Back in the day, the internet and virtual communication were a new frontier where rules around responsible use and ethical behaviour were generally a number of steps behind the day-to-day reality of online interaction.
There are many benefits of constructive engagement with the internet/social media for dental professionals, including:
- Building an online presence, alongside the bricks and mortar practice premises.
- Branding and marketing, which with clever optimisation can direct messaging in a much more targeted fashion based on, for example, locations, demographics, interests – anyone remember the blunt tool of the Yellow Pages?
- Patient education to enhance branding, provide resources and even assist with consent.
- Patient engagement/communication – everything from booking appointments to current messaging about practice activities.
- Networking and professional development with peers both locally, nationally and globally has become instant and seamless.
However, as with everything in life, with benefits and rights come downsides and responsibilities. Very quickly, from the anonymity of forums and chatrooms, the phenomenon known as ‘flaming’ emerged – the act of posting insulting, hurtful, and often offensive content on the internet.
Once identified, it was soon followed up by academic studies and one of the most well-known was Suler in 2004 who identified and named the online disinhibition effect. This study suggested, something that we all intuitively know now, that people often feel more liberated and less inhibited when communicating online, compared to face-to-face interactions. This can lead to both positive and negative behaviours.
A lowering of inhibition can have positive effects:
- Self-expression: The anonymity and perceived distance from real-world consequences can empower people to share their thoughts, feelings, and experiences more openly.
- Supportive communities: Online communities, such as support groups or forums, can foster a sense of belonging and provide individuals with a safe space to discuss sensitive issues.
- Creativity and collaboration: Online disinhibition can lead to creative collaborations and brainstorming sessions.
But categories of negative outcomes were also quickly identified:
- Cyberbullying: The anonymity and reduced empathy in online interactions can lead some individuals to engage in hurtful behaviour they might never consider in face-to-face situations.
- Trolling: Some people use anonymity as a shield to provoke reactions and create chaos, disrupting online spaces and causing harm.
- Hate speech and extremism: People may feel emboldened to express extreme views online, leading to the formation of echo chambers and radicalisation.
Suler identified the primary factors that contribute to online disinhibition:
- Anonymity: Many online platforms allow users to interact without revealing their true identities, leading to a sense of detachment from real-world consequences.
- Invisibility: Online interactions often lack physical cues, such as body language and facial expressions, making it easier for individuals to misinterpret messages and express themselves without the usual inhibitions.
- Dissociative imagination: Some individuals create personas or adopt online alter egos, further distancing themselves from their offline identities, which can result in more extreme behaviours.
- Minimisation of authority: The absence of traditional authority figures online can lead to a lack of social norms and consequences, encouraging people to express themselves more freely.
At Dental Protection when we review cases and claims, part of what can be very relevant to the genesis of a complaint is the communication between patient and the practitioner – for example additional discussions around consent or variations in plans, patients signalling dissatisfaction with some aspect of care well before things blow up, or evidence of increasing non-compliance or disengagement such as frequent rescheduling by either patient or practice. Many of these communications now occur online either by emails, messaging apps or even via online reviews.
It is a given that the practitioner, and by default the practice, must be the adult in the room in all communications – engaging responsibly and demonstrating they have the best interest of the patient at heart in all interactions. Importantly, just because a patient behaves inappropriately online does not mean we have to engage or behave the same way.
Sadly, looking over cases and how they spiral downwards, we sometimes see instances of the online disinhibition effect in both patient and practitioner communications; for example:
- Patients being abusive or swearing in online messaging, which they would never otherwise do in a face-to-face interaction at the surgery.
- Patients demonstrating impulsive behaviour or constantly changing their minds – for certain patients, every unfiltered thought bubble is offloaded into the ether for the practitioner’s consideration as they believe they have 24/7 access to the practitioner via messaging apps. Again, this erratic interaction would be impossible in a face-to-face interaction.
- Online reviews which bend or distort facts to suit a narrative or are posted as a consequence of emotional venting.
- Practitioners inadvertently breaching patient confidentiality by, for example, communicating with a party other than the patient about their care. Commonly this is a response to the emotive and hurtful online review, divulging clinical information in a public forum.
- Practitioners getting bombarded by messaging at all times of the day and responding from a place of exasperation, or even worse with a few drinks on board after hours – it is easy to see how the disinhibition effect might be compounded.
- Practitioners initiating or responding to communications with a patient that may be sailing close to or crossing personal boundaries – for example subsequent conversations of a personal nature flowing from a friend/ follow request on social media (see above reference to alcohol/ after hours).
Social media platforms are continually evolving, with new features and algorithms. If dentists are going to enter the arena and engage in the virtual world, they must not only stay informed and adapt their strategies to remain effective in reaching their audience. They must ensure they are compliant with the relevant guidelines and standards of professional conduct expected by the regulator, and be mindful of the online disinhibition effect.
In broad terms, this necessitates a commitment to ongoing learning and improvement.
- Education and training: Healthcare professionals should educate themselves in the responsible use of social media. This should cover privacy regulations, ethical considerations, and the potential risks associated with social media engagement. Beyond this, registrants need to regularly reflect upon their online activities and behaviours and temper them to ensure they are appropriate.
- Professional codes of conduct: Professionals should have a good working understanding of these codes, which can help clarify the boundaries and expectations for healthcare professionals. The GDC outlines specific standards in relation to social media use vis-à-vis confidentiality and public trust.
- Privacy controls: It goes without saying that healthcare organisations should implement strict privacy controls to protect patient information. These controls should loop back to education on privacy requirements and boundaries for appropriate behaviour online.
- Patient consent: Before sharing patient-related content on social media, healthcare providers must obtain informed consent from the patient. Patients should be informed about the potential risks and benefits of sharing their stories or medical information.
- Fact-checking and verification: To combat the spread of misinformation, healthcare professionals and organisations should be diligent in fact-checking information before sharing it. Encouraging critical thinking and providing credible sources can help patients distinguish reliable information from unreliable content.
Remember, if you want increased and targeted access to patients via direct messaging or social media, the reverse will be true – they will expect more access and responsiveness from you and your practice too.
While there is much to consider here, most of this knowledge is now embedded in the culture and something we are all conscious of as members of the digital community. The point, however, is that once we move from interactions in the presence of our patients where we can look them in the eyes, to the online space, we need to be vigilant of the online disinhibition effect – where we might be provoked into reacting without considering the consequences or even communicating innocently in a manner where we can’t see social cues and messages that may be misinterpreted.
Regardless of the medium, an old adage that is now truer than ever in this world of immediate communication – if in doubt about pressing ‘send’, sleep on it and it will still be there tomorrow – hopefully, in the cold light of day, common sense will prevail.
References available on request.