Social media and medical professionalism : Commentary in Medicial Education February 2014

This is a pre-publication version of the following paper. Cunningham, A. (2014), Social media and medical professionalism. Medical Education, 48: 110–112. doi: 10.1111/medu.12404 

In this issue, Jain et al. (1) are undoubtedly correct when they suggest that the focus on social media in the medical education literature to date has been a worry about threats to professionalism. In conducting their study, they set out to explore how students, faculty and university staff (presumed to represent the public) view the posting of certain materials to public Facebook profiles. They found agreement on the most serious transgressions such as breaching patient confidentiality. There was more disagreement, however, about other issues such as appearing in photographs with alcohol, or as part of what the authors described as ‘same sex couples’.  In general, students were more tolerant than their faculty or the public.

The focus on social media in the medical education literature has concerned threats to professionalism

What does this research on online professionalism tell us about our deeper uncertainties about what it means to be a doctor in the 21^st century?  Hafferty has described the confusion between the various conceptions of professionalism (2), indicating that to some professionalism is an identity and set of values, whereas to others it is a set of attitudes and behaviours. Medical students also employ different discourses when considering professionalism with some focussing on more superficial aspects such as how they act or appear, whilst other students have more complex and embodied understandings(3). 

To some professionalism is an identity and set of values, whereas to others it is a set of attitudes and behaviours

Let us consider the portrayal of alcohol consumption by medical students in social media. We know that excessive alcohol consumption has a long history in the culture of medical schools.  The Pithotomy Club, a  John Hopkins Medical School student society formed in Sir William Osler’s time(4), had a cherub on a beer keg as its emblem, and an annual revue, the Pithotomy Show, which ended in a ‘beer slide’(5).  (Forthcoming) research by Black and Monrouxe (6) finds that some medical students in the UK feel compelled or coerced by their fellow students to drink alcohol or take more than they had intended. Although there are concerns about the alcohol consumption of medical students and doctors (7-9), the culture in medical schools which facilitates this is rarely examined.  An online survey of medical students in the UK in 2012(10) found that only 22% thought that their medical school promoted a healthy attitude to alcohol. Is it surprising that some of the students thought that medical schools were more concerned about image than student well-being given the preponderance of messages about not sharing images of alcohol consumption through social media combined with a tacit acceptance of a pro-alcohol culture?  Students sensed that being seen to behave badly may be considered worse than actually behaving badly.  That is, the portrayal of a ‘professional demeanour’(11) was seen as more important that the actual behaviours of medical students. So when we consider the portrayal of alcohol by students in social media, might students have a more complex understanding of this than the restricted discourses often promulgated by their schools?

Is it surprising that some students think that medical schools are more concerned about image than about student well-being?

Next let us consider whether we should be concerned that personal information, not usually revealed in the consultation, may be self-disclosed through social media profiles. Thompson et el. (12) in their 2008 study of the Facebook profiles of medical students and residents in Florida were the first to postulate that the revealing of sexual orientation and political views through social media could be construed as unprofessional.   Professional boundaries are normally seen as either crossed (when no harm is done to the patient) or violated (where harm does occur), but we have no evidence that online self-disclosure through social media profiles affects subsequent consultations (13).  Still, the warnings persist.  In the study reported this month, Jain et al. (1) looked at perceptions of the expression of sexual orientation. We know that homophobia exists within medical cultures (14, 15) and that young people use social media to form networks to support them in dealing with the homophobia they meet in offline life (16). It would, therefore, be quite concerning if we were to recommend without good reason that medical students should be cautious about expressing their sexual identity online.

We have no evidence that online self-disclosure through social media profiles affects subsequent consultations

More generally,  discomfort over the disclosure of personal information is in keeping  with the tensions Frost and Regehr (17) describe between the discourses of standardisation and diversity in medical professional identity.  Is concern over releasing one’s sexual orientation or other personal information evidence that those leading medical schools, implicitly or otherwise, believe we can (or desire to) produce ‘neutral doctors’ (18) or ‘vanilla physicians’(19) who are able to leave behind their own personal values and socio-cultural backgrounds?  If so, then it is no wonder that social media is seen as a threat to a process of socialisation which Beagan (18) describes as in part involving isolation from all wider networks who might remind students of their previous identities. 

Discomfort over the disclosure of personal information is in keeping with tensions between the discourses of standardisation and diversity in medical professional identity

When we are online, just as when we are offline, we must always respect the dignity of our patients and colleagues. Beyond this, regulating and advising on behaviour in social media risks appearing, as Lerner states, ‘alarmist’(20). There are alternatives. McCartney suggests that ‘doctors, like other citizens, are entitled to express opinions online and one effect of the undoing of the medical god-complex has been to humanise medicine and populate it with doctors who are fallible but professional’(21).  Ballick describes such an approach as ‘rather thoughtful and subtle’ and acknowledging of ‘the complexity of online life’ (22).

If we recognise that ‘becoming a professional is an interpersonal and complex activity’(3) then we should aspire to research and guidance on social media and professionalism which reflects this.

Key quotes:

So when we consider the portrayal of alcohol by students in social media, might students have a more complex understanding of this than the restricted discourses often promulgated by their schools?

It would, therefore, be quite concerning if we were to recommend without good reason that medical students should be cautious about expressing their sexual identity online.

Is concern over releasing one’s sexual orientation or other personal information evidence that those leading medical schools, implicitly or otherwise, believe we can (or desire to) produce ‘neutral doctors’ (18) or ‘vanilla physicians’(19) who are able to leave behind their own personal values and socio-cultural backgrounds? 

When we are online, just as when we are offline, we must always respect the dignity of our patients and colleagues.

If we recognise that ‘becoming a professional is an interpersonal and complex activity’(3) then we should aspire to research and guidance on social media and professionalism which reflects this.

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