ORIGINAL REPORTS
Social Media and Tomorrow's Medical Students—How Do They Fit? Niamh M. Foley, MB,* Bridget M. Maher, MB,† and Mark A. Corrigan, MD*,† Breast Research Centre, Cork University Hospital, Cork, Ireland; and †School of Medicine, University College Cork, Cork, Ireland *
OBJECTIVE: The main aim of our study was to establish
the prevalence of social networking accounts among a group of second-level students (aged 15-18 years), to determine whether they used privacy settings, and to examine their attitudes to various aspects of social media use in medicine. DESIGN: A descriptive study design was employed. The
questionnaire was constructed specifically to address the attitudes of students to social media. No similar suitable validated questionnaire could be identified. The questionnaire consisted of 20 questions with a mixture of open answer, yes/no, and Likert scale response options. PARTICIPANTS: Participation was voluntary and anony-
mous. Second-level school children interested in studying medicine and aged between 15 and 18 years took part. SETTING: An annual open day organized by the School of Medicine in University College Cork, Ireland, formed the setting. The day comprised a mixture of lectures, demonstrations, and practical sessions designed to give the students insight into life as a medical student. RESULTS: A total of 96 students attended, and all were handed the questionnaires. Of them, 88 students completed the survey. Overall, 90.9% of students had Facebook accounts and 53% had Twitter accounts. Of those with social media accounts, 14.8% reported having no privacy settings. Most respondents felt that unprofessional behavior on social media sites should be a factor considered in admission to medical schools. CONCLUSIONS: Serious consequences can result from
lapses in best practice relating to social media behavior. Dedicated reflective learning modules need to be incorporated into undergraduate and postgraduate training programs as a matter of urgency. ( J Surg 71:385-390.
Correspondence: Inquiries to Niamh M. Foley, MB, BCh, BAO, Breast Research Centre, Cork University Hospital, Wilton, Cork, Ireland; e-mail: [email protected] All authors provided equal contribution to the work. Niamh Foley contributed to manuscript preparation. Mark Corrigan and Bridget Maher contributed to manuscript preparation and approval of the final version.
2014 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)
C J
KEY WORDS: social media, internet, medical education,
professionalism COMPETENCIES: Patient Care, Professionalism, Interper-
sonal and Communication Skills, Practice-Based Learning and Improvement
INTRODUCTION In December 2012, Facebook had more than one billion active monthly users.1 Expectantly, this has also affected medicine, with the use of social media by doctors proving controversial over recent years, generating concern that it may blur the traditional boundaries between professional and personal life.2 It has recently been demonstrated that younger doctors are more likely to engage with social networking websites such as Facebook, Twitter, etc.3 and in 2008, a survey of medical students and residents at the University of Florida, Gainesville, showed that 44.5% had a Facebook account.4 Just 4 years later, a group of 410 medical students from University of Barcelona reported an 89.8% use of Facebook.5 These findings are consistent with those by Bosslet et al.6 in the United States who showed online social media use of 94% among medical students, 79.4% among residents, and 42% among practicing physicians (n ¼ 455). This doubling in Facebook use by medical students between 2008 and 2012 highlights the rapid expansion in online social media use and how this surge is amplified in the youngest group of medical professionals. In the United States, a group of first-year medical students were surveyed with regard to their attitudes and behaviors relating to social media use. The students received a 2-hour seminar on professionalism pertaining to online social media use and were given questionnaires before and after the seminar. After the seminar, 40% of students
Journal of Surgical Education & 2014 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2013.10.008
385
intended editing or changing their web presence.7 In 2009, a study published in JAMA examined the posting of unprofessional content online by medical students. Of the 78 medical schools contacted, 47 had reported incidents of students posting unprofessional content online but only 28 of 73 schools had policies concerning student-posted online content.8 Although almost all US medical schools have a Facebook presence, the majority do not have professionalism policies that explicitly address online social networking behavior.9 An editorial in the NEJM (2009) describes how a doctor “only a few weeks” into his internship, received a “friend request” from a patient on Facebook. The doctor, as a medical student, had assisted at the birth of the patient’s baby. Despite having some concerns about the request, the doctor clicked “confirm.”10 This case highlights the difficulties arising from the distinction between the personal and professional lives of doctors on the Internet and is a situation that many doctors would relate to. Integrating social media into medicine has the potential to improve patient care. However, it raises a number of ethical dilemmas, not least those surrounding the delineation between personal and professional identities. A survey performed in 2012 found that 47% of consumers would like to be able to share health-related information on a social media platform with doctors (1006 respondents),11 a percentage that will presumably rise with the ageing of current social media users and their transition into becoming our primary patient cohort. Using a descriptive study design, we examined the attitudes of school-going students, intent on becoming doctors, to the role of social media in medicine. The main aims of the project were to establish the prevalence of social networking accounts among this group, to determine whether they used privacy settings, and to examine their attitudes to various aspects of social media use in medicine.
Leaving Certificate at 17 or 18 years of age, and this forms the basis for which places in third-level institutions are allocated. The average age of direct entry into Irish medical schools is 19 years. At the end of the day-long program, the students (96) were invited to complete a questionnaire. The questionnaire was constructed specifically to address attitudes of the students to social media, and despite a review of the literature, no suitably validated questionnaire could be identified. The questionnaire consisted of 20 questions that used a mixture of open answer, yes/no, and 5-point Likert scale response options. It also contained questions on unrelated topics and as such, only the responses relating to social media use were included here. Within the questionnaire, privacy settings are understood to be the choices users make to restrict the information shared on social media platforms with other users. Participation was voluntary and anonymous. No coercion was involved in the completion of the questionnaire and students were allotted ample time to complete it. Basic demographics were recorded, along with attitudes to social media use. Data were entered into an Excel spreadsheet. Descriptive statistical analysis was employed using SPSS version 18 (IBM corporation, Somers, NY).13
METHODS
Overall, 90.9% (n ¼ 80) of students had Facebook accounts, while 53% (n ¼ 47) had Twitter accounts. Less commonly, students had Bebo, YouTube, and Tumblr accounts. A total of 14.8% (n ¼ 12) of students with social media accounts reported having no privacy settings.
University College Cork, Ireland, hosts an annual open day for second-level school children who are interested in studying medicine. The students attend a specially structured program consisting of lectures, demonstrations, and practical sessions designed to give them an insight into life as a medical student.12 The morning program is based at the school of medicine and includes clinical skills training, cardiopulmonary resuscitation, and a visit to the anatomy laboratory, and the afternoon program is based at Cork University Hospital and includes discussions on ethical issues, crime scene investigation, and the opportunity to watch real-time robotic surgery. The students in attendance this year were aged between 15 and 18 years. These students normally sit the established 386
RESULTS Demographics A total of 96 students attended the Prep-for-Med School program. Of them, 88 completed the survey, giving a response rate of 90.6%. Most students were 15 (n ¼ 23) and 16 (n ¼ 62) years of age, with two 17 year olds and one 18 year old. Overall, 92% of students intended applying to study medicine at university, and 65% of students were female. Social Media and Prospective Medical Students
Behavior on Social Media In total, 56.8% (n ¼ 50) of respondents felt that unprofessional behavior on social media sites is a factor that should be considered in admission to medical school. A total of 56 students (63.6%) believed that employers were within their rights to search social media sites for information on potential candidates. Only 9% of students (n ¼ 8) felt that it was acceptable to post comments to social media sites about colleagues or patients. Overall, 10% (n ¼ 9) of
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students thought it reasonable to post advice or results to patients on social media sites and 9% (n ¼ 8) considered accepting or inviting to friend a patient on Facebook acceptable.
DISCUSSION This survey gives an interesting perspective on the opinions of this generation of students who have been dubbed the “digital natives.”14 A group of United Kingdom medical students surveyed in 2010 (n ¼ 56) revealed that 96% had Facebook accounts, and of these, 10% had no privacy settings.15 This figure is slightly less than what we have shown. More than half of the respondents in that study reported seeing unprofessional behavior on Facebook by their colleagues. In the past 20 years, there has been significant growth and interest in defining medical professionalism and methods by which to teach professionalism to young doctors and medical students. Given that an overwhelming majority of students entering medical programs have social media accounts, it is important that we identify dedicated time to teaching students how to delineate their personal and professional online profiles and pitfalls to avoid. It is worrying that our results show 14.8% of students had no privacy settings on their accounts and that 9% deemed it permissible to accept or invite to befriend a patient on Facebook. This sort of behavior allows access by the public to students’ or doctors’ online personal information that may reflect poorly on the students or doctors concerned or the institutions they work for. A research team in New Zealand performed an analysis of 220 users of a University of Otago Facebook Group who had recently qualified as medical doctors. Of these, 138 had privacy settings enabled and so those without privacy settings formed the study group. Information from these Facebook pages was accessible by others in their University or the New Zealand network and potentially accessible to members of the wider public. The most frequent unprofessional content on the “Wall” page related to alcohol and offensive language, although only a small number of students included such content.16 Serious consequences can result from lapses in best practice relating to social media behavior. A medical student detailed how, with a single click, he almost ended his medical career before it had even started. He had published unprofessional content to an online social media site; Facebook. He subsequently had to make an appearance before the Student Promotions Committee to explain what had happened and why he should be allowed to continue with his medical studies.17 According to Bosslet,18 “social media has great potential for negative professional consequences related to lapses of professionalism and the blurring of one’s professional and personal life.”
Facebook Over recent years, some hospitals, mainly in the United States, have published individual policies relating to the appropriate use of social media and the workplace. Massachusetts General Hospital is one such hospital and in their online policy, they encourage employees to “think about your content carefully... a posting on the web lives forever.”19 A recent article in the Annals of Internal Medicine highlighted the online professionalism investigations by state medical boards in the United States. The article contained certain case vignettes such as a patient who had seen photos published online of her surgeon drinking alcohol at a hospital party. Another patient reported that images of her labor and delivery were posted without her consent on her obstetrician’s practice Web site (as educational materials for other patients).20 In 2009, a group of doctors and nurses were suspended for taking part in the “The Lying Down Game.” The game involves being photographed lying face down in unusual locations with participants trying to outdo one another. The photos are subsequently published on social media sites. The group was reported to hospital management when pictures of them lying on resuscitation trolleys, ward floors, and an ambulance helipad were spotted on Facebook. The pictures were in breach of hospital regulations, National Health Service and Trust codes of conduct. The medical director for the trust stated that the group faced disciplinary action because they expected high standards of behavior from their staff and such breaches were taken very seriously.21 Twitter and Medical Blogs Physician use of Twitter has also been questioned. A US study looked at 260 self-described physician users of Twitter and found that 3% of tweets contained unprofessional content.22 A UK anesthetist referred to a maternity unit as a “birthing shed” on Twitter and added that he would prefer working on the “cabbage patch,” denoting the Intensive Care Unit.23 These terms were challenged by GP and Cardiff University Lecturer, Dr Anne-Marie Cunningham, who wrote a blog entitled “Social media, black humor and professionalism....”24 In this blog, she cites the work of Dr Ronald Berk who wrote a commentary about the negative aspects of derogatory and cynical humor among medics and how he considers these comments a form of verbal abuse, disrespect, and dehumanization of patients and the medics making these comments.25 Unfortunately, with the advent of the Internet, inappropriate, derogatory, and cynical humor such as this that was once confined to hospital corridors is now encroaching on the very public domain of the Internet and will almost certainly have negative ramifications for the medical profession. Another study by Lagu et al.26 found that of 271 medical blogs, patients were portrayed negatively in 17.7% and that 16.6% of blogs
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contained sufficient information for patients to identify their doctors or themselves. Undergraduate health care students from a range of disciplines in the United Kingdom were asked if they thought it acceptable to disclose patientrelated information on social media sites—99% agreed that this was unprofessional; however, rather surprisingly this number dropped to 40% if personal identifying information was removed.27 Only half of those surveyed deemed it unprofessional to comment on their teachers. Only 9% (n ¼ 8) of our students thought it acceptable to post comments about colleagues or patients to social media sites if personal identifying information is removed. In the United States, some medical schools are performing online searches to investigate potential candidates.28 In our survey, almost two-thirds of students felt that it was acceptable for medical employers to do this. More than 70% of employers in the United States are currently searching social media sites, including Facebook, before hiring potential candidates, including physicians.29 In Ireland, the Health Service Executive has published a guidance policy for employees relating to the use of social media.30 The Irish Medical Council has not specifically addressed the issue of social media and professionalism, though their guide to professional conduct and ethics has a clause on confidentiality relating to Facebook. Patients are entitled to expect that information about them will be held in confidence. “You should not disclose confidential patient information to others except in certain limited circumstances.”31 In 2011, the American Medical Association attempted to address the difficulties faced by doctors in relation to the appropriate use of social media and published a set of guidelines entitled “Professionalism in the Use of Social Media.” These guidelines advise that doctors can protect their professional relationship with patients, colleagues, and others by not engaging in social relationships or connections online and keeping personal social networking accounts, blogs, and other Web content separate from professional content online.32 The General Medical Council (UK) recently published draft guidelines on the appropriate use of social media. “Social media also has risks, particularly where social and professional boundaries become unclear.” The General Medical Council recommends that doctors follow the advice in their guidelines on maintaining a professional boundary between doctors and patients.33 The BMA published guidelines in 2011 on social media use, recommending that doctors and medical students who receive friend requests from current or former patients should politely refuse and explain to the patient the reasons why it would be inappropriate for them to accept the request.34 Patel et al. raised the question of who would be best suited to mentoring medical students in aspects of online professionalism and surveyed faculty, residents, and medical students for their views. Residents in the study felt that they 388
were not prepared to mentor the medical students without additional guidance; however, they did feel more confident than faculty members that they had the prerequisite knowledge to offer advice.35 Despite the above illustrations of the pitfalls of social media, we should not malign this potentially useful tool. Medical centers worldwide are seeking to incorporate social media into their medical educational programs. Our institution has previously uploaded educational presentations to a YouTube channel.36 The VIIth Nerve is a Facebook page that enables medical students to share medical cases, educational videos, and audio.37 Several groups have looked at using social media, (mainly Facebook and Twitter) to supplement learning on clinical attachment.38 A study found that students felt more comfortable asking questions on a Facebook forum than at ward rounds or clinics.39 Two pilot studies on the use of social media in undergraduate education in Penn State College of Medicine found that, outside the classroom, Twitter and blogging applications “sustained and augmented learning conversations which ultimately made the work assignments a more dynamic experience while encouraging creativity on mediums familiar to a generation of students facile with such technology.”40 Twitter and Facebook have been used to educate fourth-year medical students at Ohio State University College of Medicine on ultrasound concepts. Most students found the information useful.41 Medical institutions need to actively embrace social media for the many advantages it has in communicating with students, without losing sight of the fact that these students can have difficulties with the blurring of boundaries online. A US taskforce, set up by the American Association of Directors of Psychiatric Training, demonstrated the teaching of online professionalism to psychiatric trainees at workshops using group-generated case vignettes.42 It is prudent to introduce medical students to online professionalism at an early stage and case vignettes would be an attractive tool to use in highlighting pitfalls. Rather than prescriptive “do’s and don’ts” and institutional policies, it may be more beneficial to cultivate students to be discerning and resourceful in dealing with the many hazards that can develop online. Initial case-based discussion groups could be followed by medical jurisprudence lectures at a later stage. Perhaps, with the growing popularity of the medium as a means of communication, there may be a role for professional online communities, facilitated by existing social media sites, where members are vetted before acceptance, for example, by providing medical council membership or medical student identification.
CONCLUSION A recent article in surgery describes how, as a society, we tend to characterize groups based on the behavior of
Journal of Surgical Education Volume 71/Number 3 May/June 2014
individuals rather than by the effort of the whole.43 It is imperative that we address the growing issues surrounding professionalism in the online world. Medical students need to have dedicated reflective learning modules addressing online behavior and medical schools need to address this as a matter of urgency. Students and trainees need to have modules built into their training schemes dedicated to the ethical issues surrounding social media and qualified doctors in clinical practice also need training and guidance on the use of social media. Farnan et al.44 suggest “education on the ramifications of posting negative material is likely a more effective approach than instituting blanket institutional policy aimed at strictly regulating trainees’ online contributions.” Further, the value of social media as an educational tool should not be overlooked by medical schools and more institutions should look toward developing adjuncts to learning on popular media such as Twitter and Facebook.
9. Kind T, Genrich G, Sodhi A, et al. Social media
policies at US medical schools. Med Educ Online. 2010;15:15. 10. Jain SH. Practicing medicine in the age of facebook.
N Engl J Med. 2009;361(7):649-651. 11. Price Waterhouse Cooper Health Research Institute. Social
media “likes” healthcare. Available at: 〈Available at: 〈http://www.pwc.com/us/en/health-industries/publica tions/health-care-social-media.jhtml/〉; 2012 Accessed 07.02.13.
12. Available at: 〈http://www.youtube.com/watch?v=7Am
84otD-6c/〉. 13. SPSS Inc. PASW statistics for Windows. Version 18.0.
Chicago: SPSS Inc. Released 2009. 14. Available at: 〈http://edition.cnn.com/2012/12/04/busi
ness/digital-native-prensky/〉. 15. Garner J, O’Sullivan H. Facebook and the professional
REFERENCES at: 〈http://newsroom.fb.com/Key-Facts/〉; 2013 Accessed 05.02.13.
1. Available
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tical and ethical guidelines on using social media; 2011. 3. Available at: 〈http://www.nejmcareercenter.org/article/94/
social-media-and-physicians/〉; 2013 Accessed 07.02.13. 4. Thompson LA, Dawson K, Ferdig R, et al. The
intersection of online social networking with medical professionalism. J Gen Intern Med. 2008;23(7): 954-957. 5. Mena G, Llupia A, Garcia-Basteiro AL, et al. The
willingness of medical students to use facebook as a training channel for professional habits: the case of influenza vaccination. Cyberpsychol Behav Soc Netw. 2012;15(6):328-331. 6. Bosslet TG, Torke AM, Hickman SE, et al. The
patient–doctor relationship and online social networks: results of a national survey. J Gen Intern Med. 2011;26 (10):1168-1174. 7. Lie D, Trial J, Schaff P, et al. Being the best we can be:
behaviours of undergraduate medical students. Clin Teach. 2010;7(2):112-115. 16. MacDonald J, Sohn S, Ellis P. Privacy, professionalism
and facebook: a dilemma for young doctors. Med Educ. 2010;44(8):805-813. 17. Strausburg M. How facebook almost ended my career
with a single click. Acad Emerg Med. 2011;18 (11):1220. 18. Bosslet GT. Commentary: the good, the bad, and the
ugly of social media. Acad Emerg Med. 2011;18(11): 1221-1222. 19. Massachusetts General Hospital. Social media guidelines
for employees. Available at: 〈http://www.massgeneral. org/notices/socialmediapolicy_employees.aspx/〉 Accessed 06.02.2013.
20. Greyson SR, Johnson D, Kind T, et al. Online
professionalism investigations by State Medical Boards: first, do no harm. Ann Intern Med. 2013;158(2): 124-130. 21. Anon. Doctors suspended after playing facebook lying
down game. Available at: 〈http://www.telegraph.co.uk/ technology/facebook/6161853/Doctors-suspended-afterplaying-Facebook-Lying-Down-Game.html/〉; 2009 Accessed 07.02.2013.
medical students’ reflections on physician responsibility in the social media era. Acad Med. 2013;88(2): 240-245.
22. Chretien KC, Azar J, Kind T. Physicians on twitter.
8. Chretien KC, Greysen SR, Chretien JP, et al. Online
23. Available at: 〈http://www.telegraph.co.uk/health/health
posting of unprofessional content by medical students. J Am Med Assoc. 2009;302(12):1309-1315.
news/8768876/Online-medics-reveal-secret-names-forpatients-and-colleagues.html/〉 Accessed 07.02.13.
J Am Med Assoc. 2011;305(6):566-568.
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at: 〈http://wishfulthinkinginmedicaleduca tion.blogspot.ie/2011/09/social-media-black-humourand.html/〉 Accessed 07.02.13.
34. British Medical Association. Using social media: practical
25. Berk R. Derogatory and cynical humour in clinical
teaching and the workplace: the need for professionalism. Med Educ. 2009;43(1):7-9.
responsible use of online social networking: who should mentor medical students. Teach Learn Med. 2012;24(4):348-354.
26. Lagu T, Kaufman EJ, Asch DA, et al. Content of
36. O’Leary DP, Corrigan MA, McHugh SM, et al. From
weblogs written by health professionals. J Gen Intern Med. 2008;23(10):1642.
theater to the world wide web—a new online era for surgical education. J Surg Educ. 2012;69(4):483-486.
27. White J, Kirwan P, Lai K, et al. Have you seen what is
37. Available at: 〈http://www.facebook.com/VIIthNerve?
24. Available
on facebook? The use of social networking software by healthcare professions students Br. Med J. 2013;3(7): e003013. 28. Schulman CL, Kuchkarian FM, Withum KF, et al.
Influence of social networking websites on medical school and residency selection process. Postgrad Med J. 2013;89(1049):126-130. 29. Goldberg S. Young Job-Seekers Hiding Their Face-
book Pages. Atlanta, GA: CNN.com; 2010. 30. Social and digital media policy and guidance for HSE
employees. Available at: 〈http://www.hse.ie/eng/staff/ Resources/socialmedia/SocialandDigitalMediaPolicy% 20and%20Guidance%20for%20HSE%20Employees. pdf/〉; 2012 Accessed 06.02.2013.
31. Irish Medical Council. Guide to Professional Conduct
and ethical guidelines on using social media; 2011. 35. Patel PD, Roberts JL, Hughes Miller K, et al. The
fref=ts/〉. 38. Doran M, Williamson S, Whitehead I. #Gasclass—
integrating the virtual and traditional classroom in anaesthesia. Available at: 〈http://www.amee.org/docu ments/AMEE%202012%20ABSTRACT%20BOOK. pdf/〉. 39. Lilis LK, Ravindran R, Kashyap M. AMEE. Facebook:
the modern day classroom for the medical student. Available at: 〈http://www.amee.org/documents/AMEE %202012%20ABSTRACT%20BOOK.pdf/〉; 2012, Abstract book. 40. George DR, Dellasega C. Use of social media in
graduate-level medical humanities education: two pilot studies from Penn State College of Medicine. Med Teach. 2011;33(8):e429-e434.
and Ethics for Registered Medical Practitioners. 7th edition 2009 Available at: 〈http://www.medicalcouncil. ie/Registration/Guide-to-Professional-Conduct-andBehaviour-for-Registered-Medical-Practitioners.pdf.
41. Bahner DP, Adkins E, Patel N, et al. How we use
32. Report of the Council on Ethical and Judicial Affairs.
Professionalism and the internet in psychiatry: what to teach and how to teach it. Acad Psychiatry. 2012;36 (5):356-362.
Professionalism in the use of social media. Available at: 〈http://www.ama-assn.org/resources/doc/code-medica l-ethics/9124a.pdf/〉 Accessed 07.02.13. 33. United Kingdom General Medical Council. Doctors’ use
of social media: a draft for consultation. Available at: Available at: 〈http://www.gmc-uk.org/Draft_explana tory_guidance___Doctors_use_of_social_media.pdf_ 48499903.pdf/〉 Accessed 07.02.13.
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relationship status of digital media and professionalism: it’s complicated. Acad Med. 2009;84(11):1479-1481.
Journal of Surgical Education Volume 71/Number 3 May/June 2014
Social Media and Tomorrow's Medical Students—How Do They Fit? Niamh M. Foley, MB,* Bridget M. Maher, MB,† and Mark A. Corrigan, MD*,† Breast Research Centre, Cork University Hospital, Cork, Ireland; and †School of Medicine, University College Cork, Cork, Ireland *
OBJECTIVE: The main aim of our study was to establish
the prevalence of social networking accounts among a group of second-level students (aged 15-18 years), to determine whether they used privacy settings, and to examine their attitudes to various aspects of social media use in medicine. DESIGN: A descriptive study design was employed. The
questionnaire was constructed specifically to address the attitudes of students to social media. No similar suitable validated questionnaire could be identified. The questionnaire consisted of 20 questions with a mixture of open answer, yes/no, and Likert scale response options. PARTICIPANTS: Participation was voluntary and anony-
mous. Second-level school children interested in studying medicine and aged between 15 and 18 years took part. SETTING: An annual open day organized by the School of Medicine in University College Cork, Ireland, formed the setting. The day comprised a mixture of lectures, demonstrations, and practical sessions designed to give the students insight into life as a medical student. RESULTS: A total of 96 students attended, and all were handed the questionnaires. Of them, 88 students completed the survey. Overall, 90.9% of students had Facebook accounts and 53% had Twitter accounts. Of those with social media accounts, 14.8% reported having no privacy settings. Most respondents felt that unprofessional behavior on social media sites should be a factor considered in admission to medical schools. CONCLUSIONS: Serious consequences can result from
lapses in best practice relating to social media behavior. Dedicated reflective learning modules need to be incorporated into undergraduate and postgraduate training programs as a matter of urgency. ( J Surg 71:385-390.
Correspondence: Inquiries to Niamh M. Foley, MB, BCh, BAO, Breast Research Centre, Cork University Hospital, Wilton, Cork, Ireland; e-mail: [email protected] All authors provided equal contribution to the work. Niamh Foley contributed to manuscript preparation. Mark Corrigan and Bridget Maher contributed to manuscript preparation and approval of the final version.
2014 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)
C J
KEY WORDS: social media, internet, medical education,
professionalism COMPETENCIES: Patient Care, Professionalism, Interper-
sonal and Communication Skills, Practice-Based Learning and Improvement
INTRODUCTION In December 2012, Facebook had more than one billion active monthly users.1 Expectantly, this has also affected medicine, with the use of social media by doctors proving controversial over recent years, generating concern that it may blur the traditional boundaries between professional and personal life.2 It has recently been demonstrated that younger doctors are more likely to engage with social networking websites such as Facebook, Twitter, etc.3 and in 2008, a survey of medical students and residents at the University of Florida, Gainesville, showed that 44.5% had a Facebook account.4 Just 4 years later, a group of 410 medical students from University of Barcelona reported an 89.8% use of Facebook.5 These findings are consistent with those by Bosslet et al.6 in the United States who showed online social media use of 94% among medical students, 79.4% among residents, and 42% among practicing physicians (n ¼ 455). This doubling in Facebook use by medical students between 2008 and 2012 highlights the rapid expansion in online social media use and how this surge is amplified in the youngest group of medical professionals. In the United States, a group of first-year medical students were surveyed with regard to their attitudes and behaviors relating to social media use. The students received a 2-hour seminar on professionalism pertaining to online social media use and were given questionnaires before and after the seminar. After the seminar, 40% of students
Journal of Surgical Education & 2014 Association of Program Directors in Surgery. Published by 1931-7204/$30.00 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2013.10.008
385
intended editing or changing their web presence.7 In 2009, a study published in JAMA examined the posting of unprofessional content online by medical students. Of the 78 medical schools contacted, 47 had reported incidents of students posting unprofessional content online but only 28 of 73 schools had policies concerning student-posted online content.8 Although almost all US medical schools have a Facebook presence, the majority do not have professionalism policies that explicitly address online social networking behavior.9 An editorial in the NEJM (2009) describes how a doctor “only a few weeks” into his internship, received a “friend request” from a patient on Facebook. The doctor, as a medical student, had assisted at the birth of the patient’s baby. Despite having some concerns about the request, the doctor clicked “confirm.”10 This case highlights the difficulties arising from the distinction between the personal and professional lives of doctors on the Internet and is a situation that many doctors would relate to. Integrating social media into medicine has the potential to improve patient care. However, it raises a number of ethical dilemmas, not least those surrounding the delineation between personal and professional identities. A survey performed in 2012 found that 47% of consumers would like to be able to share health-related information on a social media platform with doctors (1006 respondents),11 a percentage that will presumably rise with the ageing of current social media users and their transition into becoming our primary patient cohort. Using a descriptive study design, we examined the attitudes of school-going students, intent on becoming doctors, to the role of social media in medicine. The main aims of the project were to establish the prevalence of social networking accounts among this group, to determine whether they used privacy settings, and to examine their attitudes to various aspects of social media use in medicine.
Leaving Certificate at 17 or 18 years of age, and this forms the basis for which places in third-level institutions are allocated. The average age of direct entry into Irish medical schools is 19 years. At the end of the day-long program, the students (96) were invited to complete a questionnaire. The questionnaire was constructed specifically to address attitudes of the students to social media, and despite a review of the literature, no suitably validated questionnaire could be identified. The questionnaire consisted of 20 questions that used a mixture of open answer, yes/no, and 5-point Likert scale response options. It also contained questions on unrelated topics and as such, only the responses relating to social media use were included here. Within the questionnaire, privacy settings are understood to be the choices users make to restrict the information shared on social media platforms with other users. Participation was voluntary and anonymous. No coercion was involved in the completion of the questionnaire and students were allotted ample time to complete it. Basic demographics were recorded, along with attitudes to social media use. Data were entered into an Excel spreadsheet. Descriptive statistical analysis was employed using SPSS version 18 (IBM corporation, Somers, NY).13
METHODS
Overall, 90.9% (n ¼ 80) of students had Facebook accounts, while 53% (n ¼ 47) had Twitter accounts. Less commonly, students had Bebo, YouTube, and Tumblr accounts. A total of 14.8% (n ¼ 12) of students with social media accounts reported having no privacy settings.
University College Cork, Ireland, hosts an annual open day for second-level school children who are interested in studying medicine. The students attend a specially structured program consisting of lectures, demonstrations, and practical sessions designed to give them an insight into life as a medical student.12 The morning program is based at the school of medicine and includes clinical skills training, cardiopulmonary resuscitation, and a visit to the anatomy laboratory, and the afternoon program is based at Cork University Hospital and includes discussions on ethical issues, crime scene investigation, and the opportunity to watch real-time robotic surgery. The students in attendance this year were aged between 15 and 18 years. These students normally sit the established 386
RESULTS Demographics A total of 96 students attended the Prep-for-Med School program. Of them, 88 completed the survey, giving a response rate of 90.6%. Most students were 15 (n ¼ 23) and 16 (n ¼ 62) years of age, with two 17 year olds and one 18 year old. Overall, 92% of students intended applying to study medicine at university, and 65% of students were female. Social Media and Prospective Medical Students
Behavior on Social Media In total, 56.8% (n ¼ 50) of respondents felt that unprofessional behavior on social media sites is a factor that should be considered in admission to medical school. A total of 56 students (63.6%) believed that employers were within their rights to search social media sites for information on potential candidates. Only 9% of students (n ¼ 8) felt that it was acceptable to post comments to social media sites about colleagues or patients. Overall, 10% (n ¼ 9) of
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students thought it reasonable to post advice or results to patients on social media sites and 9% (n ¼ 8) considered accepting or inviting to friend a patient on Facebook acceptable.
DISCUSSION This survey gives an interesting perspective on the opinions of this generation of students who have been dubbed the “digital natives.”14 A group of United Kingdom medical students surveyed in 2010 (n ¼ 56) revealed that 96% had Facebook accounts, and of these, 10% had no privacy settings.15 This figure is slightly less than what we have shown. More than half of the respondents in that study reported seeing unprofessional behavior on Facebook by their colleagues. In the past 20 years, there has been significant growth and interest in defining medical professionalism and methods by which to teach professionalism to young doctors and medical students. Given that an overwhelming majority of students entering medical programs have social media accounts, it is important that we identify dedicated time to teaching students how to delineate their personal and professional online profiles and pitfalls to avoid. It is worrying that our results show 14.8% of students had no privacy settings on their accounts and that 9% deemed it permissible to accept or invite to befriend a patient on Facebook. This sort of behavior allows access by the public to students’ or doctors’ online personal information that may reflect poorly on the students or doctors concerned or the institutions they work for. A research team in New Zealand performed an analysis of 220 users of a University of Otago Facebook Group who had recently qualified as medical doctors. Of these, 138 had privacy settings enabled and so those without privacy settings formed the study group. Information from these Facebook pages was accessible by others in their University or the New Zealand network and potentially accessible to members of the wider public. The most frequent unprofessional content on the “Wall” page related to alcohol and offensive language, although only a small number of students included such content.16 Serious consequences can result from lapses in best practice relating to social media behavior. A medical student detailed how, with a single click, he almost ended his medical career before it had even started. He had published unprofessional content to an online social media site; Facebook. He subsequently had to make an appearance before the Student Promotions Committee to explain what had happened and why he should be allowed to continue with his medical studies.17 According to Bosslet,18 “social media has great potential for negative professional consequences related to lapses of professionalism and the blurring of one’s professional and personal life.”
Facebook Over recent years, some hospitals, mainly in the United States, have published individual policies relating to the appropriate use of social media and the workplace. Massachusetts General Hospital is one such hospital and in their online policy, they encourage employees to “think about your content carefully... a posting on the web lives forever.”19 A recent article in the Annals of Internal Medicine highlighted the online professionalism investigations by state medical boards in the United States. The article contained certain case vignettes such as a patient who had seen photos published online of her surgeon drinking alcohol at a hospital party. Another patient reported that images of her labor and delivery were posted without her consent on her obstetrician’s practice Web site (as educational materials for other patients).20 In 2009, a group of doctors and nurses were suspended for taking part in the “The Lying Down Game.” The game involves being photographed lying face down in unusual locations with participants trying to outdo one another. The photos are subsequently published on social media sites. The group was reported to hospital management when pictures of them lying on resuscitation trolleys, ward floors, and an ambulance helipad were spotted on Facebook. The pictures were in breach of hospital regulations, National Health Service and Trust codes of conduct. The medical director for the trust stated that the group faced disciplinary action because they expected high standards of behavior from their staff and such breaches were taken very seriously.21 Twitter and Medical Blogs Physician use of Twitter has also been questioned. A US study looked at 260 self-described physician users of Twitter and found that 3% of tweets contained unprofessional content.22 A UK anesthetist referred to a maternity unit as a “birthing shed” on Twitter and added that he would prefer working on the “cabbage patch,” denoting the Intensive Care Unit.23 These terms were challenged by GP and Cardiff University Lecturer, Dr Anne-Marie Cunningham, who wrote a blog entitled “Social media, black humor and professionalism....”24 In this blog, she cites the work of Dr Ronald Berk who wrote a commentary about the negative aspects of derogatory and cynical humor among medics and how he considers these comments a form of verbal abuse, disrespect, and dehumanization of patients and the medics making these comments.25 Unfortunately, with the advent of the Internet, inappropriate, derogatory, and cynical humor such as this that was once confined to hospital corridors is now encroaching on the very public domain of the Internet and will almost certainly have negative ramifications for the medical profession. Another study by Lagu et al.26 found that of 271 medical blogs, patients were portrayed negatively in 17.7% and that 16.6% of blogs
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contained sufficient information for patients to identify their doctors or themselves. Undergraduate health care students from a range of disciplines in the United Kingdom were asked if they thought it acceptable to disclose patientrelated information on social media sites—99% agreed that this was unprofessional; however, rather surprisingly this number dropped to 40% if personal identifying information was removed.27 Only half of those surveyed deemed it unprofessional to comment on their teachers. Only 9% (n ¼ 8) of our students thought it acceptable to post comments about colleagues or patients to social media sites if personal identifying information is removed. In the United States, some medical schools are performing online searches to investigate potential candidates.28 In our survey, almost two-thirds of students felt that it was acceptable for medical employers to do this. More than 70% of employers in the United States are currently searching social media sites, including Facebook, before hiring potential candidates, including physicians.29 In Ireland, the Health Service Executive has published a guidance policy for employees relating to the use of social media.30 The Irish Medical Council has not specifically addressed the issue of social media and professionalism, though their guide to professional conduct and ethics has a clause on confidentiality relating to Facebook. Patients are entitled to expect that information about them will be held in confidence. “You should not disclose confidential patient information to others except in certain limited circumstances.”31 In 2011, the American Medical Association attempted to address the difficulties faced by doctors in relation to the appropriate use of social media and published a set of guidelines entitled “Professionalism in the Use of Social Media.” These guidelines advise that doctors can protect their professional relationship with patients, colleagues, and others by not engaging in social relationships or connections online and keeping personal social networking accounts, blogs, and other Web content separate from professional content online.32 The General Medical Council (UK) recently published draft guidelines on the appropriate use of social media. “Social media also has risks, particularly where social and professional boundaries become unclear.” The General Medical Council recommends that doctors follow the advice in their guidelines on maintaining a professional boundary between doctors and patients.33 The BMA published guidelines in 2011 on social media use, recommending that doctors and medical students who receive friend requests from current or former patients should politely refuse and explain to the patient the reasons why it would be inappropriate for them to accept the request.34 Patel et al. raised the question of who would be best suited to mentoring medical students in aspects of online professionalism and surveyed faculty, residents, and medical students for their views. Residents in the study felt that they 388
were not prepared to mentor the medical students without additional guidance; however, they did feel more confident than faculty members that they had the prerequisite knowledge to offer advice.35 Despite the above illustrations of the pitfalls of social media, we should not malign this potentially useful tool. Medical centers worldwide are seeking to incorporate social media into their medical educational programs. Our institution has previously uploaded educational presentations to a YouTube channel.36 The VIIth Nerve is a Facebook page that enables medical students to share medical cases, educational videos, and audio.37 Several groups have looked at using social media, (mainly Facebook and Twitter) to supplement learning on clinical attachment.38 A study found that students felt more comfortable asking questions on a Facebook forum than at ward rounds or clinics.39 Two pilot studies on the use of social media in undergraduate education in Penn State College of Medicine found that, outside the classroom, Twitter and blogging applications “sustained and augmented learning conversations which ultimately made the work assignments a more dynamic experience while encouraging creativity on mediums familiar to a generation of students facile with such technology.”40 Twitter and Facebook have been used to educate fourth-year medical students at Ohio State University College of Medicine on ultrasound concepts. Most students found the information useful.41 Medical institutions need to actively embrace social media for the many advantages it has in communicating with students, without losing sight of the fact that these students can have difficulties with the blurring of boundaries online. A US taskforce, set up by the American Association of Directors of Psychiatric Training, demonstrated the teaching of online professionalism to psychiatric trainees at workshops using group-generated case vignettes.42 It is prudent to introduce medical students to online professionalism at an early stage and case vignettes would be an attractive tool to use in highlighting pitfalls. Rather than prescriptive “do’s and don’ts” and institutional policies, it may be more beneficial to cultivate students to be discerning and resourceful in dealing with the many hazards that can develop online. Initial case-based discussion groups could be followed by medical jurisprudence lectures at a later stage. Perhaps, with the growing popularity of the medium as a means of communication, there may be a role for professional online communities, facilitated by existing social media sites, where members are vetted before acceptance, for example, by providing medical council membership or medical student identification.
CONCLUSION A recent article in surgery describes how, as a society, we tend to characterize groups based on the behavior of
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individuals rather than by the effort of the whole.43 It is imperative that we address the growing issues surrounding professionalism in the online world. Medical students need to have dedicated reflective learning modules addressing online behavior and medical schools need to address this as a matter of urgency. Students and trainees need to have modules built into their training schemes dedicated to the ethical issues surrounding social media and qualified doctors in clinical practice also need training and guidance on the use of social media. Farnan et al.44 suggest “education on the ramifications of posting negative material is likely a more effective approach than instituting blanket institutional policy aimed at strictly regulating trainees’ online contributions.” Further, the value of social media as an educational tool should not be overlooked by medical schools and more institutions should look toward developing adjuncts to learning on popular media such as Twitter and Facebook.
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