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So, Do You Want to Be Facebook Friends? How Social Media Have Changed Plastic Surgery and Medicine Forever

2017; Lippincott Williams & Wilkins; Volume: 139; Issue: 4 Linguagem: Inglês

10.1097/prs.0000000000003188

1529-4242

Rod J. Rohrich,

Web and Library Services

Social media is the ultimate equalizer. It gives a voice and a platform to anyone willing to engage. —Amy Jo Martin, American author I never thought that social media would have changed my life at all. Certainly, if you had asked me 10 years ago when Facebook and Twitter were still a toddler and infant, respectively, whether social media would change the practice of plastic surgery, I would have "unfriended" you! But, alas, social media have impacted the doctor-patient relationship, the marketing of practices and academic journal articles, and the perception of physicians by society. Much has changed in the social media sphere over the past 13 years. The landscape of social media has changed and evolved dramatically in the past 13 years. In 2003, MySpace dominated the social media market but now is virtually nonexistent. Mark Zuckerberg launched Facebook in 2004 as a closed network connecting students and then alumni from a small group of colleges. This became the disruptive technology that changed the game. It spanned generations, attracting high-schoolers, college students, parents, and even grandparents to social media, proving to be an innovative juggernaut. Then, in 2006, Twitter launched and revolutionized social media with its brevity and ability to disseminate information quickly to the masses. On a personal note, I launched my Twitter account in 2009, but did not become an active, daily user until several years afterward. At first, Twitter appeared superfluous; I thought it was nothing more than a modality for the famous (and some infamous) people to share their opinions 140 characters at a time. Although the social network may include a lot of celebrities, there are a lot of "real" people sharing information and passions on Twitter which, in my book, have truly made Twitter a success. Next came LinkedIn, which served as a platform to display your digital resume and develop an interactive, online Rolodex to open up career paths. Google Plus surfaced in 2011 and endeavored to capitalize on the search engine's popularity, but never burgeoned into everyday use like other Google products. Finally, newer media such as Pinterest, Snapchat, and Instagram are extremely popular among millennials like my children. Not all new social media survive. For example, Vine, the microvideo social network, was shuttered by the company that bought it: Twitter. Many more social media sites have gone the way of Vine because not all of them have staying power. For each social media platform that makes it, I would guess there are 10 that do not. Most are low-profile; others gather momentum and national attention but are forced out of the sphere anyway. However, the past decade has proven one thing: social media itself are not going away; they have become part of our lives, with good and bad side effects. SOCIAL MEDIA FABRIC Today, social media have become an integral part of the fabric of our lives, our society, and, of course, medicine, including plastic surgery—academically, personally, and professionally. Academic Over the years, through a learning curve, Facebook and Twitter in particular have become a way for us at Plastic and Reconstructive Surgery and PRS Global Open (@PRSJournal on Twitter; @PRSJournal and @PRSGlobalOpen on Facebook) to communicate and reach more readers. We are able to reach expanded networks of plastic surgeons and affiliated specialists, and the public, with the latest science in the field; we have been able to embark on public education campaigns to inform about board-certified plastic surgeons and true, safe, efficacious plastic surgery. Through our social media accounts, in conjunction with the accounts of the American Society of Plastic Surgeons (@ASPSNews and @ASPS_Members), we have launched award-winning communities (#PRSJournalClub) and showcased the great innovations at Plastic and Reconstructive Surgery and PRS Global Open rapidly when articles are published; we can broadcast advances in all of plastic surgery, RealSelf answers, YouTube videos that show and explain procedures and news in lay terms and show that plastic surgeons are "real people" in a good way. I share my own published articles by means of social media, and share other important works I have read—independent of the source—so that those in my networks can all be apprised of the latest science. Personal I use the networks for personal and professional purposes. For example, when I am not with my children, I routinely communicate with them by means of Facebook, Twitter, Instagram and, most recently, Snapchat (my millennial daughter's personal favorite). I consider contact with patients a personal matter too, but I do keep some boundaries: Just as I give all my patients my personal cell number and e-mail address so they can text me directly with any questions or problems and check in after their procedures, I give my patients the link to my public/professional Facebook page. They can communicate and interact with me on that platform but not in the postoperative time period; I still prefer patients to either call or text me with postoperative questions. In addition, I maintain a personal Facebook page enabling me to connect with family and friends that remains private from my patients—I never share or interact with patients from my private account! The slippery slope begins when patients become friends or friends become patients and then deciding who should gain access to which Facebook account. Many patients also find me on Twitter and interact with me there as well, asking surgical questions or providing reviews. Professional I professionally also use social media as a tool to share my life as a real plastic surgeon and my practice, the Dallas Plastic Surgery Institute, with patients and consumers. I don't think I'm alone in this: social media may soon supersede plastic surgeons' professional Web sites as the primary marketing tool for private practices. In my view, professional Facebook pages and public-facing Twitter accounts are the most common ways to market a plastic surgery practice by means of social media. However, more and more, Snapchat and Instagram have become very interesting venues to continue that social media interaction as well. A surgeon can post a photograph, video gallery, or even live, interactive surgery. However, as with most good things, there can be a darker side as well. So, let's take a closer look at the good, the bad, and the ugly sides of social media as a tool for plastic surgeons to teach the public what we do each and every day. THE UGLY One ugly side effect of social media is that they can pull you into their gravity, and make you feel you need to be connected 24/7. This can actually have a negative effect on your personal life and your practice. You can feel like you are living in a fishbowl with the world watching you and your every move. There is a healthy way to incorporate social media into your life and reap the benefits without compromising your time: it's all about setting clear boundaries, and achieving balance.1 The major ugliness on social media comes from anonymity-bolstered negativity and occasional abuse. Social media can draw a peculiar set of people who now have a voice to reach you, and affect you—and you cannot control. These trolls or cyberbullies can produce disparaging and false statements about you tantamount to vicious character assassination, mob mentality, and even emotional abuse. One can see the evidence in the recent U.S. presidential campaign, where social media have borne witness to malicious statements from both camps, and even more malevolence from the social media world at large—so much so that The New Yorker called 2016 "The Year of the Political Troll"2; the summer Olympics of 2016 showed ugly—and dangerous—to one of our American gymnasts3; the release of a female-led Hollywood reboot led to truly foul treatment of an actress.4 Often, the best way to handle these situations is to ignore the comments; in short, "don't feed the trolls." However, sometimes a response may be necessary—in cases like these, the best path forward is to be measured, evidence-based, and to not take it personally. In plastic surgery, particularly aesthetic surgery, patients who may be dissatisfied can turn to social media to unleash a tirade on their surgeon, challenging operations where millimeters produce profound changes. The challenge is to manage social media—which are essentially an open microphone for anyone to state anything, even utterly false claims—into a productive educational and marketing tool to promote patient safety and good outcomes. Knowledge is power, and having the right knowledge is the key to success in educating the patient. THE BAD Social media have no peer to peer filter. I have seen Snapchat and Instagram posts—and posts on the other social networks as well—advocating techniques and technology as if they were the gold standard, when what is being discussed has not even been written up in a peer-reviewed journal! All that is said goes unchecked and is often presumed to be true; and it is frequently not true. That is a major issue for both consumer awareness and patient safety issues. Some in medicine are mitigating the educational component and resorting to sensationalism to attract viewers. This type of social media can be extremely raw, giving viewers instant, unfiltered access to a vast array of medical information and opinions from various medical professionals (some of whom possess no credibility). This plethora of information truly puts the onus on the consumer to do more homework, more research, and more filtering to find out what information is true and useful versus what is false and potentially harmful. That is why Plastic and Reconstructive Surgery and PRS Global Open strive to promote evidence-based medicine and justify our social media comments with links to scientific studies as frequently as possible. We need to arm the public with the same information we have. That is why board-certified plastic surgeons and the Journal are in this social media arena—to promote scientifically proven methods and techniques by means of peer-reviewed articles after intense peer-review scrutiny. I encourage all plastic surgeons to ask their patients what they have read or heard about the procedure in question on social media, so you can help to set realistic expectations and weed out any misinformation. Furthermore, social media sharing of any patient image on these platforms must adhere to the same stringent patient consent process that we use to publish patient images in Plastic and Reconstructive Surgery and PRS Global Open. I have seen surgeons' live Snapchat videos of procedures such as rhinoplasty or even vaginoplasty, which can call into question ethical issues and Health Insurance Portability and Accountability Act of 1996 compliance. Any image or video including a patient, whether he or she is identifiable or not, should be approved—in writing—by the patient. If that is not possible, then at the bare minimum, any image that includes identifying imagery must have the patient's consent to post on social media. Remember: identifying imagery is not just the face or portions thereof. Tattoos, birthmarks, and even specific injuries can be used to identify a patient. It is imperative that any social media sharing that involves patients be done in a tasteful, safe, and ethical manner without compromising patient care and safety; and with consent. THE GOOD Facebook By means of your Facebook page, you can help educate the consumer about all aspects of plastic surgery and medicine. However, it takes time and some sustained effort to get enough followers to get noticed and to truly make a difference. We have found that spending even $5 on Facebook to "boost" a post can truly expand the reach of a given post; however, we are still looking through the data to learn whether that translates to lasting traffic or true conduits back to a practice site or journal article. Facebook Live is a novel tool that can be used to broadcast real-time advice and results. We at Plastic and Reconstructive Surgery are beginning to teach plastic surgery by means of Facebook Live and including, through our new "PRS Journal Grand Rounds," experts from all over the world discussing controversial topics and providing technical pearls. Twitter Twitter is a good platform for engaging a potentially large and diverse audience. Using hashtags is a good way to automatically consolidate topics and themes, especially if a certain hashtag is trending at the time. Some of the most frequent ones I use are #PlasticSurgery, #BreastReconstruction, #Rhinoplasty, #PRSJournalClub, and #ILookLikeASurgeon; of course, each of these has its own special uses. These hashtags are highly interactive and educational tools because they allow everyone talking about the same subject matter to find each other's information. Recently, I conducted a Twitter poll for 48 hours with almost 500 responses, asking which social media site gave them the most useful medical information. The public's social media response was Twitter. Obviously, it is clearly biased, because only Twitter users were surveyed, but is an interesting exercise nevertheless demonstrating the interactive component (Fig. 1).Fig. 1.: Final results of the author's Twitter poll: "Where do you currently get your best medical information using social media?"Snapchat and Instagram Snapchat and Instagram have rapidly evolved in plastic surgery into vast marketing tools. These applications have totally leveled the playing field for mass marketing of plastic surgery and medicine. An individual can make a huge splash with a single Snapchat or Instagram post, gaining social media traction quickly. There is an innate public affection for witnessing surgery, particularly live and interactive, that now some plastic surgeons are using to their advantage by sharing streaming videos from the operating room. If done well, these streaming live feeds can convert followers into patients, epitomizing social media's outreach as the ultimate marketer. However, there is an inherent challenge for all of us to prevent sensational marketing gimmicks that may lead patient or the consumer to believe or think we can solve all problems with a short video clip on Instagram or Snapchat. Some plastic surgeons have gained thousands (even millions!) of followers and become online stars by means of Snapchat and Instagram with campaigns such as live surgery broadcasts; however, this has been problematic at times by drawing attention to incorrect techniques and non–board-certified practitioners. However, in the hands of ethical, board-certified plastic surgeons, this extended educational and practice-marketing technique can be a positive experience if done in a fair and ethical manner to preserve the dignity and safety of the patient. Campaigns Consumers need to be aware of the differences between board-certified plastic surgeons and noncertified individuals. This is a huge opportunity for members of the largest plastic surgery societies to engage a large number of potential consumers and the public about who and what real board-certified plastic surgeons are, and what they do each day. The challenge is to present great and useful information that patients can use to find a real plastic surgeon, committed to safety and success with long-lasting, effective outcomes. The American Society of Plastic Surgeons has a recurring theme and "Do your Homework" campaign (#DoYourHomework) on social media encouraging patients to educate themselves on procedures and surgeons (Fig. 2). A recent article5 documented the early results of the "#PlasticSurgery" (Fig. 3) hashtag campaign on Twitter as a public education tool for true, board-certified plastic surgery and evidence-based results and research. Campaigns such as this can be used to combat online bullies and misinformation alike; and the upswell of communities following high-profile negative attacks of a few often reaffirm my faith in humanity, and social media.Fig. 2.: Twitter post from the American Society of Plastic Surgeons demonstrating the use of the "#DoYourHomework" hashtag as a public education tool.Fig. 3.: Twitter post from Plastic and Reconstructive Surgery demonstrating the use of #PlasticSurgery as a promotional tool for evidence-based medicine and peer-reviewed science.CONCLUSIONS Of course, social media have become an integral part of our lives. We use them to connect with family and friends; to market to patients; and to learn about novel operations, cutting-edge science, and what is happening in the world. Nevertheless, we must remain in control of how social media affect us, and how we use them. Otherwise, the consequences can be disastrous. Some days, I find myself checking my Twitter and Facebook accounts multiple times, often as much as my e-mails, as they provide a social release and an educational resource. Other days, I don't even look at social media at all. Although online platforms can initiate introduction to new people, they cannot and will never supplant face-to-face interaction, which I believe is crucial to creating and maintaining long-term friendships and meaningful doctor-patient interaction and education. It is essential to not let social media control your life and engross you, consuming your already limited time. Social media can be a powerful tool; it is up to you—the operator—to remain in control of this tool to maximize the presentation of your practice, your papers, and your profession. 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, activist for female education; youngest-ever Nobel Prize laureate ACKNOWLEDGMENTS The author would like to thank Anup Patel, M.D., and Aaron Weinstein for assistance editing this Editorial.