commentaries resources required to deal with intrinsic load.9–11 In other words, it is the self-effort engaged by learners to learn new information. It can be particularly challenging for learners to exert this form of effort in a manner that drives their learning efficiently because they are often highly uncertain of their roles as learners within the health care team. Principles that have been identified as optimising germane load include variability and self-explanation.10 By promoting observation and feedback in multiple clinical encounters such as those available in the T-MEX, we can facilitate learning by helping team members to compare and contrast differences in teamwork that may occur across different situations, and thus to come to a richer understanding of what is needed to perform well in this regard. Similarly, prompting learners to explicitly reflect on why their experiences may have occurred as they did creates opportunities for learners to better incorporate any feedback they might receive from observers with their own often implicit understanding of the variable situations they experience. We can facilitate learning by helping team members to compare and contrast differences in teamwork that may occur across different situations
In short, the work presented by Olupeliyawa et al.,5 addressing the educational impact of collaborative assessment practices, leads us to advocate for the adoption of a programmatic approach to providing feedback that is constructed intentionally to manage intrinsic load, reduce extraneous load and optimise germane load through regular evaluation and continuous quality improvement. The use of CLT as a framework from which to evaluate programmatic feedback efforts offers a promising approach to enhancing the effectiveness of feedback on the learning of complex skills such as those required in teamwork.
REFERENCES 1 Hattie J, Timperley H. The power of feedback. Rev Educ Res 2007;77 (1):81–112. 2 Archer JC. State of the science in health professional education: effective feedback. Med Educ 2010; 44:101–8. 3 Molloy E, Boud D. Seeking a different angle on feedback in clinical education: the learner as seeker, judge and user of performance information. Med Educ 2013;47:227–9. 4 Stiggins RJ, Arter JA, Chappuis J, Chappuis S. Classroom Assessment for Student Learning: Doing It Right – Using It Well. Canada: Pearson Education 2004.
5 Olupeliyawa A, Balasooriya C, Hughes C, O’Sullivan A. Educational impact of an assessment of medical students’ collaboration in health care teams. Med Educ 2014; in press. 6 Issa N, Mayer RE, Schuller M, Wang E, Shapiro MB, DaRosa DA. Teaching for understanding in medical classrooms using multimedia design principles. Med Educ 2013;47:388–96. 7 Paas F, Renkl A, Sweller J. Cognitive load theory: instructional implications of the interaction between information structures and cognitive architecture. Instr Sci 2004;32 (1):1–8. 8 Sweller J. Evolution of human cognitive architecture. In: Ross B, ed. The Psychology of Learning and Motivation. San Diego, CA: Academic Press 2003;215–66. 9 Plass JL, Moreno R, Brunken R. Cognitive Load Theory. New York, NY: Cambridge University Press 2010. 10 van Merri€ enboer JJG, Sweller J. Cognitive load theory in health professional education: design principles and strategies. Med Educ 2010;44:85–93. 11 Paas F, van Gog T, Sweller J. Cognitive load theory: new conceptualisations, specifications, and integrated research perspectives. Educ Psychol Rev 2010; 22 (2):115–21. 12 Miller GA. The magical number seven, plus or minus two: some limits on our capacity for processing information. Psychol Rev 1956;63 (2):81–97.
Social media and medical professionalism Anne Cunningham In this issue, Jain et al.1 are undoubtedly correct when they suggest that the focus on social media in the medical education
110
literature to date has concerned threats to professionalism. In conducting their study, they set out to explore how students, faculty
members and university staff (presumed to represent the public) view the posting of certain materials to public Facebook profiles.1 They
ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 48: 104–112
commentaries found agreement on the most serious transgressions, such as the breaching of patient confidentiality.1 There was more disagreement, however, about other issues, such as appearing in photographs with alcohol, or as part of what the authors describe as ‘same sex couples’.1 In general, students were more tolerant than their faculty staff 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 of our deeper uncertainties about what it means to be a doctor in the 21st century? Hafferty2 describes the confusion between the various conceptions of professionalism, 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: some students focus on more superficial aspects of professionalism, such as how they act or appear, whereas others 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
Cardiff, UK
Correspondence: Dr Anne Cunningham, Institute of Medical Education, School of Medicine, Cardiff University, Neuadd Meirionydd, Heath Park, Cardiff CF14 4YU, UK. Tel: 00 44 29 20688101; E-mail: [email protected]
Let us consider the portrayal in social media of alcohol consumption by medical students. We know that excessive alcohol consumption has a long history in the culture of medical schools. The Pithotomy Club, a Johns Hopkins Medical School student society formed in Sir William Osler’s time,4 had a cherub on a beer keg as its emblem and ran an annual revue, the Pithotomy Show, that ended in a ‘beer slide’.5 Forthcoming research by Black and Monrouxe6 finds that some medical students in the UK felt compelled or coerced by their fellow students to drink alcohol or to 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 that facilitates this is rarely examined. An online survey of medical students in the UK in 201210 found that only 22% thought that their medical school promoted a healthy attitude towards alcohol. Given the preponderance of messages about the dangers of sharing images of alcohol consumption through social media, combined with a tacit acceptance of a pro-alcohol culture, is it surprising that some students think that medical schools are more concerned about image than about student well-being? Students sense that being seen to behave badly may be considered worse than actually behaving badly: that is, the portrayal of a ‘professional demeanour’11 may be seen as more important than the actual behaviours of medical students. So when we consider the portrayal of alcohol by students in social media, might it be that 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 selfdisclosed through social media profiles. Thompson et al.,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 (when 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 cultures14,15 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 described by Frost and
doi: 10.1111/medu.12404
ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 48: 104–112
111
commentaries Regehr17 between the discourses of standardisation and diversity in medical professional identity. Is the concern over an individual’s releasing of information on his or her 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 the social media are seen as representing a threat to a process of socialisation which Beagan18 describes as in part involving isolation from all wider networks that 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 godcomplex 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
112
should aspire to conduct research and develop guidance on social media and professionalism that reflect this. 11 REFERENCES 1 Jain A, Petty E, Jaber R, Tackett S, Purkiss J, Fitzgerald J, White C. What is appropriate to post on social media? Ratings from students, faculty and the public. Med Educ 2014;48:157–69. 2 Hafferty FW. Professionalism and the socialisation of medical students. In: Cruess R, Cruess S, Steinert Y, eds. Teaching Medical Professionalism. New York, NY: Cambridge University Press 2009;53–73. 3 Monrouxe LV, Rees CE, Hu W. Differences in medical students’ explicit discourses of professionalism: acting, representing, becoming. Med Educ 2011;45 (6): 585–602. 4 Jarrett WH. The Pithotomy Club: RIP. Proc (Bayl Univ Med Cent) 2011;24 (1):35. 5 Harrell R. History of the Pithotomy Club. 2009. http:// www.pithotomy.com/history.html [Accessed 25 November 2013.] 6 Black L, Monrouxe LV. ‘Being sick a lot, often on each other’: students’ alcohol-related provocation. Med Educ 2014 (in press). 7 Boland M, Fitzpatrick P, Scallan E, Daly L, Herity B, Horgan J, Bourke G. Trends in medical student use of tobacco, alcohol and drugs in an Irish university, 1973–2002. Drug Alcohol Depend 2006;85 (2):123–8. 8 Keller S, Maddock J, Laforge R, Velicer W, Basler H. Binge drinking and health behaviour in medical students. Addict Behav 2007;32 (3):505–15. 9 Thakore S, Ismail Z, Jarvis S, Payne E, Keetbaas S, Payne R, Rothenberg L. The perceptions and habits of alcohol consumption and smoking among Canadian medical students. Acad Psychiatry 2009;33 (3):193–7. 10 Rourke E. Work hard, play hard: medical students’ and schools’
12
13
14 15
16
17
18
19
20
21
22
attitudes to alcohol. Student BMJ 2012. http://student.bmj.com/ student/view-article.html?id=sbmj. e5326. [Accessed 25 November 2013.] Snyder L. American College of Physicians Ethics Manual, 6th edn. Ann Intern Med 2012;156 (1 Part 2):73–104. Thompson L, Dawson K, Ferdig R, Black E, Boyer J, Coutts J, Black N. The intersection of online social networking with medical professionalism. J Gen Intern Med 2008;23 (7):954–7. Mostaghimi A, Crotty BH. Professionalism in the digital age. Ann Intern Med 2011;154 (8):560–2. Rose L. Homophobia among doctors. BMJ 1994;308 (6928):586. Kan R, Au K, Chan W, Cheung L, Lam C, Liu H, Ng L, Wong M, Wong W. Homophobia in medical students of the University of Hong Kong. Sex Educ 2009;9 (1):65–80. Hillier L, Mitchell KJ, Ybarra ML. The Internet as a safety net: findings from a series of online focus groups with LGB and nonLGB young people in the United States. J LGBT Youth 2012;9 (3): 225–46. Frost HD, Regehr G. ‘I AM a Doctor’: negotiating the discourses of standardisation and diversity in professional identity construction. Acad Med 2013;88 (10):1570–7. Beagan BL. Neutralising differences: producing neutral doctors for (almost) neutral patients. Soc Sci Med 2000;51 (8): 1253–65. Duffin J. Lighting candles, making sparks and remembering not to forget. In: Wear D, ed. Women in Medical Education: An Anthology of Experience. New York, NY: State University of New York Press 1996;33–46. Lerner BH. Policing online professionalism: are we too alarmist? JAMA 2013;173 (19):1767–8. McCartney M. How much of a social media profile can doctors have? BMJ 2012;344:e440. Balick A. The Psychodynamics of Social Networking. London: Karnac 2014.
ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 48: 104–112
In short, the work presented by Olupeliyawa et al.,5 addressing the educational impact of collaborative assessment practices, leads us to advocate for the adoption of a programmatic approach to providing feedback that is constructed intentionally to manage intrinsic load, reduce extraneous load and optimise germane load through regular evaluation and continuous quality improvement. The use of CLT as a framework from which to evaluate programmatic feedback efforts offers a promising approach to enhancing the effectiveness of feedback on the learning of complex skills such as those required in teamwork.
REFERENCES 1 Hattie J, Timperley H. The power of feedback. Rev Educ Res 2007;77 (1):81–112. 2 Archer JC. State of the science in health professional education: effective feedback. Med Educ 2010; 44:101–8. 3 Molloy E, Boud D. Seeking a different angle on feedback in clinical education: the learner as seeker, judge and user of performance information. Med Educ 2013;47:227–9. 4 Stiggins RJ, Arter JA, Chappuis J, Chappuis S. Classroom Assessment for Student Learning: Doing It Right – Using It Well. Canada: Pearson Education 2004.
5 Olupeliyawa A, Balasooriya C, Hughes C, O’Sullivan A. Educational impact of an assessment of medical students’ collaboration in health care teams. Med Educ 2014; in press. 6 Issa N, Mayer RE, Schuller M, Wang E, Shapiro MB, DaRosa DA. Teaching for understanding in medical classrooms using multimedia design principles. Med Educ 2013;47:388–96. 7 Paas F, Renkl A, Sweller J. Cognitive load theory: instructional implications of the interaction between information structures and cognitive architecture. Instr Sci 2004;32 (1):1–8. 8 Sweller J. Evolution of human cognitive architecture. In: Ross B, ed. The Psychology of Learning and Motivation. San Diego, CA: Academic Press 2003;215–66. 9 Plass JL, Moreno R, Brunken R. Cognitive Load Theory. New York, NY: Cambridge University Press 2010. 10 van Merri€ enboer JJG, Sweller J. Cognitive load theory in health professional education: design principles and strategies. Med Educ 2010;44:85–93. 11 Paas F, van Gog T, Sweller J. Cognitive load theory: new conceptualisations, specifications, and integrated research perspectives. Educ Psychol Rev 2010; 22 (2):115–21. 12 Miller GA. The magical number seven, plus or minus two: some limits on our capacity for processing information. Psychol Rev 1956;63 (2):81–97.
Social media and medical professionalism Anne Cunningham In this issue, Jain et al.1 are undoubtedly correct when they suggest that the focus on social media in the medical education
110
literature to date has concerned threats to professionalism. In conducting their study, they set out to explore how students, faculty
members and university staff (presumed to represent the public) view the posting of certain materials to public Facebook profiles.1 They
ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 48: 104–112
commentaries found agreement on the most serious transgressions, such as the breaching of patient confidentiality.1 There was more disagreement, however, about other issues, such as appearing in photographs with alcohol, or as part of what the authors describe as ‘same sex couples’.1 In general, students were more tolerant than their faculty staff 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 of our deeper uncertainties about what it means to be a doctor in the 21st century? Hafferty2 describes the confusion between the various conceptions of professionalism, 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: some students focus on more superficial aspects of professionalism, such as how they act or appear, whereas others 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
Cardiff, UK
Correspondence: Dr Anne Cunningham, Institute of Medical Education, School of Medicine, Cardiff University, Neuadd Meirionydd, Heath Park, Cardiff CF14 4YU, UK. Tel: 00 44 29 20688101; E-mail: [email protected]
Let us consider the portrayal in social media of alcohol consumption by medical students. We know that excessive alcohol consumption has a long history in the culture of medical schools. The Pithotomy Club, a Johns Hopkins Medical School student society formed in Sir William Osler’s time,4 had a cherub on a beer keg as its emblem and ran an annual revue, the Pithotomy Show, that ended in a ‘beer slide’.5 Forthcoming research by Black and Monrouxe6 finds that some medical students in the UK felt compelled or coerced by their fellow students to drink alcohol or to 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 that facilitates this is rarely examined. An online survey of medical students in the UK in 201210 found that only 22% thought that their medical school promoted a healthy attitude towards alcohol. Given the preponderance of messages about the dangers of sharing images of alcohol consumption through social media, combined with a tacit acceptance of a pro-alcohol culture, is it surprising that some students think that medical schools are more concerned about image than about student well-being? Students sense that being seen to behave badly may be considered worse than actually behaving badly: that is, the portrayal of a ‘professional demeanour’11 may be seen as more important than the actual behaviours of medical students. So when we consider the portrayal of alcohol by students in social media, might it be that 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 selfdisclosed through social media profiles. Thompson et al.,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 (when 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 cultures14,15 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 described by Frost and
doi: 10.1111/medu.12404
ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 48: 104–112
111
commentaries Regehr17 between the discourses of standardisation and diversity in medical professional identity. Is the concern over an individual’s releasing of information on his or her 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 the social media are seen as representing a threat to a process of socialisation which Beagan18 describes as in part involving isolation from all wider networks that 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 godcomplex 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
112
should aspire to conduct research and develop guidance on social media and professionalism that reflect this. 11 REFERENCES 1 Jain A, Petty E, Jaber R, Tackett S, Purkiss J, Fitzgerald J, White C. What is appropriate to post on social media? Ratings from students, faculty and the public. Med Educ 2014;48:157–69. 2 Hafferty FW. Professionalism and the socialisation of medical students. In: Cruess R, Cruess S, Steinert Y, eds. Teaching Medical Professionalism. New York, NY: Cambridge University Press 2009;53–73. 3 Monrouxe LV, Rees CE, Hu W. Differences in medical students’ explicit discourses of professionalism: acting, representing, becoming. Med Educ 2011;45 (6): 585–602. 4 Jarrett WH. The Pithotomy Club: RIP. Proc (Bayl Univ Med Cent) 2011;24 (1):35. 5 Harrell R. History of the Pithotomy Club. 2009. http:// www.pithotomy.com/history.html [Accessed 25 November 2013.] 6 Black L, Monrouxe LV. ‘Being sick a lot, often on each other’: students’ alcohol-related provocation. Med Educ 2014 (in press). 7 Boland M, Fitzpatrick P, Scallan E, Daly L, Herity B, Horgan J, Bourke G. Trends in medical student use of tobacco, alcohol and drugs in an Irish university, 1973–2002. Drug Alcohol Depend 2006;85 (2):123–8. 8 Keller S, Maddock J, Laforge R, Velicer W, Basler H. Binge drinking and health behaviour in medical students. Addict Behav 2007;32 (3):505–15. 9 Thakore S, Ismail Z, Jarvis S, Payne E, Keetbaas S, Payne R, Rothenberg L. The perceptions and habits of alcohol consumption and smoking among Canadian medical students. Acad Psychiatry 2009;33 (3):193–7. 10 Rourke E. Work hard, play hard: medical students’ and schools’
12
13
14 15
16
17
18
19
20
21
22
attitudes to alcohol. Student BMJ 2012. http://student.bmj.com/ student/view-article.html?id=sbmj. e5326. [Accessed 25 November 2013.] Snyder L. American College of Physicians Ethics Manual, 6th edn. Ann Intern Med 2012;156 (1 Part 2):73–104. Thompson L, Dawson K, Ferdig R, Black E, Boyer J, Coutts J, Black N. The intersection of online social networking with medical professionalism. J Gen Intern Med 2008;23 (7):954–7. Mostaghimi A, Crotty BH. Professionalism in the digital age. Ann Intern Med 2011;154 (8):560–2. Rose L. Homophobia among doctors. BMJ 1994;308 (6928):586. Kan R, Au K, Chan W, Cheung L, Lam C, Liu H, Ng L, Wong M, Wong W. Homophobia in medical students of the University of Hong Kong. Sex Educ 2009;9 (1):65–80. Hillier L, Mitchell KJ, Ybarra ML. The Internet as a safety net: findings from a series of online focus groups with LGB and nonLGB young people in the United States. J LGBT Youth 2012;9 (3): 225–46. Frost HD, Regehr G. ‘I AM a Doctor’: negotiating the discourses of standardisation and diversity in professional identity construction. Acad Med 2013;88 (10):1570–7. Beagan BL. Neutralising differences: producing neutral doctors for (almost) neutral patients. Soc Sci Med 2000;51 (8): 1253–65. Duffin J. Lighting candles, making sparks and remembering not to forget. In: Wear D, ed. Women in Medical Education: An Anthology of Experience. New York, NY: State University of New York Press 1996;33–46. Lerner BH. Policing online professionalism: are we too alarmist? JAMA 2013;173 (19):1767–8. McCartney M. How much of a social media profile can doctors have? BMJ 2012;344:e440. Balick A. The Psychodynamics of Social Networking. London: Karnac 2014.
ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 48: 104–112
