The rise of social media—content created by Internet users and hosted by popular sites such as Facebook, Twitter, YouTube, and Wikipedia, and blogs—has brought several new hazards for medical professionalism. First, many physicians may find applying principles for medical professionalism to the online environment challenging in certain contexts. Second, physicians may not consider the potential impact of their online content on their patients and the public. Third, a momentary lapse in judgment by an individual physician to create unprofessional content online can reflect poorly on the entire profession. To overcome these challenges, we encourage individual physicians to realize that as they “tread” through the World Wide Web, they leave behind a “footprint” that may have unintended negative consequences for them and for the profession at large. We also recommend that institutions take a proactive approach to engage users of social media in setting consensus-based standards for “online professionalism.” Finally, given that professionalism encompasses more than the avoidance of negative behaviors, we conclude with examples of more positive applications for this technology. Much like a mirror, social media can reflect the best and worst aspects of the content placed before it for all to see.
KEY WORDS: professionalism, internet use, medical ethics, health policyGo to:INTRODUCTION
The Internet has changed many interactions between professionals and the public. The recent development of Web 2.0 applications (also known as “social media”) has created particular hazards for public views of certain professions. School teachers1 and lawyers2 across the country have been sanctioned or fired for online indiscretions felt to violate societal expectations for how they represent their personal lives in the public sphere. Recently, similar incidents have also involved physicians. In one instance, physicians and other health professionals delivering aid in Haiti posted pictures online of naked and unconscious patients in operating suites, and of physicians drinking or posing with grins and “thumbs up” in front of patients or coffins.3 While it is tempting to view such incidents as rare events, recent research has shown that posting of unprofessional content is common among medical students, residents, and other health care providers.4–6 In many cases, users of social media may simply fail to consider issues of professionalism in their online actions and may, in fact, routinely display exemplary ethics and character in their offline actions. As a case in point, the professionals cited above exemplified principles of altruism and social justice through their volunteer work in Haiti and were ultimately exonerated by licensing authorities.7 Still, damage to public perceptions of the medical aid effort was already done. Rather than blaming the technology or vilifying the user, we believe this example underscores the need for improved education and communication about the use of social media by professionals.8,9
Go to:ONLINE ACTIVITY, MEDICAL PROFESSIONALISM, AND THE PUBLIC
Although principles and commitments for medical professionalism already exist,10 we believe that many physicians may have difficulty applying these principals to their online actions for at least three reasons. First, some of the online content that has been identified as unprofessional in both the medical literature and mass media may not clearly violate existing principles of medical professionalism. For example, some physicians may not realize that images of off-duty drinking on a social networking site may raise questions from the public about unprofessional behavior, especially if intoxication is implied. A second and related concern is that many people experience a sense of disinhibition in their online actions. Social media in particular can create a perception of anonymity and detachment from social cues and consequences for online actions.11 Thus, medical professionals may say or do things they would not say or do in person, such as disclosure of confidential information (including pictures of patients), or display speech and behaviors that are disrespectful to colleagues or patients and their families. Third, the potential impact of such indiscretions is much greater than typical face-to-face interactions because of the wide reach of this media. While physicians must always be vigilant to avoid violating patient confidentiality, a slip made online can have far greater impact than one made over lunch with a colleague.
Regrettably, social media can enable content posted in a momentary lapse in judgment to spread rapidly beyond the intended audience with a simple “click.” In this sense, social media can act as a mirror reflecting intimate thoughts and behaviors back to oneself as well as to others around the world. For an increasingly Internet-savvy public, “images” reflected by this social media mirror may prove very important in sizing up not only the credentials, but also the character of professionals. Moreover, when amplified by press coverage, unprofessional images of professionals in the social media mirror may also be magnified or distorted as in the case of the physicians providing aid in Haiti.
While rigorous studies on patient perceptions of physicians’ social media use are lacking, recent media coverage of the topic12 and online reader responses, such as the following, are illuminating: “Medicine is a very serious profession…[but] teetering on the edge of respectability and trust in some areas. Soon there will be so little trust that it will undermine the respectable people who have chosen this profession.”13 Other readers posted similar comments, “Anybody who isn’t smart enough to figure out what’s OK to post on the Internet has absolutely no business being in charge of other people’s health,” and “As professionals, doctors, teachers, lawyers, etc., are held to a certain standard. If that’s not your cup of tea, find a different job.” These comments suggest that some may view a physician’s online activity as a proxy for the common sense and trustworthiness needed to handle the responsibilities of patient care. Moreover, when technology such as social media has the ability to alter ways in which physicians can interact with individual patients and the public at large, physicians must reconsider the implications of their professional commitments.14 While it may not be necessary to expand the existing framework for professionalism, physicians should at least consider the issues raised by social media and make informed decisions for themselves, or in collaboration with colleagues or superiors, to decide what is appropriate and inappropriate for their group, institution, or workplace as they represent themselves in a new web where user-generated content abounds.
Go to:SUGGESTIONS FOR INDIVIDUALS AND INSTITUTIONS
To illustrate the impact of an individual’s online actions, the Pew Internet and American Life Project has advanced the idea that each Internet user creates a “digital footprint.”15 This concept encourages individuals to think of downstream consequences for each online action they take and become aware that as they “tread” through the World Wide Web, they leave behind a “footprint.” This footprint is visible to others and may have unintended negative consequences, such as diminishing one’s chances to obtain a desired training position or job. But beyond the self-interested rationale for monitoring online activity to protect themselves, physicians also have a duty to consider the broader impact of their “digital footprint” and how their online actions reflect on the profession at large—much in the way that the concept of a “carbon footprint” invokes the greater cause of environmentalism. Thus, the concept of “think globally, act locally” applies to physician behavior online in the same way it applies to human behavior in relation to the environment; each individual physician should develop a greater consciousness of the potential impact of their online actions for the entire profession.
Beyond the role of individuals, institutions have an important role to play in defining and exemplifying what might be called “online professionalism.” As yet, there are no widely accepted guidelines to assist individuals and institutions in navigating challenges and opportunities for medical professionalism while online. Even medical schools, which oversee the youngest members of the profession and the most frequent users of social media, have not universally formed policies specifically addressing this issue.4 Accordingly, we suggest that institutions—from medical schools and residencies to hospitals and group practices—should take a proactive stance in setting guidelines and standards for their members. We propose that institutional standards for “online professionalism” utilize valuable concepts such as the digital footprint and emphasize the power of social media to reflect professional values to the public. We also believe that the best way to develop institutional concepts for online professionalism is to engage various users of these technologies in a consensus-oriented dialogue that involves students, patients, educators, clinicians, and administrators. Such dialogue, especially if it is sustained over time, also has the potential to reduce the number of problems arising from the use of social media by virtue of the shared educational impact of discussing the standards for online professionalism that are agreeable to all parties involved. Indeed, emerging research with medical students and residents suggests that most feel responsibility to represent themselves professionally online, and while they oppose strict regulation of their online behavior, increased dialogue and guidance is welcomed.16,17
Go to:THE POWER OF SOCIAL MEDIA TO PROMOTE MEDICAL PROFESSIONALISM
Problematic uses of social media by physicians have garnered a great deal of public attention to date. Yet an equally important challenge for medical professionals is to use the mirror of social media positively. For example, respectful clinical narratives written by medical students that avoid disclosing any personally identifiable information about patients can promote understanding, reflection, and greater appreciation of the patient-physician relationship.18,19 Students have also used social media to improve patient safety by promoting the World Health Organization’s Surgical Checklist.20 Practicing physicians can use social networking and other Web 2.0 tools to share sound medical information and help the public interpret medical studies, thereby becoming sources of credible medical information on the Internet. Some have even argued that maintaining an online presence that is accessible and useful to patients is a must for physicians.21 Indeed, a compelling case for quality improvement through better communication via social media can be made,22 and medical professionalism encompasses a commitment to quality improvement.10 An increasing number of public health organizations, hospitals, and medical centers are using social networking applications to provide medical information to the public.23 Collectively, these interactions can serve as a counter-balance to less trustworthy sources of information as the public increasingly turns to the Internet to find health information.
If social media is a mirror, what kind of reflections does the public see of physicians? While many Internet sites offer ratings of physicians,24 and it is believed that patients already search the Internet for information about their physicians frequently,25 we do not yet know the net impact of positive and negative online behaviors on the public’s overall view of physicians’ professional values. Certainly, the principle of “first, do no harm” should apply to physicians’ use of social media, but we can do better. Just as we must look beyond harm reduction towards health promotion in clinical practice, we must go farther than curtailing unprofessional behavior online and embrace the positive potential for social media: physicians and health care organizations can and should utilize the power of social media to facilitate interactions with patients and the public that increase their confidence in the medical profession. If we fail to engage this technology constructively, we will lose an important opportunity to expand the application of medical professionalism within contemporary society. Moreover, a proactive approach on the part of physicians may strengthen our patients’ understanding of medical professionalism and provide an example of “online professionalism” for other professions to consider.
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