By Alexandra S. Levine

As more Americans turn to social media for health advice, medical professionals who double as influencers are toeing tricky ethical and professional lines.

Vanna Padilla, a licensed nurse practitioner specializing in dermatology, has built an online following of 92,000 by offering skincare advice on TikTok and Instagram.

Recently, that led to her firing.

“It was shocking, because I’d been there for eight years,” she said of the private practice where she worked in Tennessee. “If there'd been any issue in the beginning—[like] ‘Hey, this is in our handbook, this is in your contract, you can't do this’—I wouldn’t have pursued it.”

Padilla, a mother of two, said she began posting skincare and beauty content on social media three years ago to reach more people and bring in extra income—offering acne and anti-aging tips, recommendations for over-the-counter drugstore products, and makeup tutorials. Though board-certified nurse practitioners can generally prescribe medications, diagnose conditions and offer counseling to patients, Padilla in some videos urges viewers to consult a dermatology provider to “make a safe, educated decision” or understand the risks of stronger treatments. And none appear to disclose information about patients, which would violate the medical privacy law known as HIPAA.

Through partnerships with healthcare apparel and beauty brands, Padilla slowly began monetizing her content: One popular TikTok video promoting a product from Kopari Beauty brought in the equivalent of two weeks’ pay on her day job, where her base salary was less than $100,000, she said. But Padilla seemed to have crossed a line when she began offering virtual consultations and announced plans this fall to launch a “Skincare Expert Course” that would teach other healthcare providers and skincare enthusiasts about acne, routines and “the frameworks I use to treat patients in dermatology.”

She was terminated soon after for breach of contract. Her employer viewed the course and consultations as a way of competing with and harming the practice—and hurting the field more broadly by sidestepping having to refer to dermatologists altogether. Padilla claims she kept her boss apprised of her plans in advance.

Medical professionals have been moonlighting as social media stars for years, and still more got into it during the pandemic to reach wider audiences with health information, debunk myths about Covid-19 and illuminate what was happening on the frontlines. One in 5 Americans seeking help with a health issue now turn to TikTok for advice before approaching their doctor, a recent CharityRx survey of 2,000 U.S. adults found, and nearly the same number “trust health influencers more than medical professionals in their community.” The nonprofit Association for Healthcare Social Media was formed in 2019 to help the medical community responsibly use these platforms as educational tools. And Google-owned YouTube, the most lucrative social platform for creators, is actively encouraging licensed doctors and nurses to share their expertise online, launching a program recently to label and boost medical creators’ videos in search and discovery. (Previously, only academic institutions, public health departments, government groups and hospitals were eligible.)

“People are going to be going online and looking for information… and they’re going to be acting on the information they see,” said Dr. Garth Graham, a practicing cardiologist who is director and global head of healthcare for Google and YouTube. “Having a presence—as long as it is evidence-based, accurate information—is valuable. It’s valuable at scale, and it allows an opportunity for people to get access to information that they may not have had before.”

Blurred lines

Though it’s difficult to quantify the volume of medical staffers that have been fired for social media missteps, people from a range of specialties at all stages of their careers have been affected. In some cases, it’s easy to see why employers are terminating employees—like the group of Emory Healthcare nurses who lost their jobs this month over a TikTok video making fun of labor and delivery patients; the chair of Columbia’s department of psychiatry who was suspended for a racist, sexist tweet; the Texas dental practice that was dinged $10,000 by the U.S. government for HIPAA violations on Yelp; and the nursing home workers who were fired for posting explicit photos of seniors on Snapchat, Facebook and Instagram.

But less clear-cut disciplinary matters are becoming increasingly common in healthcare, where social media policies are often vague, inconsistent or outdated, leaving workers and employers alike navigating tricky terrain. Further complicating matters are platforms’ varied, ever-changing rules for health content, including rampant mis- and disinformation. (Medical professionals including Joseph Mercola and other osteopathic physicians have been among the most powerful spreaders of Covid vaccine disinformation, according to the Center for Countering Digital Hate.)

Physician groups and nursing groups, as well as medical schools and publications like HIPAA Journal, offer broad social media guidelines that emphasize the importance of upholding patient privacy and maintaining professional boundaries with those receiving care. But many don’t get more granular than that—stopping short of addressing potential conflicts of interest or competitive issues; best practices for those partnering with brands or monetizing their posts; or how social media policies should be enforced. (YouTube’s Graham, for one, believes physician creators should have the opportunity to be paid: “As they are financially rewarded in other aspects of their professional career, their time spent here is equally valuable.”)

“Beyond those ‘never’ events, like never posting private HIPAA [covered] information… I don’t get the sense that there’s really stringent rules out there with regards to people’s social media use,” said Kayhan Parsi, a professor of bioethics and health policy at Loyola University Chicago who has published research on ethical issues with social media in healthcare. “It doesn’t get down to the granular level of what is appropriate, what’s not appropriate.”

Nanette Elster, a co-author of that research and associate professor at Loyola University Chicago’s medical school, added that “so many policies just kind of collect dust in a binder somewhere and don’t get updated. … And then if you are thinking about individual practices… they don't really have the bandwidth to be updating a policy and procedure manual.”

One recent nursing school graduate, Anthony Scarpone-Lambert, said that it was drilled into the curriculum “pretty much day one” to not post photos or anything related to his role as a nurse on social media. He said that while he understands and agrees with the need to protect patients’ privacy, he was “disheartened” by educators’ broader approach to the technology.

“This archaic mentality of healthcare workers not being able to express themselves or live their lives outside of their role as healthcare workers can sometimes feel a little bit dehumanizing and also just not very empowering—especially when our jobs are so stressful and hard as it is,” he said. He added that nearly everyone in his orbit knows a nurse (or someone else who knows a nurse) “that has been let go in their role or had some sort of repercussions for posting on social media.”

Many such stories find their way to Katie Duke, a longtime nurse and advocate for medical creators who has 142,000 followers on Instagram.

Duke, an early healthcare influencer who began building her online audience a decade ago, was herself fired in 2013 for sharing an Instagram photo of an empty trauma room at NewYork-Presbyterian/Weill Cornell, where she was an ER nurse. She was, at the time, on the ABC docuseries NY Med, which showed what goes on behind hospital doors. As part of that, she was encouraged to post about life on the job, she said. When she reposted a photo of the messy aftermath of a “miraculous case” that a chief resident had already shared on his own Instagram, she ran into trouble with higher-ups who viewed it as insensitive. She was fired shortly after by her then-manager who she said told her: “‘You’ll never be famous like Dr. Oz; you're just a nurse. No one cares about you using your voice on social media. Social media will get you nowhere. I want nurses here who are just going to come here, be a nurse and go home. You’re trying to do too much.’” NewYork-Presbyterian did not respond to a request for comment about Duke’s termination and the hospital’s approach to workers’ use of social media.

Duke said she realized in retrospect how the post could be upsetting to the patient (who was not pictured) or family members. “I learned a lesson from that,” she said. “But did I need to be fired for that? A competent, leading, compassionate nurse, with so many years of experience who was loved and respected by people on the unit?”

She said she gets messages “every week from nurses all across the country” who are being fired for social media situations where the mistake doesn’t match the punishment. One nurse she heard from recently said she’d been fired for posting a photo celebrating a colleague’s last day at the hospital. (It was taken in a nondescript hallway but the name of the facility was visible, running afoul of its policy prohibiting photos on hospital grounds.) Duke said another nurse who posted on her private Facebook about a tough day in her short-staffed unit, simply hoping for some support, was fired for speaking negatively about the hospital on a public forum.

“Hospitals and healthcare employers aren’t exactly using these as opportunities to grow and learn together; they're just saying you posted this on social media, it went viral, cancel culture, people are calling for your heads, we’re just going to fire you,” said Duke, now a board certified acute care nurse practitioner. “They’re firing nurses who are taking good care of patients in an environment where we are already so strapped for safe staffing. It’s sad. And it’s really frustrating.”

One physician group it would not comment on disciplinary actions taken by health employers. But its code of medical ethics emphasizes that “actions online and content posted may negatively affect [workers’] reputations among patients and colleagues, may have consequences for their medical careers (particularly for physicians-in-training and medical students), and can undermine public trust in the medical profession.”

New York-Presbyterian “respects the right of its staff to use social media as a medium of self expression and does not discriminate against employees who use these media for personal interests,” according to policies from one network hospital. But they emphasize, among other guidelines, the need for workers to “establish a clear line between their personal and Hospital-related activities,” with violations potentially leading to suspension or termination.

Companies toe the line

Despite the challenges of navigating social media in medicine, businesses from small upstarts to corporate giants like YouTube are pushing the envelope for healthcare creators.

Clove, a company making sneakers tailored to frontline healthcare workers, is one of the first startups in this space to have built a business around them. Since its founding in 2019—by CEO Joe Ammon, whose wife is herself a registered nurse—Clove has made medical creators central to its growth strategy and built a sprawling influencer program involving hundreds across the country, from nursing students to physician assistants and surgeons.

Medical professionals should be able to be “unapologetically themselves” in order to provide the best patient care, said Clove’s chief brand officer, Jordyn Amoroso. “These are real people with real emotions and real passions, and in order for them to take care of their patients, they need to take care of themselves,” she said. “If social media is an outlet in which they are able to do so, that should absolutely be supported.”

“If knowledge can be shared with patients across the country—where there’s a financial block or geographical block from getting that type of care—why not provide that knowledge about X, Y and Z if they have it at their fingertips?” she added.

Dr. Blair Peters, a plastic and reconstructive surgeon in Oregon and transgender advocate who goes by @queersurgeon on Instagram, has helped his 36,000 followers around the world understand options for gender-affirming care. (Peters said that any funds he generates online are put into a research foundation supporting transgender health and LGBTQ mentorship.) And veterinarian Thomas Hamilton, known to his nearly 4 million TikTok followers as Dr. Tom, has transformed the conversation around care for animals that are often misjudged as aggressive. Both Peters and Hamilton have partnered with Clove—as has Padilla, the nurse practitioner in Tennessee.

Graham, the cardiologist who runs YouTube’s health arm, added that elevating qualified medical creators is key to pre-bunking and debunking misinformation for patients: “Who else to get information early in their journey from than a licensed, qualified clinician who knows the topic?”

We’re only in the early stages of figuring out how these fast-evolving technology platforms can be used effectively in the healthcare ecosystem, Graham said, but gone are the days when patients would wait until their next office visit to ask their doctor a question. Looking up health information online is now a regular part of their journey, so “we have to be where consumers and patients are,” he said. “Not being in there creates a void."

Doctors get into this field to have impact, and beyond the one-to-one patient relationship, many physicians now want to reach more people at scale, Graham said. He believes that’s a good thing.

“We should start to go even further with this conversation and not just say, ‘Should clinicians be engaged?’—because they should be,” he said. “How do we not only encourage it, but think about how physicians can be creative in communicating with patients?”