Whether we like it or not, social media is playing an increasing part in our everyday lives. In a recent survey, the Office for National Statistics (ONS) reported that 66% of adults in Great Britain used the internet for social networking. In April 2016, Facebook attracted 38.9 million active users in the UK and Twitter 20.9 million; approximately 59% and 32% of the UK population, respectively.

Instagram, discussion forums, content communities and blogs are all increasingly popular and have many advantages in allowing better communication and widespread discussion and debate. Given this, it is maybe not surprising that patients are increasingly ready to go online to post comments and complaints about their medical care.

While many comments may be positive, by no means all are favourable, and hearing of a complaint or a criticism on social media may be very distressing.

Other than being the subject of overtly critical or unpleasant postings after a clinical interaction at work, there are other issues arising from the increasing use of social media which may lead to problems for MDU members.

• The blurring of boundaries between personal and professional life. For example where patients make 'friend requests' to their doctor.
• The perception of anonymity in comments posted online. Some members might choose to comment on matters they feel are important in what is clearly a very public forum (for example, in a letter to a newspaper or a tweet), but not all members may be aware that what they perceive to be a private site may be visible to the public. In the absence of carefully managed privacy settings, patients, employers and organisations may easily access, and then react to, information left on social media.
• The widespread impact a posting may have. Once a comment has been shared, it is very hard to control and may be viewed very widely - not just locally but globally. Any comment posted online has the potential to be shared indefinitely.

Over a 12 month period between February 2016 and February 2017, the MDU assisted 24 members who were concerned about critical comments made by patients online. While these numbers are small, this is a growing area of calls to the MDU.

Concern about online criticism is not only an issue in the UK; new US research shows that over three quarters of doctors asked were stressed by such comments.

The Harvard Medical School study surveyed 828 doctors and 494 patients from four hospitals across Massachusetts. The study found that:

• 78% of doctors thought the possibility of negative online comments added to the stress of their job
• 46% said online rating websites could harm the doctor/patient relationship.

So what can doctors and health care workers do? If you are aware of a critical comment posted on social media or believe your reputation has been damaged online, there are a number of options available to you. These include:

• responding directly to the negative comment
• complaining to the website and asking for the offending material to be removed
• a defamation action
• using the 'right to be forgotten online' to remove the page from search results.

None of these options are without their risks and some aspects to consider are discussed briefly below.

Responding directly: points to consider

Patient confidentiality and inadvertent disclosure

It may be tempting to fire off a 'rapid response' to a comment viewed online, but before doing so it is important to consider the GMC guidance.

The GMC says: 'You must not use publicly accessible social media to discuss individual patients or their care with those patients or anyone else.'

Even if you choose to respond, reacting to an online posting may be extremely hard without inadvertently revealing personal information about the patient. The GMC accepts that it can be frustrating for doctors to see inaccurate or misleading information about them, but says this 'does not relieve you of your duty to respect your patient's confidentiality'.

Doctors who discuss patients or their care in a public forum are therefore vulnerable to criticism from the GMC.

Avoiding escalation

In trying to have a post removed, or in responding directly to criticism made about you or your work, you may inadvertently end up drawing more attention to the issue (and yourself) than the posting originally attracted.

Equally, taking legal action against a defamatory poster and having the matter considered publicly in court could generate further, possibly unwelcome, publicity.

Considering a public response, the GMC says: 'Disputes between patients and doctors conducted in public can also prolong or intensify conflict and may undermine public confidence in the profession, even if they do not involve the disclosure of personal information without consent.'

When a response may be helpful

It may be upsetting to receive criticism, but once you become aware of a concern, you are presented with the opportunity to respond in a positive way.

The NHS complaints procedure makes it clear that it is important to be open and honest with complainants and to learn lessons from complaints. One option that some practices choose is to reply to negative feedback on the NHS Choices site, thanking patients for their comments, apologising if they are not happy with their treatment and inviting them to get directly in touch to discuss any concerns.

Complaining to the website

The policy of the service provider

Most websites and forums prohibit the posting of abusive or offensive material. In the event that such material is posted, users are often able to report the posts to the service provider.

For example, Facebook says it may take action where material violates its Community Standards, such as hate speech. But it also reminds users that that 'something you don't like on Facebook may not go against our Community Standards.'

NHS Choices also makes it clear that, 'Just because you disagree with the opinion or believe it is wrong, it doesn't mean it is defamatory if published.' However, patient feedback on NHS Choices should comply with its Comments Policy. Any comments which breach their terms and conditions will be rejected. Contributors are advised to keep their comments 'constructive, relevant and civil'.

If you're concerned about the content of a post on NHS Choices, you can report using the link provided directly beneath each comment. Once reported as unsuitable, a comment will be temporarily removed. Following this a moderator will review the post, and decide if it is to be permanently removed or reinstated.

Correcting misleading information in the press or on TV or radio

It may be possible to seek a correction, clarification and/or apology if you feel your clinical practice has been misrepresented.

If you have concerns about the contents of a newspaper or magazine, or if an article has breached the Editors' Code of Practice, you can complain to the Independent Press Standards Organisation (IPSO, formally the Press Complaints Commission).

If you're concerned about the content of TV or radio programmes, you can approach the individual broadcaster or Ofcom. It is still important to consider patient confidentiality and the risk of the offending content being made more prominent.

If you're an MDU member and you are concerned about press reporting or media coverage, we would strongly advise you to contact our press office, who can advise further.

A defamation action

'Defamation' arises when a false statement is made which lowers someone's reputation in the view of right thinking people and its publication has caused, or is likely to cause, serious harm to their reputation.

However, The Defamation Act 2013 provides a number of defences for those who have made alleged defamatory comments, including:

• the matter imputed was substantially true
• that it was an honestly held opinion
• that it was a statement on a matter of public interest
• the statement is in a scientific or academic journal and is protected by privilege
• that the website operator did not themselves post the comment.

In order to be successful, a defamation action must prove that the comment made is false and that it has or is likely to cause serious harm to that individual's reputation.

Defamation actions can be lengthy, expensive and unfortunately it is difficult to predict the outcome with any certainty. Particularly if an action goes to trial, the publicity generated often means the defamatory comment reaches a wider audience than the original statement. It is therefore not generally in the interests of MDU members to use our mutual fund to pursue defamation actions.

The right to be forgotten online

In 2014, the Court of Justice of the European Union (CJEU) ruled that search engine operators are data controllers and that individuals had the right to ask them to remove search results on privacy grounds if these 'appear to be inadequate, irrelevant or no longer relevant, or excessive'.

The ruling said 'a fair balance should be sought' between the right to privacy and the public interest, which may depend on:

• the nature of the information in question and its sensitivity for the individual's private life
• public interest in having that information, which may vary according to the individual's role in public life.

The major search engines Google, Bing and Yahoo have created web forms to request the removal of search results. For example, Google says:

'In evaluating your request, we will look at whether the results include outdated information about your private life. We'll also look at whether there's a public interest in the information remaining in our search results – for example, we may decline to remove certain information about financial scams, professional malpractice, criminal convictions, or public conduct of government officials.'

When considering whether to make a request, you should also remember:

• web pages and documents will not be removed from the internet, only the opportunity to access them via a search engine link.
• the judgment also only applies to EU countries; it may still be possible to navigate to the particular page by using a completely different search term, or the same search term entered into a search engine outside the EU
• having a website link erased may not be the end of the matter and may itself attract comment.

Summary

We understand that it may be distressing to receive criticism or a complaint arising from the care of patients from any source, but the MDU can help its members deal with and resolve these situations. If concerned about online criticism, we would strongly suggest members contact the MDU directly for advice.