Monday, 1 February 2010

What is more important: behaving badly or being seen to behave badly?

Doctors behaving badly
Yesterday, CNN carried a story ("Photos of drinking, grinning aid mission doctors cause uproar")
that doctors from Puerto Rico, volunteers in Haiti, may be disciplined because pictures of them holding soldiers' guns, drinking alcohol and with patients (possibly without their consent) have been posted on Facebook. The comments on the story are interesting, as some say the doctors are being treated too harshly. They may be traumatised by events and should be allowed to relax. Others who have seen all of the photos are in no doubt that the activities of the doctors are unprofessional. But in nearly all cases, commenters are talking about the act of taking the photo, rather than the sharing of the photo in social media.I have not read all 1411 comments but there does not seem to be anyone advocating that the photos could be OK in private, but inappropriate in public.

Medical students behaving badly
The conduct of medical students in social networking sites has been recieving increasing press. In September 2009,  Chrieten et al. published the reults of a survey in JAMA which found that the majority of US medical schools has had to take disciplinary action against some students because of their activities on social networking sites. And in November 2009, Farnen et al. described a case where first-year medical students posted a sketch from a medical talent show on YouTube. The sketch was of a hip-hop song accompanied by medical students playing  with plastic skeletons and  body bags. It was removed when a more senior student complained that it portrayed the medical school poorly, although there was student resistance to that action as the video had been very popular with students. The author's state:
" Our students' video has become our digital liaison. Prospective medical school applicants often comment on viewing it before their interview day. Alumni and senior faculty responded with significant concerns about the video's representation of the medical profession and how patients may react to this depiction of physicians' training. " (my emphasis) Students do not seem to have been disciplined for any unprofessional conduct in the production of the video,instead it is the sharing of the activity through social media which is the focus of the article. This seems to suggest that activities may be acceptable in private but not in public. In a further response to letters on their work, Chrieten et al. state "the medical profession is responsible for maintaining the public's trust. It is necessary to understand how online behavior is viewed by the public and how that affects trust in the medical profession."
Hayter (2006) has wrote about the medical student show. He says that it has various functions including "the collective ventilation of emotional reactions to the process of becoming a doctor". There are links to some of the skits from these shows in this Slate article. What we do not know is how the general public views these shows. Did they know of them? Did they think the conduct was appropriate? Since medical faculty often participate, and attend, they may be seen to approve of the content. If this is the case then why is it not appropriate to share the content publicly.

What does it mean to bring the profession into disrepute?
In the UK, both nursing ("You must uphold the reputation of the profession at all times") and pharmacy (where one should report any circumstances that may "bring the pharmacy professions into disrepute") bodies imply that not upholding the reputation of the profession is in itself something that a member may be disciplined for. For UK doctors, the GMC document "Good Medical Practice", states that "You must make sure that your conduct at all times justifies your patients' trust in you and the public's trust in the profession." But it is not clearly stated what conduct may contravene that trust. Older GMC guidance, prior to the first publication of Good Medical Practice in 2005, states that "convictions for drunkenness or other offences arising from misuse of alcohol (such as driving a motor car when under the influence of drink) indicate habits which are discreditable to the profession". Although this terminology is no longer used in Good Medical Practice, when discussing the case of a doctor convicted of driving with a blood alcohol level three times above the upper legal limit, it is stated that, "Public confidence in the medical profession is likely to be undermined by such conduct." The doctor was suspended for three months, in order to "send the right message to the public". In the case of medical students, GMC guidance states that drunk driving and "alcohol consumption that affects clinical work or the work environment" is unacceptable.There is no mention of drunkenness away from patients.

What do patients think?
Research conducted by Mori for the Royal College of Physicians in the UK consistently shows that doctors are the profession thought most likely to be telling the truth. This is routinely reported as "Public Still Trust Doctors". Smith (2001) distinguishes between trust, which exists at the level of individual interaction, and confidence, which relates to abstract systems.  Boudreau et al (2008) asked members of the public about the attributes of the ideal physician. They were reformulating the medical curriculum and wanted patient input. Patients wanted doctors who listened to them and didn't treat them as a 'number'. When asked "If I said to you that a doctor was very professional, what would that mean to you?", some patients responded negatively suggesting that it might mean someone 'stuffy-nosed' or who didn't want to bother with 'menial things'. But generally being professional was associated with behaviours that concerned individual interaction with the patient: bedside manner and interpersonal skills. 
But what of trust (or confidence) in the wider medical profession?  It is understudied. Hall et al.(2002) found, using a new scale, that trust in one's own physician is higher than trust in the physicians generally. They say that might not be a surprise as one might settle with a doctor one trusts, after experience of others who are less good. Calnan and Sanford (2004) in the UK, sudied general trust in the healthcare system rather that trust in the 'medical profession', and found that trust that patients would be provided with patient-centred care, was strongly associated with trust in the system. 

Professional bodies still talk about individuals conducting themselves at all times in a way that does not reduce trust in the profession. But the very limited studies which look at how the public view the medical profession suggest that it is the interactions with individual doctors in the healthcare setting which determine trust. Patients value patient-centred doctors.
Pattison and Wainright (2010) suggest that the ethics of a profession should be determined in conjunction with the wider public. It is not something that a profession can do alone. But I think that after that  behaviour is either unacceptable because it is unprofessional, and therefore should be disciplined, or it is acceptable. If it is acceptable it can be shared through social media.The use of social media is a secondary consideration.

But what do you think?
  1. How do you feel about medical student shows?
  2. Are medical student shows appropriate to share online?
  3. Would seeing photos or videos of doctors, nurses or pharmacists in a state of drunkenness on Facebook affect your view of the profession as a whole?
  4. Would it affect your view of the individuals involved as professionals?
  5. What determines your trust of the medical profession as a whole?
Feel free to answer these questions or leave any other comments.

(This post resulted from a rather long discussion with @psweetman, @bitethedust, @drmarcustan and @mtnmd earlier today. I am currently studying for a module on Changing Modes of Professionalism for my EdD course, and writing an essay on deprofessionalisation in medicine. This writing is only tangentially related... as yet!)

Boudreau JD, Jagosh J, Slee R, Macdonald ME, & Steinert Y (2008). Patients' perspectives on physicians' roles: implications for curricular reform. Academic medicine : journal of the Association of American Medical Colleges, 83 (8), 744-53 PMID: 18667888
Calnan MW, & Sanford E (2004). Public trust in health care: the system or the doctor? Quality & safety in health care, 13 (2), 92-7 PMID: 15069214
Checkland K, Marshall M, & Harrison S (2004). Re-thinking accountability: trust versus confidence in medical practice. Quality & safety in health care, 13 (2), 130-5 PMID: 15069221
Chretien KC, Greysen SR, Chretien JP,  Kind T (2009). Online posting of unprofessional content by medical students. JAMA : the journal of the American Medical Association, 302 (12), 1309-15 PMID: 19773566
Chretien KC, Greysen SR,  Kind T (2010). Medical Students and Unprofessional Online Content—Reply JAMA : the journal of the American Medical Association, 303 (4) 329
Farnan JM, Paro JA, Higa JT, Reddy ST, Humphrey HJ,  Arora VM (2009). Commentary: The relationship status of digital media and professionalism: it's complicated. Academic medicine : journal of the Association of American Medical Colleges, 84 (11), 1479-81 PMID: 19858794
Hall MA, Camacho F, Dugan E, & Balkrishnan R (2002). Trust in the medical profession: conceptual and measurement issues. Health services research, 37 (5), 1419-39 PMID: 12479504
Hayter CR (2006). Medicine's moment of misrule: the medical student show. The Journal of medical humanities, 27 (4), 215-29 PMID: 17123173
Pattison, S., Wainwright, P. (2010). Is the 2008 NMC Code ethical? Nursing Ethics, 17 (1), 9-18 DOI: 10.1177/0969733009349991
Smith, C. (2001). Trust and confidence: possibilities for social work in 'high modernity' British Journal of Social Work, 31 (2), 287-305 DOI: 10.1093/bjsw/31.2.287


  1. A worthy topic. I can only speak from my own perspective. This past year I've moved from seeing physicians as highly trained specialists (presumably always at top of craft), to seeing them as being fallible (though I never saw it as disgraceful), to ultimately seeing them as highly trained specialists who've taken on a REALLY challenging job.

    A while back I commented that I'd realized that when the docs I talk with hesitate, it's usually that they're being careful. And I realized that in all my computer work, I live by my "undo" key - a luxury an MD often doesn't have.

    And that augments the "highly trained, challenging job" view.

    In that context, I have no problem at all letting go of demands on appearances.

    But I also don't assert that everyone should think and act like me.

  2. Hi,

    Our medical school revues were always open to the public. However, what is acceptable in the context of attending a revue where frivolity and black humour is expected, may be less acceptable when seen in another context (e.g. shared with social media). It may be a bad idea to show these things out of context - first impressions count.

    Your point about being seen to behave properly is a good one. I would think most people don't have a a problem with doctors drinking - unless they're wearing a sign saying 'I'm a doctor' while they do it! Otherwise, the maxim: "an alcoholic is someone who drinks more than their doctor" would make everyone alcoholics. That is the problem with social media sharing of photos of doctors drinking - they are identified as such.

    Doctors must be allowed to behave frivolously and drink alcohol in their time off if they so wish - after all we're human too - we just can't let it affect our work, and probably shouldn't let it be identified with our work either.


  3. I don't mind if my doctor drinks off-duty; he's a person, not just a doctor, and thus deserves to have a life beyond his profession. Additionally, it's a stressful job and he needs to be allowed to relax in order to be effective when working. As a professional though, especially in a field that can literally be life or death, I do expect him to be sober (and not heavily hungover) when he's on the job.

    That said, self-regulation is important. Two key traits of a doctor are discretion and good judgment. Getting very drunk, or otherwise acting recklessly, demonstrates poor judgment. Doing so on camera and posting it (or letting someone untrustworthy record it for possible posting) demonstrates very poor judgment and a lack of discretion. If he's that careless about his OWN image and private information, how can I be confident of his discretion with MY private information?

  4. @Dave After being over on the epatients site I'm aware how very poor this comment system is. I want threading (that works) on blogger!
    Thank you so much for your thoughts. You describe your transition in how you see physicians. What are the changes based on? Your individual interactions with them face to face as a patient, meeting them in conferences or meetings as a peer, or what the write and say in social media? I'm really curious how (if we do) form ideas about the nature of professional groups.

    @Chris. Thank you too. I wonder though if the concept of 'out of context' is fading fast. If something is digitised the context it will be seen in is unknown. How does one stop a public event from being recorded and shared. In the future this will be even less of an option. Yes, public and private are merging.

    @Bill Great to have your comments. I hadn't thought about the fact that the way someone manages their own digital identity might be perceived to be signifier of how they might manage that of others. Thank you very much.

  5. Thanks for drawing attention to an increasingly important topic. Agreed, public and private worlds are definitely merging with the continued rise of social media. As a result, it's incumbent upon us to teach students to pay careful attention to what is allowed to be recorded and/or disseminated.

    Med student shows are perfectly acceptable, and give students a chance to express their feelings in a creative outlet. But these shows should NOT be shared with a non-medical audience who shouldn't have to (and therefore wouldn't) understand our sometimes skewed humor.

    Medical professionals need to be able to relax and have a good time - but posting pictures of drunken evenings on Facebook does seem to cross a line. We don't merely have a "job" - we have all chosen to be part of a profession that serves the public. Taking care of people and keeping their secrets is a sacred duty to many of us; as a result maintaining the public's trust is an important aspect of what we do.

  6. @pcore Thank you for your comments.

    Are your medical revues not open to the public? And is it acceptable to the public that developing professionals indulge in a 'skewed' sense of humour, that is not even acceptable for them to be exposed to? Does that send a good message about the 'medical profession'?

  7. Great post and great questions.

    Most of my experience of medical professionals has been as a patient or carer...and to be honest when my dad's surgeon told me he was 'going home to have a beer' after over 12hours of operating on him, I was grateful. That comment stuck with me...not just because he'd had a really hard day and stuck at it and saved my dad's life in the process (altho that helped), but because it was so human....and exactly what I'd have done in his shoes. So yes I guess my views are based on how I relate with that person, not so much what they do in their spare time.

    I'm not sure that students should be judged on their socialising really...I'm sure we'd have a shortage of most professionals if student lifestyle choices were used to filter people out. I guess I might be quite relaxed but the way I see it medics (students or professionals) are no different from the rest of us, they're human, they make mistakes, they drink too much occasionally, so no big deal. I'd be far more interested in us concentrating our efforts on communication skills...maybe a chat over a pint would help develop those ;)

    As for how to present yourself (professionally) in an online environment or whether you should differentiate, this has been something I've pondered for a bit lately. For example, my twitter account is personal (lots of boring everyday dross) and I dont link it to my work...although I do occasionally talk about work on there and have made some great contacts via it. In the end I've decided to just be myself, be genuine and hope that I'm accepted as an individual (flaws and all)whilst not associating myself directly with the organisation I work for (so I dont have to be overly aware of being professional all the time) but only time will tell whether this is a naive step or whether it is acceptable. Having said that I'm aware anything I tweet about could very easily be linked back to my organisation...and so I guess it's a bit of a redundant conversation (sorry for waffling on).

  8. Anne Marie,
    this is a great post and love the thoughtful comments.
    Some random thoughts:
    1. Why is there so much agreement that alcohol is a good way to relax? It sounds a bit like my patients who say that smoking helps them deal with stress.
    2. People go through life with multiple faces (masks) depending on the environments. If we can create a society that everyone is comfortable presenting their true selves maybe we would not have to worry about what is caught on camera/facebook/YouTube! Maybe we will have less stress and won't need alcohol to relieve it?

  9. Hi Neil,
    Good to hear from you!
    1. I'm not sure that there is agreement that alcohol is a good way to relax. I mention it because it's use to excess is specifically mentioned by the GMC.
    2. I think the concern is that the behaviours which shouldn't be shared are the 'true face'. Maybe the true face is not as pleasant as we would want.

  10. Interesting post, Anne Marie, and a good discussion.
    I'm interested in the way that social media decontextualises our acts and utterances, too... you're clearly right. But I don't think the correct way to react to that is to condemn everything that *might* be interpreted by the public or patients as inapropriate (not that I think you're doing that, by the way - this is clearly a really reflective and well-thought-out airing of important issues).
    I'd far prefer it if people could be a bit more tolerant of potential ambiguities and ironies and a bit more able to leniently construct the likely context of social media texts for themselves. It's part of social media literacy.
    The med student with the "methadone craving" you tweeted about earlier being a case in point, imo.
    Anyone with a bit of cultural understanding should, I think, be able to empathise with what's clearly an ironic joke... and it doesn't take much to reconstruct the likely context (student hi-jinks, medical black humour, etc).
    He's obviously been a bit naive tweeting that, and is clearly somewhat unaware of the way that this kind of public statement can be interpreted. He's also obviously reacted to your questions with dodgilly.
    But the point still stands irrespective of whether he's an idiot or not. It'd be a pity if ironic jokes (even ones which touch on senstive ethical issues like the theft of drugs) become out of bounds because some in the audience lack the ability to decode the message.

  11. Personally, I think if one's parent or the patient's family can't watch the show, then it's probably inappropriate. That we even have to ask if it is/isn't begs the question and says maybe someone should have made wiser choices.

    I don't think we should judge the medical profession any harder than other professions. I'd say we'd come down pretty hard on teachers doing the same, however. When our families may be touched by what someone does, we tend to be more judgmental, and probably rightly so.

    Yes, states of drunkenness in any public venue would affect how I perceive anyone. I would probably judge (if judge is the right word) each person individually and not the profession, however. None of us would want our professions judged on the acts of a few.

    Ah, trust of the medical profession. Often, it boils down to the fact I have no other option. Honestly, I'm not very trusting of it. There are some individuals within the profession whom I trust to care. I don't always trust them to handle my testing/diagnoses/treatments in my best interest, however.

    Wow, what a difficult topic, and very difficult for me to answer. I can think of a dozen "but if" things to add, and there is no one good answer to those.

  12. Hi Anne Marie. Thanks for a thoughtful post on a topic that I hope is going to become increasingly relevant with so many in the health sciences beginning to make use of online social media.

    I've had similar conversations with my students, some of whom have posted patient-related comments in semi-public spaces. I've also had the unfortunate experience of discovering comments made by a colleague, about students, during clinical exams! In most cases, it seems that individuals weren't aware of the implications of their actions, and in no cases were they considering the impact of their actions on the public perception of the profession.

    I have no problem with students and colleagues who use social media in public or semi-public spaces, as I believe that they are among the tools that can fundamentally change our professional practices. However, I do feel that those of use who are more aware of the nature of those spaces, should do more to educate those around us.

    It's easy to point fingers and say "They should know better", but the truth of it is that often, they don't. As educators, surely it's part of our role to make sure that patient privacy and dignity is respected all the time, but especially in the public domain.

  13. Fantastic post. I too grapple with the dilemma. As a general rule, I favor and value transparency - within reason. In the end, it will be up to each of us to self-regulate our public online "footprint" in the digital world. Some may feel more comfortable than others with sharing more. Others less. Each then takes his/her own risk in what is put out there. I don't think you're going to get the whole medical profession to agree on the definition of online professionalism. Heck, you probably can get 3 providers in the same room to agree! Great topic.

  14. Great post, great comments.

    I'm not a medic, but I have observed quite a lot of online interactions.
    My answers to your questions would be:
    1) I love medical student shows - the first one I saw was one recorded in the 60s when my Mum was a nurse. It was great, with some off-beat humour, and I would not like to think anyone should be denied either the opportunity to let off some steam in this way or the opportunity to see them.
    2)Yes, I think they are suitable to share online. I think some people may have trouble contextualising them, but that is a different matter. I can't help but feel that trust and reputation of a profession can be earned and lost both by individuals and institutions - and high-handedness on the part of institutions is just as likely to reduce trust as some dodgy behaviour by an individual. We all (well, most people!) know that the emergency services employ a level of gallows humour to get through the stressful jobs they have. If that is hidden completely from the public view, *what else is being hidden*? If an institution censors what its staff are allowed to express, I have little trust in either that institution or, sadly, its staff, precisely because if there was nothing to hide, there wouldn't be any rules to tell people to hide them.
    3) No, absolutely not. If I see a policeman behaving badly, but find out they have had their knuckles wrapped, I feel more trust in the police service. If, on the other hand, I hear about it third-hand, and nobody ever mentions it officially, I know there has been a cover up and that makes me nervous. The same applies with any profession. Additionally, people should be allowed their private lives, even if those private lives include being public in some way. I know there are some (and the Daily Mail will find and amplify their voices...) who will think that anything other than exemplary behaviour at all times is deserving of a sound thrashing, but I don't think it is appropriate, and I don't think the majority of the younger generations do either.
    4) I find it quite hard to be sure of the level of intoxication of someone from a photograph, to be honest. If it is obvious someone has had far too much and will be working again before it has had time to get completely out of their system (an amazing feat in a photo!) then yes, I would think they are in the wrong. Of course, if one of the GPs I see who bangs on about the dangers of drinking (clearly wilfully ignoring the fact I point out I seldom drink at all!) were to have pictures of them getting legless, I would be a tad incensed. It is all about context, and I am not good at accepting hypocrisy!)
    5) My level of trust in the medical profession is influenced by whether individuals make good professional decisions (less said about that the better, I suspect), whether institutions seem capable of good decisions, sound rules, being open and honest (again, less said the better!).

    I wonder how much social views will change over the next decade. Not only do we have these social media tools to contend with, allowing people to share things that previously remained within close circles of friends, but we have the global reach which means different cultures will potentially clash (as well as inter-generational cultures) and the persistence of information on the Net has an impact too. Add in to that the apparent increase in the litigiousness of the population in the UK and it becomes a complicated mix to try to predict. For the time being caution on the part of individuals would appear to be the best bet, but that is also very boring, and I suspect we will have several backlashes to endure before society and technology start working in harmony...

  15. LondonMedStudent6 May 2013 at 19:00

    It's an interesting issue. Certainly as social media becomes more widespread more "slip-ups" will occur. I've seen my student friends post inappropriate things, and I've found stuff that I posted in my past that was highly embarassing to be out in public on the internet (luckily I managed to take it down)!

    I think social media is calling into account something that never used to be an issue. Before, assumedly, a Doctor could go to the pub after a hard day and make some black humour jokes with their colleagues to let off steam. Someone could go home and rant about how much they hate their co-workers to their significant other, or someone on the end of a phone, and it goes no further. Suddenly now people are using social media to do the same kind of things, and it throws professionalism into account, as these things are recordable and able to be shared.

    I'm quite torn with this. As I'm about to become a Doctor, I'm aware both of how my behaviour represents my profession, but also how I need to let off steam sometimes!

    1. Thanks you LondomMedStudent- always a pleasure to have a med student comment:)

      Let's start with one thing... do you feel that the face to face ways that people used to address these challenges are being closed off now? Is that why people are using social media to address them?

      By the way, I hope that my post makes clear that I don't think that any one doctor or student does in a social media space can really affect the reputation of a profession. But it might affect the reputation of that individual. Some things are completely off- breaking confidentiality is one- but otherwise I think that people are likely to primarily determine how good we are as a doctor by how we actually doctor. But I could be wrong.

      However, I would hope that if a patient was to explore my social media presence they would be reassured rather than worried.


I am reintroducing word verification to cut back on spam posts. I'm sorry if you find it frustrating,