Dear Editor,

Seeking a remote second opinion (RSO) is common practice in medicine. Given the inherently complex diagnoses and treatment options, RSOs are particularly widespread in neurosurgery. Today, social media platforms have become spaces where patients and caregivers may explore opinions on treatment options.[ 9 ] Some may search for care without prior consultation with a physician, while others may seek a second opinion online after receiving an initial diagnosis or an offer of treatment.

However, there is limited literature addressing this growing trend in neurosurgery. Whether this gap exists due to the practice being rare or underreported remains unclear. We believe that the former is more likely, and we propose four possible explanations for this.

Language barrier: While English is widely regarded as the medical language of choice globally, only about 19% of the world population (1.5 billion people) speaks English, and comprehension levels vary significantly.[ 4 , 5 ] Since most social media content related to medical advice is in English, many users may struggle to understand the content fully. This language gap may be a barrier for non-English speakers to seek online second opinions.

While the barriers mentioned may explain the limited use of social media for second opinions in neurosurgery, the shift in the role of social platforms in medical communication has been notable.

The surge in social media usage, accelerated by the social isolation during the COVID-19 pandemic, has dramatically increased the speed at which these platforms grow and diversify.[ 1 - 3 ] Today, they are not only used for marketing or collegial feedback but also for sharing scientific knowledge, opinions, and even interesting cases.[ 7 , 11 ]

Nowadays, social media seems to offer a potential space for credible decision-making within the boundaries of established standards of care.[ 12 ] For physicians in underserved areas who lack access to advanced neurosurgical training, platforms such as Facebook, Instagram, and X offer valuable resources, including surgical videos, that can help close educational and training gaps. Neurosurgery, which requires repetitive practice and observation to master technical skills, can benefit from the sharing of such material.

However, this ease of access also extends to the general public. Physicians are not only connected with peers but also with patients, raising the concern that the sharing of clinical information can unintentionally turn into a medical consultation. Patients who identify with a condition discussed in a post may reach out to the physician for a virtual consultation. In such cases, if a physician provides medical recommendations without formally evaluating the patient, they step outside the bounds of the physician-patient relationship, which is key to maintaining accountability and adhering to the standard of care.[ 2 ]

It is critical that physicians clearly explain the limitations of any interactions on social media to such patients.

When considering offering a second opinion through social media, the complexity of pathologies and the high stakes of surgical interventions in neurosurgery make ethical considerations paramount. In our view, there are two main reasons why ethical concerns are particularly significant in neurosurgery.

Neurosurgery is a highly specialized field, with expertise often concentrated in certain academic or tertiary care centers. As a result, access to expert opinions may be limited, making it more challenging for patients to seek second opinions.

As technology continues to evolve, we may eventually see social media consultations regulated in a way that ensures protection for both patients and physicians, reinforcing the formal relationship that is the foundation of modern medicine.

Regardless of the timing of when social media consults will have formal regulation, providing a second opinion should follow certain unwritten rules. These rules apply to both providers and patients.

For providers, our advice is that a second opinion on diagnosis, treatment, and/or prognosis should be delivered based on the expertise and training of the provider, even if the second opinion leads to the same conclusion as the original one. Second opinions do not necessarily have to differ from the original, and it is only ethical to deliver an opinion that is as unbiased as possible. When a physician delivers a second opinion that differs significantly from the original, they should refrain from adding comments on the previous advice as a sign of professionalism toward the colleague and respect for the patient. Patients may not be well-versed in medical education, and adding comments, either positive or negative, might only increase their stress level and could damage their relationship with the original provider. Social media is not a peer-reviewed platform, which means there is always a risk that what is presented as a surgeon’s work may not accurately reflect their actual practice. The motivations behind such postings go beyond the scope of this discussion, but they raise important concerns about professionalism. Ultimately, it is a matter of intellectual honesty for a surgeon to ensure that the work they share on social media is genuinely their own. Moreover, the ethical foundation for second opinions in neurosurgery rests on the principles of beneficence and nonmaleficence. In fact, neurosurgical interventions often involve significant risks, including potential disability or mortality. Ensuring that the recommended procedure is indeed the best course of action aligns with the physician’s duty to act in the patient’s best interest while minimizing harm.

For patients, we would recommend contacting the neurosurgeon (or institution) directly to inquire about their RSO programs. While the initial inquiry can be directed through social media, we do not recommend furnishing personal information, history, and imaging through these platforms. Our recommendation is to follow the neurosurgeon’s practice or institution on their platform of choice that aligns with health insurance portability and accountability act (HIPPA) and compliance protocols.

To conclude, the potential benefits of social media in neurosurgery are potentially limitless, especially for patients in underserved regions where access to specialized care may be lacking. However, it is crucial to balance these advantages against the fundamental principles of medical ethics, patient confidentiality, and professionalism. The onus lies on the neurosurgeon to deliver RSOs in an ethical and compliant manner.

Ethical approval

The Institutional Review Board approval is not required.

Declaration of patient consent

Patient’s consent was not required as there are no patients in this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Use of artificial intelligence (AI)-assisted technology for manuscript preparation

The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.

Disclaimer

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.

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