The doctor will fave you now.
Sarah’s Instagram feed is pretty typical for a 21-year-old model-slash-influencer living in Florida. Here she is standing dreamily in front of some ferns. Over here she’s clutching Starbucks’s new Cloud Macchiato. She poses on porches, by murals, in bathrooms, often with lengthy captions that reveal what she’s up to this weekend (wedding planning, working), words of inspiration, and her very relatable love of donuts.
There’s one important difference: In all of them, she’s wearing scrubs.
Which is appropriate, considering “shesinscrubs” is her username. Along with modeling, Sarah, who asked not to reveal her last name, is a registered nurse. Over the course of just four months she has amassed an Instagram following of more than 11,000 people.
Being a nursefluencer, a term that I have admittedly made up but that describes a growing population, is similar to being a regular influencer: You get someone to take pictures (for Sarah, it’s her little brother), you post often (once a day or else the algorithm will bury you, Sarah tells me), and promote products (like almost everyone I spoke to for this piece, Sarah receives free scrubs from the brand Figs).
On the other hand, regular influencers don’t usually have to worry about whether promoting, say, CBD oil violates medical ethics. HIPAA, the law that protects patient privacy and medical records, is also presumably not a high-priority consideration.
But for Sarah, and many young health care professionals like her, a sizeable Instagram following is a salve for a litany of problems experienced by those in the field: burnout, odd hours, and a lack of a creative outlet, to start. So it’s not surprising that within the past few months, tons of accounts like hers have popped up, gaining huge followings — largely made up of fellow medical professionals — by posting an insider’s view of the industry.
It’s also raised questions about the ethics of being a health care influencer. After all, isn’t the only person who should be influencing anyone’s health their own doctor?
Where did medical influencers come from?
Instagram is a place where you are supposed to show off how “well” you’re doing, even if you’re not doing very well at all. Scroll through the feed and you’re likely to see signifiers of social wellness (friends), mental wellness (books and bathtubs), and physical wellness (yoga and photogenic health foods) that might bear negligible resemblance to one’s actual life.
Those who have succeeded at performing that wellness the most palatably for the platform have been rewarded with millions of followers, which in turn can bring brand deals and, with that, money. It’s created a new class of microcelebrities who, intentionally or not, wield enormous influence over how others live their lives, or at least how they present their lives on social media.
While most of the time when we think of wellness influencers, we might think of acro-yoga couples or, on the extreme end, people like Freelee the Banana Girl, the nude vegan vlogger who lives in a South American jungle and eats exclusively fruit, there are some accounts that are actively harmful: Instagram has contended with a serious anti-vaccine conspiracy theory problem, for instance. Its algorithmic recommendation engine can also conflate many types of “health” content, so that following one anti-vaccination account might push you to follow dozens of others, but could also group them alongside accounts promoting innocuous things like plant-based diets.
Health care influencers who have flooded the site within the past few years say they’re fighting back against that kind of social media misinformation. Many nurses and doctors on Instagram combine the cute, aspirational lifestyle aesthetic of regular fashion and beauty influencers with actual medical tips from a vetted professional.
There are now so many medical professionals on Instagram that at least one hospital has created an entire position to govern it. Austin Chiang, MD, a gastroenterologist and assistant professor of medicine at Jefferson Health in Philadelphia, also holds the position of chief medical social media officer, which he guesses might be the first of its kind in the country. “I always felt strongly that we need a stronger clinician presence on social media in order to really battle misinformation out there,” he says.
It’s why last fall, he and a few peers launched the hashtag campaign #VerifyHealthcare, which encouraged health care professionals on social media to list their qualifications, such as their education, specializations, and board certifications. “A lot of us had started noticing health professionals who were saying that they were some sort of practitioner when they actually were not,” he says. “If they’re talking about health and marketing themselves as doctors, then the public could be misled.”
Many of the top Instagram posts related to plastic surgery, for instance, are from doctors not specially trained in plastic surgery despite the fact that they’ve marketed themselves as “cosmetic surgeons.” Naturopaths, chiropractors, and aestheticians are also typically not medical doctors, but some may present themselves on social media as such.
Concerns like these have been top of mind for people like Arthur L. Caplan, the founding director of NYU’s Division of Medical Ethics. “I see people all the time advertise things like, ‘My specialty is cosmetic dentistry.’” he says. “There is no specialty of cosmetic dentistry. It’s not a recognized dental subspecialty.”
On Instagram, health care isn’t just a day job anymore, it’s a personal brand, and an increasingly lucrative one at that: All the health care influencers I spoke to had seen their followings skyrocket in the past year, which some hope will lead to bigger brand deals.
But wait, why do doctors need side hustles?
Dentist Joyce Kahng has more than 13,000 followers on the account she launched just a year ago, @joycethedentist. When she first started, she posted up-close images of teeth (she used her family members’ due to HIPAA concerns) because that’s what she saw other dentists doing. But, she said, laughing, “those weren’t being received well by normal people.”
Instead, the content that performs best on the page now is about her life as a dentist in addition to owning her own practice and being a professor at USC. Being likable and accessible, she says, has also translated into business: Around three-quarters of her new patients have found her via Instagram. “It gives you a competitive edge against the already saturated dental market,” she explains.
Despite health care being a relatively stable and high-paying industry, Kahng sees her growing Instagram following as an investment. “In some future, I do want to start to monetize it because at some point I need to have kids,” she says. “I just haven’t figured out the way in which to do it that doesn’t make me feel like a sellout.”
This is when I ask her the very obvious question: If an extremely successful dentist, business owner, and professor is worried about not being able to afford children, what hope do the rest of us have?
“Dentistry does pay well,” she explains. “The thing is, you have to work in order to be paid. It’s not like a corporate job where you can call in sick. If I don’t come in, every single person that I employ cannot work that day. I just imagine being pregnant and having to miss work for a month, [and] the office cannot run. That concerns me.”
It’s not as if health care professionals haven’t always had side hustles. The internet is filled with tips on how to make extra money as a nurse — RNs can make, on average, from $50,000 to nearly $100,000 depending on the state where they live, but when adjusted for cost of living, that number can be lower. It’s also a job that has a high rate of burnout due to the stressful work environment and difficult working conditions, which means that not everyone can or wants to make it a lifelong career.
Many nurses have recently turned to multilevel marketing as a way to supplement their incomes or as a path out of the field. And though none of the influencers I spoke to were making serious (if any) money on Instagram, most acknowledged the possibility of doing so in the future.
“I don’t think it’s fair to be like, ‘You’re a nurse, you care for other people, therefore you’re not allowed to benefit yourself financially,’” says Katy B (who also asked to keep her last name private), a registered nurse in San Francisco with more than 25,000 followers. “Most of us have a lot of student debt and trying to stay afloat. I don’t think there’s anything wrong with it as long as you’re being transparent about what you’re doing.”
Spon con, HIPAA, and medical advice: the ethics of being an Instagram doctor
That transparency, of course, comes hand in hand with the question of sponcon, or sponsored content. For the average influencer, it’s pretty simple: A brand pays them a sum of money to endorse a product, like laxative teas or viral YouTube toys, in a way that leverages their large following.
It’s different, though, when you’re also leveraging your expertise and reputation as a doctor, dentist, or nurse. Scroll through most health care influencers’ Instagram feeds and you’re likely to see at least a few #ads. Some are innocuous: Many influencers have deals with the aforementioned scrubs brand Figs, while others promote products like stethoscope charms shaped like Disney characters that can help keep nervous kids calm during checkups.
Though few peddle the kind of questionable medical treatments shilled by celebrities like Dr. Oz (rapid weight-loss pills with harmful side effects, for instance) some toe the very blurry line about what’s appropriate for a health care professional to post. Mike Varshavski, a cartoonishly handsome New York City physician who goes by the name Doctor Mike on Instagram and has more than 3 million followers, regularly posts sponsored content for everything from Clorox bleach to Quaker Oats and American Express, which could create the perception that these corporations are somehow medically approved by this doctor. (Disclosure: Doctor Mike has participated in a Vox Media panel event.)
Even average Instagram influencers now shill drugs and medical devices paid for by Big Pharma, without necessarily any real knowledge of how they work. When products fall under the health umbrella, the ethical questions are even more complicated. The Federal Trade Commission does have specific guidelines for doctor endorsements. For example, doctors should not misrepresent their specific areas of expertise. But it still raises the question: Should a doctor be paid to promote essential oils? What about NyQuil?
“I’m not sure [doctors] have any place [promoting over-the-counter products] other than to say, ‘I’m a regular user.’ I think it still undermines their professional credibility,” Caplan says. “When you start endorsing, say, aromatherapy, you’re saying you had a great time at a spa and you felt it really helped your anxiety or something. You’re getting into pseudo-medicine stuff. Some of those things can make you feel better, but you don’t want to give them scientific endorsement.”
It’s a debate that’s somewhat reminiscent of decades-long concerns about pharmaceutical companies paying or wooing doctors to prescribe their products. But this, Caplan explains, isn’t the way it works anymore. “You don’t have the old, ‘We’re gonna bring you donuts every week and you keep writing prescriptions for our drug.’”
“It’s not that everybody suddenly became ethical,” he said, laughing. Rather, now pharmaceutical companies can market directly to the patient. “There’s the ads that are like, ‘Ask your doctor about this cancer medication.’ If you have to ask your doctor about a cancer medication, you need a new cancer doctor.”
Sponcon, however, is not the main ethical concern for most health care influencers — after all, doctors and nurses endorse products all the time; as long as they comply with FTC advertising disclosure guidelines, there’s nothing in the Hippocratic oath that claims thou shalt not hashtag #ad.
Instead, that concern is HIPAA, or the Health Insurance Portability and Accountability Act of 1996, a federal law that provides privacy and security protections for patients’ medical information. Under HIPAA, all patients have the ability to see how and where their medical records are being used and prevent them from being seen by their employer or insurance company. And unlike shilling over-the-counter drugs, violating HIPAA is a fireable offense. The problem, though, is that HIPAA existed a decade and a half before Instagram did.
“It’s not as simple as not mentioning someone’s name,” Chiang explains. “Instagram is visual, so you see a lot of procedural photos. There are certainly risks in that. There’s even risks in geo-tagging or talking about a case that you’re doing.”
Some doctors and surgeons have achieved enormous followings on social media by posting procedural videos from the gross (Sandra Lee, who goes by the nickname “Dr. Pimple Popper”) to the straight-up gory. In 2015, Dr. Michael Salzhauer, or “Dr. Miami” began posting graphic videos of himself performing butt lifts, breast surgery, and liposuction on Snapchat, which regularly garnered more than a million views.
Dr. Miami reportedly secured permission from his patients to do so. Every influencer I spoke to listed HIPAA as one of their top concerns and said they were diligent about not posting anything that might cross a line.
“You can change the date, gender, or demographic, but someone from [their] work or family could recognize the case no matter how much you change about it,” Sarah says. “I would be scared to even think about posting about any of my patients. Maybe one of them saying, ‘You were a nice nurse.’”
Instagram is offering prospective doctors and nurses a look inside their world, and a way to deal with the stress
Though weighing the ethical questions like HIPAA and sponcon can be thorny, health care influencers also provide a genuine service for those interested in joining the field.
Like Kahng, Katy started her Instagram page after seeing similar accounts, and today, the majority of her followers are fellow health care professionals or aspiring ones. Though she originally went to college with the goal of being a physician, she realized it wasn’t for her. Now she’s on track to receive her master’s in June, when she will become a pediatric primary care nurse practitioner.
“My main goal is to share what my journey looks like, because in health care, especially for folks that aren’t familiar with the professional fields, there’s so many different things that you can do,” she says. “It’s cool when we all share our unique perspective of what it actually looks like on the human side.”
This explains why accounts like hers have been able to grow so quickly in such short amounts of time: There’s a real hunger among prospective medical professionals to get a sense of what the job and the lifestyle really look like.
“We’re so at risk for burnout, because we spend a lot of time taking care of other people, and I think sometimes we forget how to take care of ourselves,” she adds. “We have to brag about the cool things that we do!”
What you don’t see on Katy’s Instagram page — for reasons that are very obvious and very necessary — is her actual job. She’s currently in an emergency pediatric psychiatric care unit, where she works with children up to age 17 who are experiencing immediate psychiatric crises.
It’s difficult to imagine how the stress of such an environment can affect a person, but it does help explain why so many Instagram nurses and doctors fill their feeds with a heavily curated stream of bright and shiny images. For those who work in emergency rooms, it’s impossible to predict what the day will bring. But on Instagram, everything’s perfectly controlled.
Dustin Harris, a resident emergency room physician in Chicago, deals with the stress using humor. He’d done some standup, and started posting the funny things patients would say to Facebook. On his Instagram page, where he has nearly 18,000 followers, he posts jokes, memes, and sometimes even haikus relating to the job.
“My favorite part about it is making people laugh. It keeps me balanced. I’ll be working and I’ll see some disease, and be like, ‘Oh man, I could write a funny rap about this.’ The human body is a funny thing sometimes.”
“TV has portrayed medicine as being very dramatic or sexy,” he adds. “I felt that I could show the more real version of it. Not that those things that happen don’t ever happen, like awesome procedures or people coming back to life, but that’s not every day.”
Making light of the often dark professional realities of health care is how Sarah, the nurse in Florida, built her following in the first place. She’d started the meme account @scrublifenurses last June, which then gave her the skills and platform to launch her own personal page. Memes there range from the silly (a video of a possum carrying her babies captioned with “When you’re the only seasoned nurse on the floor with a bunch of new grads”) to the serious (the phrase “A national effort for safe staffing ratios for nurses” combined with the viral clip of Mo’nique saying “I would like to see it.”).
“A lot of our job is dealing with human emotion, and you can bring that home pretty easily,” Sarah says. “If you just bottle it all up and you already have issues with your own mental health, it can be extremely detrimental and then you lose your love for your passion.”
On both her meme account and her personal page, Sarah often posts about topics like mental health, the importance of nurses’ unions, and other national health care issues. That, of course, in addition to the stylized photos typical of influencers. “I like to post [photos that show] this isn’t what it really is, but at the same time have an aesthetically pleasing feed. It’s kind of like you have control over something, but when you’re at work it’s chaos.”
Nursefluencers aren’t going anywhere anytime soon
The benefits of being a health care professional with a big Instagram following — having a creative outlet, the ability to market oneself, and the sense that you’re combating misinformation on the internet, for instance — mean that the phenomenon isn’t likely going to slow down.
One problem, though, is that medical students aren’t exactly taught how to use Instagram responsibly. Caplan, the medical ethicist, says that at most they’ll get a single lecture on social media, which he attributes to the generation gap. While most current medical students have grown up using social media, their professors didn’t, and may not be prepared to advise them on the peculiarities of the health care internet.
In a piece for Slate in November 2018, medical student Vishal Khetpal wrote about how organizations and companies would approach him and his classmates to appear in white coats while endorsing products or attending events despite the fact that they weren’t actually doctors yet.
“The uncharted ethics of social media are already confusing,” he writes, “and that’s before you add in the influence of outside interests, many of which are ready to take advantage of students’ ability to offer some stamp of medical authority to the general public about a product or idea without asking too many questions.”
Confusion over what’s okay to post is a constant struggle. It’s why Chiang has launched the Association for Healthcare Social Media, which is currently in the process of obtaining a 501c3 designation before opening itself up to members.
“I think a lot of physicians are almost scared to get on social media because of the restrictive nature of how things were worded in the past,” he says. “We want people to share their experiences and share their expertise.”
Traditionally, health care professionals were discouraged from revealing anything about their personal lives in the public. But, thanks in part to Instagram, that’s changing.
“[There are] some old fogies who think, ‘Well, doctors shouldn’t be sharing personal information or talking about their lives in places the patients could find it, blah, blah,’” Caplan says. “Anyone who thinks they’re going to stop the use of social media by physicians or nurses is over 40. It’s just not going to stop. We have to adjust.”
Kahng, for her part, says that now, she makes sure to teach her USC students to build up their social media presence. “They invest so much money into their education and at the end of it, who knows?” she says. “They may not like dentistry, and I want them to have a following so that they don’t feel quite as trapped. They have something to lean on.”
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