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By Neil Graham, medical student, University College London andIncreasing numbers of doctors and medical students are turning to websites such as Facebook to make friends, chat, and organise social events. These innovations have made some aspects of life easier and are a powerful tool for communication, but they also blur the line between our personal and professional personas. With the veneer of friendship that’s offered on these sites, it’s all too easy to reveal more information than is appropriate. If this information falls into the wrong hands, problems can arise about your integrity, employment, and fitness to practise medicine.
In a recent study in the Journal of General Internal Medicine, the Facebook profiles of a group of medical students in Florida were scrutinised with the aim of establishing how dangerous Facebook could be in the intersection of personal and professional identities. The study found some profiles publicly displaying photographs of trainee medics drinking to excess, engaging in sexual behaviour, and, in one instance, posing with a dead racoon. Three of the 10 students in the sample had also joined groups on Facebook that could be interpreted as sexist or racist.
Whether the private activities of a medical professional have an impact on their ability to practise is debatable, but it cannot be denied that putting private material in such a public arena has the potential to undermine trust in the profession.
Online social networking in the medical community is a worldwide phenomenon and one that is no longer the sole domain of medical students (Box 1). With 90 million active users around the world, it’s a fairly safe bet that your colleagues and boss are on there, not to mention many of your patients. You don’t need a degree in computer science to go online and see who is using this technology.
Box 1. What is Online Social Networking?| These websites offer a virtual space where people can share information and communicate with other people. This is usually in the form of a personal “profile,” elements of which other people, “friends,” can see. |
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Many students now rely on this technology for organising social activities and keeping up with their friends. “Without it you wouldn’t know what was going on,” said a student at St George’s Medical School, London. Students are using these networking tools to show their support for causes, exchange answers to exam questions, and disseminate course notes, in addition to sharing the mandatory photos of alcohol fuelled antics. In a remarkably diligent act of altruism, a group of medical students (“podmedics”) have even taken to recording and sharing their notes as audio files for others to download and enjoy on the road.
Junior doctors are making time for the technology too, with most UK schools boasting groups with a few hundred members. In a quick survey, 36 regional groups of trainee general practitioners were found, and these are often open to all to observe, interact with, and market to. “Protect general practice” groups had 5,000 members from diverse clinical and non-clinical backgrounds, including some of the few specialist registrars making use of the technology. In addition, a small but active group of tech savvy senior professionals use Facebook to upload videos of endoscopy cases and discuss them with small groups of colleagues.
Medicopolitics thrives in this environment. More than 10,000 individuals took action through Facebook to show opposition to recent changes in the provision of hospital accommodation for young doctors in the United Kingdom, while others weighed in to the debate about medical education. More diverse groups such as “The NHS is sucking my soul dry” and “I am a doctor and I hope my patients don’t see me on Facebook” are also popular, though much to the disappointment of its 5,700 members the latter was recently closed down. Perhaps a patient found it.
The General Medical Council guidance from Good Medical Practicehasn’t changed—”You must make sure that your conduct at all times justifies your patients’ trust in you and the public’s trust in the profession” —but it’s undeniable that the advent of online social networking has increased the chances of being caught acting disreputably.
One of the problems arising is how we choose to define a friend online. If one’s personal profile—detailing hobbies, groups, interests, photos, and videos—were available only to true friends, there would be little cause for concern. But the online environment breeds a false sense of security, where online friendships are often formed with little thought for the possible consequences. Michael Anderson, one of the growing ranks of junior doctors in the United Kingdom keeping a blog, was recently added by a patient, and though he was touched by the sentiment, he decided that his privacy would be compromised if he accepted.
Notably, the profiles of two thirds of the medical students in the Florida study were available to Facebook users not listed as friends. This may have been a conscious decision in some cases, but more likely it reflects a widespread ignorance of the enhanced privacy settings that are available. This is hardly surprising, given that website providers, in their efforts to reassure nervous users, have produced a multitude of confusing options. There are no prizes for guessing that the default situation is to share information with users and advertisers alike.
Aside from the risk of identity theft (two in five Facebook profiles reveal information that can be used to set up bank accounts and so on), it is the professional implications that are of greatest concern to the medical community. Recently the Highland Deanery suspended a trainee in general surgery for “scatological” comments made about a senior medical colleague in an online discussion, which was seen by a concerned friend who felt duty bound to take action.
A senior tutor at the University of Cambridge admitted to viewing applicants’ Facebook profiles out of curiosity during the admission process. Although he maintained that this had no bearing on his decisions, one wonders what he may have thought had Amy Polumbo applied to Emmanuel College that year. Ms Polumbo, Miss New Jersey 2007, was thrust into the public eye last year when her title dangled perilously in the balance after lewd images from her Facebook profile surfaced in the national press.
“The cost to a person’s future can be high if something undesirable is found by the increasing number of education institutions and employers using the internet as a tool to vet potential students or employees,” says David Smith, for the Information Commissioner’s Office, in relation to recent UK governmental guidance on online social networking.
To some extent the medical regulators are playing catch-up with the advances in social networking, but guidance is available and it’s well worth observing in your online activities.
The American Medical Association advises doctors to “recognise that your personal conduct may affect your reputation and that of your profession,” and a spokesperson for the General Medical Council made it clear that regulators appreciate the need for balance. “Medical students and doctors are entitled to a private life, and to use their time away from studying and work as they wish [they] should consider whether the images of what was fun at the time could cause embarrassment if they were accessed by patients, or the public, later. In extreme cases such images could lead to a complaint being made.”
The fact is that doctors and would be doctors are held to higher standards of personal conduct than other groups in society. Saintly behaviour is neither demanded nor expected, but with the job there comes an expectation of a reasonable level of common sense and decency. It is possible to protect one’s personal and professional reputation while enjoying positive interactions with patients and colleagues outside the professional arena.
With the potential for such difficulties you might wonder about the rightful place in our lives for this technology. It is no doubt here to stay, but it doesn’t have to be a minefield of ethics or mistrust. With a little care and attention (Box 2), online social networking has the potential to make life a good deal easier for medics: to connect us with our friends and colleagues, facilitate learning and communication, arrange events, and share our knowledge with the wider world. You could even join the General Medical Council’s Facebook group and continue the discussion there, but bear in mind that when you’re online, you’re anything but off duty.
| Short of severing your electronic umbilical cord and suspending yourself in a box over the Thames, is there any way of using services without jeopardising your privacy or integrity? |
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Recognizing the need for clinicians to debrief/vent in appropriate contexts, the Australian College of Critical Care Nurses recommends discussion of appropriate methods with trainees with the recognition of the absolute permanence of electronic communications. The organization also recommends that institutions develop and publish clear institutional criteria for dismissible offenses.
The 2011 summer issue of the Journal of Clinical Ethics focused its attention on the American Medical Association’s (AMA’s) Council on Ethical and Judicial Affairs (CEJA) recent report on social media and the medical profession. The CEJA report was prepared in response to Policy D-478.985, Physicians and Electronic Social Networking, which was a request from the Medical Students Section that asked the AMA to address the issue of online professionalism. The report recognizes that use of social media can provide benefits, such as an online professional presence, and allows collegial support, fostering of positive relationships, and sharing of views in the public health interest. However, the report also urges physicians to honor the social contract expected of them. The underpinning of the recommendations for physician use of social media is derived from the AMA Code of Medical Ethics, which emphasizes that physicians in positions that do not directly involve patient care should not suspend their ethical obligations.
The 2011 AMA guidelines for the use of social media provide a compass for physicians’ online presence. They urge physicians to:
Similar recommendations have been previously endorsed or suggested by others from disciplines that include surgery, psychiatry, internal medicine, and pediatrics.
A number of practical suggestions for the social networking savvy professional can be found in the multitude of articles on this topic available in the literature. Some include:
The majority of current expert opinion advises caution in the use of social media, emphasizing that the risks of interacting with patients in online social forums may outweigh potential benefits. In fact, some contend that absolute separation of personal and professional life is virtually impossible and recommend only a professional presence online.
Next: Back to the Cases
Consider the following situations:
These situations raise some key questions. Can physicians, nurses, pharmacists, and other healthcare professionals separate their personal and professional identities online? What are the duties of healthcare providers to maintain the integrity and status of their respective professions when it comes to other clinicians’ use of social media?
Online social networks are locations on the Internet where one can create a personal profile and connect to others to create a personal network, among the most popular of which are Facebook, Twitter,Friendster, and LinkedIn. Other tools that permit interaction and spread of information include blogs, wikis, and file-sharing sites. Examples of some healthcare-seeking sites used by patients include Medhelp and DailyStrength. Physician rating sites such as123people use a meta search engine to categorize findings from publicly available records and sites (such as licensing agencies and property tax records) into information clusters that include email addresses, phone numbers, and social network profiles. The use of such networks and sites has exploded in recent years to include a substantial proportion of patients and practicing clinicians.
A recent study of physician use of Twitter examined the self-identified profiles of 260 physician users and reported that 30% posted 20 tweets within 1 day or less. An analysis found that 3% of tweets were unprofessional; 0.7% violated patient privacy, 0.6% contained profanities, 0.3% included sexually explicit material, and 0.1% included discriminatory statements. The public profiles posted by physicians in this study included their names in 78% of cases, a photograph of themselves in 78%, and a link to a Website in 92% of cases.
A national, randomly stratified survey conducted earlier in 2011 found that 93.5% of medical students, 79.4% of residents, and 41.6% of practicing physicians used online social networks. Practicing physicians were most likely among the 3 groups to have visited the profile of a patient or their family member (15.5%). However, a sizeable majority of respondents, 68.3%, indicated that interacting socially with patients was unethical. The survey also found that patient-doctor interactions within social networks were typically initiated by patients.
A 2009 survey conducted in France found that 73% of residents and fellows had Facebook profiles, with over 90% displaying real names, birth dates, and personal photographs. Among the respondents, 85% reported that they would automatically decline a request by a patient to “friend” them and 15% would decide on an individual basis. Moreover, 76% believed that the patient-doctor relationship would be altered by patients having open access to their doctor’s Facebook page.
Landman and colleagues reported that 64% of residents and 22% of faculty in surgical specialties at 1 institution had Facebook accounts, of which half were publicly accessible. A cross-sectional study conducted in New Zealand of 338 recent medical school graduates revealed that 63% had active Facebook accounts. While a majority, 63%, had activated privacy options, among those with publicly available information, 37% revealed the user’s sexual orientation, 16% noted religious views, and 43% indicated their relationship status. Almost equal numbers displayed photographs of themselves using alcohol (46%) as included photographs of themselves demonstrating healthy behaviors (45%).
One university in the United States reported 44.5% of residents and medical students using Facebook, with over three quarters including at least 1 personally identifiable piece of information and only a third availing themselves of privacy settings.A significant proportion showed potentially unprofessional behaviors (photographs of intoxication, overt sexuality, and foul language). A 2009 survey of deans at US medical schools found that 60% had experienced incidents of students posting unprofessional content and 13% had found violations of patient confidentiality occurring as a result of online postings by students within the past year.
The Downside to Social Media; Professional Associations Respond; and Back to the Cases.
Last week’s horrific London riots have been blamed on everything from solar flares to incredibly good design, but one contributing factor has been villainized above all others: social media.
The Daily Mail ran the headline, “Rioting thugs used Twitter to boost their numbers in thieving store,” and police officials and members of parliament called for a suspension of BlackBerry Messenger service.
But the riots seem to be the iceberg’s tip of social media unrest this week. In the U.S., Twitter-organized flash mobs have been descending on convenience stores and department stores, allowing dozens of congregating vandals to loot goods and then leave, shielded by the anonymity of a crowd. Such mobs have been reportedin D.C., Philadelphia, Cleveland, Los Angeles and elsewhere. In one case in April, a “gang incited” Twitter mob trashed Venice Beach shops and left a man shot.
Twitter also facilitated what was essentially a denial of service attack on the Compton Sheriff’s station phones on Friday. Rapper “The Game” tweeted the police station’s phone number to his 580,000 followers saying they should call to apply for a music industry internship. As a result, police phone lines were tied up for several hours, affecting 911 service. The rapper may now be facing charges.
Back in the U.K., police are beginning to crack down. On Friday, Essex police arrested a man for sending a BBM text message encouraging people to take part in a mass water-gun fight. And two men from Cheshire have been sentenced to four years in jail for posting Facebook messages inciting rioting and looting. (Their pleas were unsuccessful.)
“Everyone watching these horrific actions will be struck by how they were organized via social media,” Prime Minister David Cameron told Parliament after the riots. “Free flow of information can be used for good. But it can also be used for ill.”
And there’s the rub.
Twitter and other social media are value-neutral tools, and they can be put to incredibly destructive uses. Let’s never forget, though, that the vast majority of the time social media is used constructively, connecting friends and family, facilitating expression and creativity, and even spawning amazing spontaneous efforts like the volunteer clean-up after the riots.
It’s perfectly legitimate to be concerned over its potentially destructive uses, but let’s be careful what we do about it. Cameron went on to tell parliament that he had asked police if they needed new powers to tackle social media hooliganism. If that includes the ability to shut down new media or restrain people from speaking, that’s a bad idea.
One reason is that police and politicians are not going to be very good at distinguishing between harmless fun flash-mobbing, legitimate political protest, and incitements to crime. They will tend to err on the side of caution—and the side of avoiding any potential controversy at all.
Last week saw a case in point when San Francisco transit authorities shut down cell phone service at some of their subway stations after they got word that a group would be protesting a recent fatal shooting of an unarmed man by BART Police. That’s the kind of preemptive censorship of protestors that Western government railed against this spring when it was Arab regimes pulling the plug.
Police will tend to ignore the overwhelming amount of good that social media facilitates at the first sign of a potential threat. That’s a dangerous tendency, and that’s why governments—democratic or autocratic—should not have the power to pull the plug on communications.
What’s the alternative? Police should police and apprehend and prosecute the small minority of delinquents who use the new tools for ill. There’s uncertainty in that, and a real possibility that new media will be used for crime. It’s also a lot more work for officials. But that is the small price we must pay for a free society.
Jerry Brito is a contributor to TIME. Find him on Twitter at @jerrybrito.
FROM
http://techland.time.com/2011/08/17/dont-blame-social-media-for-social-unrest/
Talk About Anything Under The Sun 