Ethical Considerations in Pediatricians' Use of Social Media - OHSU
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CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care
Ethical Considerations in Pediatricians’
Use of Social Media
Robert Macauley, MD, FAAP,a Nanette Elster, JD, MPH,b Jonathan M. Fanaroff, MD, JD, FAAP,c COMMITTEE ON BIOETHICS,
COMMITTEE ON MEDICAL LIABILITY AND RISK MANAGEMENT
Increasing use of social media by patients and clinicians creates opportunities abstract
as well as dilemmas for pediatricians, who must recognize the inherent
ethical and legal complexity of these communication platforms and maintain
a
Department of Pediatrics, Oregon Health and Science University,
professionalism in all contexts. Social media can be a useful tool in the Portland, Oregon; bNeiswanger Institute for Bioethics, Stritch School of
practice of medicine by educating both physicians and patients, expanding Medicine, Loyola University Chicago, Chicago, Illinois; and cDepartment
access to health care, identifying high-risk behaviors, contributing to research, of Pediatrics, School of Medicine, Case Western Reserve University and
Rainbow Center for Pediatric Ethics and Division of Neonatology,
promoting networking and online support, enhancing advocacy, and nurturing University Hospitals Rainbow Babies and Children’s Hospital, Cleveland,
professional compassion. At the same time, there are confidentiality, privacy, Ohio
professionalism, and boundary issues that need to be considered whenever Clinical reports from the American Academy of Pediatrics benefit from
potential interactions occur between physicians and patients via social media. expertise and resources of liaisons and internal (AAP) and external
reviewers. However, clinical reports from the American Academy of
This clinical report is designed to assist pediatricians in identifying and Pediatrics may not reflect the views of the liaisons or the
organizations or government agencies that they represent.
navigating ethical issues to harness the opportunities and avoid the pitfalls of
social media. Drs Macauley and Elster drafted the article; and all authors
participated in conception and design of the report, data collection,
analysis, and interpretation, and critical revision of the article and
approved the final manuscript as submitted.
The guidance in this report does not indicate an exclusive course of
INTRODUCTION treatment or serve as a standard of medical care. Variations, taking
into account individual circumstances, may be appropriate.
Increasing use of social media by patients and clinicians creates
All clinical reports from the American Academy of Pediatrics
opportunities as well as dilemmas for pediatricians, who must recognize automatically expire 5 years after publication unless reaffirmed,
the inherent ethical and legal complexity of these communication revised, or retired at or before that time.
platforms and maintain professionalism in all contexts. This clinical report This document is copyrighted and is property of the American
Academy of Pediatrics and its Board of Directors. All authors have filed
is designed to assist pediatricians in identifying and navigating ethical conflict of interest statements with the American Academy of
issues to harness the opportunities and avoid the pitfalls of social media. Pediatrics. Any conflicts have been resolved through a process
As Parikh et al1 rightly observe, “Connectivity need not come at the price approved by the Board of Directors. The American Academy of
Pediatrics has neither solicited nor accepted any commercial
of professionalism.” In fact, striking a proper balance may be considered involvement in the development of the content of this publication.
an ethical imperative, with the goal that social media (to the extent that it DOI: https://doi.org/10.1542/peds.2020-049685
is used) augment in-person care rather than take the place of it.
Address correspondence to Robert Macauley, MD. E-mail: macauler@
More than 300 million people in the United States now use the Internet,2 ohsu.edu
with more than 90% of them also using e-mail to communicate.3 With the
creation of social media outlets (also known as Web 2.0) at the dawn of To cite: Macauley R, Elster N, Fanaroff JM, AAP COMMITTEE
the 21st century, the capacity for sharing information among huge ON BIOETHICS, COMMITTEE ON MEDICAL LIABILITY AND RISK
numbers of people with little or no time lag reached new heights. “Social MANAGEMENT. Ethical Considerations in Pediatricians’ Use
of Social Media. Pediatrics. 2021;147(3):e2020049685
media” refer to Web-based services that allow users to create personal
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PEDIATRICS Volume 147, number 3, March 2021:e2020049685 FROM THE AMERICAN ACADEMY OF PEDIATRICSprofiles and post content4 as well as and “digital immigrants” (defined as maintains a list of more than 700
“articulate a list of other users with people born before 1980) and, thus, tweeting AAP members, known as
whom they share a connection.”5 have varying understanding and “Tweetiatricians.”17
E-mail and other forms of electronic facility with social media.13 This
Overall, 90% of physicians today use
communication specifically designed relative unfamiliarity, coupled with
social media for professional
to be used between a single user and reports of violations of online
purposes, including finding and
another, such as electronic patient professionalism (which more than
reading relevant medical
portals, are not considered social 90% of state medical boards have
information.18 Social media are
media6 and are not the focus of this received, leading to sanctions ranging
especially popular with early-career
report. Seventy-two percent of from suspension to revocation of the
pediatricians who may be more
Americans, including 90% of physician’s license15), may cause
familiar with digital technology, have
teenagers, engage in social media,7–9 some pediatricians to be reluctant to
received mentoring in its use during
with Facebook among the best known engage with social media.
training, or attend conferences in
and most frequently used by adults.
Avoiding social media, however, which tweeting is encouraged to ask
Others include Instagram, Twitter,
sacrifices opportunities for questions or provide feedback. Social
LinkedIn, Tumblr, Snapchat, and
communication, education, and media allow learners to express their
Pinterest. Newer social media options
advocacy with patients and families. opinions and ask questions without
are being created regularly as public
As Parsi and Elster16 note, “If we fail fear of embarrassment and has been
needs and demands shift.10 Social
to engage this technology observed to “flatten the hierarchy” of
channels are evolving and changing
constructively, we will lose an medicine by giving each person an
with time, allowing for instant and
important opportunity to expand the equal voice.19
disappearing messages, back-channel
application of medical
connections, live video streaming, and Patient Education and Advocacy
professionalism within contemporary
one-to-many communications. Some
society.” Both the potential benefits Studies have revealed that 8 in 10
social channels have been specifically
and risks of social media need to be Internet users go online for health
designed for physician
considered to appropriately information,20 and more than half of
communication, either with peers,
incorporate it into one’s clinical these people get medical information
patients, or the public.
practice. specifically from social media.21
Because of social media’s ubiquity Social media tools can be used to
and ease of use, a high percentage of share relevant and important public
patients want or expect to use it to POTENTIAL BENEFITS OF SOCIAL MEDIA
health topics and to guide the public,
communicate with their physician. In Professional Education and patients, and families who follow
a recent Harris Poll survey conducted Collaboration a physician’s channels to creditable
on behalf of the American resources that have been reviewed by
Faced with multiple competing
Osteopathic Association, it was found physicians (such as online media
obligations and rigorous productivity
that “more than half of millennials articles, blogs, journal articles, or
expectations, physicians may need to
(54%) and more than four out of 10 important recall or safety
consult with colleagues about
(42%) adults are or would like to be information). Communication may
challenging cases or research current
friends with or follow their health range from general advice, such as
evidence quickly. Social networking
care providers on social media.”11 encouragement to get the seasonal
sites can help close this gap, as long
Research reveals that patients who do influenza immunization, to broad-
as they are compliant with privacy
not currently use social media would ranging notifications about public
requirements of the Health Insurance
consider doing so to improve health emergencies.
Portability and Accountability Act
physician-patient communication.12
(HIPAA) (which would include Beyond mere ease and scope,
This is particularly true of pediatric
identity verification and sufficient education via social media may be
patients, who as “digital natives” (ie,
encryption). Physician-to-physician preferable for patients who have
people born or raised in the age of
communication can also occur on moved beyond the model of acquiring
digital technology13) are more
public channels such as Twitter, knowledge from a medical
familiar with communicating with
through which groups of physicians professional in the clinical workspace.
and expressing themselves through
congregate and “follow” each other Some patients prefer
social media than are many adults.14
for information sharing, thought “disintermediation,” or gathering
Pediatricians, however, are, leadership, and advocacy in pediatric information directly from online
depending on their generation and public health. The American Academy sources. Recognizing that not every
experience, a blend of digital natives of Pediatrics (AAP), for example, such source is trustworthy, physicians
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2 FROM THE AMERICAN ACADEMY OF PEDIATRICScan encourage a middle ground. The community health needs. For Increased Patient Access
so-called “apomediary model” allows instance, appeals for voluntary blood In regions with inadequate
physicians to guide patients to donation on social media can help to infrastructure to support optimal
reliable information that they can mitigate acute shortages. Organ telemedicine, social media sites, such
access independently before turning donation recruitment has also as Facebook, have been used
to their physician for consultation increased in response to Facebook instead.37 Ideally, social media should
and clarification.22 appeals.27 not replace face-to-face encounters
Social media can also be used to with physicians, but social media may
implement advocacy initiatives to Patient Empowerment supplement those encounters by
enhance public health. Examples creating virtual clinics, thus allowing
Social media have made the world a more rapid response to an urgent
include appeals to contact elected
smaller and have provided a global health care situation.
officials to advocate for policies and
community to support patients with
legislation that improve the health of
special needs and chronic health Clinical Research and Recruitment
children and their families and the
conditions as well as individuals who
promotion of public and community Social media can expand research
may be experiencing social isolation
health via immunization campaigns. opportunities and connect
or discrimination. Peer-to-peer health
Recent polls suggest that fully two- researchers to peers, novel ideas, and
care affords patients the
thirds of Americans believe that potential human subjects or study
opportunities to develop a support
social media are important for getting participants. Social media tools are
network, share experiences, and learn
elected officials to pay attention to not only used to broadcast ideas; they
about new opportunities for research
issues and that social media can also be used to search for
or treatment.28 Many private
platforms are “at least somewhat information, opinions, and ideas or
companies,29,30 including some
important for creating sustained simply to listen. Such tools allow
focused on pediatrics,31 have such
movements for social change.”23 researchers to contact patients with
online communities for patients to
rare conditions and locate research
These social media opportunities are connect with each other and work to
subjects lost to follow-up as well as
widely accessible to, and can be used systematically improve their health
reach out to younger patients who
to influence, public opinion, as recent outcomes. Facebook32 and Twitter33
might otherwise not learn about or
interference in US elections attests.24 have both allowed the creation of
become interested in participating in
Opponents of certain medical “supportive disease subcultures.” As
research.38 Social media can inform
recommendations or public policies one patient noted, “The internet has
researchers about patient responses
can provide conflicting or inaccurate made our small disease larger and we
to treatment and adverse drug effects
information that may trigger are able to educate many more people
and trigger modifications in
discussions and debate.25 Although now.”34
treatment plans.39
currently only 9% of physicians use
social media to comment on posts or In addition to fostering community Use of social media in research is
participate in group discussions or and providing education, social ethically complex, however. Whereas
online chats,18 physicians media also hold the promise of most research studies are developed
participating in social media may help improved diagnostics. Patients (and by experienced researchers and
prevent misconceptions from their advocates) can now share approved by their organization’s
dominating online discussions. reports online of unusual symptom institutional review board or human
complexes that have stumped local subjects committee, studies involving
Social media can help patients and
physicians. These disclosures may social media may bypass this review
families understand the range of
be similar to diagnostic dilemmas process because social media use is
expertise of a given practice and learn
among other patients and provide seen as public, thus calling into
of additional resources in their
physicians with diagnostic clues.26 question whether it is necessary to
community. In some cases, with
Identifying groups of patients obtain the participants’ informed
patient authorization, social media
with a common condition can also consent.40 Protection of human
can permit the transmission of
spur further research on that subjects is critical, however, and
personalized information (such as
disease’s pathophysiology and researchers who use social media in
appointment or medication refill
treatment. 35,36 This process has their studies should continue to
reminders), which can help improve
been likened to crowdsourcing, or follow the policies of their
adherence to treatment regimens.26
bringing together the collective institution’s ethics committee or
Social media can also benefit patients wisdom of diverse groups of institutional review board.
by increasing awareness of patients and physicians.22 Investigators should disclose that
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PEDIATRICS Volume 147, number 3, March 2021 3a research study is being considered, indiscriminate queries (sometimes addresses, or other traditionally
be clear about the risks and benefits referred to as “patient-targeted verifiable information is not
of the research, and, if possible, googling”) present significant ethical a guarantee that one’s identity will
obtain consent from potential study complexity and concerns, which will remain anonymous.
subjects before proceeding with the be addressed below.
study rather than merely lurking to
obtain data.38 Without such Nurturing Compassion Through POTENTIAL RISKS OF SOCIAL MEDIA
transparency, potential subjects Narrative
Inappropriate Self-Disclosure
might post personal items on social Medical practice today can be
media that they would have kept challenging and exhausting. Sharing Despite the potential benefits of
private if they had been aware of the inspirational anonymized patient social media, significant risks remain.
research taking place (from stories can nurture compassion One important risk is inappropriate
a practical viewpoint, there should be among health professionals, personal self-disclosure by physicians
no expectation of privacy for reminding them about why they online, which can negatively impact
information voluntarily posted chose the profession in the first a physician-patient relationship or
online41). place.47 Humor has also been shown one’s employment. Even if an
to prevent burnout,48 and so-called inappropriate posting on social media
Identification of and Counseling for “collective venting” can be cathartic.49 is entirely unrelated to one’s medical
High-risk Behaviors practice, it nevertheless reflects on
By the same token, because social one’s professionalism.55 As the
As digital natives, most pediatric
media are publicly accessible, American Medical Association Code of
patients expect to communicate
insufficiently anonymized patient Ethics states, “The ethical obligations
through social media. Adolescents, in
narratives (and even sufficiently of physicians are not suspended when
particular, spend a great deal of time
anonymized ones that are written in a physician assumes a position that
online42 and may feel more at ease
a negative venting tone) may reflect does not directly involve patient
sharing personal information in that
negatively on the authoring physician. care.”56 This includes online
context rather than in face-to-face
Even deidentified patient information disclosures, and all professionals, not
conversation. Teenagers may also be
holds the potential to be hurtful, both just physicians, are judged by how
more open to health-related messages
to that specific patient and to other they comport themselves online.57
and advice communicated through
patients who might fear that their
social media.43 Social media can,
private information could be shared By its very nature, social media invite
therefore, be used to identify self-
in a similar manner. Denigrating inappropriate posting because
disclosed high-risk behaviors and
language is inherently personal and “anonymity can breed
explore ways of mitigating risk and
reflects poorly on the physician and disinhibition.”58 Some posts are
accessing appropriate resources.44,45
the profession of medicine itself.50 clearly inappropriate, such as selfies
Such conversations are more
There is evidence that sharing of grinning clinicians posing with
straightforward when the pediatric
dehumanizing narratives and weapons during a humanitarian
patient has specifically granted the
language begins early in medical mission59 or uncivil microblog posts
physician access to material posted
training, with medical students (eg, tweets).60 Some posts may be
on social media, although such
shown to frequently express more ambiguous but in the absence of
communication itself raises issues
themselves in this way online.51 A nonverbal cues can easily be
related to blurring of appropriate
majority of medical schools now misinterpreted. Comments
boundaries (as discussed below).
report unprofessional online addressing patients, as well as those
Greater discretion is required
conduct.48 For precisely this reason, regarding one’s employer or clinical
regarding social media information
schools are starting to put forth setting, reflect negatively on both the
that is in the public domain.
policies regarding social media subject, the poster, and the
Acquisition of Important Information expression.52 professional, potentially leading to
disciplinary action or even
In rare cases, social media have been Even when details are deidentified termination. Tweeting or posting
used to obtain specific and important and a patient narrative is expressed from work, especially if excessive,
information relevant to patient care. in respectful terms, a majority of may be perceived as not paying
For instance, the authors of one case medical educators still believe that attention to clinical duties and may
study describe how a Facebook discussing it on social media requires violate institutional policy.61
search allowed a medical team to explicit patient consent.53,54 Given the
locate the family of a patient with abundance of readily accessible There are permanent implications to
amnesia.46 Taken too far, however, information, nondisclosure of names, such disclosure, too, because despite
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4 FROM THE AMERICAN ACADEMY OF PEDIATRICSsubsequent attempts to purge one’s belief that the law requires [them] to patient’s self-report, should the
online profile, what goes online stays do so.”66 physician raise this issue with the
online. Unflattering social media patient directly? How might that
Simply having a presence on
content may affect a clinician’s future discussion impact the patient’s
Facebook could permit a process
employment opportunities.62 Despite perception of privacy? Accepting
called tagging. Tagging involves
this risk, one study revealed that only a friend request may also raise
a facial recognition algorithm that
one-third of medical students set expectations of off-duty availability or
identifies an individual from
their Facebook pages to private.63 that clinical questions will be
photographs posted online. An
This may be significant given that answered via less secure
unprofessional pose from a friend’s
some institutions may consider social social media.
party could end up appearing on
media and the content of postings in
one’s own Facebook feed. To prevent Recognizing this ethical challenge,
promotion and tenure.64 being tagged, Facebook settings can 75% of physicians decline friend
be modified. requests from patients18 and only 5%
From a specifically pediatric
Unfortunately, tagging may also occur have ever initiated one.7 More than
perspective, poor digital citizenship
from many social media platforms 80% of medical educators believe
undermines a pediatrician’s
through comments and tweets. Even that it is never or rarely acceptable to
important duty to serve as a role
if a pediatrician were to elect not to become social networking friends
model for patients and families using
have a social media presence at all, with patients.53,54 The American
social media. The AAP has previously
College of Physicians,69 American
encouraged pediatricians “to increase others are able to post information
and photographs about the physician, Medical Association,26 British Medical
their knowledge of digital technology
including videos recorded and Association,70 and Federation of State
so that they can have a more
photographs taken without the Medical Boards15 all discourage
educated frame of reference for the
physician’s knowledge or consent. For accepting (and certainly initiating)
tools their patients and families are
this reason, routinely monitoring and friend requests with current or
using, which will aid in providing
curating one’s online presence is former patients, although the recent
timely anticipatory media guidance as
recommended. Pediatricians can get American College of Obstetrics and
well as diagnosing media-related
a sense of their online “footprint,” as Gynecology statement permits some
issues should they arise.”42
well as their online “fingerprint” measure of discretion in this area.71
To prevent inappropriate disclosure, generated by their online work and Additionally, some employers
it is best to pause before posting by advocacy, by regularly searching their prohibit friending patients.
taking a moment to reflect on the online presence. This question becomes more
potential impact of a post should it be complex in a pediatric context given
seen by one’s colleagues, patients, or Blurring Relationship Boundaries the reliance of pediatric patients on
families. It is in a physician’s best As stated above, a recent poll found social media as a forum for
interest to consider separating their that most millennials and nearly half expression and communication. It is
personal and professional social of adults want to follow or connect generally inadvisable for
media presence and efforts. The with a health care provider on social pediatricians to accept friend
professional platforms can have media.11 In one study, nearly 20% of requests from current patients (and
public settings and content for adult patients attempted to certainly to initiate them). However,
education and advocacy, and the communicate with their physician declining a friend request might
personal platforms can be set to through Facebook.67 Accepting this seem like it could compromise
private. Restricting access to one’s type of relationship can be communication or even give offense
private social media accounts may be problematic, however. “Friending” to the requestor. If so, the physician
beneficial in light of reports of a few blurs the boundaries of the should meet face to face and talk
patients using social media to stalk professional relationship, not only with the requestor and discuss with
their physicians.65 It is also wise to heightening the possibility of them why a dual relationship is not
remember that online postings are inappropriate physician self- wise or in the patient’s best interest.
discoverable in legal proceedings. disclosure68 but also introducing An alternative way to maintain
Facebook’s privacy policy clearly a level of mutuality that can communication would be to redirect
states that they may “access, preserve undermine a patient’s privacy and the requestor to the pediatrician’s
and share your information…in patient-physician interactions. For professional site or a separate
response to a legal request (like example, if a physician discovers platform on which no other
a search warrant, court order, or something on a patient’s Facebook personal or professional posts
subpoena) if [they] have a good faith page that is not consistent with the are made.
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PEDIATRICS Volume 147, number 3, March 2021 5Unlike in other specialties, pediatric This does not require an in-person online profiles and biographies
patients “age out” of the therapeutic meeting and could conceivably occur whenever possible.
relationship with their physicians. online. Although specific
Social media present a way for requirements vary from state to state, Confidentiality
pediatricians to stay in contact with it is likely that, regarding social
The Hippocratic Oath states, “I will
former patients. When not doing so is media, the broadest notion of what
respect the privacy of my patients, for
felt to represent a significant mutual constitutes a physician-patient
their problems are not disclosed to
loss, it is up to the pediatrician’s relationship could be adopted.71
me that the world may know.” The
discretion whether to remain in touch Clinical questions posed through
HIPAA Privacy Rule, which covers
with former patients via social media. social media could, therefore,
“individually identifiable health
potentially create a professional
Becoming social media friends with information” based on 18 possible
obligation with documentation and
the parent of one’s patient is also not identifiers, including “full-face
follow-up requirements similar to
without ethical complexity given that photographic images (and any
those of an office visit as well as
that the parent is usually tasked with comparable images),”76 also applies
a potential liability risk, which may
making decisions for the patient and to social media, as do state privacy
not be covered by malpractice
may be unduly influenced in the laws.50 Physicians have an ethical and
insurance. What began as a kind-
decision-making by the friend legal obligation to keep protected
spirited attempt to offer general
relationship. Such friending may also health information confidential.
assistance could ultimately result in
create an avenue of communication Despite this duty, there have been
medicolegal obligations (and
that could lead to an unintended reports of physicians sharing details
liability), underscoring the need for
disclosure of identifiable health about patients or inadequately
physicians to be extremely cautious
information to the patient and family. deidentifying facts and
about health care communications
Ethical issues in this friendship may photographs77,78 because even
with personal friends and about
become even more complicated if the blocked-out faces in photographs may
posting anything that could be
social media relationship continues still be identifiable. Social media
construed as representing a diagnosis
once the pediatric patient reaches the postings that reference a medical
or treatment.
age of majority and the parent is no encounter with a specific time and
longer responsible for making Conflict of Interest date could be seen by patients and
decisions for the patient. It is, damage trust in the physician-patient
As noted above, social media provides
therefore, problematic to engage in relationship and likely violate HIPAA.
valuable opportunities for health
social media contact with parents of advocacy and patient education but To facilitate appropriate use of such
patients if social media are the only can also raise the possibility of digital communication, several legal
basis of the relationship. conflict of interest. For example, 11% issues need to be addressed. These
In some instances, however (such as of physician-written health care blogs include licensure across state lines or
small communities or areas in which include named products.73 Tweets international borders,79 adequate
the physician and the parent have may involve “suspect promotions.”74 malpractice insurance coverage,
other mutual interests), such contact Because using social media is reimbursement for telecare (if
can be a normal expression of relatively easy, many more clinicians available), and maintaining
friendship. Once again, it is may be tempted to consider a paid confidentiality (because HIPAA also
imperative to maintain proper promotion without understanding the applies to social media
boundaries by reserving clinical ethical and legal implications of such communications). When a physician
discussions for separate forums. conflicts of interest if promulgated is communicating about health care
without appropriate disclosure. Such or rendering advice directly to
Up to this point the discussion has arrangements have also occurred in patients or families, HIPAA
been focused on established patients traditional media and violate compliance requires the use of
attempting to become friends on journalistic and educational ethics a secure site with encryption.
Facebook, but the reverse process (ie, (not to mention Federal Trade Removing any identifiable patient
friends on Facebook becoming Commission regulations75) if not details preserves the patient’s
patients) has also occurred. Generally publicly disclosed. Even an individual anonymity and underscores the
speaking, a physician-patient message on Twitter (a tweet) allows practice’s compliance with state and
relationship consists of a patient pediatricians to include a conflict of federal law. The option of 24/7
seeking assistance in a health-related interest statement despite the 280- patient communication also demands
matter and the physician agreeing to character limit. Employment appropriate attention to the
undertake diagnosis and treatment.72 relationships should be revealed in physician’s own work-life balance.
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6 FROM THE AMERICAN ACADEMY OF PEDIATRICSImpact on Professional Reputation in such reporting, which include information gathered from social media
A significant number of patients use having to determine what content sources.54 For example, if an adolescent
online rating sites to choose their crosses the line and not wanting patient denies drinking alcohol but has
physician. Given the impact of one’s a colleague to get in trouble, may posted on social media about drinking
online presence on professional explain why few other codes include to excess, should the pediatrician
reputation, it is advisable for this requirement, although it is confront the patient with this newfound
physicians to monitor the status of frequently included in social media information? To do so might
their online identity.80 Although most guidelines written by hospitals, compromise trust, but not doing so
physician ratings are positive,71,81,82 academic centers, and other health might preclude thoughtful intervention.
there have been reports of ratings care employers.
The other type of information patient-
sabotage (ie, fabricated negative Given these concerns, pediatric targeted googling may generate
reviews) by competing professionals practices and other health care comes from third-party sources,
or disgruntled patients.81 Given the organizations may wish to ranging from news articles to posts
anonymity of many reviews, such formulate social media policies for from someone other than the patient.
a situation may be difficult to their employees, which can clarify Such non–user-generated Internet
remedy.83 expectations, provide valuable tools content presents a different set of
and information, and ultimately challenges. First, there is no
Responding thoughtfully and
protect patient confidentiality guarantee that the information is
positively to critical reviews can be
and privacy. These policies may accurate. Even if it is, acquiring
helpful. Physicians must remember
also include expectations and knowledge about a patient that the
that patients can post whatever they
standards for communicating with patient did not directly provide (and
want about a situation, but the
patients through social media, may not be aware that the physician
physician remains bound by
such as response time and is in possession of) threatens to
confidentiality obligations. Responses
documentation.84 compromise trust. Uncertainty
must always be generalized, not
specific to an individual. It is Inappropriate Acquisition of remains as to whether to reveal one’s
important to recall that HIPAA Information via Social Media knowledge of this information to the
regulations prevent physicians from patient, either to confirm its veracity
As noted above, there may be
disclosing any protected health or engage in discussion about its
instances in which social media can
information about the patient, content.
be used to obtain specific and
including acknowledging that the relevant information about patients Before pediatricians engage in
person is or was a physician’s patient. (such as the example of locating the patient-targeted googling, it is
Unfair or potentially fabricated family of a patient with amnesia important to identify the information
reviews can be reported to the rating through Facebook). This practice has they are seeking to acquire and
Web site or, depending on one’s work become increasingly common. In one determine if it is of sufficient
context, to the public relations study, 1 of 6 pediatric trainees had importance to justify such a search.
division of one’s employer. Another conducted Internet or social media Clinton et al87 suggest 6 questions to
solution can be to optimize search searches for more information about consider before engaging in patient-
engine results so that one’s own a patient, and a similar percentage of targeted googling:
practice site comes up first, before faculty believed they would do so if
• “Why do I want to conduct this
any potentially negative reviews. that might help in patient care.85
search?”
Encouraging more patients to review This practice could, however, expand • “Would my search advance or
the practice online will likely provide to indiscriminate searches for compromise the treatment?”
a balanced and generally information about patients.86 So-called
positive view. patient-targeted googling can be • “Should I obtain informed consent
motivated by a genuine desire to from the patient prior to
The American Medical Association searching?”
Code of Ethics not only mandates understand more about one’s patients
and perhaps gauge their adherence to • “Should I share the results of the
ethical behavior on the part of
treatment plans. But it can also stem search with the patient?”
physicians but also requires
physicians to report unprofessional from “curiosity, voyeurism, and habit.”15 • “Should I document the findings of
behavior on the part of their peers.56 Patient-targeted googling can generate 2 the search in the medical record?”
This mandate extends to the types of information, the first coming • “How do I monitor my motivations
unprofessional use of social media by from the patient directly. Physicians may and the ongoing risk-benefit profile
other physicians. Difficulties inherent understandably be unsure how to use for searching?”87
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PEDIATRICS Volume 147, number 3, March 2021 7It is generally advisable to disclose social media policies of their 10. Searching for patient information
any relevant patient information health care organization and any through the Internet or social
discovered through the Internet or professional society to which media should have a specific
social media to the patient so that they belong. purpose with clear clinical
everyone is working with the same 5. Independent practitioners relevance. Any information
set of facts. This disclosure is should develop social media obtained through this route
especially important before entering policies for their practices to should be shared directly with
any information gleaned through that protect patients and clarify the patient to maximize
route into the patient record.88 expectations. These policies transparency and before
should be in writing and widely recording any such information
distributed to all staff and in the patient’s chart.
CONCLUSIONS
clinicians. If restrictions on 11. Pediatricians should monitor
Social media can be a useful tool in communicating with patients are their online profile to protect
the practice of medicine by educating in place in such policies, this against inaccurate postings.
both physicians and patients, should be shared with patients. Negative online reviews warrant
expanding access to health care, Given advances in technology, a thoughtful response that
identifying high-risk behaviors, these policies should be honors confidentiality
contributing to research, promoting reviewed regularly and updated requirements, including the fact
networking and online support, as needed. that the reviewer is or was the
enhancing advocacy, and nurturing 6. Conflicts of interest, including in physician’s patient.
professional compassion. At the same tweets, blog postings, and media 12. Pediatricians should recognize
time, there are confidentiality, appearances by pediatricians, that providing specific medical
privacy, professionalism, and should be disclosed. advice to an individual through
boundary issues that need to be social media may create
considered whenever potential 7. Pediatricians should use
a HIPAA-compliant secure site a physician-patient relationship
interactions occur between that may have documentation,
physicians and patients via social with encryption when
communicating about health care follow-up, state licensing, and
media. The following liability implications.
recommendations can help or rendering advice directly to
pediatricians use social media patients or families. Individually
appropriately and effectively. identifiable protected health
LEAD AUTHORS
information should not be shared
through social media without Robert Macauley, MD, FAAP
Nanette Elster, JD, MPH
RECOMMENDATIONS documented authorization from Jonathan M. Fanaroff, MD, JD, FAAP
the patient or guardian.
1. Pediatricians who choose to use
social media should have 8. Before posting on social media,
protected health information COMMITTEE ON BIOETHICS, 2019–2020
separate personal and
professional social media pages, should be deidentified (and Robert Macauley, MD, FAAP, Chairperson
clearly noted to be so) and Ratna Basak, MD, FAAP
with patients and their parents
presented respectfully. Gina Marie Geis, MD, FAAP
directed to the professional page. Naomi Tricot Laventhal, MD, FAAP
2. A pediatrician’s personal page 9. Professional boundaries should Douglas J. Opel, MD, MPH, FAAP
should have adequate privacy be maintained in the use of social Mindy B. Statter, MD, FAAP
settings to prevent unauthorized media. Accepting (and certainly
access. Professional pages should initiating) friend requests from
LIAISONS
be set to prevent tagging. current patients is discouraged. It
Mary Lynn Dell, MD, DMin – American
3. It is wise to pause before posting, is up to the pediatrician’s Academy of Child and Adolescent Psychiatry
given that information posted discretion whether to accept such Douglas S. Diekema, MD, MPH, FAAP –
online can exist in perpetuity and requests from former patients. It American Board of Pediatrics
can be captured and David Shalowitz, MD – American College of
may be appropriate to accept
Obstetricians and Gynecologists
redisseminated by viewers a friend request from a patient’s Nanette Elster, JD, MPH – Legal Consultant
before it can be deleted. parent if the physician’s
4. Pediatricians should follow state relationship to that person
and federal privacy and extends beyond the clinical STAFF
confidentiality laws as well as the environment. Florence Rivera, MPH
Downloaded from www.aappublications.org/news at Oregon Health & Science University on March 2, 2021
8 FROM THE AMERICAN ACADEMY OF PEDIATRICSCOMMITTEE ON MEDICAL LIABILITY AND Susan M. Scott, MD, JD, FAAP
RISK MANAGEMENT, 2019–2020 Laura J. Sigman, MD, JD, FAAP ABBREVIATIONS
W. Michelle Terry, MD, FAAP
Jonathan M. Fanaroff, MD, JD, FAAP, AAP: American Academy of
Robert A. Turbow, MD, JD, FAAP
Chairperson Pediatrics
Steven A. Bondi, JD, MD, FAAP HIPAA: Health Insurance Portabil-
Richard L. Oken, MD, FAAP ity and Accountability Act
John W. Rusher, MD, JD, FAAP
STAFF
Karen A. Santucci, MD, FAAP Julie Kersten Ake
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2021 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
REFERENCES
1. Parikh SM, Liu E, White CB. Connectivity 8. Pew Internet Project. Social media fact technologies. Comput Educ. 2011;56(2):
need not come at the expense of sheet. 2019. Available at: www. 429–440
professionalism. Acad Med. 2010;85(6): pewinternet.org/fact-sheets/social-
15. Federation of State Medical Boards.
930 networking-fact-sheet. Accessed
Model Guidelines for the Appropriate
October 16, 2016
2. Statista. Internet usage in the United Use of Social Media and Social
States - statistics & facts. 2018. 9. Lenhart A. Mobile access shifts social Networking in Medical Practice.
Available at: https://www.statista.com/ media use and other online activities. Washington, DC: Federation of State
topics/2237/internet-usage-in-the- 2015. Available at: https://www. Medical Boards; 2012
united-states/. Accessed February 14, pewresearch.org/internet/2015/04/09/ 16. Parsi KP, Elster N. Why can’t we be
2019 mobile-access-shifts-social-media-use- friends? A case-based analysis of
and-other-online-activities/. Accessed ethical issues with social media in
3. Statista. E-mail usage penetration in the
January 20, 2021 health care. AMA J Ethics. 2015;17(11):
United States from 2013 to 2019. 2019.
Available at: https://www.statista.com/ 10. Smith A, Anderson M. Social media use 1009–1018
statistics/462159/usa-email-usage- in 2018. 2018. Available at: www. 17. American Academy of Pediatrics.
reach/. Accessed February 14, 2019 pewinternet.org/2018/03/01/social- Tweetiatricans. 2019. Available at:
media-use-in-2018/. Accessed February https://twitter.com/AmerAcadPeds/
4. Obar JA, Wildman S. Social media
18, 2019 lists/tweetiatricians. Accessed February
definition and the governance
challenge: an introduction to the 11. American Osteopathic Association. 15, 2019
special issue. Telecomm Policy. 2015; Survey finds patients want to be friends 18. Modahl M, Tompsett L, Moorhead T.
39(9):745–750 with their physicians on social media. Doctors, Patients, and Social Media.
2018. Available at: https://osteopathic. Waltham, MA: QuantiaMD; 2011
5. Boyd DM, Ellison NB. Social network
org/2018/05/14/survey-finds-patients-
sites: definition, history, and 19. Hillman T, Sherbino J. Social media in
want-to-be-friends-with-their-
scholarship. J Comput Mediat Commun. medical education: a new pedagogical
physicians-on-social-media/. Accessed
2007;13(1):210–230 paradigm? Postgrad Med J. 2015;
May 17, 2019
6. Spooner SA; Council on Clinical 91(1080):544–545
12. Fisher J, Clayton M. Who gives a tweet:
Information Technology, American 20. Fox S. Health information is a popular
assessing patients’ interest in the use
Academy of Pediatrics. Special pursuit online. 2011. Available at:
of social media for health care.
requirements of electronic health https://www.pewresearch.org/internet/
Worldviews Evid Based Nurs. 2012;9(2):
record systems in pediatrics. 2011/02/01/health-information-is-a-
100–108
Pediatrics. 2007;119(3):631–637 popular-pursuit-online/. Accessed
13. Prensky M. Teaching Digital Natives: January 20, 2021
7. Bosslet GT, Torke AM, Hickman SE, Terry
Partnering for Real Learning. Thousand
CL, Helft PR. The patient-doctor 21. ReferralMD. 24 outstanding statistics &
Oaks, CA: Corwin Press; 2010
relationship and online social figures on how social media has
networks: results of a national survey. 14. Margaryan A, Littlejohn A, Vojt G. Are impacted the health care industry.
J Gen Intern Med. 2011;26(10): digital natives a myth or reality? 2017. Available at: https://
1168–1174 University students’ use of digital getreferralmd.com/2013/09/healthcare-
Downloaded from www.aappublications.org/news at Oregon Health & Science University on March 2, 2021
PEDIATRICS Volume 147, number 3, March 2021 9social-media-statistics/. Accessed 30. Smart Patients. Smart patients. 2019. for a new meme? Am J Bioeth. 2014;
August 17, 2017 Available at: https://www.smartpatients. 14(10):60–61
com/. Accessed February 15, 2019 41. People v Harris, 36 Misc 3d 868 (NY City
22. Eysenbach G. From intermediation to
disintermediation and apomediation: 31. Improve Care Now. Improve care now. Crim Ct 2012)
new models for consumers to access 2019. Available at: https://www.
42. O’Keeffe GS, Clarke-Pearson K; Council
and assess the credibility of health improvecarenow.org/. Accessed
on Communications and Media. The
information in the age of Web2.0. Stud February 15, 2019
impact of social media on children,
Health Technol Inform. 2007;129(pt 1): 32. Greene JA, Choudhry NK, Kilabuk E, adolescents, and families. Pediatrics.
162–166 Shrank WH. Online social networking by 2011;127(4):800–804
23. Anderson M, Toor S, Rainie L, Smith A. patients with diabetes: a qualitative
43. Selkie EM, Benson M, Moreno M.
Public attitudes toward political evaluation of communication with
Adolescents’ views regarding uses of
Facebook. J Gen Intern Med. 2011;26(3):
engagement on social media. 2018. social networking websites and text
287–292
Available at: www.pewinternet.org/ messaging for adolescent sexual health
2018/07/11/public-attitudes-toward- 33. Pagoto S. Refer patients to Twitter for education. Am J Health Educ. 2011;
political-engagement-on-social- weight loss. 2012. Available at: www. 42(4):205–212
media/. Accessed February 14, kevinmd.com/blog/2012/03/refer-
44. Vyas AN, Landry M, Schnider M, Rojas
2019 patients-twitter-weight-loss. Accessed
AM, Wood SF. Public health
October 16, 2016
24. Lucas R. New reports detail expansive interventions: reaching Latino
Russia disinformation scheme 34. Fox S. The social life of health adolescents via short message service
targeting US. 2018. Available at: https:// information. 2014. Available at: https:// and social media. J Med Internet Res.
www.npr.org/2018/12/17/677390345/ www.pewresearch.org/fact-tank/2014/ 2012;14(4):e99
new-reports-detail-expansive-russia- 01/15/the-social-life-of-health-
45. Radovic A, Gmelin T, Stein BD, Miller E.
disinformation-scheme-targeting-u-s. information/. Accessed January 20,
Depressed adolescents’ positive and
Accessed February 18, 2019 2021
negative use of social media. J Adolesc.
35. Mnookin S. One of a kind: what do you 2017;55:5–15
25. Burki T. Vaccine misinformation and
do if your child has a condition that is
social media. Lancet Digital Health. 46. Ben-Yakov M, Snider C. How Facebook
new to science? The New Yorker. July
2019;1(6):e258-e259. Available at: saved our day!. Acad Emerg Med. 2011;
14, 2014. Available at: https://www.
https://www.thelancet.com/journals/ 18(11):1217–1219
newyorker.com/magazine/2014/07/21/
landig/article/PIIS2589-7500(19)30136- 47. Johna S, Rahman S. Humanity before
one-of-a-kind-2. Accessed January 20,
0/fulltext. Accessed January 20, science: narrative medicine, clinical
2021
20212589-7500 practice, and medical education. Perm
36. Wazny K, Chan KY; Crowdsourcing CHNRI
26. Shore R, Halsey J, Shah K, Crigger BJ, J. 2011;15(4):92–94
Collaborators. Identifying potential uses
Douglas SP; AMA Council on Ethical and of crowdsourcing in global health, 48. Chretien KC, Greysen SR, Chretien JP,
Judicial Affairs (CEJA). Report of the conflict, and humanitarian settings: an Kind T. Online posting of unprofessional
AMA Council on Ethical and Judicial adapted CHNRI (Child Health and content by medical students. JAMA.
Affairs: professionalism in the use of Nutrition Initiative) exercise. J Glob 2009;302(12):1309–1315
social media. J Clin Ethics. 2011;22(2): Health. 2018;8(2):020704 49. Hayter CR. Medicine’s moment of
165–172
37. Garcia-Romero MT, Prado F, Dominguez- misrule: the medical student show.
27. Healy M, Molina B. New Facebook Cherit J, Hojyo-Tomomka MT, Arenas R. J Med Humanit. 2006;27(4):215–229
feature encourages organ donation. Teledermatology via a social 50. Pow H. Doctors caught revealing secret
USA Today. May 1, 2012. Available at: networking web site: a pilot study patient information in Facebook posts.
http://rss.tmsfeatures.com/websvc-bin/ between a general hospital and a rural 2010. Available at: https://www.news.co
rss_story_read.cgi?resid= clinic. Telemed J E Health. 2011;17(8): m.au/technology/doctors-caught-reveali
201205012045GANNETT_GANNETTN_New- 652–655 ng-secret-information-on-facebook/ne
Facebook-feature-encourages-organ-do 38. Gelinas L, Pierce R, Winkler S, Cohen IG, ws-story/879b335aa08ba13d8a1a0a
nation. Accessed January 20, 2021 Lynch HF, Bierer BE. Using social media 7b9decf7a4. Accessed January 20, 2021
28. Fox S. Peer-to-peer healthcare. 2011 as a research recruitment tool: ethical 51. Yoder v University of Louisville, 526 F.
Available at: https://www.pewresearch. issues and recommendations. Am App’x 537 (6th Cir 2013)
org/internet/2011/05/12/peer-to-peer- J Bioeth. 2017;17(3):3–14
52. Northwestern University Feinberg
healthcare-2/. Accessed January 20, 39. Powell GE, Seifert HA, Reblin T, et al. School of Medicine Office of
2021 Social media listening for routine post- Communications. Social media
29. PatientsLikeMe. Patients like me. 2019. marketing safety surveillance. Drug Saf. guidelines. Available at: https://www.
Available at: https://www. 2016;39(5):443–454 feinberg.northwestern.edu/
patientslikeme.com/. Accessed 40. Swirsky ES, Hoop JG, Labott S. Using communications/guidelines/social-
February 15, 2019 social media in research: new ethics media.html. Accessed January 20, 2021
Downloaded from www.aappublications.org/news at Oregon Health & Science University on March 2, 2021
10 FROM THE AMERICAN ACADEMY OF PEDIATRICS53. Chretien KC, Farnan JM, Greysen SR, 64. Cabrera D, Vartabedian BS, Spinner RJ, 73. Lagu T, Kaufman EJ, Asch DA, Armstrong
Kind T. To friend or not to friend? Social Jordan BL, Aase LA, Timimi FK. More K. Content of weblogs written by health
networking and faculty perceptions of than likes and tweets: creating social professionals. J Gen Intern Med. 2008;
online professionalism. Acad Med. 2011; media portfolios for academic 23(10):1642–1646
86(12):1545–1550 promotion and tenure. J Grad Med 74. Chretien KC, Azar J, Kind T. Physicians
54. Kind T, Greysen SR, Chretien KC. Educ. 2017;9(4):421–425 on Twitter. JAMA. 2011;305(6):566–568
Pediatric clerkship directors’ social 65. Campbell D. Infatuated patients use 75. Federal Trade Commission. FTC staff
networking use and perceptions of Facebook to stalk doctors. The reminds influencers and brands to
online professionalism. Acad Pediatr. Guardian. October 27, 2012. Available at: clearly disclose relationship. 2017.
2012;12(2):142–148 https://www.theguardian.com/society/ Available at: https://www.ftc.gov/news-
55. Gabbard GO, Kassaw KA, Perez-Garcia G. 2012/oct/28/lovesick-patients-stalk- events/press-releases/2017/04/ftc-staff-
Professional boundaries in the era of doctors-online. Accessed January 20, reminds-influencers-brands-clearly-
the Internet. Acad Psychiatry. 2011; 2021 disclose. Accessed February 15, 2019
35(3):168–174 66. Facebook. Data policy. Available at: 76. Health Insurance Portability and
56. American Medical Association. Code of https://www.facebook.com/policy.php. Accountability Act, 45 CFR x160.103
Medical Ethics: Current Opinions with Accessed October 16, 2016 (1996)
Annotations, 2002–2003 ed ed. Chicago, 67. Lee JL, Choudhry NK, Wu AW, Matlin OS, 77. Boston.com. RI doctor reprimanded
IL: American Medical Association Press; Brennan TA, Shrank WH. Patient use of over Facebook post. 2011. Available at:
2012 email, Facebook, and physician http://archive.boston.com/news/local/
57. Greysen SR, Kind T, Chretien KC. Online websites to communicate with rhode_island/articles/2011/04/18/ri_do
professionalism and the mirror of physicians: a national online survey of ctor_reprimanded_over_facebook_po
social media. J Gen Intern Med. 2010; retail pharmacy users. J Gen Intern st/. Accessed October 16, 2016
25(11):1227–1229 Med. 2016;31(1):45–51
78. Stickney R. Hospital will fire workers in
58. Chretien KC, Kind T. Social media and 68. Guseh JS II, Brendel RW, Brendel DH. Facebook scandal. 2010. Available at:
clinical care: ethical, professional, and Medical professionalism in the age of www.nbcsandiego.com/news/health/
social implications. Circulation. 2013; online social networking. J Med Ethics. Hospital-Fires-Emps-in-Facebook-
127(13):1413–1421 2009;35(9):584–586 Scandal-95794764.html. Accessed
59. Valencia N, Fernandez B, Deaton J. October 16, 2016
69. Farnan JM, Snyder Sulmasy L, Worster
Photos of drinking, grinning aid BK, Chaudhry HJ, Rhyne JA, Arora VM; 79. Taylor HA, Kuwana E, Wilfond BS. Ethical
mission doctors cause uproar. CNN. American College of Physicians Ethics, implications of social media in health
February 3, 2010. Available at: www.cnn. Professionalism and Human Rights care research. Am J Bioeth. 2014;
com/2010/WORLD/americas/01/29/haiti. Committee; American College of 14(10):58–59
puerto.rico.doctors/. Accessed October Physicians Council of Associates; 80. Pho K, Gay S. Establishing, Managing,
16, 2016 Federation of State Medical Boards and Protecting Your Online Reputation:
60. Vartabedian B. Unprofessional Special Committee on Ethics and A Social Media Guide for Physicians
physician behavior on Twitter. 2011. Professionalism*. Online medical and Medical Practices. Phoenix, MD:
Available at: https://33charts.com/ professionalism: patient and public Greenbranch Publishing; 2013
unprofessional-physician-behavior- relationships: policy statement from the
American College of Physicians and the 81. Kadry B, Chu LF, Kadry B, Gammas D,
twitter/. Accessed October 16, 2016 Macario A. Analysis of 4999 online
Federation of State Medical Boards. Ann
61. Kitsis EA, Milan FB, Cohen HW, et al. Intern Med. 2013;158(8):620–627 physician ratings indicates that most
Who’s misbehaving? Perceptions of patients give physicians a favorable
unprofessional social media use by 70. British Medical Association. Using rating. J Med Internet Res. 2011;13(4):
medical students and faculty. BMC Med Social Media: Practical and Ethical e95
Educ. 2016;16:67 Guidance for Doctors and Medical
82. Lagu T, Hannon NS, Rothberg MB,
Students. London, United Kingdom:
62. Du W. Job candidates getting tripped up British Medical Association; 2011 Lindenauer PK. Patients’ evaluations of
by Facebook. 2007. Available at: www. health care providers in the era of
nbcnews.com/id/20202935/ns/ 71. American College of Obstetricians and social networking: an analysis of
business-school_inc_/t/job-candidates- Gynecologists. Professional Use of physician-rating websites. J Gen Intern
getting-tripped-facebook/ Digital and Social Media. Washington, Med. 2010;25(9):942–946
#.WaRnF8iGM2w. Accessed August 27, DC: American College of Obstetricians
83. American Medical Association. Negative
2017 and Gynecologists; 2015
online reviews leave doctors with little
63. Thompson LA, Dawson K, Ferdig R, et al. 72. Federation of State Medical Boards. recourse. American Medical News.
The intersection of online social Model Guidelines for the Appropriate October 4, 2010. Available at: www.
networking with medical Use of the Internet in Medical Practice. amednews.com/article/20101004/
professionalism. J Gen Intern Med. Washington, DC: Federation of State profession/310049938/5/. Accessed
2008;23(7):954–957 Medical Boards; 2002 October 16, 2016
Downloaded from www.aappublications.org/news at Oregon Health & Science University on March 2, 2021
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