This article was modeled after The New York Times’ opinion feature, The Conversation, and has been lightly edited for clarity.

Tiffany: Good morning, Gaetan! Having just checked my Instagram feed and Twitter for the latest #FOAMed (free open access medicine) news and pearls, I couldn’t help but notice the occasional product advertisement or self-promotion. Physicians are carving out side gigs and businesses that complement their clinical jobs and/or transition to entirely non-clinical jobs, sometimes working in a non-health care industry altogether. Also, Instagrammable moments are harder to pass up for bigger and broader swaths of generations.¹ So here’s the next conversation starter: where should the ethical line be drawn between the clinical practice of medicine—and and our Hippocratic oaths to patients’ health and well-being—and modern physician work or leisure that involves social media?

Gaetan: Greetings, Tiffany. What a timely topic. Maybe you noticed that last week, I was invited by a Twitter friend to post one photo (without people or explanations) per day for seven days, and to invite a new friend to participate with each post. And didn’t you join in with a photo of one of those lovely Amsterdam canals? It’s a modern take on the chain letter format that was popular when I was a kid, only now I’m a physician with a “professional” Twitter profile that identifies me as a “clinician and educator.” That’s the kind of bio that makes me think twice about posting glamor shots of cheesesteaks and hoagies (as I might have in my younger days). And then there’s the related issue of physicians’ relationships to industry. I think all of this falls under the heading of “professionalism,” and raises questions about the images we project and the influence we wield on social media.

Tiffany: Indeed, I joined in and chain tweeted, posting a photo at dusk from Ghent, Belgium (#nofilter)! More importantly, you’ve raised a key part of the conflict here: professionalism. As physicians, we practice: professionalism. As physicians, we practice a profession, meaning we are experts who are specially trained in a particular field and are expected to abide by certain social and behavioral norms that reflect the expertise we practice.² Related to this is also the ethical and moral obligation for physicians to disclose conflicts of interest, even—or especially—when those conflicts potentially are ones created on their own. Consider, for example, the history of pharmaceutical companies’ influence on physicians’ prescribing behaviors and, in turn, their effect on patient care, outcomes, and related costs. Could using social media make us more vulnerable to behavioral nudges, conflicts of interest, and consequent unintended effects on patient care?

Gaetan: I don’t know that social media necessarily invites conflicts of interest as much as it may amplify ones that already exist, but I’m more interested in the professionalism question. You mentioned #FOAMed, the twitter hashtag for Free Open Access Medicine, which is emblematic of a major shift in the way doctors receive and share information. Platforms like Twitter have allowed physicians to circumvent traditional channels—like the peer-reviewed publication process—to communicate directly with each other and the general public. This feels like a mostly positive development; it seems like every day someone is giving Grand Rounds on how to leverage Twitter to advance careers in academic medicine. But the open access model has some potential drawbacks. For an impulsive and often impassioned tweeter, the lack of editorial oversight is a bit frightening. On one hand, I’m free to offer an unlimited quantity of unsolicited advice and opinion. On the other, we’re all just one poorly-considered post away from undermining our professional standing. One question is how much does professionalism depend on the kind of “professional distance” that social media is erasing?

Tiffany: Your point raises a really interesting crossroads between what is means to be “open access” versus just microblogging via social media. Has “open access” been co-opted to mean something on social media that is different from what it was originally intended? In academic publishing, open access refers to removing paywalls between publishers and readers—and to this day remains a point of contention that is a whole other ethical quandary in itself. But is #FOAMed the same thing? Are we claiming to remove a paywall from something that was never intended to have one in the first place? At this point, I’m feeling obligated on the note of social media and professionalism to highlight key guidance statements on this for physicians from the American Medical Association,³ American College of Physicians and the Federation of State Medical Boards.⁴ The latter I think touches precisely on what you’re referring to: “It is paramount to...ensure trust in physicians and in the medical profession...To protect patients and the public and promote quality health care.”

Gaetan: i just double checked and can confirm that #FOAMed is indeed a free for all of tweetorials, evidence-based medicine, stories, and opinions related to the medical profession. The vast majority of contributors are physicians, suggesting that this and other hashtags (I’m looking at you #medtwitter) have become important online spaces for doctors to teach, learn, reflect, and network. Not surprisingly, advertisers have noticed. A brief scroll through one of my personal favorites, #medhumchat, revealed ads for a urine biomarker to detect bladder cancer, a popular over-the-counter cold medicine, and… wait for it… Red Lobster!

Tiffany: This sounds like a concept again appropriated and morphed into something different than it originally was intended to convey, which is both unsurprising in how human language and communication has evolved, but also could be viewed as a disappointment regarding the devaluation of scientific method and medical knowledge. I risk antiquating myself in saying that, and should clarify that I am absolutely an advocate for change and progress. And I am also grateful for the serendipitous opportunities to connect with people from all over the world via social media: it happens with increasing frequency every year that I “meet” a researcher or advocate or clinician through social media interactions well before I ever meet them in-person. But the virtual community and network brings us into each other’s orbit to be able to foster connections around a common value or belief, cause, or more simply, a shared academic topic of interest. So, Gaetan, what can we say in closing about where social media and physicians’ personal and professional lives intersect? What responsibilities and positions should we be taking as a community to ensure the veracity and integrity of all that #FOAMed along with the (mis)information out there?

Gaetan: Well it doesn’t sound like either of us are willing to give up the #FOAMed or Twitter, so how about “Tweet like your patients are watching.” (Because they are.)