publish and comment on online content (blogs), such as WordPress and Tumblr.Although there are many services that facilitate communication among individuals, this publication will focus primarily on those platforms that facilitate bidirectional patient-provider interaction. The use of patient portals embedded in the electronic medical re- cord to communicate with patients and standard email are outside the scope of this document.

WHAT ARE THE POTENTIAL BENEFITS AND PITFALLS OF SOCIAL MEDIA IN PRACTICES SPECIALIZING IN REPRODUCTIVE MEDICINE?

Advertising and Patient Outreach

Social media, with its ability to reach large numbers of current and potential patients, can be a powerful tool for advertising and patient recruitment by increasing practice visibility (10). For example, social media can provide medical information about conditions that the practice specializes in evaluating and treating (such as infertility or pregnancy loss); attempt to recruit individuals to donate oocytes or for approved research studies; provide patients and potential patients with notifications about planned events or schedule changes, and can announce the addition of a new provider to the practice. The use of social media promotes the active engagement of users. Popular social media sites connect patients and providers with mutual interests via interactive dialogue. The generation of a successful campaign involving social media requires a constant stream of new, interesting, and relevant content that highlights the benefits of a particular center or the strengths and reputation of a healthcare provider. Because of this continuous need for new, unique, and interactive content, sites using social media must be managed more closely and updated more frequently than informational websites.

Measuring the return on investment in social media outreach for clinical practices can be challenging. Although it is straightforward to gather data about the number of page views and the number of patients who ‘‘like’’ particular posts, it can be much more difficult to measure if this social media engagement is translating into greater patient recruitment and satisfaction. Given the time required to establish, maintain, and evaluate the benefit of a presence on social media, practices may want to consider dedicating a staff member and/or hiring a third-party marketing agency to produce original content and to keep website information up to date, although this approach can add additional costs.

Social media may also be misused. Disseminating unsubstantiated or erroneous information, intentionally or unintentionally, may create a disservice to the public, who often lack the ability to analyze and verify information. Medical providers have an ethical obligation to provide accurate and transparent information and avoid misrepresenting or overestimating important metrics such as pregnancy success rates, both on websites and social media posts. Assisted reproductive technology (ART) programs in the United States are required by law to report success statistics annually to the Centers for Disease Control (11). The document ‘‘SART Policy for Advertising by ART Programs,’’ published by the Society for Assisted Reproductive Technology (SART), provides guidance on fair and truthful advertising and marketing campaigns, including those involving social media (12). Compliance with advertising guidelines is a requirement for membership in SART, whose member clinics perform the vast majority of ART procedures in the United States.

Additionally, it is understood that the provision of information and education is the central purpose of many social media posts by healthcare providers. However, this must be balanced against the medicolegal and ethical risks posed by giving medical advice to individuals who are not established patients of a particular healthcare practice or physician.

Professional Decision-Making and Scholarly Activities

Platforms using social media can provide clinicians with the opportunity to interact in private closed networks with other colleagues and experts from around the world (13). Such interactions can allow for online discussion and the collection of opinions regarding challenging patient issues, ethical dilemmas, surgical techniques, career strategies, legislative advocacy, and practice management (10). Social media platforms also can be used to promote scholarly publications, foster academic communication and dialogue, and promote research collaboration (13). Although physicians may discuss general experiences and issues involving patients in online networks and social media outlets, attention to patient confidentiality is of the utmost importance (14). In accordance with the Health Insurance Portability and Accountability Act (HIPAA) and state privacy regulations, information that may identify a specific patient should never be disclosed.

HOW SHOULD PHYSICIANS AND PRACTICES ESTABLISH A PRESENCE ON SOCIAL MEDIA?

Physicians can create individualized profiles on social media by developing content on sites such as LinkedIn, Doximity, Facebook, Instagram, and Twitter, among others. In addition, practices may consider establishing a group presence on social media. With either approach, physicians and/or practices should consider in advance the time and financial resources needed to develop and maintain their presence on social media. Although establishing and performing basic maintenance of any single account can be done easily, the time requirements can grow quickly depending on factors such as the number of platforms used, the number of physicians in the practice, the size of the practice, and viewership and engagement. However, maintenance of an up-to-date website or presence on a given platform is important, because patients often actively research multiple medical professionals and consider various treatment options on the internet before initiating contact with a clinic.

Ideally, practices should create formal policies about the plans and expectations of account management (15). These policies could include, but may not be limited to, the specific types of platforms on which a presence will be maintained, the frequency with which the site will be monitored, the minimum frequency with which new posts will be added, identification of specific personnel who are responsible for maintaining the posts (with plans for backup personnel as needed), and protocols for addressing posts from consumers or others that contain inflammatory content, reveal private health information, make requests for clinic or physician contact, or solicit medical advice. Security settings should be adjusted so that ‘‘tags’’ (i.e., identifiers that may be attached to a comment or video posted online) from consumers are blocked or must be approved by authorized administrators of the accounts. Security settings also can be adjusted so that only authorized page administrators can post content if desired (12). Practices also should be familiar with their institutional or group policies regarding the use of social media.

Medical practices should direct all online traffic to the practice’s professional page and discourage staff from sending ‘‘friend’’ requests to, or accepting requests from, patients directly. Instead of responding to personal ‘‘friend’’ requests, many professional organizations either recommend or insist on encouraging patients to ‘‘follow’’ a practice or professional profile on social media (13). It is important for staff members and medical providers to recognize that proper patient-provider etiquette applies equally to in-person and online interactions. Providers and patients also should not exchange protected health information through accounts on social media, as these channels are not encrypted, and patient confidentiality is thus at risk. For clinics that wish to post baby pictures or patient stories, documented consent from the patient should be obtained before publication. (16).

WHAT CONTENT SHOULD BE SHARED ON A PROFESSIONAL PAGE ON SOCIAL MEDIA?

Appropriate professional content on various platforms of social media can include, but may not be limited to:

1. Updates on administrative changes in the practice, including new staff members, closures, and holidays.
2. Videos or brief biographies of physicians and staff.
3. ‘‘Insider’’ views into the office, embryology laboratory, and other workings of the ART practice.
4. Educational material including:
   1. Updated national guidelines.
   2. Breaking medical news and discoveries.
   3. Research updates.
   4. Relevant, patient-directed videos.
5. Interactive activities to engage patients, including polls and general questions for patients.
6. Relevant legislation and issues related to advocacy.
7. Links to other appropriate websites, with appropriate disclaimers.

 It is important to remember that posts that facilitate engagement (including ‘‘likes,’’ shares, and comments) are more likely to increase exposure. Although social media may not impact traditional search engine optimization (often referred to by its acronym SEO), it provides a different type of sharing and reach that can augment a user’s ability to find one’s clinic or individual presence online. Briefly, a traditional online search has allowed people to find answers to specific questions, while social media leads people to discover answers to questions that may not have immediately been thinking of. Both search and social media can help drive patients to one’s services. These forces are not competitive but complimentary and, as a result, it is important to keep social media content updated and current.

HOW SHOULD PRACTICES AND PROVIDERS MANAGE NEGATIVE COMMENTS POSTED ONLINE?

Regardless of whether physicians engage directly with patients using social media, patients can easily research and discuss physicians and practices online. Patients may leave a negative review either on an online medical review website or through posts on social media. Thus, monitoring the practice’s online reputation allows for proactive management of any negative reviews that might arise.

Patient complaints and concerns should be addressed directly and quickly. Details of a particular patient interaction should not be addressed online, because of concerns about patient privacy and the potential for the practice or physician to appear defensive. Instead, consideration should be given to contacting the patient directly (if identifiable) to address any complaints or concerns or, if this is not an option, publicly acknowledging the posted concerns and providing the patient with a direct contact for ‘‘offline’’ discussion of the issue, which can further demonstrate a commitment to patient satisfaction. Attention to legitimate concerns also provides an opportunity for corrective action at the practice level. Furthermore, a professional, responsible, yet courteous response to an inflammatory post can reflect positively about the integrity of the clinic and/or individual. Another strategy commonly employed to address negative posts involves increasing positive ‘‘traffic’’ by encouraging patients to provide ratings online, which can help divert attention from negative comments (17).

The use of social media can reach a wider audience; however, it also carries the potential for unknown users to interact with the site and post undesired or derogatory content, including comments or photos that are inflammatory and/ or offensive. Examples of problematic posts include those containing obscenity, pornography, hate speech, or ‘‘trolling’’ posts (those made in a deliberately offensive or provocative manner with the intention of eliciting angry responses or up- setting others). Most platforms allow the administrator to either approve a post before it is published, hide a post after it is published, or delete a post or specific comment if inappropriate (17). Management of potentially offensive posts requires close monitoring by the platform’s designated administrator.

HOW SHOULD REQUESTS FOR PERSONAL MEDICAL ADVICE BE HANDLED?

Patients may attempt to use social media platforms for medical advice. Practices should develop plans and policies for monitoring these platforms and responding to posts, which could be as simple as directing patients to schedule an appointment for consultation. Medical advice geared toward a specific patient should not be offered online under any circumstances. However, patient education can be an important part of a presence on social media and should be encouraged. For example, educational articles or links posted by the practice would not constitute medical advice. It is advisable to include a disclaimer statement to this effect on posts of this nature or in the profile section of the account.

SHOULD PROVIDERS MAINTAIN SEPARATE PERSONAL AND PROFESSIONAL ACCOUNTS ON SOCIAL MEDIA?

The use of separate personal and professional accounts should be considered. With the increasing prevalence, variety, and use of social media sites, it is understandable that many physicians will maintain a personal presence. Posted ‘‘personal’’ content is public and may be visible to current or future patients and other providers; it is generally a good policy to assume that anything said or posted online may be visible to anyone and available forever. To make it difficult for patients to find personal pages on social media, physicians should consider altering their names on their personal accounts (such as replacing a letter in their name with a space or character or using a pseudonym altogether) or making personal accounts private. The use of appropriate security settings (e.g., making an account ‘‘private’’ instead of ‘‘public’’) may mitigate liability but cannot assure privacy. Because of such considerations, it has been argued that when having both personal and professional social media accounts, physicians should maintain these separately (18). Alternatively, some have argued that this separation is inconsistent with the general concept of professional identity as an extension of personal identity, that physicians are not required to avoid patient interactions in other arenas (such as in small or rural communities), and that patients may in fact benefit from a more ‘‘personalized’’ online interaction with their physicians (19, 20).

Regardless of the approach taken, physicians would do well to remember that physician professionalism includes adherence to high ethical and moral standards, a commitment to excellence, and the demonstration of core humanistic values including honesty, integrity, caring and compassion, altruism and empathy, trustworthiness, and respect for others, regardless of whether they are using their personal or professional account (21). With these thoughts in mind, physicians using social media should avoid discussion of specific patient conditions, depictions of ‘‘unprofessional’’ behavior, or other posts that might be perceived as ‘‘unprofessional’’ at any time (20). Physicians using social media may also inadvertently see unintended things about patients that influence patient care. Ultimately, patients view physicians first as professionals, and anything they see online about their physicians can influence their opinions of them, whether that is a political or religious belief or personal information they find offensive. The content of the online presence of physicians may also influence their reputation among other providers and therefore could have ramifications for their medical career. Physicians should consider notifying other professionals or colleagues when they see posts they have made that may be considered inappropriate, as the issue may have arisen unintentionally.

It is imperative for physicians to remember that state medical boards and workplaces have the option to discipline physicians for inappropriate online conduct, including inappropriate HIPAA disclosures, with actions ranging from a reprimand to revocation of license (22). It also should be explicitly noted that legal cases should never be discussed on social media, as even anonymous posts may be linked to a specific person or incident and are usually considered ‘‘discoverable’’ by law. For example, a disclaimer on Face- book, a commonly used platform, states that ‘‘we may access, preserve, and share your information in response to a legal request’’ (12).

In conclusion, the use of social media presents both opportunities and challenges for physicians. Interactions on social media may be perceived by healthcare professionals as being overly casual and lacking structure compared with the traditional physician-patient relationship. However, the use of social media offers many opportunities for patients to communicate and interface with their physicians and practices in a more personal way, and the increase in patient satisfaction that may result can improve the physician-patient relationship. The use of social media may lead to better compliance, communication, understanding, and patient care, as well as an improved experience both for the physician and the patient. Social media is a powerful tool for patient communication that can increase awareness and education regarding health and ultimately lead to better health equity and access.

RECOMMENDATIONS

1. Practices/clinicians that encourage contact through social media accounts should dedicate sufficient resources to respond to patient queries, as patients could perceive this as a standard way of contacting the clinic.
2. Content, including any protected health information, should have documented patient consent before publication.
3. Practices/clinicians should consider developing formal policies outlining the expectations of how social media accounts should be created and managed.
4. Practices/clinicians should discourage their employees from interacting with patients through their personal accounts on social media.
5. Providers should have separate professional and personal accounts and consider tightening the security settings on their personal accounts, while recognizing that all social media posts, regardless of whether they are personal or professional, will reflect on the physician.
6. Practices/clinicians should be aware of and follow group policies pertaining to accounts on social media if they are part of a group practice or employed by an academic institution.

Acknowledgments: This report was developed under the direction of the Practice Committee of the American Society for Reproductive Medicine (ASRM) in collaboration with the ASRM Technology Committee and the Society for Assisted Reproductive Technology (SART) Advertising Committee as a service to its members and other practicing clinicians. Although this document reflects appropriate management of a problem encountered in the practice of reproductive medicine, it is not intended to be the only approved standard of practice or to dictate an exclusive course of treatment. Other plans of management may be appropriate, taking into ac- count the needs of the individual patient, available resources, and institutional or clinical practice limitations. The Practice Committee, the Technology Committee, and the Board of Directors of ASRM and the SART Advertising Committee have approved this report. This document was reviewed by ASRM members and their input was considered in the preparation of the final document. The Practice Committee acknowledges the special contribution of Eli Reshef, M.D.; Amanda Kallen, M.D.; Serena Chen, M.D.; Jason Yeh, M.D.; Keenan Omurtag, M.D.; and the ASRM Technology Committee and the SART Advertising Committee in the preparation of this document. The following members of the ASRM Practice Committee participated in the development of this document. All Committee members disclosed commercial and financial relationships with manufacturers or distributors of goods or services used to treat patients. Members of the Committee who were found to have conflicts of interest based on the relationships disclosed did not participate in the discussion or development of this document. Alan Penzias, M.D.; Ricardo Azziz, M.D., M.P.H., M.B.A.; Kristin Bendikson, M.D.; Samantha Butts, M.D., M.S.C.E.; Christos Coutifaris, M.D., Ph.D.; Tommaso Falcone, M.D.; Clarisa Gracia, M.D., M.S.C.E.; Micah Hill, D.O.; Karl Hansen, M.D., Ph.D.; Sangita Jindal, Ph.D.; Suleena Kalra, M.D., M.S.C.E.; Jennifer Mersereau, M.D.; Randall Odem, M.D.; Robert Rebar, M.D.; Richard Rein- dollar, M.D.; Mitchell Rosen, M.D.; Catherine Racowsky, Ph.D.; Jay Sandlow, M.D.; Peter Schlegel, M.D.; Chevis N. Shannon, Dr.P.H., M.P.H., M.B.A.; Anne Z. Steiner, M.D., M.P.H.; Dale Stovall, M.D.; Cigdem Tanrikut, M.D.; Hugh Tay- lor, M.D.; Belinda Yauger, M.D.; and Michael Vernon, Ph.D.

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