 So thank you so much. I'm delighted to be here. I must say that in doing my work on surgical ethics I never thought that I would be invited back to tell you a story where I have very little data, but I think this story has largely been neglected and I hope it at least sort of makes you think. I'd like to in advance thank Lainey Ross for helping me prepare a manuscript in relation to this, but also to Mark Siegler and Dan Sulmasey and Peter Angelos and Saba for encouraging me to pursue this moral dilemma that I encountered. So this is not my Facebook page and my Twitter handle is at specialkdmd, but I should disclose that I'm an active user of social media and I would go even further than that and say that I feel like I have a moral obligation as a physician to participate in social media to get good information out there to an increasingly social media driven population. And so this talk is truly not intended to blame any technology which has the power for good just as much as it does for bad. So last year when I was a fellow here in Chicago I was given the opportunity to go on a medical mission to the Philippines to treat thyroid diseases as well as I was a fellow here with Dr. Angelos both in ethics and in endocrine surgery. So I went to the Philippines on this phenomenal mission where I connected with all kinds of local physicians as well as physicians from the US and had an amazing experience treating patients and I felt like I had certainly done some good in terms of treatment and education and when I returned I started perusing the Facebook profiles of the friends I had made while over there. Okay, how do we, it's locked one second. Nope. Okay, do you want to, I'm usually just forwards. Where's the keyboard control? Oh, okay we're gonna do this not full screen so that it, you guys can still see that up there. Okay, sorry about that. So as I was perusing I saw, started by seeing this photo, this is a photo of me holding a breast that I had just removed and also I just wanted to say that I agreed to photography but that only I was being taped and please not to tweet or take pictures of these photos that I'm gonna show you. It was another dilemma I had whether to use them or not in this forum but I think they really are important to get the point across and you can certainly disagree with me on that. So I saw this photo and then I saw these photos and I started becoming increasingly uncomfortable about the photos that were being shared on Facebook here and thinking about the responsibility that I had to the patients that I had treated and also to my profession at large. So here's the young woman with a big goiter she's smiling at the camera I don't think that is really informed consent but even if we had obtained informed consent for this patient not sure that applies to sharing with friends on Facebook. This woman is clearly unaware that a photo is being taken and I would imagine that years back when people went on these missions they would share these types of photos around the dinner table or with their colleagues at rounds and so I'm not sure that this is any more or less inappropriate than what happened in the past but clearly the scope of distribution is increased unbelievably. Here's a photo of a Filoides tumor this is unidentified so technically doesn't breach any particular privacy laws but I'm not sure that again these photos are the types of things that I want to be associated with my profession and my colleagues on a medical mission and finally this photo really doesn't identify a patient here and in fact you might guess it's the woman but in fact I took out her husband's gallbladder that day and he requested the photo off before he was going home and so I'm not sure is this one okay to share and be posted. I was really faced with this real-life dilemma these photos didn't belong to me I hadn't posted them and I didn't really know what to do what would you have done I could certainly speak to the individuals that were posting them and ask them to remove at least the photos of myself. I can unfriend someone on Facebook just associate myself so I'm not connected but the photos are still up and out there and being shared. I can you can write to Facebook so they do have a mechanism for reporting sort of abusive content but I'm not sure that it's the role of social media networks to curate this type of content and finally I could certainly go so far as to report these this behavior but you know I started thinking about aren't we a self-regulated profession if so who regulates this and I even tried to contact I met this I saw this medical student group on Facebook and I contact them and I said are you concerned about the photos you're posting on Facebook and they were kind of like who are you random surgeon in Toronto contacting us but whose jurisdiction does this really fall under and in my case I was a Canadian surgeon being educated in Chicago traveling to the Philippines on the worldwide web so you know who's going to regulate this and in order to really consider the problem I had to think about not only the most important stakeholders the patients but also the other people involved so the visiting health care professionals that I went with the local health professionals that we worked with there medical professionalism as a whole and also missionary groups in general and so we'll go through all of each one of these in terms of patients you know we all in this group especially espoused the value of privacy but I thought it was important to remind myself or convince myself why this was so important and I learned that as early as the 5th century BCE Hippocratic tradition encouraged medical secrecy and from a utilitarian standpoint it's thought that people will be more likely to obtain health care and even preventative care if it's done privately it also encourages people to be frank about their medical discussions with respect to autonomy confidentiality shelters medical decisions from outside judgment and really promotes respect for human dignity because caregivers are displaying concern by keeping information private confidentiality also speaks to justice knowledge is power and it's only fair that a patient's information is released by themselves and not controlled by other people and even virtue ethics argues that confidentiality turns into a particular brand of excellence in the care of vulnerable patients so next with respect to the local health care professionals could I assume that the values are the same or could I impose my professional standards on all these nurses and physicians working in the Philippines who were posting just as many photos as anyone else I had taken this sign in the patient waiting room a patient has the right to every consideration of privacy concerning his or her own medical care program and I even found much later the Philippines Patients Bill of Rights and it says this the privacy of the patients must be assured at all stages of his treatment should say his or her the patient has the right to be free from unwarranted public exposure except in the following cases and they go on to sort of list circumstances where perhaps privacy is less essential so I turn to the colleagues that I had collaborated with on this mission and initially I sent a friendly email to them disclosing my discomfort I got some people agreeing to remove the photos and other people telling me that you know they'll think about it and so I had to sort of think of other ways to convince people that this was a very different standard from what we use at home I did find some literature on the subject in this study program directors of medical schools and residencies were surveyed about unprofessional posts by trainees and trainees are really only used as a easy sample sample to obtain but I think this applies across the board in any case 43% of unprofessional posts were related to confidentiality this is not the study that I'm going to tell you about but another cross sectional study by Thompson et al scanned a thousand Facebook profiles of students and found 12 breaches of confidentiality unfortunately even within unprofessional behavior there's a double standard because all of these breaches were for medical missions I hope this is still coming across okay I tried to convey to those posting that even if they were posting unidentifiable information that still may harm them their patients and their careers and that they also have to consider as we always do with social media who else they might be exposing like how they exposed me there are several guidelines regarding social media in general but none of them specifically address this problem the AMA does say this when physicians see content posted by colleagues that appear unprofessional they have a responsibility to bring that content to the attention of the individual so that he or she can remove it and take other appropriate actions if the behavior significantly violates professional norms and the individual does not take appropriate action to resolve the situation the physician should report the matter to appropriate authorities they must recognize that actions online and content posted negative may negatively affect their reputations among patients and colleagues and may have consequences for their medical careers and can undermine a public trust in the medical profession so when I presented this dilemma to friends and colleagues and our ethics group they said well of course you should do something about this you should report them but I also was thinking about my medical mission group and I did not want to harm the excellent work that they were doing and is this really that uncommon so if you search for medical mission on Google this is what you will find millions of photos updated daily furthermore this organization actually has a very strict social media policy and it's used only for philanthropy and fortunately it's impossible to find their social media policy took me several emails and phone calls to reach their public relations person who did send me their policy but I do believe that they lead by example even more interesting while I did a lot of this about a year ago I researched this issue in preparation for today and looked at medical mission privacy policies most websites indeed had one but like operations smile they the privacy policy refers to donors and people visiting the websites and not to the patients that they're treating so luckily in my circumstance with a more serious plea to the participants all of these photos were actually removed but clearly we have some work to do and here are some of the recommendations I would like to suggest oops sorry and again considering that any of this should only be done with a very specific audience and purpose so treat privacy controls online cautiously be even more vigilant in protecting patients rights when traveling abroad to provide medical care to vulnerable populations de-identified images should not be the minimum standard as they may still endanger public trust informed consent for photos if necessary should be written and specific to the purpose and method of information sharing and sought out only if there are clear benefits to public health follow local privacy laws where they exist engage global communities in this conversation and prior to embarking on a medical mission groups should really establish guidelines and so I'm delighted to report that one of the first guidelines I've ever seen comes out of a current McLean fellow Alex Langerman who's right there and so that has come sort of from our discussions on the missions that he's going on and so I hope that if any message goes viral via Twitter Facebook or other that this is the one that does thank you any questions for Karen sure just come to the microphone we'll take those two quick ones yourself and yourself there good so let's take both questions at the same time and then you can respond to both so one is has you addressed it with doctors without borders and is that Vinny Aurora it is you look just like you do on Twitter oh I got my hair cut so it matched Karen is lovely to meet you in person and I appreciate your professional use of social media my question is regarding our trainees and our medical students we now have a global health track and I was thinking about this with Shola's presentation regarding global health ethics many times we're sending as a medical school our students out there not through endorsed programs that we have with our faculty but through other programs that we we actually can't police and so where did is the medical school and sort of protecting our trainees come into place because as you mentioned trainees are most at risk in terms of not knowing and being sort of on the cusp of not understanding what's the correct correct black and white professional and ethic for social media so I'll answer the first question first in terms of doctors without borders I was in communication with them and they gave me their statement and then they received I published this essay in JAMA in May about this and so they received sort of they know that they're in in the paper and they received this there hasn't been any further communication but that's not a bad idea to reconnect with them in particular since they are such a large organization with respect to training so I think in general before we talk about specifically missions I think that social media training is going to be going to have to be part of medical education and in fact being adept at this is going to be part of professionalism in the future the definition of professionalism in terms of specifically students going on missions again I think it absolutely needs to be part of the training and Mark has invited me a second year now to talk to the medical students at the University of Chicago in the doctor-patient relationship course specifically about this but I think most definitely it should be part of any kind of training for anyone going on a mission and so that's something we could certainly work on a curriculum or something like that so thank you great all right terrific thank you very much