Physician Violations of Online Professionalism and Disciplinary Actions: A National Survey of State Medical Boards FREE

To the Editor: The use of social media by physicians to post unprofessional content online has been well documented.^1- 2 While concerns about online professionalism have prompted the creation of guidelines for social media use from professional societies such as the American Medical Association,³ there is no information about oversight by licensing authorities for physician uses of the Internet or disciplinary consequences for violations of online professionalism.

We surveyed the 68 executive directors of all medical and osteopathic boards in the United States and its territories about violations of online professionalism reported to them and subsequent actions taken. The survey was developed with input from key informants from a representative sample of 10 state boards to determine online actions by physicians most likely to directly affect patients. This study was conducted in partnership with the Federation of State Medical Boards (FSMB) and was approved by the institutional review board at Yale University School of Medicine.

The response rate was 71% (48/68). These 48 boards are responsible for the medical licensure and discipline of 88% of the approximately 850 000 physicians in the FSMB database with an active license in the United States and its territories.

The majority of respondents (44/48; 92% [95% CI, 86%-98%]) indicated that at least 1 of several online professionalism violations had ever been reported to their board (Figure). The most common violations reported were inappropriate patient communication online, eg, sexual misconduct (33/48; 69% [95% CI, 58%-80%] for ≥1 violations); use of the Internet for inappropriate practice, eg, Internet prescribing without an established clinical relationship (30/48; 63% [95% CI, 52%-74%]); and online misrepresentation of credentials (29/48; 60% [95% CI, 48%-72%]). Most boards indicated that incidents had been reported to them by patients or their families (31/48; 65%), although report by other physicians was common as well (24/48; 50%) (Table).

In response to such violations within their jurisdiction, 71% (34/48) of boards held disciplinary proceedings, including formal disciplinary hearings (50%; 24/48) and issuing of consent orders (physician agrees to sanctions without a hearing: 40%; 19/48) (Table). In additional, 40% (19/48) of boards issued informal warnings and 25% (12/48) reported at least 1 instance in which no action was taken. Collectively, serious disciplinary outcomes of license restriction, suspension, or revocation occurred at 56% (27/48) of the boards.

Most US medical licensing authorities reported incidents of online professionalism violations by physicians, many of which resulted in serious disciplinary actions. While the total number of these actions is relatively small compared with the approximately 65 000 lifetime board actions taken against all licensed physicians currently in the FSMB database, this is likely to change as the use of social media continues to grow. Furthermore, these violations also may be important online manifestations of serious and common violations offline, including substance abuse, sexual misconduct, and abuse of prescription privileges.⁴ In addition, these incidents are highly problematic in their own right because they reflect poorly on physicians' values to the public.⁵

Our study has limitations. First, these violations are not currently tracked in the FSMB database and our survey data may be subject to recall bias. Second, we did not match individual violations with specific disciplinary actions or outcomes. In addition, we inquired about lifetime events so we cannot describe yearly incidence or trends over time.

Professionalism is a core competency required for maintenance of licensure and specialty recertification. Regulators and physicians should therefore address emerging online practices. In addition, as state licensing boards monitor physicians for breaches of professionalism, categorizing online professionalism violations separately could be of value to better gauge the extent of this problem. Our findings highlight the need to promote physician understanding and self-monitoring of online professionalism⁶ and to create consensus-driven, broadly disseminated principles to guide physicians toward high-integrity interactions online.