P. Neville*1 and A. Waylen1
IN BRIEF
• Discusses research that found instances
EDUCATION
Social media and dentistry: some reflections on e-professionalism
where US healthcare and medical students’ social media activity has been considered unprofessional. • Identifies ways unprofessional social media usage can erode the social contract between dentistry and society. • Argues that social media awareness resonates as a professional skill for the practice of dentistry in the twenty-first century.
The proliferation of digital technology is impacting on the training and development of healthcare professionals. Research on the online behaviour of medical and pharmacy students indicates that social media poses a number of risks to the professional practice of healthcare professionals. General Dental Council guidelines on the use of social media also suggest that it has the potential to expose dental professionals to a variety of breaches of professional conduct. This paper explores the various ways social media can help, as well as hinder, the practice of dental professionalism. However, the lack of primary research on the social media behaviour of dental students and qualified dental practitioners alike acts as a barrier to increasing social media awareness within dentistry. The paper concludes by calling for more research-led discussion on the role social media plays in shaping our understanding of dental professionalism in the twenty-first century. INTRODUCTION In 2014 it was estimated that approximately three billion people used the internet.1 According to the Office for National Statistics2 36 million (73%) British adults have access to the internet every day, and a further 53% access the internet via mobile devices. The widespread availability of information online, and our easy ability to access and share this information through various mobile devices means that social media is changing how we communicate with each other. Social media is defined as the ‘software that enables individuals and communities to gather, communicate, share and in some cases collaborate or play’.3 These include Social Networking Sites (SNS) such as Facebook, and micro blogging platforms such as Twitter, Snapchat and Instagram.4 The role that social media plays in the training and continued development of healthcare professionals is worth assessing. Recent UK health policy documents have announced the social and health benefits of a social media savvy healthcare workforce in which social media can act as a vehicle for personal and professional development and lifelong learning.5,6 Many dental schools use social media to promote their courses and School of Oral and Dental Sciences, University of Bristol, Lower Maudlin Street, Bristol, BS1 2LY *Correspondence to: Dr P. Neville Email: [email protected] 1
Refereed Paper Accepted 3 February 2015 DOI: 10.1038/sj.bdj.2015.294 © British Dental Journal 2015; 218: 475-478
communicate with their students.7 Dental educators also use YouTube and blogs to enhance the classroom learning experience and increase reflective thinking and learning.8–10 Social media has also been used to promote new dental techniques (through uploaded videos on YouTube and vimeo), advertise private dental practices, as well as the sharing of dental research through twitter and the RSS news feeds of leading journals and conferences. Nevertheless, regulatory bodies in the UK, such as the General Medical Council (GMC) and GDC, are holding a more hardline approach regarding the effects of social media by focusing on its impact on the conduct of healthcare professionals. 11–13 This situation contrasts with the American experience, where individual medical schools rather than national professional bodies have drafted and locally enforced social media guidelines for their students. American research indicates that medical and pharmacy students are confused about the ethical, legal and professional implications of their online behaviour and activities.3,14 There is also US evidence that student healthcare professionals struggle to understand a) what e-professionalism is and b) the difference between being professional and unprofessional in their online activities.14 Based on this body of literature it would appear that e-professionalism, or ‘behaviour related to professional standards and ethics when using electronic communications’,15 could pose a formidable challenge for dentists and dental students alike.
BRITISH DENTAL JOURNAL VOLUME 218 NO. 8 APR 24 2015
On 30 September 2013, the GDC published its Guidance on using social media.16 This document highlighted the various ways in which social media, digital communications and online activities can adversely impact on professional practice. While the prescriptive approach taken by the GDC guidelines assures that they are performing their legal responsibility towards their members and the public at large, the task of educating or informing dental health professionals about how to use social media responsibly is less clear. In this paper, we will present some of the challenges that social media presents to dental professionalism. Much of this literature frames social media usage and the internet as risky behaviour, exposing dental health professionals to various counts of unprofessionalism. Admittedly, dental health professionals need to be made aware of the risks associated with online communications and behaviour. However, research suggests that a didactic teaching approach on ‘the do’s and don’ts’ of social media is not particularly effective.17 The challenge of teaching social media awareness as a professional skill will be taken up at the end of the paper. We contend that social media awareness resonates as a professional skill for the practice of dentistry in the twenty-first century and that more research needs to be undertaken on how social media practice is changing perceptions of dental professionalism (Table 1).
SOCIAL MEDIA AND PROFESSIONALISM: A LITERATURE REVIEW The advancement of digital technology over the past ten years has resulted in the 475
© 2015 Macmillan Publishers Limited. All rights reserved
EDUCATION Table 1 Teachable scenarios of e-professionalism Standards for the dental team (GDC 2005, 2014)
Example of not being e-professional
Example of being e-professional
Communicate effectively with patients
Eager to increase prospective patients to his dental practice, Michael uses his Facebook page to communicate with his patients and post dental health information and updates.
Michael creates another Facebook page, separate to his personal Facebook account, which he advertises on the practice website. He uses this SNS to communicate with patients and post dental health updates.
Obtain valid consent from patients
In an attempt to increase the profile of the practice Emily decides that the practice website would benefit from some patient testimonials. She ‘cuts and pastes’ quotes from the queries and comments patients have posted on the clinic’s Twitter account and includes them on the website. The names of the patients are included on the website.
In an attempt to increase the profile of the practice Emily decides that the practice website account would benefit from some patient testimonials. She identifies some individuals from the clinic’s Facebook page and twitter feed and writes to them requesting permission to use their comment on the practice’s website. The anonymity of the patient is upheld as no names will be used with the quotes.
Maintain and protect patient information
After a long and stressful day at clinic, Fatima posts on Snapchat: ‘Had my worst day in Leeds Dental Hospital today. Screaming kids and even more annoying parents! Why are the blonde kids such a handful!!’
After a long and stressful day at clinic, Fatima posts on Snapchat: ‘Busy day’.
Work with colleagues in a way that serves the interests of the patients
The practice website is in need of updating. Raj looks at photographs he took of the last staff night out and posts them on the website. He thinks the informal photographs (complete with Christmas hats) will make the staff appear friendly and approachable.
The practice website is in need of updating. Raj asks the staff if they would like their photograph included on the website. If they agree to this, he will arrange a photographer to come and take their photo while they are at work. Staff members are free to withdraw their permission at any time and they decide which photographs are posted of them on the website. If the dental team are not happy to have their photograph taken for the website, Raj will use stock photos of actors on the website instead.
Maintain, develop and work within your professional knowledge and skills
A patient tweets your twitter account looking for some advice. They have noticed some swelling on the floor of their mouth and on the side of their jaw and wonder if it is anything serious. You tweet that it sounds like head and neck cancer and that they should go to their GP at once.
A patient tweets your twitter account looking for some advice. They have noticed some swelling on the floor of their mouth and on the side of their jaw and wonder if it is anything serious. You reply that the swelling could be caused by a number of different factors and invite them to come into the surgery for a consultation
Raise concerns if the patient is at risk
A patient arrives for an emergency appointment. She has bruising to her face and one of her teeth has become loose. You ask her how the injury occurred and she replied that she walked into a door. She closes down when you attempt to probe the circumstances of the incident further. That evening you post information on intimate partner violence on the practice website, twitter and Facebook page.
A patient arrives for an emergency appointment. She has bruising to her face and one of her teeth has become loose. You ask her how the injury occurred and she replied that she walked into a door. She closes down when you attempt to probe the circumstances of the incident further. You discuss your thoughts about her injuries and say that if she has been the victim of intimate partner violence she needs to report this to the police.
Make sure your personal behaviour maintains patients’ confidence in you and your dental profession
Lee has a Facebook page with public settings. His friend uploads photographs of his birthday the previous week. There is a photograph of Lee taking tequila shots with friends. Another photograph is of Lee asleep in a nightclub with a beer bottle in his hand. Lee writes the following comment: ‘That was a great night, pity about the hangover the next morning!’
Lee has a Facebook page with public settings. He attended his friend’s birthday the previous week but asks that no photographs of him be posted on Facebook as it would reflect badly on his reputation and on the dental profession as a whole.
emergence of a new ‘communications culture’.18 Digital communication is no longer exclusively concerned with sharing information – it also enables social interactions between people who may or may not be known to each other.19 The relative ease with which users can create, share, upload, tag and comment on information posted on social media platforms also means that social media allows users to be more expressive and participatory online.20 This mix of the expressive nature of social media in combination with its inherent ability to forge connections between people underpins the popularity and attractiveness of social media to the current generation. While authors like Marc Prensky contend that people born after 1980 are ‘digital natives’ and are better equipped to
live with ‘the instantaneity of hypertext, downloaded music, phones in their pockets, a library on their laptops, beamed messages and instant messaging’,21 the fact of the matter is that all working professionals, regardless of their age, have a more dynamic and immersive relationship with digital technology than previously18 and one which can overlap with their working life. This ‘always-on/always-on-us’18 relationship with technology and social media has particular implications for healthcare professionals and our construction of professionalism. While some insist that professionalism is hard to define,22 at its most general ‘professionalism refers to the conduct and/or behaviour of the individual in upholding the social contract between society and the
476
profession’.23 This social contract refers to the position of trust and authority which is conferred on the profession by society and which the professional, as a representative of their profession, must uphold through their norms, values and behaviour. The research literature reveals four ways in which digital technology and social media are undermining the social contract of the healthcare professions. Firstly, social media blurs the personalprofessional divide: many dental practices have their own practice websites and Facebook pages through which they post practice opening hours, updates on health topics and often, testimonials from satisfied patients.24 While such online activities can be interpreted as a form of community service, the increased availability of professional BRITISH DENTAL JOURNAL VOLUME 218 NO. 8 APR 24 2015
© 2015 Macmillan Publishers Limited. All rights reserved
EDUCATION people online also has the effect of reducing the social distance that traditionally separated healthcare professionals from the public. Such a blurring of the boundary between public and private spheres and its potential impact on professionalism needs to be recognised.25 Most SNS sites such as Instagram and Facebook have privacy settings which, when activated, can help limit the number of people who can access the content you post on these platforms. However, the terms of reference for these privacy policies are regularly updated so social media users need to remain vigilant in terms of ensuring they have the full protection they require when using social media. Secondly, social media content can colour personal and professional reputations: the advent of SNS means that an array of personal information is now available online. Personal Facebook pages can reveal a detailed account of someone’s personal life. For healthcare professionals, this ‘online persona’26 can adversely impact on patient trust. Garner and O’Sullivan27 found that 52% of undergraduate medical students admitted to having embarrassing photos of themselves on Facebook. In a 2013 survey of 377 pharmacy students in the UK, 45% stated that they have posted items online that they would not like a future employers to see.28 Although, to our knowledge, there is no similar survey of dental students it is easy to see that prospective and current patients might question a dentist’s professional competency if they were to find online photographs of their dentist drunk or involved with some high jinks. Because ‘the distribution capacity of social media’7 is so fast and global, any unprofessional behaviour captured online will have an untold, and possible permanent impact on an individual’s professional reputation and career. This ‘digital footprint’29 detracts from one’s reputation and reflects badly on the profession as a whole, calling into doubt the trust that exists in the profession of dentistry.7,30 While it may be unfair to judge an individual’s professional competency based on historic online content, the fact remains that all online content is potentially retrievable and permanent. Healthcare professionals need to become more circumspect about the content they create and post online in order to ensure that they do not skew patients’ perception of dentistry and the level of care they expect to be provided with. Another way in which social media can have an undermining effect is via the dangers of self-expression in social media: by using and posting information on SNS sites, clinicians risk disclosing inappropriate information about themselves, thereby violating
their own privacy.24. They may also violate patient confidentiality if they choose to discuss their work online. Lagu et al.31 analysed 271 medical blogs and found enough information in 56.8% of them for the author to be identified, and an additional 16.6% had information from which patients or their doctor were identifiable. Chretien et al.32 analysed 5,156 tweets from 216 selfidentified physicians over one month and found 4.7% to be unprofessional in content; 38 individual tweets potentially violated patient confidentiality. Dental health professionals must also be cautious in terms of the photographs they post online themselves as well as those they are willing to pose for that may be posted by others. An awareness of e-professionalism will direct dentists to always ask where a photograph will be displayed and refuse permission for the images to be posted if necessary. Finally, it is important to consider patient confidentiality in a multi-media world: computer mediated communications are not only text-based (that is, emails, Facebook posting and twitter feeds), but also increasingly visual in nature as photographs and videos are regularly uploaded (for example, Instagram). Although the same standards of patient consent and confidentiality apply to the use of patient photographs in the clinical setting and online, evidence suggests that healthcare professionals are less circumspect about what constitutes professional online visual communication. Thompson et al.33 analysed 1023 Facebook profiles from medical students and residents and found 12 instances of potential patient privacy violations. All of these consisted of photographs that students uploaded from a medical outreach trip to a developing country. In 2009 a Swedish nurse was suspended from her position after she posted a photo of her holding a piece of flesh during an operation onto a SNS.34 It is also important to note that photographing one’s place of work or study also exposes employers and institutions to the risk of negative public responses. In this instance, the repercussions of unprofessional online conduct can be serious, requiring the employer or institution to put a ‘risk management’7 strategy in place.
PROMOTING SOCIAL MEDIA AWARENESS AS A FORM OF PROFESSIONALISM It is clear that there is a degree of urgency about raising awareness of the risks and benefits of social media for professional practice. Though regulatory bodies like the GDC issue social media guidelines to clarify what breaches of e-professionalism entail, little is known of dental students’ and, more
BRITISH DENTAL JOURNAL VOLUME 218 NO. 8 APR 24 2015
generally, dental care professionals’ and qualified dentists’ perceptions of e-professionalism. Attention should also be paid to the public’s perception of e-professionalism and what they consider to be appropriate or inappropriate online behaviour. In their study, Jain et al.35 found that the public’s perception of simulated Facebook pages that contained various examples of inappropriate content was much more critical than that of medical students. Media studies research points to the importance of striking the right balance in the message or tone of social media teaching. Considering how mundane and omnipresent social media is in our lives it would be unrealistic to insist that professionals stop using social media altogether. Nevertheless, social media users and the public need to be made aware of the online risks they may be exposing themselves to. We need to empower social media users about their choices and options when online so as to protect their own reputation, the profession itself and the interests of the public at large.36 This means that any dental practitioner, at any stage of their career, should know to pause and reflect before they tweet or post a comment or photo in any context; they must know and be enabled to always ask where a comment or photograph will be displayed and be willing to refuse permission for inappropriate content to be posted if necessary. That said, little research has been conducted on how best to teach or increase awareness of e-professionalism both within the classroom context and as part of lifelong learning/continuing professional development.37 The traditional method of teaching professionalism relies on role modelling.35 However, this approach may not be suitable in this instance. One email survey of 221 educators across five different dental schools in the US found that the majority of university faculty used social media for personal and not educational purposes8 and so might not necessarily act as positive role models of professional online communications. In media studies, research suggests that online awareness is best taught by combining offline with online elements.38,39 Furthermore, since social media is expressive and participatory in nature, it has been remarked that an active experiential learning approach might be best.20 One such approach is the living lab model.38 Real-life scenarios are presented as practical learning opportunities for students, such as getting students to create examples of appropriate and inappropriate Facebook pages or devising social media tips sheet. As a result, learners do not assume the position of passive subjects but are active co-creators of the learning 477
© 2015 Macmillan Publishers Limited. All rights reserved
EDUCATION experience.38 By acknowledging the existing social media skills, knowledge of our students and their ability to guide the learning experience,38 one assumes that students will be more receptive to messages about the risks and benefits of online behaviour. However, until more empirical research has been carried out in the classroom learning environment, we will continue to be at a disadvantage on how best to teach e-professionalism.
CONCLUDING THOUGHTS Since the drafting of social media guidelines in 2013 we can expect that complaints about how practitioners and students use social media will feature increasingly in the fitness to practice cases investigated by the GDC. However, the lack of discipline specific research on these issues makes it difficult to plan a way forward for the teaching and learning of social media awareness. It is in the best interests of patients and the profession as a whole that more research is undertaken on the types of online behaviour that dental students, and practitioners alike, engage in so as to identify areas where online behaviour compromises professional standards. From this research base we will be better able to design specific training activities and approaches for the raising of awareness about professional social media practice. 1. Internet live stats. Internet users. 2014. Online information available at http://www.internetlivestats. com/internet-users (accessed March 2015). 2. Office for National Statistics. Internet access households and individuals 2013. 2013. Online information available at http://www.ons.gov.uk/ons/ dcp171778_322713.pdf (accessed March 2015). 3. Von Muhlen M, Ohno-Machado L. Reviewing social media use by clinicians. J Am Med Informatics 2012; 19: 77–781. 4. Hardey M. eHealth. In Gabe J, Monaghan L F. (eds) Key concepts in medical sociology. 2nd ed. pp 133–136. London: SAGE Publications, 2013. 5. Department of Health. Digital strategy: leading the culture change in health and care. 2012. Online information available at https://www.gov.
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uk/government/uploads/system/uploads/attachment_data/file/213222/final-report1.pdf (accessed March 2015). NHS Employers. HR and social media in the NHS. 2013. Online information available at http://www. nhsemployers.org/~/media/Employers/Publications/ HR-social-media-NHS.pdf (accessed March 2015). Oakley M, Spallek H. Social media in dental education: a call for research and action. J Dent Ed 2012; 76: 279–287. Arnett M R, Loewen J M, Romito LM. Use of social media by dental educators. J Dent Ed 2013; 7: 1402–1412. Knösel M, Jung K, Bleckmann A. YouTube, dentistry, and dental education. J Dent Ed 2011; 75: 1558–1568. Wetmore A O, Boyd L D, Bowen D M, Pattillo R E. Reflective blogs in clinical education to promote critical thinking in dental hygiene students. J Dent Ed 2010; 74: 1337–1350. Royal College of General Practitioners. Social media highway code. 2013. Online information available at http://www.rcgp.org.uk/social-media (accessed March 2015). General Medical Council. Doctor’s use of social media. 2013. Online information available at http:// www.gmc-uk.org/guidance/ethical_guidance/21186. asp (accessed March 2015). Megele C. Social care in the e-professionalism era. The Guardian, 25 April 2012. Online information available at http://www.theguardian.com/socialcare-network/2012/apr/25/eprofessionalism-socialcare (accessed March 2015). Chretien K C, Goldman E F, Beckman L, Kind T. It’s your own risk: medical students’ perspective on online professionalism. Acad Med 2010; 85 (Suppl 10): 568–571. Harte H A. E-professionalism for early care and education providers. Dimens Early Child 2011; 39: 5–9. General Dental Council. Guidance on using social media. 2013. Online information available at http:// www.gdc-uk.org/Dentalprofessionals/Standards/ Documents/Guidance%20on%20using%20 social%20media%20%28Sept%202013%29.pdf (accessed March 2015). Third A, Richardson I, Collin P, Rahilly K, Bolzan N. Intergenerational attitudes towards social networking and cybersafety: a living lab. 2011. Online information available at http://www. youngandwellcrc.org.au/knowledge-hub/publications/intergenerational-attitudes-towards-socialnetworking-cybersafety/ (accessed March 2015). Turkle S. Always-on/always-on-you: the tethered self. In Katz J E (ed) Handbook of mobile communications studies. pp 121–137. Cambridge, MA: MIT Press, 2008. Chandler D, Munday C. Oxford dictionary of media and communications. Oxford: Oxford University Press, 2011. Trier J. ‘Cool’ engagements with YouTube: part 1. J Adolesc Adult Lit 2007; 50: 408–412. Prensky M. Digital natives, digital immigrants.
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On the Horizon 2001; 9: 1–6. Online information available at http://www.marcprensky.com/writing/ Prensky%20-%20Digital%20Natives,%20Digital%20 Immigrants%20-%20Part1.pdf (accessed March 2015). Evetts J. Short note: the sociology of professional groups. new directions. Curr Sociol 2006; 54: 133–143. Fricker J P, Kiley M, Townsend G, Trevitt C. Professionalism: what is it, why should we have it and how can we achieve it. Aust Dent J 2011; 56: 92–96. Eckler P, Worsowicz G, Wesley Rayburn J. Social media and health care: an overview. PM R 2010; 2: 1046–1050. Turkle S. The tethered self: technology reinvents intimacy and solitude. Contin High Educ Rev 2011; 75: 28–31. Cain J, Romanelli F. E-professionalism: a new paradigm for a digital age. Curr Pharm Teach Learn 2009; 1: 66–70. Garner, J, O’Sullivan H. Facebook and the professional behaviour of undergraduate medical students. Clin Teach 2010; 7: 112–115. Hall M, Hanna L A, Huey G. Use and views on social networking sties of pharmacy students in the United Kingdom. Am J Pharm Educ 2013; 77: 9. Greysen S R, Kind T, Chretien K C. Online professionalism and the mirror of social media. J Gen Intern Med 2010; 25: 1227–1229. Newsome P R H, Langley P P. Professionalism, then and now. Br Dent J 2014; 216: 497–502. Lagu T, Kaufman E J, Asch B. Contents of weblogs written by health professionals. J Gen Intern Med 2008; 23: 1642–1646. Chretien K C, Azar J, Kind T. Physicians on twitter. JAMA 2011; 305: 566–568. Thompson C A, Black E, Duff W P. Protected health information on social networking sites: ethical and legal considerations. J Med Internet Research 2011; 13: e8. Thompson C. Facebook-cautionary tales for nurses. Nurs N Z 2010; 16: 26. Jain A, Petty E M, Tackett S, Purkis J, Fitzgerald J, White C. What is appropriate to post on social media? Ratings from students, faculty members and the public. Med Educ 2014; 48: 157–169. Livingstone S. Maximising opportunities and minimising risks for children online: from evidence to policy. Intermedia 2009; 37: 50–53. Kumar K. Views of medical e-professionalism: a comparison, Clin Teach 2014; 11: 70–73. Strider J, Locke K, Richardson I, Third A. Intergenerational approaches towards enhancing parent’s knowledge and practice of online safety. 2011. Online information available at http://www.youngandwellcrc.org.au/wp-content/ uploads/2014/03/Living_Lab_Research_Report_.pdf (accessed March 2015). Livingstone S, Helsper E. Parental mediation and children’s internet use. J Broadcast Electron Media 2008; 52: 581–599.
BRITISH DENTAL JOURNAL VOLUME 218 NO. 8 APR 24 2015 © 2015 Macmillan Publishers Limited. All rights reserved
IN BRIEF
• Discusses research that found instances
EDUCATION
Social media and dentistry: some reflections on e-professionalism
where US healthcare and medical students’ social media activity has been considered unprofessional. • Identifies ways unprofessional social media usage can erode the social contract between dentistry and society. • Argues that social media awareness resonates as a professional skill for the practice of dentistry in the twenty-first century.
The proliferation of digital technology is impacting on the training and development of healthcare professionals. Research on the online behaviour of medical and pharmacy students indicates that social media poses a number of risks to the professional practice of healthcare professionals. General Dental Council guidelines on the use of social media also suggest that it has the potential to expose dental professionals to a variety of breaches of professional conduct. This paper explores the various ways social media can help, as well as hinder, the practice of dental professionalism. However, the lack of primary research on the social media behaviour of dental students and qualified dental practitioners alike acts as a barrier to increasing social media awareness within dentistry. The paper concludes by calling for more research-led discussion on the role social media plays in shaping our understanding of dental professionalism in the twenty-first century. INTRODUCTION In 2014 it was estimated that approximately three billion people used the internet.1 According to the Office for National Statistics2 36 million (73%) British adults have access to the internet every day, and a further 53% access the internet via mobile devices. The widespread availability of information online, and our easy ability to access and share this information through various mobile devices means that social media is changing how we communicate with each other. Social media is defined as the ‘software that enables individuals and communities to gather, communicate, share and in some cases collaborate or play’.3 These include Social Networking Sites (SNS) such as Facebook, and micro blogging platforms such as Twitter, Snapchat and Instagram.4 The role that social media plays in the training and continued development of healthcare professionals is worth assessing. Recent UK health policy documents have announced the social and health benefits of a social media savvy healthcare workforce in which social media can act as a vehicle for personal and professional development and lifelong learning.5,6 Many dental schools use social media to promote their courses and School of Oral and Dental Sciences, University of Bristol, Lower Maudlin Street, Bristol, BS1 2LY *Correspondence to: Dr P. Neville Email: [email protected] 1
Refereed Paper Accepted 3 February 2015 DOI: 10.1038/sj.bdj.2015.294 © British Dental Journal 2015; 218: 475-478
communicate with their students.7 Dental educators also use YouTube and blogs to enhance the classroom learning experience and increase reflective thinking and learning.8–10 Social media has also been used to promote new dental techniques (through uploaded videos on YouTube and vimeo), advertise private dental practices, as well as the sharing of dental research through twitter and the RSS news feeds of leading journals and conferences. Nevertheless, regulatory bodies in the UK, such as the General Medical Council (GMC) and GDC, are holding a more hardline approach regarding the effects of social media by focusing on its impact on the conduct of healthcare professionals. 11–13 This situation contrasts with the American experience, where individual medical schools rather than national professional bodies have drafted and locally enforced social media guidelines for their students. American research indicates that medical and pharmacy students are confused about the ethical, legal and professional implications of their online behaviour and activities.3,14 There is also US evidence that student healthcare professionals struggle to understand a) what e-professionalism is and b) the difference between being professional and unprofessional in their online activities.14 Based on this body of literature it would appear that e-professionalism, or ‘behaviour related to professional standards and ethics when using electronic communications’,15 could pose a formidable challenge for dentists and dental students alike.
BRITISH DENTAL JOURNAL VOLUME 218 NO. 8 APR 24 2015
On 30 September 2013, the GDC published its Guidance on using social media.16 This document highlighted the various ways in which social media, digital communications and online activities can adversely impact on professional practice. While the prescriptive approach taken by the GDC guidelines assures that they are performing their legal responsibility towards their members and the public at large, the task of educating or informing dental health professionals about how to use social media responsibly is less clear. In this paper, we will present some of the challenges that social media presents to dental professionalism. Much of this literature frames social media usage and the internet as risky behaviour, exposing dental health professionals to various counts of unprofessionalism. Admittedly, dental health professionals need to be made aware of the risks associated with online communications and behaviour. However, research suggests that a didactic teaching approach on ‘the do’s and don’ts’ of social media is not particularly effective.17 The challenge of teaching social media awareness as a professional skill will be taken up at the end of the paper. We contend that social media awareness resonates as a professional skill for the practice of dentistry in the twenty-first century and that more research needs to be undertaken on how social media practice is changing perceptions of dental professionalism (Table 1).
SOCIAL MEDIA AND PROFESSIONALISM: A LITERATURE REVIEW The advancement of digital technology over the past ten years has resulted in the 475
© 2015 Macmillan Publishers Limited. All rights reserved
EDUCATION Table 1 Teachable scenarios of e-professionalism Standards for the dental team (GDC 2005, 2014)
Example of not being e-professional
Example of being e-professional
Communicate effectively with patients
Eager to increase prospective patients to his dental practice, Michael uses his Facebook page to communicate with his patients and post dental health information and updates.
Michael creates another Facebook page, separate to his personal Facebook account, which he advertises on the practice website. He uses this SNS to communicate with patients and post dental health updates.
Obtain valid consent from patients
In an attempt to increase the profile of the practice Emily decides that the practice website would benefit from some patient testimonials. She ‘cuts and pastes’ quotes from the queries and comments patients have posted on the clinic’s Twitter account and includes them on the website. The names of the patients are included on the website.
In an attempt to increase the profile of the practice Emily decides that the practice website account would benefit from some patient testimonials. She identifies some individuals from the clinic’s Facebook page and twitter feed and writes to them requesting permission to use their comment on the practice’s website. The anonymity of the patient is upheld as no names will be used with the quotes.
Maintain and protect patient information
After a long and stressful day at clinic, Fatima posts on Snapchat: ‘Had my worst day in Leeds Dental Hospital today. Screaming kids and even more annoying parents! Why are the blonde kids such a handful!!’
After a long and stressful day at clinic, Fatima posts on Snapchat: ‘Busy day’.
Work with colleagues in a way that serves the interests of the patients
The practice website is in need of updating. Raj looks at photographs he took of the last staff night out and posts them on the website. He thinks the informal photographs (complete with Christmas hats) will make the staff appear friendly and approachable.
The practice website is in need of updating. Raj asks the staff if they would like their photograph included on the website. If they agree to this, he will arrange a photographer to come and take their photo while they are at work. Staff members are free to withdraw their permission at any time and they decide which photographs are posted of them on the website. If the dental team are not happy to have their photograph taken for the website, Raj will use stock photos of actors on the website instead.
Maintain, develop and work within your professional knowledge and skills
A patient tweets your twitter account looking for some advice. They have noticed some swelling on the floor of their mouth and on the side of their jaw and wonder if it is anything serious. You tweet that it sounds like head and neck cancer and that they should go to their GP at once.
A patient tweets your twitter account looking for some advice. They have noticed some swelling on the floor of their mouth and on the side of their jaw and wonder if it is anything serious. You reply that the swelling could be caused by a number of different factors and invite them to come into the surgery for a consultation
Raise concerns if the patient is at risk
A patient arrives for an emergency appointment. She has bruising to her face and one of her teeth has become loose. You ask her how the injury occurred and she replied that she walked into a door. She closes down when you attempt to probe the circumstances of the incident further. That evening you post information on intimate partner violence on the practice website, twitter and Facebook page.
A patient arrives for an emergency appointment. She has bruising to her face and one of her teeth has become loose. You ask her how the injury occurred and she replied that she walked into a door. She closes down when you attempt to probe the circumstances of the incident further. You discuss your thoughts about her injuries and say that if she has been the victim of intimate partner violence she needs to report this to the police.
Make sure your personal behaviour maintains patients’ confidence in you and your dental profession
Lee has a Facebook page with public settings. His friend uploads photographs of his birthday the previous week. There is a photograph of Lee taking tequila shots with friends. Another photograph is of Lee asleep in a nightclub with a beer bottle in his hand. Lee writes the following comment: ‘That was a great night, pity about the hangover the next morning!’
Lee has a Facebook page with public settings. He attended his friend’s birthday the previous week but asks that no photographs of him be posted on Facebook as it would reflect badly on his reputation and on the dental profession as a whole.
emergence of a new ‘communications culture’.18 Digital communication is no longer exclusively concerned with sharing information – it also enables social interactions between people who may or may not be known to each other.19 The relative ease with which users can create, share, upload, tag and comment on information posted on social media platforms also means that social media allows users to be more expressive and participatory online.20 This mix of the expressive nature of social media in combination with its inherent ability to forge connections between people underpins the popularity and attractiveness of social media to the current generation. While authors like Marc Prensky contend that people born after 1980 are ‘digital natives’ and are better equipped to
live with ‘the instantaneity of hypertext, downloaded music, phones in their pockets, a library on their laptops, beamed messages and instant messaging’,21 the fact of the matter is that all working professionals, regardless of their age, have a more dynamic and immersive relationship with digital technology than previously18 and one which can overlap with their working life. This ‘always-on/always-on-us’18 relationship with technology and social media has particular implications for healthcare professionals and our construction of professionalism. While some insist that professionalism is hard to define,22 at its most general ‘professionalism refers to the conduct and/or behaviour of the individual in upholding the social contract between society and the
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profession’.23 This social contract refers to the position of trust and authority which is conferred on the profession by society and which the professional, as a representative of their profession, must uphold through their norms, values and behaviour. The research literature reveals four ways in which digital technology and social media are undermining the social contract of the healthcare professions. Firstly, social media blurs the personalprofessional divide: many dental practices have their own practice websites and Facebook pages through which they post practice opening hours, updates on health topics and often, testimonials from satisfied patients.24 While such online activities can be interpreted as a form of community service, the increased availability of professional BRITISH DENTAL JOURNAL VOLUME 218 NO. 8 APR 24 2015
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EDUCATION people online also has the effect of reducing the social distance that traditionally separated healthcare professionals from the public. Such a blurring of the boundary between public and private spheres and its potential impact on professionalism needs to be recognised.25 Most SNS sites such as Instagram and Facebook have privacy settings which, when activated, can help limit the number of people who can access the content you post on these platforms. However, the terms of reference for these privacy policies are regularly updated so social media users need to remain vigilant in terms of ensuring they have the full protection they require when using social media. Secondly, social media content can colour personal and professional reputations: the advent of SNS means that an array of personal information is now available online. Personal Facebook pages can reveal a detailed account of someone’s personal life. For healthcare professionals, this ‘online persona’26 can adversely impact on patient trust. Garner and O’Sullivan27 found that 52% of undergraduate medical students admitted to having embarrassing photos of themselves on Facebook. In a 2013 survey of 377 pharmacy students in the UK, 45% stated that they have posted items online that they would not like a future employers to see.28 Although, to our knowledge, there is no similar survey of dental students it is easy to see that prospective and current patients might question a dentist’s professional competency if they were to find online photographs of their dentist drunk or involved with some high jinks. Because ‘the distribution capacity of social media’7 is so fast and global, any unprofessional behaviour captured online will have an untold, and possible permanent impact on an individual’s professional reputation and career. This ‘digital footprint’29 detracts from one’s reputation and reflects badly on the profession as a whole, calling into doubt the trust that exists in the profession of dentistry.7,30 While it may be unfair to judge an individual’s professional competency based on historic online content, the fact remains that all online content is potentially retrievable and permanent. Healthcare professionals need to become more circumspect about the content they create and post online in order to ensure that they do not skew patients’ perception of dentistry and the level of care they expect to be provided with. Another way in which social media can have an undermining effect is via the dangers of self-expression in social media: by using and posting information on SNS sites, clinicians risk disclosing inappropriate information about themselves, thereby violating
their own privacy.24. They may also violate patient confidentiality if they choose to discuss their work online. Lagu et al.31 analysed 271 medical blogs and found enough information in 56.8% of them for the author to be identified, and an additional 16.6% had information from which patients or their doctor were identifiable. Chretien et al.32 analysed 5,156 tweets from 216 selfidentified physicians over one month and found 4.7% to be unprofessional in content; 38 individual tweets potentially violated patient confidentiality. Dental health professionals must also be cautious in terms of the photographs they post online themselves as well as those they are willing to pose for that may be posted by others. An awareness of e-professionalism will direct dentists to always ask where a photograph will be displayed and refuse permission for the images to be posted if necessary. Finally, it is important to consider patient confidentiality in a multi-media world: computer mediated communications are not only text-based (that is, emails, Facebook posting and twitter feeds), but also increasingly visual in nature as photographs and videos are regularly uploaded (for example, Instagram). Although the same standards of patient consent and confidentiality apply to the use of patient photographs in the clinical setting and online, evidence suggests that healthcare professionals are less circumspect about what constitutes professional online visual communication. Thompson et al.33 analysed 1023 Facebook profiles from medical students and residents and found 12 instances of potential patient privacy violations. All of these consisted of photographs that students uploaded from a medical outreach trip to a developing country. In 2009 a Swedish nurse was suspended from her position after she posted a photo of her holding a piece of flesh during an operation onto a SNS.34 It is also important to note that photographing one’s place of work or study also exposes employers and institutions to the risk of negative public responses. In this instance, the repercussions of unprofessional online conduct can be serious, requiring the employer or institution to put a ‘risk management’7 strategy in place.
PROMOTING SOCIAL MEDIA AWARENESS AS A FORM OF PROFESSIONALISM It is clear that there is a degree of urgency about raising awareness of the risks and benefits of social media for professional practice. Though regulatory bodies like the GDC issue social media guidelines to clarify what breaches of e-professionalism entail, little is known of dental students’ and, more
BRITISH DENTAL JOURNAL VOLUME 218 NO. 8 APR 24 2015
generally, dental care professionals’ and qualified dentists’ perceptions of e-professionalism. Attention should also be paid to the public’s perception of e-professionalism and what they consider to be appropriate or inappropriate online behaviour. In their study, Jain et al.35 found that the public’s perception of simulated Facebook pages that contained various examples of inappropriate content was much more critical than that of medical students. Media studies research points to the importance of striking the right balance in the message or tone of social media teaching. Considering how mundane and omnipresent social media is in our lives it would be unrealistic to insist that professionals stop using social media altogether. Nevertheless, social media users and the public need to be made aware of the online risks they may be exposing themselves to. We need to empower social media users about their choices and options when online so as to protect their own reputation, the profession itself and the interests of the public at large.36 This means that any dental practitioner, at any stage of their career, should know to pause and reflect before they tweet or post a comment or photo in any context; they must know and be enabled to always ask where a comment or photograph will be displayed and be willing to refuse permission for inappropriate content to be posted if necessary. That said, little research has been conducted on how best to teach or increase awareness of e-professionalism both within the classroom context and as part of lifelong learning/continuing professional development.37 The traditional method of teaching professionalism relies on role modelling.35 However, this approach may not be suitable in this instance. One email survey of 221 educators across five different dental schools in the US found that the majority of university faculty used social media for personal and not educational purposes8 and so might not necessarily act as positive role models of professional online communications. In media studies, research suggests that online awareness is best taught by combining offline with online elements.38,39 Furthermore, since social media is expressive and participatory in nature, it has been remarked that an active experiential learning approach might be best.20 One such approach is the living lab model.38 Real-life scenarios are presented as practical learning opportunities for students, such as getting students to create examples of appropriate and inappropriate Facebook pages or devising social media tips sheet. As a result, learners do not assume the position of passive subjects but are active co-creators of the learning 477
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EDUCATION experience.38 By acknowledging the existing social media skills, knowledge of our students and their ability to guide the learning experience,38 one assumes that students will be more receptive to messages about the risks and benefits of online behaviour. However, until more empirical research has been carried out in the classroom learning environment, we will continue to be at a disadvantage on how best to teach e-professionalism.
CONCLUDING THOUGHTS Since the drafting of social media guidelines in 2013 we can expect that complaints about how practitioners and students use social media will feature increasingly in the fitness to practice cases investigated by the GDC. However, the lack of discipline specific research on these issues makes it difficult to plan a way forward for the teaching and learning of social media awareness. It is in the best interests of patients and the profession as a whole that more research is undertaken on the types of online behaviour that dental students, and practitioners alike, engage in so as to identify areas where online behaviour compromises professional standards. From this research base we will be better able to design specific training activities and approaches for the raising of awareness about professional social media practice. 1. Internet live stats. Internet users. 2014. Online information available at http://www.internetlivestats. com/internet-users (accessed March 2015). 2. Office for National Statistics. Internet access households and individuals 2013. 2013. Online information available at http://www.ons.gov.uk/ons/ dcp171778_322713.pdf (accessed March 2015). 3. Von Muhlen M, Ohno-Machado L. Reviewing social media use by clinicians. J Am Med Informatics 2012; 19: 77–781. 4. Hardey M. eHealth. In Gabe J, Monaghan L F. (eds) Key concepts in medical sociology. 2nd ed. pp 133–136. London: SAGE Publications, 2013. 5. Department of Health. Digital strategy: leading the culture change in health and care. 2012. Online information available at https://www.gov.
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