By Sheila Kaplan

Physicians across the United States routinely offer medical advice on social media — but often fail to mention that they have accepted tens and sometimes hundreds of thousands of dollars from the companies that make the prescription drugs they tout.

An examination of hundreds of social media accounts shows that health care professionals virtually never note their conflicts of interest, some of them significant, when promoting drugs or medical devices on sites such as Facebook, Instagram, and Twitter. The practice cuts across all specialties.

Among the cases of note:

Women’s health specialists who serve as consultants for the company that developed Addyi, the female libido drug, use Twitter to promote that medication and related treatments.

A child psychiatrist featured on YouTube steers viewers to the website for Saphris, an antipsychotic drug made by Allergan, which has paid her to promote it.

An internist posts on Facebook about the positive effects of a cholesterol drug manufactured by a company that paid him nearly $60,000.

There is no evidence any of these doctors meant to deceive or mislead patients. And they were not legally obligated to disclose payments from drug companies in their social media posts.

But the growing use of social media by medical professionals raises serious ethical questions — and makes it impossible for patients or other doctors to know whether a physician’s enthusiasm or disdain for any particular drug may have been influenced by payments from the pharmaceutical industry.

The ties between doctors and private industry have come under scrutiny in recent years.

Under legislation passed in 2010, drug and medical device companies are required to report payments to doctors for promotion, consulting, and other services. The information is collected by the federal Department of Health and Human Services and posted in a public database. Most medical journals now also require researchers who submit articles to disclose payments they have received from the industry.

But social media is a new frontier.

Some doctors say disclosure is impractical in the limited space that social media offers when they have financial ties with multiple drug makers. “It’s become very unwieldy and problematic and it’s ridiculous for a tweet,” said Dr. James Simon, a physician who frequently uses Twitter to promote drugs made by companies that have paid him as a consultant and promoter.

But Reuben Guttman, an attorney in Washington who specializes in food and drug law, said the system leaves patients vulnerable to misinformation.

“Doctors who accept these dollars and then turn around and promote on social media corrupt the market for honest medical information,” Guttman said. “And drug companies that pay these doctors are similarly poisoning the market for honest information.”

A disclosure requirement in Massachusetts

Although many doctors believe payments from drug makers do not influence their rate of prescribing certain medicines, studies have repeatedly shown that they do.

“I think it’s important to disclose relevant financial relationships if you are using social media to share health information,” said Dr. Katherine Chretien, an associate professor at George Washington University medical school who studies the issue.

Chretien said doctors could easily attach a screenshot of their disclosures to tweets or online posts, without taking up a lot of space.

“It’s about being honest and up-front about conflicts of interest, whether addressing medical audiences or the public,” she said.

Some doctors are moving toward that view.

In December, the Massachusetts adopted a rule requiring its members to divulge all financial relationships regarding any medical procedure or service they review or discuss online. They even have to disclose any free products or services they’ve received from drug or device companies.

Dr. Lloyd Fisher, a pediatrician who helped develop the state guidelines, said they grew out of member concerns that doctors were endorsing products on social media.

“They make it sound like these are just products that they themselves find useful for their patients,” Fisher said, “and when you dig deeper it becomes clear that the physician has a financial interest in the product they are endorsing. Some of them do sell products at a profit. There is nothing inherently wrong with that, it just needs to be transparent.”

Fisher said some other state medical societies are considering similar rules.

Promoting ‘female Viagra’

Simon, a women’s health specialist who also teaches at George Washington University medical school, received more than $475,000 from companies that make hormone replacement drugs and related medications and devices between August of 2013 and the end of 2014.

Some of his most passionate tweets are about Addyi, which was developed by Sprout Pharmaceuticals and has been popularly dubbed “the female Viagra.”

“Female Viagra is HERE! Share this post to spread awareness about #ADDYI and #HSDD” — hypoactive sexual desire disorder — he tweeted in the fall, shortly after the drug went on sale for the first time.

Simon previously worked part-time for Sprout to help develop Addyi, and is still a consultant for the company.

Many of his other tweets mention or link to other products made by the companies that pay him for consulting and other services.

The tweet links to a blog post he wrote promoting the medication Brisdelle. It’s made by a company that paid him $142,000 in 2013 and 2014.

In an interview, Simon acknowledged that he does not disclose that affiliation on his Twitter account. But he said it’s impractical to require doctors to disclose conflicts of interest in a 140-character tweet.

In the past year, he noted, he has worked as an adviser or consultant to AbbVie, Inc., Amgen, Shionogi Inc., Merck, Sanofi, and other businesses. He’s also in a “speakers bureau” and gets paid by Amgen, Shionogi, Merck, Noven Pharmaceutical, and other drug makers to give talks.

“To me, disclosure is primarily about transparency and honesty, and not about relationships,” Simon said. “Pharma needs academic clinicians — and clinicians and patients need and deserve new and important discoveries from Pharma. All too often, the bureaucracy gets in the way of both sides of that equation to the detriment of all. ”

Another doctor, Florida cardiologist Dr. Seth J. Baum, has frequently tweeted links to a vitamin company that he founded. Baum declined to be interviewed.

Some financial relationships are tough to tease out when it comes to health care professionals and social media.

Dr. Adelaide Robb, a pharmacologist who runs the psychology department of the National Children’s Health System in Washington, has been featured on YouTube interviews discussing treatments for bipolar disorder in children.

“What’s really exciting is we just had the first new one out in five years and that’s called Saphris,” Robb told one interviewer. “There are a couple of things that are special that make Saphris even more helpful for our kids and teenagers.”

Not mentioned is that Robb has received payments to promote the drug from Saphris manufacturer Actavis (now Allergan.)

Robb did not actually post the video about Saphris. That was done by a writer named Candace Rose Anderson, who maintains a website that sometimes includes interviews on health subjects.

In an email, Anderson said she was not paid for the video interview. She did the piece after being contacted by a public relations representative for the drug company, who was looking for opportunities to have Robb discuss the drug, she said.

For her part, Robb said she was paid by Actavis to do a “media tour.” She said those payments would be noted in the company’s 2015 disclosures, which have not yet been made public.

Hidden conflicts on video channels

YouTube, Vimeo, and other video sites are fertile ground for promoting medical advice — and for potential conflicts of interest.

Patient advocacy groups, medical societies, and drug marketing companies have set up special channels on those sites focused on certain diseases or fields of medicine.

One channel, Oncology TV, describes itself as a news outlet specializing in medical news about cancer, but provides no information about who produces the videos. In fact, the channel is operated by Pennsylvania-based NSCI Group, a marketing, education, and communications firm for the drug industry.

Robert Bieber, a principal at NSCI, called Oncology TV “educational programming targeting health care practitioners.”

Some of the video programs are developed in partnership with medical societies, but others are funded by pharmaceutical companies. These payments are not noted in the videos on the site. Bieber said there was no need for them to be disclosed to viewers.

“We invite the physician to sit down and we post our news,” Bieber said. “It’s no different from ABC News. We report on both good and bad information … Do you want physicians to understand the information, or would you rather have the patients and physicians to be in the dark?”

Some doctors who are active on social media agree that more disclosure would be valuable — at least, in principle.

Dr. James Underberg, a clinical assistant professor at NYU medical school who specializes in preventive cardiology, has used his Facebook and Twitter accounts to highlight the drug Zetia, made by companies that have compensated him.

He doesn’t disclose those ties, but when asked, he said he’d be willing to do so, if it were required.

“I applaud the state of Massachusetts,” for its new rule, he said. “It’s not an unreasonable request. If New York made such a rule, I’d comply with it.”