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 21st
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.
5. Harrell R. History of The Pithotomy Club 2009
[29/9/2013]. Available from: http://www.pithotomy.com/history.html.
