This article, an opinion by Daniel Sokol, barrister and ethicist was recently published in the BMJ. In the short time that has passed since its publication the article has had a number of rapid responses. These can be read here and are shared, in full, below [most recent first]:
23 February 2025
Jay Ilangaratne
Dear Editor
Dr Kar says, “It perhaps raises the question of the benefit of having supervisors/RO names in the public domain too – not available at present.” [1].
In fact, ROs names are already in the public domain. If one searches GMC’s ‘Our registers’ for relevant doctor, those who have a licence to practice, will be identified, among others, with the name of relevant Responsible Officer (RO). Further the email address of relevant designated body too, is available online. Hence, it should not be an onerous task to contact any relevant RO electronically if one wishes to do so.
Whether contacting a RO initially or complaining directly to the GMC is a personal choice. No one should be denied such choice. There could be sound reasons for complaining to the GMC rather than a RO despite the risk of greater distress it might cause to the doctor concerned. Regrettably, widely known ‘cover-up culture’ within NHS could be a reason why some prefer to contact the GMC. It is also arguable whether internal NHS procedures provide an adequate level of independence, impartiality and transparency when investigating complaints by patients and others. ROs in particular, must declare all conflicts of interests (actual and potential) before getting engaged in investigations involving colleagues in order inspire the confidence of the public. How often and to what extent such conflicts are openly declared is questionable.
Another reason why whistleblowers in particular, would not raise concerns with NHS Trusts or ROs, is “recurring pattern of hospitals intimidating whistleblowers rather than taking their concerns seriously” [2]. So, taking matters to the GMC in such circumstances might be a better and safer option.
References
[1] https://www.bmj.com/content/388/bmj.r315/rr-4
[2] https://www.theguardian.com/society/2024/mar/17/nhs-ombudsman-warns-hosp…
Competing interests: No competing interests
19 February 2025
Daniel Sokol,
Dear Editor,
Thank you for the opportunity to comment on the responses to my BMJ column.I appear to have been misunderstood by some respondents. I did *not* argue that doctors must be silenced on the subject of Physician Associates (PAs). The final paragraph is unambiguous: “To be clear, the misconduct in question is not doctors expressing critical views about PAs. Doctors have every right to voice their opinions”. Doctors are free to raise their concerns, even in strong terms, about PAs or any other group. I wrote that concerns must not be expressed in language that is grossly offensive. I further suggested the General Medical Council enforce its rules by selecting a clear-cut case of an egregious transgression for potential disciplinary action.
The issue of abusive posts by doctors is no trivial matter. It goes far beyond an aesthetic preference of tone, as some have suggested. The abuse can cause harm. It can result in psychological harm to the receiver of the message (and their families), harm to members of the professional group attacked (whether it be PAs, doctors, or other healthcare professionals), and harm to the hard-earned reputation of the medical profession. This last harm can erode public trust in doctors, with adverse consequences on the doctor-patient relationship and the ability of doctors to help patients.
It is correct that the article featured few examples of doctors violating the rules. The original submission did contain examples but these were rightly removed by the editorial team to minimise the risk of legal challenge.
Some have remarked that a number of PAs have also behaved dreadfully online, yet I made no mention of this in the article. Given the readership of the journal, and my knowledge of the rules and regulations pertaining to doctors, the focus was on the medical profession. I am less familiar with the PA profession and their expected standards, but I believe they too should adhere to high ethical and professional standards when posting on social media. They too should face consequences if in breach of these standards.
Another criticism was that the article failed to appreciate the broader context of the PA debate, and the anger and frustration from sections of the medical profession. I can well see why some doctors feel distressed about the current state of affairs and their future in medicine. In my opinion, anger and frustration may explain the posts but they do not excuse abusive behaviour. There is no derogation from the demands of professionalism for doctors who are upset, however heartfelt their grievance. Again, the duty is not to keep silent. It relates to the manner in which the upset is expressed in public.
Another complaint was that the article promoted a #bekind attitude which detracts from the core PA issues. The article did not call for kindness but a basic level of civility and professionalism in communication. This forms an integral part of ethical conduct for doctors. Unless doctors post grossly abusive or offensive posts, I doubt they have much to fear from the GMC. Ill-intentioned colleagues or others may of course refer doctors to the GMC vexatiously, but this is already the case.
There are posts whose degree of offensiveness is open to reasonable disagreement. Some might call them poorly phrased, others rude, and others grossly offensive. These are not the posts which I believe warrant referral. The ‘test case’ should involve a post which no reasonable person would deny is highly insulting, abusive and malicious.
Did my article detract from the broader PA issues? It was a 600-word column in the online section of the BMJ, setting out one person’s opinion on an aspect of social media ethics for doctors. I am not a PA or a medical doctor. I feel no obligation to champion the cause of one group or another (COI: I am married to a doctor).
Finally, one respondent has suggested that, as I provide ethics training to doctors undergoing disciplinary procedures, I stand to profit from my call for one particularly offensive doctor to be disciplined. It is theoretically possible but unlikely that my call is answered, that this doctor decides to undergo remedial ethics training and that, out of all the available options, he or she chooses me to deliver it. If my article achieves its aims, fewer doctors will write grossly offensive posts for fear of disciplinary action or, better still, out of recognition of its ethical impropriety. If this occurs, fewer doctors will seek remedial ethics training. I would certainly welcome such an outcome.
Sincerely,
Daniel Sokol (I am the author of the article)
Competing interests: I am the author of of the article
18 February 2025
Shibley Rahman
Dear Editor,
Social media platforms, such as Twitter or BlueSky, have an important rôle to play in knowledge sharing and discussion of physician associates. The recent opinion piece by Daniel Sokol attracted much interest.(1) Despite some nuance in its approach, there are some important issues which merit far greater scrutiny. My main argument is that overly zealous regulation of the social media could have a major adverse consequence in exacerbating a culture of fear amongst registered doctors, stifling free speech, and will not even substantially improve the quality of debate about the relevance of physician associates (PAs) to the NHS workforce.
I have an extensive training in law, business management as well as internal medicine and medical research. I am a current General Medical Council (GMC) registrant with a license-to-practise.
The GMC is a regulator which traditionally has attracted a huge ‘culture of fear’ amongst registrants even to the point of making some ill (2).
Definitions matter in law, so Sokol’s sop to ‘ordinary meaning’ is quite irrelevant to me. For example, there is no statutory definition of ‘bullying’. Sokol’s claim that many cases will be ‘obvious’ is totally unevidenced.
The positive aspects for registered doctors to use the social media are extensive, well known and diverse, including counteracting misinformation (3). Guidance on the use of the social media by registered doctors arises from a number of important sources, including the GMC itself (4) and British Medical Association (5). Proportionality is very evident in the sanctions guidance (6).
This article dwells on the alleged treatment of PAs by doctors, but there is absolutely no mention of numerous episodes of ‘goading’ or other behaviours in the other direction. This omission undermines the credibility of Sokol’s overall argument unnecessarily.
Registered resident doctors have powerful genuine concerns about patient safety and misconduct of physician associates, but have not been afforded any basic psychological safety. They have not been properly consulted on the matter by any major NHS leaders; this is unacceptable especially since it is known that morale of NHS doctors has been consistently so low (7).
It is clear that nobody is arguing for doctors to be given a free rein to dispense abuse or vitriol in the social media. Sokol indeed refers to disciplinary action only for persistent offenders. My concern here, however, is the piece focuses on the portrayal of adverse treatment of PAs, totally ignoring the harsh treatment which doctors have blatantly received.
I reject the notion that registered doctors act with “impunity” under anonymous accounts. Many anonymous accounts offer invaluable and informed insights. It is already possible to ‘uncloak’ defendants under common law, for example accused of harassment or other malicious communication, through a number of established legal devices such as the Norwich Pharmacal order.
The question that leaders should be asking, rather than simply attacking this anonymity, is why doctors prefer or need this anonymity. The parsimonious explanation is that many do not feel resilient enough in their own practitioner health, or feel unsafe due to toxic cultures within the NHS. It is an established fact that certain demographics, for example BAME doctors, have been particularly susceptible to increased referral to the GMC (8).
If anything, the impunity actually lies in the fact that the register for PAs is currently voluntary, and uptake minimal.
The best way to protect the reputation of the medical profession is to take active steps to train doctors properly, including improving their welfare. There has never been an improvement in quality of services or wellbeing through excessive regulation of the NHS.
1. doi:10.1136/bmj.r315
2. doi:10.1136/bmj.g6796
3. doi:10.1136/bmj.p1932. PMID: 37648268.
4. https://www.gmc-uk.org/professional-standards/the-professional-standards…
5. https://www.bma.org.uk/advice-and-support/ethics/personal-ethics/ethics-… 28 August 2024
6. https://www.gmc-uk.org/-/media/documents/DC4198_Sanctions_Guidance_Feb_2…
7. https://www.kingsfund.org.uk/insight-and-analysis/briefings/10-actions–…
8.https://www.gmc-uk.org/news/news-archive/discrimination-and-disadvantage…
Competing interests: No competing interests
17 February 2025
Yerdah Sellsavon
Dear Editor
I have read your article concerning the General Medical Council’s (GMC) guidance on doctors’ use of social media and would like to share some thoughts.
While I appreciate your call for professionalism and your concern about unprofessional conduct online, I am troubled by what appears to be an oversimplification of a complex issue. In your article, you mention your previous engagements with physician associates (PAs) – including teaching and speaking at PA events – and these ties raise questions about a potential conflict of interest. Such associations might inadvertently colour your support for stricter enforcement of social media guidelines, particularly when it comes to discussions about PAs.
Moreover, I fear that your approach may unintentionally stoke controversy. By framing your argument in a way that highlights the need for disciplinary action against doctors who express critical views, you risk giving PA leaders additional ammunition. They might well point to the responses from some doctors as evidence that the profession is biased against open debate, thereby validating their concerns rather than fostering constructive dialogue.
The debate surrounding PAs is undeniably multifaceted, involving valid concerns about training, clinical competence and patient safety. It is important to distinguish between unprofessional, abusive conduct and the legitimate expression of critical opinions intended to safeguard high standards in healthcare. Silencing or punishing doctors for voicing concerns could chill an essential discourse that ultimately benefits patient care.
I believe that a more balanced approach would be to encourage respectful, open dialogue among all stakeholders. Acknowledging potential biases and the complex motivations behind these debates would strengthen your argument and help prevent the polarisation of views that only serves to widen existing divides.
Thank you for your attention to these concerns. I hope that future discussions will address these complexities and promote a more inclusive conversation about the standards that truly serve our healthcare community.
Competing interests: No competing interests
17 February 2025
Partha Kar
Dear Editor,
The opinion piece from Daniel Sokol makes some bold claims – yet without much evidence – which makes it more of a statement of conjecture rather than any one of substance
The article refers to “The social media platform X is full of doctors violating the rule” – yet the references appear not to mention such instances. There indeed have been unpleasant and personal comments – yet most documented ones are from anonymous accounts – which are condemned openly by non-anonymous doctors on social media. The same is visible from anonymous – allegedly PA accounts – and for the record, I wouldn’t suggest referring them either to their regulatory body – ironically the GMC itself.
Importantly – and worryingly – a casual approach to referrals seems to ignore the distressing evidence of impact such referrals can have (Ref: https://www.gmc-uk.org/news/news-archive/gmc-publishes-report-on-deaths-…) and it is unfortunate that a medical ethicist would recommend such – when a more appropriate issue would be – perhaps – for it be raised to their Supervisor or Responsible Officer rather than such drastic measures which potentially destroys many lives. It perhaps raises the question of the benefit of having supervisors/RO names in the public domain too – not available at present.
The debate about PA has been heated – but at the base of it – lest we forget – it is one about non-qualified individuals working beyond their training and putting the wider public at harm – as now recognised by Royal Colleges by their setting of scope.
We should not lose sight of this fundamental issue around safety where recent cases have – again – shown how far the public has to go to flag safety problems – and the need for whistle-blowers. Neither should we casually suggest interventions to harm others for a social media post.
Competing interests: No competing interests
17 February 2025
George C A Reid
Dear Editor,
Undeclared conflict of interest
I write in response to Dr Sokol’s article [1] arguing that the GMC should discipline doctors who misuse social media.
Of course, abuse is unacceptable in any form and appropriate action must be taken. However, his article conflates genuinely abusive communication with legitimate criticism of both the GMC and “the PA issue”. In particular, the examples he gives of comments made by doctors to GMC staff are not prima facie abusive in the “natural and ordinary meaning”, and he seeks therefore to broaden the definition of abuse from this basis to encompass entirely reasonable analysis of regulatory behaviour and workforce issues.
If indeed “X is full of doctors” violating Good Medical Practice in this way, then the pool of potential referrals to the GMC would grow enormously.
It is surprising therefore that he has not declared as a conflict of interest that he provides “ethical training” to doctors undergoing GMC investigation, and thus may stand to profit from the increase in regulatory action for which he argues.
References
1. Sokol D. Why the General Medical Council should discipline doctors who misuse social media. BMJ. 2025 Feb 14;388:r315. doi: 10.1136/bmj.r315. PMID: 39952660.
Competing interests: I am vocally (but never abusively) opposed to the substitution of medical staff by lesser-trained individuals.
16 February 2025
Valerie E Humphreys
Dear Editor
I write as an occasional patient with respect to the opinion piece by Mr Daniel Sokol published on 14th February, concerning the conduct of doctors towards Physician Associates, on social media.
Mr Sokol’s piece makes the important point that bullying, targeting and abuse have no place in this often fraught debate. No right-minded person would think it appropriate to subject others to such behaviour. However, PAs are not the only, or even the most egregiously targeted, of victims in this situation. A more balanced piece might also have referred to the conduct of some PAs towards doctors and indeed, towards patients.
I have seen many instances online of doctors being abused and harassed, threatened with referral to their professional regulator and to the police by PAs, but doctors do not need me to speak on their behalf – I will leave it to them to express their views on this.
Whilst I support Mr Sokol in his wish to call out unprofessional behaviour by doctors on social media, a more balanced approach might also have made at least passing mention of such matters.
Yours sincerely
Valerie Humphreys
Former Head of the School of Law, Birmingham City University
Competing interests: “New Year, New Rules, New Obligations” anaesthetistsunited.com 3rd January 2025. No fee paid
16 February 2025
Richard J Marks
Dear Editor
Why the anger?
It is easy to criticise doctors for their open anger over the PA situation (Why the General Medical Council should discipline doctors who misuse social media, BMJ 2025; 388 doi: https://doi.org/10.1136/bmj.r315, Published 14 February 2025). But this anger must be viewed in context. Doctors are not typically abusive or malicious—on the contrary, they are trained to be reflective, compassionate, and professional.
We enter the profession after overcoming significant academic, emotional, and personal hurdles,. All of these – so we are told – are essential for us to practice safely. And yet we see PAs bypassing these hurdles, with no clear distinctions over role or scope, creating a profound sense of injustice. We feel let down.
Is it any wonder doctors are angry? Our leaders must acknowledge the deep frustrations and legitimate grievances fueling this. A barrister warning people to “Just be nice, or else!” is neither helpful nor constructive.
Competing interests: I am a director of Anaesthetists United and am involved with legal action over the PA/AA issue,
15 February 2025
Balazs Hollos
Dear Editor,
The wider context flaming tensions on social media
I read with interest Daniel Sokol’s opinion piece on the use of social media by doctors (1). I appreciate and agree with his underlying message. As he states, “[t]he problem lies in the insulting, abusive, and malicious way in which these opinions are expressed.” In an NHS where 19% of us have experienced bullying from colleagues in the last year (2), I’m sure you won’t find many who disagree. Such behaviour serves as a distraction from valid points being made and helps no-one. He does however miss the wider context in which these issues are occurring.
In referencing the GMC’s guidance on social media use for doctors, he states that social media is full of doctors violating it. Indeed he says the situation is “so serious that something must be done”. He calls on the GMC to “identify a clear-cut case of wrongdoing and initiate disciplinary proceedings if necessary”.
After using such alarming language I would expect it to be followed by examples as substantiation. It is curious then that no such thing happens. Indeed when he mentions doctors trolling other doctors, he cites an article written by a pathology resident in Michigan, USA. This hardly relates to doctors practising medicine in the UK or to the theme of physician associates (PAs) that serves as a backdrop for his article. He calls the debate toxic and highlights how the GMC are disappointed about the “tone of language being used”, yet again without any specifics.
It is therefore frustrating that in this paucity of examples—much like in the communications we have seen from NHS leaders—there is not one mention of the abuse and vitriol doctors receive.
In the 17 month period ending July 2024, 17 doctors were referred to the GMC in relation to criticisms about PAs or AAs (3). Were any of these serious enough to initiate disciplinary proceedings? I don’t know. I do know some doctors who have been referred whose complaint against them was closed as not meeting the threshold for investigation.
Of course I don’t mean to say that all complaints towards doctors are vexatious or that doctors haven’t acted inappropriately. They have, and I have personally called out other accounts on social media. But when the narrative being driven publicly is on PAs being the victim of bullying from doctors (4)(5), when NHS England is concerned that the debate is affecting the “health and wellbeing of MAPs” (6), and when institutional leaders from the likes of The Academy of Medical Royal Colleges dismiss our concerns as a “whirlwind of anecdotes” (7) it is exhausting that little attention seems to be given towards either the matter at hand or doctors.
When people are ignored and concerns minimised, as doctors have been, they act out. Their frustrations can be misdirected in ways that are unproductive and harmful to others. Nothing can ever justify abuse, harassment, or bullying. Yet I would say that this “adverse commentary” is in large part due to the system and its leaders refusing to acknowledge doctors’ concerns. Mr Sokol’s article would resonate better if it was more balanced and acknowledged the context in which these issues were occurring.
Dr Balazs Hollos
1. https://www.bmj.com/content/388/bmj.r315
2. https://www.nhsemployers.org/articles/tackling-bullying-nhs-infographic
3. https://www.whatdotheyknow.com/request/doctor_referrals_for_investigati
4. https://www.bbc.co.uk/news/articles/c2dly5ldrxjo
5. https://www.thetimes.com/uk/healthcare/article/the-medical-staff-harasse…
6. https://www.hee.nhs.uk/our-work/medical-associate-professions/open-lette…
7. https://www.aomrc.org.uk/wp-content/uploads/2024/09/PA_AA_letter_300924.pdf
Competing interests: I am a member of Anaesthetists United who are currently in litigation with the GMC on the subject of physician associates. I have previously held regional and local roles in the BMA and have campaigned on the subject of physician associates.
14 February 2025
David Nicholl
Dear Editor,
The author states doctors should be reported to the GMC over their social media posts. He also admits he does not know much about the physician associates debate. I called Prof Stephen Powis of NHS England and Colin Melville of the GMC out on social media over their silence to speak up over the use of a physician associates in one Trust in child protection cases(1).
Should I now report myself to the GMC?
Maybe if people stop using this #Bekind argument as a distraction and actually dealt with the serious and legitimate patient safety arguments and spoke up, we would all move on.
1. https://x.com/djnicholl/status/1880646130754797603?s=46
Competing interests: I led the call for an Extraordinary General Meeting of the Royal College of Physicians in March 2024