The #ethics behind social media influencers in dentistry

Kathleen Nichols, DDS, Renee Pappas, DDS

QI have engaged a social media influencer to promote my dental practice on various social media platforms. They have agreed to share messages and content regarding my practice in exchange for financial compensation, as well as for dental services. When my messages are shared under their byline, I have seen increases in patient engagement. The social media influencer was not a patient of record in my practice when I engaged them to share testimonials and other social media content. Later, the influencer became a patient through a services exchange agreement. Using the American Dental Association Principles of Ethics and Code of Professional Conduct (ADA Code) as a guide, are these arrangements ethical?

AAdvertising and promoting one’s practice through social media is not, per se, unethical. In fact, patients increasingly are turning to online reviews to assist in choosing a health care provider.1 Although the use of a social media influencer in marketing your practice may or may not include a “review” of services, being aware that patients are making choices on the basis of what they see on social media, you are obligated to adhere to principles of ethics and standards of professionalism. It may be helpful to understand what a social media influencer is before discussing the ethical considerations in using them as part of your marketing strategy. “Social media influencers are people who have large audiences of followers on their social media accounts, and they leverage this to influence or persuade this following to buy certain products or services.”2 The influencer creates impact through interactions and posts, usually regarding a specific topic.3 An influencer may disseminate content targeted toward those involved in their respective field, and they can also encourage dialogue and discussion regarding the content. “An influencer’s impact can be measured through connectedness (number of users following and users followed) and the effect the posts create in the topic community (likes, retweets, visibility).”3

The scenario described presents 2 potential ethically problematic issues: compensation to the influencer and the type of content that is being shared. If the influencer is merely sharing information about hours and services available, this likely does not present any ethical concerns, but if they are sharing “reviews” of services or product and procedure promotions, this may be more problematic. The California Dental Association Code of Ethics, for example, states that, “A dentist who compensates or gives anything of value to a representative of the press, radio, television or other communication medium in anticipation of, or in return for, professional publicity must make known the fact of such compensation in such publicity.”4 Even more problematic is if the reviews are of services that were provided as part of a quid pro quo exchange, wherein you provide the service at no cost so that the influencer will then favorably review the care and services received.

The preamble of the ADA Code states that the primary goal of all conduct must be the benefit of the patient.5 Applying this concept, the dentist must ensure that the patient’s best interests are at the forefront. For example, patients would benefit from promotions that would encourage dental health–related topics, such as frequency of visits to the dentist. All marketing efforts, including any posting from social media influencers, should reflect honesty, compassion, kindness, integrity, fairness, and charity.5 All social media content should reflect the dentist’s efforts to strive to do that which is right and good.5

Section 1 of the ADA Code, principle: Patient Autonomy (“self-governance”), would require that the patient is engaged in their treatment decisions.5 As such, when promoting specific procedures or products available in your office, it must be clear that each case is unique and specific criteria (such as periodontal health or occlusal function) must be individually evaluated to assist the patient in their decision-making process. When using an influencer on social media to promote one’s practice, photographs of a specific type of treatment are often included. In that case, it is necessary to safeguard the patient’s privacy according to Section 1 of the ADA Code.5

If a patient’s photograph is used in which they may be identified, they must give their informed consent to have their photo used in advance of the post, or it would be considered unethical and may be a violation of state or federal laws regarding patient privacy in health care. Certainly, a more ideal option would be to avoid using a photograph with any identifiable characteristics in the first place.

The principle of Patient Autonomy also obligates dentists to involve patients in making treatment decisions in a meaningful way.5 Many potential patients seeking options in esthetic dentistry may turn to social media platforms to acquire information before choosing which dental practice they will call to initiate a consultation for such treatment. Therefore, a dentist who is compensating someone to influence the choice of these patients can possibly compromise the patient’s best interests. Although internet searching may be efficient, a patient’s expectations can be altered greatly by means of the information they find online. This information may directly affect a patient’s autonomy in making important decisions about their treatment. Search engine optimization of a particular dental treatment or of a specific practice in their area may lead them to a website that directly affects decisions they make about their own treatment. In some instances, it may lead them to seek a second opinion from a dentist other than the one they are already seeing for oral health care. This is not necessarily unfavorable unless the treatment they are interested in having done on the basis of an internet search is not evidencebased. Therefore, it is especially important that the information posted is factual and accurate.6 Social media is a powerful tool that can educate potential patients, but it can also be misleading by means of falsely advertising a certain level of expertise simply because of the dentist’s prominent social media presence as a result of using influencer marketing.6 Patients may perceive influencers as experts or unbiased and, as such, could accept the information presented on social media without hesitation, thereby projecting specific results or opinions as appropriate for the specific patient or condition.

Section 2, principle: Nonmaleficence (“do no harm”) details the importance of a dentist keeping one’s skills and knowledge up to date, as well as avoiding interpersonal relationships that could impair their professional judgment or risk the possibility of exploiting the confidence a patient placed in them.5 Furthermore, the influencers should never encourage treatments or products that are potentially harmful to the patients’ health, but instead should encourage patients to explore options that are appropriate for their health based on consultation with the dentist regarding their own circumstances.

According to Section 5, principle: Veracity (“truthfulness”), experimental or nonsubstantiated claims or proclamations that are not evidencebased should be avoided at risk of harm to the patient.5

Beneficence obligates the dentist to improve the health of the community.5 The influencer’s posts should advance knowledge rather than upsell services. The dentist also has an obligation to maintain a professional demeanor in the work-place at all times, which may include any social media interactions.5 The influencers must be encouraged to establish posts that are not demeaning to the profession and that promote the integrity of the particular practice, as well as the general practice of dentistry.

According to Section 4, principle: Justice (“fairness”), social media posts must avoid offering rebates or other fee incentives.5 Offering fee differentials or waivers of copayment may not be legal or ethical based on the circumstance but may also lure a patient to a practice on the basis of misrepresentations. Any testimonials should be based on actual patient experiences and if a post or testimonial is compensated monetarily or with a free or discounted service, this should be disclosed.

Of all the important principles listed, Veracity is particularly applicable. “The dentist has a duty to communicate truthfully.”5 Using social media influencers in a way that would misrepresent outcomes, fees, or safety would not be ethical. Unsubstantiated information may mislead a patient to make a decision on the basis of inaccurate information. https://doi.org/10.1016/j.adaj.2022.07.008

Social media influencers are going to be more and more common in patients’ decision making about the dentist they choose to see and the services they may request. It is critical that dentists adhere to the highest standards of ethics, not just in practice but in social media marketing as well.

Copyright ª 2022 American Dental Association. All rights reserved.

This article was reprinted with permission from The Journal of the American Dental Association (JADA) and published in JADA, Vol 153, Issue 10, Kathleen Nichols, DDS; Renee Pappas, DDS, The #ethics behind social media influencers in dentistry, pp 10101011, ©2022 American Dental Association (ADA). Reprinted with permission from the ADA. All rights reserved.

Dr Nichols practices general dentistry in Lubbock, Texas, and is a member of the American Dental Association Council on Ethics, Bylaws and Judicial Affairs. Address correspondence to the American Dental Association Council on Ethics, Bylaws and Judicial Affairs, 211 E Chicago Ave, Chicago, IL 60611.

Dr Pappas practices general dentistry in Arlington Heights, Illinois, and is a member of the American Dental Association Council on Ethics, Bylaws and Judicial Affairs.

Disclosures: Drs Nichols and Pappas did not report any disclosures.

The views expressed are those of the authors and do not necessarily reflect the opinions of the American Dental Association Council on Ethics, Bylaws and Judicial Affairs or official policy of the ADA.

References

1. Lin Y, Hong YA, Henson BS, et al. Assessing patient experience and healthcare quality of dental care using patient online reviews in the United States: mixed methods study. J Med Internet Res. 2020;22(7):e18652. https://doi. org/10.2196/18652

2. Kirwan D. Are social media influencers worth the investment? Forbes. August 21, 2018. Accessed March 2, 2022. https://www.forbes. com/sites/forbesagencycouncil/ 2018/08/21/are-social-mediainfluencers-worth-the-investment/ ?sh¼66999f34f452

3. Elson NC, Le DT, Johnson MD, et al. Characteristics of general surgery social media influencers on Twitter. Am Surg. 2021;87(3):492-498.

4. CDA Code of Ethics. California Dental Associ- ation. Accessed February 28, 2022. https://www. cda. org/Portals/0/pdfs/code_of_ ethics/code-of-ethics-2020. pdf

5. American Dental Association Principles of Ethics & Code of Professional Conduct. With Official Advisory Opinions Revised to November 2020. Accessed July 29, 2022. https:// www.ada.org/-/media/project/ ada-organization/ada/ada-org/ files/ about/ada_code_of_ethics. pdf?rev 86aeaa6fb0d0467f8 a380a3de35e8301&hash

89BAA88FB9305B8F134414

E337CAE55A

6. Gupta N, Dorfman R, Saadat S, Roostaeian J. The plastic surgery social media influencer: ethical considerations and a literature review. Aesthet Surg J. 2020;40(6):691-699.

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