Abstract
Social media (SoMe) has established itself in the arena of healthcare, both as an educational tool and as a portal to connect healthcare professionals [1]. While SoMe has a number of benefits, there are concerns regarding online professionalism and patient confidentiality [2]. Accompanying images and videos have become popular content for surgeons to share when posting online [3]. However, content of this kind is sensitive and questions concerning patient consent can therefore arise. Indeed, while the cases remain at least isolated for now, lawsuit actions against healthcare professionals have been successfully filed for breaching General Data Protection Regulation, and medical licensing bodies have carried out suspensions and terminations based on inappropriate SoMe behaviour [4]. On certain platforms, such as X (formerly referred to as Twitter), all content is in the public domain, profiles are not private, and all posts are freely accessible and can never be truly deleted. We wished to explore this topic further and sampled 250 posts on X that were related to urological surgery. One by one, the nature and content of these posts was scrutinised. This is not an exhaustive and truly rigorous method; however, no blueprint for this kind of task exists and, moreover, a random snapshot was the goal. This was not a search for individuals to blame, nor did we register the details of who made the posts. Rather, this experiment represented an opportunity to take a step back and explore a general theme. The findings generate many questions, many more than we can cover here and for which simple solutions often do not exist. For better or worse, SoMe is here to stay. We feel our observations should allow readers to reflect on how they can improve their own practice at least. These observations can also serve as a starting point for dialogue in the surgical community as to how the situation can be improved while preserving the core values of the profession and the consent process. In not one of the 250 posts where either a video or image had been shared was there any comment made regarding the patient having given their consent to post it. Of course, it is fully possible that consent had been gained but not explicitly stated in the post. Perhaps, if we had sampled a further 250 posts, the same results may not have been found. However, if we explore the theme that perhaps many do not gain consent, it is worth reflecting that this is deeply problematic in many ways. How would a patient feel if they knew their surgeon did this? It may seem unlikely that a patient would ever come across such content but increasing numbers in the general public use SoMe to learn about the surgical treatments they will undergo as well as to search for the surgeon who will treat them [5, 6]. Even if a patient does consent to the images of their surgery being shared on SoMe, it is hard to know whether they understand what they are agreeing to. Arguably, patients should not be approached in the peri-operative period as they may feel pressured to agree. Furthermore, if consent is gained postoperatively, the patient may still be under the influence of anaesthesia or opioids. While it was largely surgeons sharing content, anaesthetists, medical device representatives and medical students also posted images. A camera phone was the most common equipment used to capture content in two thirds of cases. The frequent use of personal phones to take images is perhaps not a surprise but is nonetheless unsettling and, again, problematic. For example, the image or video may have already been uploaded to an online storage space even if deleted from the personal device. Users can add a content warnings and flag their own posts as containing sensitive content, but this was only done for one post. In several cases, the focus was on filming residents performing a procedure, often for the first time according to the video description. Had the patients been informed that a resident was the lead surgeon as well as it being their first case? Not to mention that it would be filmed and posted online? In two cases, the patient's face was fully visible, with no blurring, and further examples of the patient's date of birth and hospital identification number being clearly visible were also encountered. Even more concerning, is that paediatric surgical cases were found in this group too. Surgeons do use online video material to learn and, when it is a procedure that involves the genitals, it is necessary to see the anatomical area that is relevant to the specific operation, without blurring. However, SoMe is not a platform designed for surgical training. The minimum age for holding an account on X, for example, is 13 years, therefore, minors may encounter such posts. Furthermore, sharing images where a patient is bare and lying exposed in the lithotomy position is compromising and undignified for the patient. The onus should therefore really be placed on us as a surgical community to lead any changes rather than to criticise any specific platform that is currently available. So where do we go from here? Our random sample could present a bleaker picture than is the reality. A new secure platform for international learning, with accounts restricted to individuals with appropriate credentials, would be welcomed but is unlikely to materialise in the near future. Completely stopping sharing surgical images on SoMe would be another possibility, albeit perhaps an unrealistic one. Indeed, videos make for appealing content, generate attention and draw in more SoMe followers. Would people be willing to give this up? Perhaps too, even if someone does not post such content but simply ‘likes’ it, could they be unintentionally endorsing, and thus perpetuating this practice? Interim measures could be explored. For example, in other specialties, dedicated consent forms for SoMe have been created and these can be stored in the patient journal. Character limits in posts are appreciated. Could an acronym be used to help improve things? An example could be Consented to Image shaRe on SoCiaL mEdia (CIRCLE). This could be further shortened to a circle symbol. Moving forward and in conclusion, we challenge the individual reader to reflect on patient consent regarding the content of SoMe because upholding the core values of patient consent must be a constant, even if the world around is changing. None of the authors of this manuscript have any conflicts of interest to declare. All data were openly available in the public domain and ethical approval was therefore not deemed necessary.