European Journal of Dental Education ISSN 1396-5883
Clicking on professionalism? Thoughts on teaching students about social media and its impact on dental professionalism Professionalism is a key aspect of the teaching and training of dental students. Whilst society values professions and the work they do, the task of instructing professionalism to dental students can be challenging. A recent paper by Ziljstra-Shaw, Robinson and Roberts (1) details the complexities involved in assessing dental professionalism when there is such variety of opinion on how to define professionalism. As the search for a ‘validated operationalised construct’ (1) of professionalism continue apace, practitioners, academics and dentists alike would do well to reflect on social and technological changes that have occurred in the past 20 years as part of their deliberations. The Internet and digital media has shaped peoples help seeking behaviours and has had an impact on how dentists and other health professionals work. For instance, in the UK 36 million adults or 73% of British adults had access to the Internet every day in 2013. Forty-three percent of these adults used the Internet to seek health information online (2). Moreover, a growing body of research from the United States suggests that the online activities of student health professionals, such as their social media posts, have been found to be unprofessional by breaking patient confidentiality or posting patient photographs (3). The seriousness of these breaches has resulted in many registration bodies, including the General Dental Council (4) in the UK, issuing social media guidelines to it members. This commentary contends that the Internet and social media poses a particular challenge to our existing ‘professional paradigm’ (5) because it forces us to critically reflect on the types of interactions we engage in online. Dental educators need to show students how their online behaviour has a bearing on their offline/real-world life and professional status. To offer as practical a resource as possible on this issue, the commentary follows a problem–solution format. Three ways in which social media challenge our existing understanding of professionalism are outlined. Harte Arbouet’s (6) four-step model for encouraging reflection about online behaviour will be used to offer guidance on how students can ensure that they are being professional in their offline and online activities. In this commentary, social media is understood as the websites and technologies that allow for user-generated content to be easily uploaded and shared online. These include social networking sites (SNS), blogs, wikis, Twitter etc. (7). ª 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 20 (2016) 55–58
Problem #1: the experience of going online does not ‘feel’ like the ‘real’ world
One aspect of professional behaviour is ‘the interaction of persona and context, and the importance of situational judgement’ (8). The traditional model of professionalism prefaces face-to-face interactions, bound by the physical setting of the dental surgery. In this professional context, dentists use and exchange verbal and non-verbal cues to communicate and build rapport with their patient. The physical layout and design of the dental surgery, complete with dental equipment and uniforms, also underlines the medical and cultural authority of dentists which in turn creates a boundary between the dentist and the patient. The dental clinic setting also primes the dentist that they will be performing an exam or procedure. To this extent then, dental professionalism can display a pragmatic and experiential quality, emerging as a ‘second-order competence’ (9) that is demonstrated in the action of ‘doing’ dentistry. Unfortunately, it would appear that this aspect of professionalism can be compromised when healthcare students go online. Clauson et al. (10) analysed 44 pharmacy student blogs, and whilst 68.2% of them were written anonymously, 57% contained negative language about patients. Focus group research with medical students in one American medical school found that whilst most students agreed that sexually suggestive material was inappropriate, there was less agreement on whether negative comments about ones colleagues and medical school faculty were considered unprofessional (11). Chretien et al. (12) analysed 5156 tweets from 216 self-identified physicians over a month and found that 4.7% of their tweets to be unprofessional (i.e. contained sexually suggestive or discriminatory comments), and 38 individual tweets had potential patient confidentiality violations. Thompson et al. (13). analysed 1023 Facebook profiles from medical students and residents and found 12 instances of potential patient privacy violations. In this particular case, all of these indiscretions referred to a student medical trip to a developing country. In the above examples, patient details were exposed, showing a fundamental lack of respect towards patients. Such unprofessional action exposes the student to possible legal actions by the patient in question as well as sanction from their professional body. These examples beg the question, why do students fail to apply professional and ethical standards to their online communications? Studies on regular Internet users inform us that going online is an immersive experience. People remark on how time can take on a different quality when
online-where minutes can quickly dissolve into hours. Going online also allows people to transport themselves beyond the physical restrictions of their room or daily life and see other parts of the world in a matter of seconds. Time and space then have less of a structuring effect in online activities than in offline/real-world scenarios. This has led many researchers to conclude that cyberspace is a decontextualised space which ‘feels different’ from real life but also is experienced as being a space, which is somewhat removed from real life (14). This sense of being ‘elsewhere’ when online can help explain why the enacting of professionalism may be difficult for students. The absence of the situational cues which typically prompt professional behaviour (e.g. the dental uniform, the environs of the dental clinic and the presence of the dental team) can disorientate students causing them to lapse in their professional judgement and conduct. The ‘collapsed context’ (15) of the online world poses a threat to this model of professionalism based on context-specific situational judgement. Solution Dental educators need to impress upon students that their online actions have a direct and perceptible impact on their ‘real’ and professional lives. One strategy to help re-instate this sense of ‘situational judgement’ to their online activities would be to encourage students to PAUSE and to get into the habit of asking themselves some key questions before they post, upload or share anything online. These questions can include why am I sharing/posting this? What response do I hope to get? What might the response be? Who are the intended recipients? Who else might see it? What would their response be to this post? Is there anyone who should not see it? (6). By running through such a checklist, students introduce a real-life context to their online actions and potentially avoid unprofessional online behaviour. Problem #2: social media encourages expression not reflection
The principle mode through which people communicate online is via text rather than face-to-face interactions. The emphasis on text over talking has another potentially damaging impact on students understanding of and practice of professionalism because it can lead to a ‘disembodied’ form of online interaction. In online communications, the person’s physical presence is reduced to a textual description or exchange (16) with ‘speed and brevity’ (14) as its guiding principles. Accordingly, private concerns such as passing feelings, annoyances and fancies are increasingly posted online and made available for all to see and read. As a result, most social media postings merely establish the current emotional state and feelings of its author (14). In this regard, social media is generally a vehicle for (unfiltered)
self-expression rather than self-reflection amongst the general public (14). The reactive nature of social media can be counterproductive for the building of the clinical and professional reputation of dental students. Social media is littered with postings full of ‘simple conscious awareness statements’ (17), such as students posting that they have had a bad day on clinic or in the clinical skills laboratory. These posts help to forge the impression that these dental students are ‘nonreflectors’ (18) and as such are limited in their clinical competence (19). With the guidance of dental educators, this ‘non-reflector’ stage is a temporary one, eventually giving way to other stages in their professional development. However, having such an insight into the emotional states of dental students is not only unhelpful but also resonates as unprofessional. When the public read petulant posts from dental students they come to doubt the maturity and clinical skills of the student. Reading petulant or banal posts from student dental health professionals can also raise doubts in the public mind as to their ability to put the interests of the patient first (20). Such a negative first impression can skew a patient’s perceptions of their dentist and alter patient expectations and confidence. This in turn can call into question the degree of trust that exists between the patient and the dentist. Trust implies a duty of care that the dentist has towards their patients, but also reflects the ‘social contract’ that exists between society and dentistry as a profession (21). Negative perceptions of the skills and abilities of one dentist can actively detract from the commonly held belief that dentists promote and protect the oral health of the public. These unreflective postings can erode at this key tenet of professionalism. Solution The expressive nature of social media is one of the endearing qualities of social media usage. However, for health professional students, its informal and fleeting nature also appears to encourage them to be unreflective in their online communications and to appear as unreflective students. There is an increased emphasis placed on the merits of being a reflective health professional (18). Reflective practice is deemed to help students move from simply ‘knowing how’ to provide dental care to ‘actually providing care’ (22) to patients. Dental students need to be more circumspect about what they post online to avoid this negative association. In addition to the earlier strategy of PAUSING, students also need to reiterate their PROFESSIONAL status in all their online activities (6). In order for students to use social media in a professional manner they need to have a clear understanding about what dental professionalism means. We have already highlighted the pedagogic challenge that this task presents to dental educators and students alike (1). In this particular context of online activities, we can
ª 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 20 (2016) 55–58
begin this process by giving students some practical examples of the difference between personal and professional actions online. For instance, the posting ‘bad day on clinic’ is unprofessional because it mentions your place of work whereas ‘having a bad day’ is a personal comment. Another effective way of establishing one’s professional status would be to create separate Facebook pages or Twitter accounts for personal and professional use. In this way, students can help distinguish between their personal and professional lives online and restrict the circulation of any unreflective posting, inappropriate photographs (e.g. with images of intoxication) or photographs you have not consented to have uploaded or shared online. Problem #3: social media breaks down the social distance that traditionally separates professionals and the public
Social media not only encourages its users to be expressive, but it also makes it relatively easy to share personal information online. Thanks to user-generated technology people create ‘profile’s’ on multiple digital platforms, such as Facebook, Twitter or Instagram. These profiles are composed of photographs they have uploaded or being tagged in and the profile information they have written about themselves such as their hobbies and musical interests (23). As a result, social media is awash with countless pieces of personal information. The online predominance of personal data means that the social distance that traditionally separated people from each other has been reduced. This loss of social space is significant for dental students and other health professionals because it calls into question the social distinction that defines professionals, as a group of individuals removed from the rest of society. Although health professionals always had a private life, with social media, the public have more opportunities to know what this might be, such as seeing their dentist’s holiday photos or knowing what their favourite pastime is. To this extent, the ‘digital footprint’ (24) of health professionals may in part erode the cultural authority or mystique that surrounds them as an expert group in society. It is also worth remembering that the current cohort of dental students have lived their childhood and adolescences in the full glare of the Internet. As a result, we can expect them to have a deeper and diverse ‘digital footprint’ than older graduates and professionals. Whilst these online activities predate their enrolment on their professional programme, its content may cast them in an unfavourable and unprofessional light if prospective patients came across them online. A study by Garner and O’Sullivan (25) found that 52% of undergraduate medical students in its sample admitted to having embarrassing personal photos on Facebook. Although it may be considered unfair that the professionalism of current dental students is being judged by
ª 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 20 (2016) 55–58
earlier actions, fewer and fewer aspects of our personal lives are not digitally documented. Dental students need to become more vigilant and circumspect about what they upload or allow to be uploaded about them. Solution The relative ease and readiness with which people search for information on other people online means that friends, colleagues, patients, peers and prospective employers are just a click away from finding all about you. Whilst deleting ones SNS account might prove an ultimate solution to this problem, the reality is that many dental students want and like having a Facebook account. If dental students want to continue to use SNS’s two strategies can be useful here: PRIVACY and PROACTIVE. Dental students should regularly check and use the privacy settings of their SNS. In this way, they can limit the access that any inquiring Internet user can have to their personal information. Dental students should also be more proactive about how they and their friends use the Internet. They will need to remind family, friends and colleagues to ask for permission when posting any information or images of them online 6. In that way, they can begin to have some control over their digital footprint and the digital impression they are portraying before the public.
Conclusion Dentistry in the twenty-first century is being practiced in a digital age. Digital technology is not only changing the treatment options and diagnostic tools used in clinical practice, but is also changing the lives of dentists and their patients. Whilst dental educators have been keen to introduce digital technology into the dental classroom (18, 22), the widespread availability of smartphones amongst students and their digital recording capabilities can mean that the classroom experience, including faculty–students interactions, can be recorded, uploaded and shared on social media platforms, often without the permission of the parties’ in question. Clearly, we need to consider how social media is impacting on our understandings and perceptions of dental professionalism. This commentary contends that the discipline of dentistry has not yet tackled how social media and general online behaviours can add to the challenge of being a professional in the 21st century. The current cohort of dental students live full online and offline lives, effortlessly moving between the ‘real’ and ‘virtual’ world (16) and so we need to teach them about how to be professional across both platforms. As a virtual reality, the experience of ‘going online’ can register as professionally disorientating. Its immersive quality can make it hard for student professionals to engage their situational judgement and as a result, expose them to breaches in patient confi-
dentiality. The mode of interacting online is also different from ‘real’ life by emphasising textual exchanges rather than face-to-face interactions. The lack of embodied interactions in social media appears to encourage users to freely express and disclose personal, and at times, private information online. The permeability of personal boundaries online has direct implications on the ability to enforce and upheld professional boundaries offline. The informal and expressive quality of social media postings projects an unreflective and unprofessional image of the health professionals. Moreover, the relative ease with which people can search the Internet and find information about people also runs the risk of shrinking the social divide that traditionally fuelled the private–public boundary of professionalism. In outlining the challenges that social media pose to dental professionalism, this commentary hopes to be a useful resource to dental educators teaching professionalism to their students. Whilst it identifies three main problems with social media for the dental student, it also offers practical solutions on how to overcome these potential pitfalls by introducing the 4 Ps approach (PAUSE, PRIVACY, PROACTIVE and PROFESSIONAL) to social media usage by professionals, as developed by Arbouet Harte (6). By framing the issues and their solutions in such an applied, realworld manner students and educators alike can become more reflective about their use of social media and see this digital awareness as part of their professional development. In this way, it is hoped that the advice given in this commentary will help safeguard the best interests of the public as well as the professional status of the profession.
Acknowledgements The author would like to thank Dr Andrea Waylen, Senior Lecturer in Social Sciences, School of Oral and Dental Sciences, University of Bristol for her useful comments on an earlier version of this manuscript.
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P. Neville School of Oral and Dental Science, University of Bristol, Bristol, UK E-mail: [email protected]
ª 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Eur J Dent Educ 20 (2016) 55–58