Good afternoon, my name is Tricia Pendergrass, and I am a resident physician in the Department of Anesthesiology at University of Michigan. My disclosures for this session are that I receive salary support for work as a digital media editor for the Journal of Health Advocacy, and I would encourage all of you to participate in this conversation today about healthcare violence using the hashtags you see on the slide. COVID-19 was not the first time healthcare professionals used social media to share public health information, but the impact that the pandemic had on the way we use social media was absolutely unprecedented. Twitter, especially, became this real-time news source and the first line of defense in a fight against misinformation which persists to this day. Social media applications allowed, I'm sure, many people in this room to share stories of patients with COVID in ICUs, sedated, intubated, alone, trying to convince people to finally take this virus seriously. At the request of the Surgeon General himself, clinicians took to social media to encourage people to mask up, get vaccinated, and participate in social distancing. And this allowed us to make our public health messaging personal because there is power in personal narratives. However, when we make things personal, that makes us vulnerable. Our group conducted two survey studies of physicians who use social media. One data set was collected pre-pandemic and one intra to post-pandemic in 2022. In 2022, we found that 66 percent of our respondents reported harassment on social media compared to 23.3 percent in 2019. Unfortunately, harassment frequently occurred due to physicians' public health advocacy on social media. Almost all clinicians who reported some sort of harassment cited advocacy as the reason why they were harassed. And we found that those using social media to post public health messaging were significantly more likely than those who did not to report online harassment. Harassment also occurred on the basis of gender, race, ethnicity, sexual orientation, and disability, with 31 percent of our respondents reporting sexual harassment. These findings are of particular concern because they suggest that the most diverse voices in medicine are the ones disproportionately being silenced on social media, a venue known for networking opportunities, mentorship opportunities, and a space that exists sort of separate from the traditional academic hierarchy. Additionally, 18 percent of respondents reported that their private information had been shared on the internet without their consent. This is a practice known as doxing. One respondent writes, I've had my office address posted, I've had people leave false reviews, I've received death threats, have received harassment related to social media at my home address, and have had people repeatedly try to have my job terminated or cause harm to my career. So what do we do? There's a fairly obvious and perhaps simple option, which is to just bow out and say social media is no longer safe for healthcare professionals, and therefore we will no longer inhabit these spaces. But as Wu and McCormick write in the slide you have in front of you, healthcare professionals have an ethical obligation to correct false or misleading health information, to share truthful health information, and to direct people to reliable sources of health information within their communities and spheres of influence. This is of course a lot more straightforward when you have someone sitting in front of you, when you have someone in a family meeting in the ICU, or you have a patient with you in clinic who shares a false or misguided health belief. It is both professionally appropriate and ethically necessary to try to redirect them back to an accurate understanding of the healthcare of themselves or that of their loved ones. This is a component of the principle of autonomy, because it's a part of informed consent, which is fundamental to the practice of medicine itself. So no, we can't just bow out, we can't just leave social media applications, because if we absent all healthcare voices from these spaces, all that will be left is health misinformation, and we can't allow that to happen. I'd like to turn our attention now to a framework I designed that can be used if someone, a colleague, someone you work with, a mentee, someone in your department, shares that they are a victim of harassment on social media. The first thing, and the most important thing, is to evaluate for the most immediate physical danger. Same thing as the ABCs when you walk into a recess. The first thing you're going to do as a first responder is read through the attacker's posts. I want you to ask yourself, have threats been made against the victim's safety, the safety of their family, or perhaps other employees in your workplace? Has the attacker included evidence they know where to find the victim? For example, did they share the address of the victim's home, clinic, or hospital? It's really hard to do this thoroughly when you are the person under attack. So if you are the first responder to the situation, this is of incredible importance for you to do. And if the answer is yes to either of those questions, with the permission of the victim, escalate this issue as quickly as possible to clinical supervisors, perhaps security personnel at your hospital, or law enforcement. The next step is to assist the victim in securing their internet presence. So once you've evaluated for threats to physical danger, start working on securing their internet presence by changing the security settings on all of their social media profiles, not just the one where harassment is occurring, removing identifiable information from social media profiles, personal photos, information, professional affiliations, pictures of children, change passwords to email addresses associated with those social media profiles. And this last one is going to sound like overkill, but I promise it's happened. Consider informing credit card companies about potential breaches. Doxing can involve the sharing of credit card information online. This is also a good time to start blocking reporting the harasser's accounts and posts. You've addressed for threats to physical health. You're working on securing their social media profiles. The next thing to do is to address threats to emotional health. Do not underestimate the very real impact on emotional health that online harassment can have. Individuals who experience harassment online report emotional distress and fear. Healthcare workers already experience hugely high rates of burnout and depression and anxiety, and harassment can only compound these issues, especially when some individuals may fear retribution from their workplace, even as the victim in these situations. All of this together can contribute to moral injury or burnout in physicians who use social media. And again, reflecting on the data I shared earlier, this emotional distress may disproportionately impact groups such as women, racial and ethnic minorities, persons with disabilities, and members of the LGBTQ community, because that's where harassment is targeted online. When you respond to threats to emotional health, validate what the victim's feeling. They might feel frightened, angry. They might be embarrassed this is happening to them. They might feel numb. Perhaps they're having trouble concentrating at work, having trouble sleeping. Remind them that, unfortunately, these are all expected impacts of online harassment, and it's not their fault. Remind them that they're not alone. You're in this with them, and it's not their responsibility to fix the situation. This is also an excellent opportunity to offer to moderate the victim's social media accounts as the first responder. Take over their account, log in with their username and password, and give them the chance to step back, log out, and remove themselves from the situation. The reality is, if there's a potential for threats to physical health or threats to professional reputation, someone should be monitoring the harassment for progression from perceived to real threats, but this is better delegated to someone who is not the victim of the situation. Finally, I'm going to ask you to begin a record of the harassment. It's a very human, very understandable instinct if you're being harassed to want to delete the post, delete your account, throw your computer out the window, but it's really important to engage in record keeping, even if the victim does not plan to report the harassment. Eventually, they may want evidence to provide to law enforcement, security personnel, or the social media platform itself, and if any threats of violence or attempts to damage the victim's professional reputation have occurred, this step is absolutely vital. And this step is something that amplifiers can be helpful with, so before I conclude, I want to introduce the concept of an amplifier on social media. These are private groups on social media filled with people who share a similar mission. I use this term very loosely. It can be people who are interested in children's advocacy. It could be a group of international people putting together social media content for an SCCM journal. It can be folks within the Division of Critical Care at your hospital who all use social media and want to promote each other's work. These spaces have different names on the social media applications. They're messages on Twitter or X. They are groups on Instagram. They're messages on LinkedIn. Really, all this is is intentional use of these spaces for professional advancement. They allow for well-coordinated dissemination of accurate medical information, as well as can be used to combat disinformation and counter harassment. So if an amplifier participant in that group finds themselves a target of harassment, other members can counter with data or evidence. Perhaps they're being attacked with health misinformation. People can say, no, here's the data to counteract that. They can all together report the offending social media accounts and can assist with documentation, which is usually the form of screenshots. This amplifier can also serve as a private space to debrief about this harassment with colleagues. Once all is said and done, you as the first responder have to evaluate your mental health and emotional well-being. You cannot care for others in crisis if you neglect yourself. Take time to check in with your support system and personally take a step back from social media if you feel like you need it. To conclude, harassment on social media applications of healthcare workers is a large and growing problem. In our data, we found that two in three physicians on social media report some form of harassment. I provided you with a framework to respond to online harassment that's on an individual basis. It includes evaluating for physical danger, addressing threats to emotional health, keeping a record of the harassment, securing social media accounts, and using amplifiers. There are many ways that you can support a colleague as they move through online harassment. You can review the offending posts for safety threats. You can validate their emotional response. You can moderate their social media profile. You can record evidence of the harassment and you can assist them in securing their social media profiles. However, these are all individual responses to a much larger problem. And if healthcare workers are going to be continued to expect to engage with the public on social media by our institutions, often to the financial benefit of these organizations, we need interventions that take place on an institutional basis. Resources through things like our hospitals, academic medical centers, and licensing bodies. Examples of this support could include a hospital system designating a communications professional, someone who can be the point of contact for healthcare workers during coordinated attacks, an academic medical center creating a social media crisis response team composed of a multidisciplinary team of communications professionals, public relations professionals, security personnel, and hospital leadership who can assist healthcare workers under attack. From the perspective of our research group, our future research will engage these stakeholders, health communications, security, public relations professionals, to examine how institutions support healthcare workers who are under attack on social media. We will describe resources available and we will make suggestions for improvement. These are the references that I have included in this talk and I'd like to acknowledge Drs. Regina Royan, Shikha Jain, and Vineet Arora for their mentorship and collaboration on the research that I presented here today. Thank you so much.

social media

public health communication

healthcare harassment

COVID-19

support framework