This column is a collaboration between AGD and the American College of Dentists. 

“What is interesting is the power and the impact of social media … So we must try to use social media in a good way.” – Malala Yousafzai, Nobel Peace Prize laureate 

Social media has changed the way we live and work — from the way we interact with our friends, families and patients to the way we get and disseminate information. Social media is powerful; it’s everywhere, and it’s unavoidable. Like any other tool, however, it can be helpful when used responsibly. As commonplace as social media sites like Facebook, Twitter and Instagram have become, the relational boundaries that separate healthcare professionals and patients when they interact on such sites have become blurred. As enjoyable and harmless as social media may seem, dentists, as well as all healthcare professionals, must manage their online presence with decorum and professionalism.¹ 

The relationship between dentists, patients and society is one based on trust and the premise that dental providers place patients’ best interests before their own. Dentists alone have the specialized knowledge and skills necessary to practice their profession and, as a result, are rewarded with great autonomy. In turn, dentists have a significant responsibility to honor that position of power in both their professional and personal lives. 

Regardless of how widespread and casual social media has become, dentists must represent the profession in a positive way, even on private time. As seen in recent headlines, at least one dentist has lost his right to practice and was sentenced to jail time in part for posting something unprofessional on a social media site.² While this case is egregious and such incidents are rare, when a dentist makes the national news for engaging in illegal or unethical acts online or otherwise, the whole profession suffers to some degree. 

When dentists choose to get personal with patients and become “friends” via social media, private and professional lives intertwine. Boundaries, which are the rules, limits and expectations health professionals create to define an appropriate professional relationship, become blurred. When intact, these boundaries help preserve trust, keep professional goals primary in the healthcare relationship and help the relationship run smoothly.³ 

Participating in social media with patients can cause boundary violations, which enable patients and professionals to get personal information about each other or interact in ways that fundamentally change the nature of the relationship into one that could potentially be inappropriate. These boundary violations not only confuse roles, but also create “dual relationships.” Dual relationships in healthcare occur when a dentist or other provider enters into or is inherently involved in a second, nonprofessional relationship with a patient. An example of this is when a dentist provides care to a friend or family member. A dual relationship exists because the person is both a patient at the professional level and a friend or family member on a personal level. Thus, the two relationships exist simultaneously.⁴ Compare this to a traditional provider-patient relationship that exists purely on the professional plane. While dual relationships in healthcare have always existed, social media has made it easier to form them. 

Conflicts arise in dual relationships when roles become unclear or the provider fails to place the patient’s best interest above their own — consciously or unconsciously. In a dual relationship, the circumstances can become awkward and even dangerous. Patients may not want to disclose private health information, such as certain medications or medical diagnoses, with the provider because they are embarrassed as a friend. This information could be very relevant to their care. The provider may also discover information about the patient that they did not want or need to know because of the social ties, leading to that patient being treated differently than others. Conversely, the patient may learn a little too much about the dentist’s private life. 

Privacy and confidentiality boundaries, which are firmly observed in a conventional professional relationship, become exceedingly more difficult to maintain in the presence of a dual relationship, especially when it involves social media. In addition to confidentiality concerns, some of the other potential consequences of boundary violations include issues such as patients expecting preferential or discounted treatment from their friend/dentist, inappropriate treatment requests, disregard for treatment advice and after-hours communication on a personal device, just to name a few. In the event of an adverse outcome, dual relationships have the potential to become awkward as both the patient and provider struggle with the dual roles. An unhappy patient might just leave a practice if the relationship was purely professional. However, a patient in a dual relationship may feel obligated to continue with care for fear of losing a friend, even if they are unsatisfied with the services provided. 

While social media is an excellent way to communicate and to interact casually with others, caution should be heeded when interacting with patients on such platforms. Personal and professional boundaries should be respected to prevent dual relationships and the ethical pitfalls that may result. 

Toni M. Roucka, RN, DDA, MA, FACD, is associate dean for academic affairs and a professor at the University of Illinois at Chicago College of Dentistry. To comment on this article, email impact@agd.org. 

References 
1. Kearney, Rachel. “Maintain Professionalism in a Digital Age.” Dimensions of Dental Hygiene, October 2016, dimensionsofdentalhygiene.com/article/maintain-professionalism-in-a-digital-age/. Accessed Nov. 2021.
2. Hauser, Christine. “Hoverboard-Riding Dentist, Found Guilty of Fraud, Is Sentenced to 12 Years.” The New York Times, 14 Oct. 2020, nytimes.com/2020/09/18/us/alaska-dentist-hoverboard.html. Accessed 2 Nov. 2021. 
3. “Ethical Boundaries in the Patient-Clinician Relationship.” National Ethics Committee of the Veterans Health Administration, July 2003, yumpu.com/en/document/read/29381048/Ethical-boundaries-in-the-patientclinician-relationship-nec-. Accessed 2 Nov. 2021. 
4. Barfield, E., and D. D’Angelo. “The Ethical Complexities of Dual Relationships in Dentistry.” Journal of the American College of Dentists, vol. 67, no. 2, 2000, pp. 42-46.

Professionalism in the Use of Social Media 

The American Medical Association (AMA) has issued a policy, “Professionalism in the Use of Social Media,” to help guide physicians in the appropriate use of social media. Dentists also need to be aware of their online presence and evaluate their digital impact. Concerning boundary-setting on social media, the AMA advises the following: 

1. Physicians should be cognizant of standards of patient privacy and confidentiality that must be maintained in all environments, including online, and must refrain from posting identifiable patient information online. 
2. When using social media for educational purposes or to exchange information professionally with other physicians, follow ethics guidance regarding confidentiality, privacy and informed consent. 
3. When using the internet for social networking, physicians should use privacy settings to safeguard personal information and content to the extent possible, but they should realize that privacy settings are not absolute and that, once on the internet, content is likely there permanently. Thus, physicians should routinely monitor their own internet presence to ensure that the personal and professional information on their own sites and, to the extent possible, content posted about them by others, is accurate and appropriate. 
4. If they interact with patients on the internet, physicians must maintain appropriate boundaries of the patient-physician relationship in accordance with professional ethics guidance just as they would in any other context. 
5. To maintain appropriate professional boundaries, physicians should consider separating personal and professional content online. 
6. When physicians see content posted by colleagues that appears unprofessional, they have a responsibility to bring that content to the attention of the individual so that he or she can remove it and/or take other appropriate actions. If the behavior significantly violates professional norms and the individual does not take appropriate action to resolve the situation, the physician should report the matter to appropriate authorities. 
7. 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 (particularly for physicians-in-training and medical students) and can undermine public trust in the medical profession. 

Source: “Professionalism in the Use of Social Media.” American Medical Association, ama-assn.org/delivering-care/ethics/professionalism-use-social-media. Accessed 2 Nov. 2021.