Tuesday, December 30, 2014

Facebook and unprofessional behavior among surgical residents

Have you ever wondered about the behavior of surgical residents on Facebook? I have. A study from the Journal of Surgical Education posted online in June 2014 looked at the issue.

The paper, "An Assessment of Unprofessional Behavior among Surgical Residents on Facebook: A Warning of the Dangers of Social Media," identified 996 surgical residents from 57 surgical residency programs in the Midwest and found that 319 (32%) had Facebook profiles.

Most (73.7%) displayed no unprofessional content, but 45 (14.1%) exhibited possibly unprofessional material. Clearly unprofessional behaviors were noted in 39 (12.2%) resident profiles. The paper said, "binge drinking, sexually suggestive photos, and Health Insurance Portability and Accountability Act (HIPAA) violations were the most commonly found variables."

There were no differences in the rates of unprofessional behavior between male and female residents or by postgraduate year.

I have blogged previously about the ill-defined nature of professionalism, and the papers' authors acknowledged that it can be subjective. Some of the behaviors they felt were potentially unprofessional such as photos of residents holding an alcoholic drink, holding a gun while hunting, or making political or religious comments are debatable.

They referenced another paper that found similar rates of unprofessional behavior (16%) on Facebook among applicants to an orthopedic surgery residency program.

A 2005 New England Journal of Medicine case-control study found that practicing physicians disciplined by state medical boards were significantly more likely to have had documentation of unprofessional behavior in medical school as well as lower Medical College Admission Test scores and poorer grades in the first two years of medical school.

Unprofessional behaviors listed in the New England Journal paper were irresponsibility, diminished capacity for self-improvement, immaturity, poor initiative, impaired relationships with students, residents, nurses, or faculty, impaired relationships with patients and families, and unprofessional behavior associated with anxiety, insecurity, or nervousness.

Some of those \ seem a bit vague. Are diminished capacity for self-improvement and poor initiative really unprofessional behaviors?

Facebook unprofessional behavior and the unprofessional behavior documented in the NEJM paper which pre-dated the widespread use of Facebook may not be comparable.

But I suppose one could say that some of the Facebook behaviors could be categorized as immature or irresponsible.

Until stories about residents being rejected for jobs after training start emerging, there probably won't be a change in the way they use Facebook or other social media.

Or maybe society will change.

In 1987, politician Gary Hart had to withdraw as a candidate for the Democratic Party's presidential nomination because he had an extramarital affair, and just a few years later, the president himself had a dalliance with an intern in the White House and survived.

Who thought marijuana use would ever be legalized?


Anonymous said...

This is drmuchogusto from twitter. I have limited my facebook profile to just family and really close friends. I really monitor what I post too due to the lack of privacy. I don't allow my friends or family to check me in or post pics of us having a good time as this can be judged. While I'm involved in the surgical side, I have a classmate who matched in Family medicine and was a big time social media geek. His posts varied and could be considered unprofessional. I believe he had to agree to closing his facebook account before joining that program. I was quite amazed they had him do that. I thought they would just inform him to be careful. While I was ms3, there was a resident who posted a pic on FB with a celebrity patient. He was immediately let go for violating HIPPA. This is quite obvious. I'm on the fence though to forcing a resident to close his/her account. Maybe it is for their own good anyhow. The two programs I am affiliated with luckily encourage social media as we have a department page, the chairman has a twitter account, and many residents as well. Twitter I use more to connect with other MD's and to stay current on topics. I encourage other MS and residents to do the same.

Anonymous said...

From my very unscientific assessment as a current surgical resident, Facebook profiles of residents don't differ much from those of non-physicians of the same age. They're mostly full of pictures of groups of friends (frequently with visible alcohol), travel, families and the occasional person who posts every thought that seemingly crosses his or her mind. The occasional resident will have pictures from inside the hospital but I don't remember ever seeing any patients or patient-identifying data involved in any posts like that.

My point here is that residents are no different from anyone else of their current generation with respect to social media. You could make an argument either way about how we should all be more private or that society needs to catch up with the generations that have come of age with these technologies.

I do think it's interesting, however, that there are residents out there with non-private profiles. I myself keep mine private (though I pride myself on having an extremely boring and un-revealing profile) and would expect most people who deal with patients to do the same.

Interestingly, a friend of mine who works in the tech arena says that it's considered "poor form" in his line of work if privacy filters are enabled for people in that field. Everyone expects people to cultivate professional social media imprints and is suspect of those who "try to hide" anything. Perhaps that's a more enlightened approach.

Another interesting thought worth mentioning is that I once asked some of the RNs in our ICU why they all put stickers over their last names on their name tags (which seems to have near 100% penetrance in more than a few nursing units I've encountered) and they said it's to stop patients from seeking them out on social media.

My last thought is that Facebook is practically old news at this point. Where's the follow-up paper on Instagram?

Anonymous said...

Talk to members of the military -OPSEC, PERSEC (operational security, and personal security). I began using their guidelines a few years ago and I work as a housekeeper at a hotel. If you don't want the world to know about it, don't put it on the internet.

Anonymous said...

If you want to be stupid just like every other college graduate at some point in their life, on your time and dime, enjoy. Holding a drink, a gun for hunting, political or religious comments, have at it. Doctors are human. Act like it. Maybe you would understand patients a lot better. We all put our skivvies on one leg at a time.

Another story would be DUI's, getting toasted when on call, suggestive photos of their patients, HIPAA violations. This is true for MANY professions in terms of standards. When you are off duty, you are free to do what you want within a fair reason. Lets face it: there is a big difference for a doc getting arrested for blocking traffic to an abortion clinic than bringing scalpels to said clinic and threatening to use them. Even those with govt. clearances would get a pass for the first.

I'm not too in favor of FB friending docs, unless it is over shared medical interests in terms of research. Complaining about MOC, insurance companies, administrations, patients should be allowed to join in, as some of us would probably buy you a round or two while we complained together about our mutual enemies.

Leave the nurses alone though. :)

That being said if you have do interests that some of your patients do: sky diving, running, for example, when people are friending lots of others in the same group, you are probably just "another name in the crowd" that people friend nowadays. No problems there. Just because you are a doctor doesn't mean you shouldn't be like others. Medicine is a job, and while yes, there are some items you have to watch, it wouldn't be unlike Navy Seals, FBI people, etc. where you can't take a few precautions and still be normal like the rest of pretend to be.

As for complaining about coworkers, patients, make it generic enough that no one can tell. Saying you had a patient with VD as a PCP who said you were dumb, is not in the same group as John Doe's HIV test was positive, which is what sleeping around like a drunk 'ho will get you, is.

Skeptical Scalpel said...

Thanks for the interesting and thoughtful comments. Professionalism is in the eye of the beholder.

artiger said...

I have avoided Facebook and other social media just to steer clear of blurring the lines between physician-patient relations, as well as to avoid even a hint of any privacy violations. I do however use LinkedIn but that is more of a professional site, which suits my purposes.

I think society changes before resident social media habits do, but posting anything right now is at the poster's own peril. Don't cry when you're called out. As for me, maybe I'm different, but I don't want the world seeing everything about me. I've got plenty of friends that see more of me than they probably like anyway.

Anonymous said...

"...Medicine is a job..."

I think that is the root of the issue. If Medicine is a profession, a calling, then it is not just a job. Unfortunately, as physicians, we just have to take the high road.

Anonymous said...

What is medicine a calling to? Higher pay?

When medicine acts like the rest of us, drug testing, open disclosures in peer reviews, medical boards, NPDB, and full due process rights during medical board hearings, when no gag clauses are allowed in any settlement, then we can talk about it being a calling.

When someone can explain how someone can be called when whistleblowers like Patricia Moleski, Briana Aguirre, are punished, but Charles Cullen and Christopher Duntsch are allowed to let go, when doctors who act unprofessional are never worked with and stopped because they bring $$$ in, then I'll give some credence to calling.

Btw, when those who are lower class or lower middle class can be in med school and the average $$$ value of the families med students come from are more reflective of America, I'll believe that we're all in this for good. When a teaching doc says 60-70% of their class talks about $$$ and not the patients, hard for me to believe anything about calling someone to a life of $$$.

Btw get rid of tort reform (which has been proven to help lawyers and do nothing for hurt patients) and do something about medical bankruptcy bills when CEO's are millionaires and hospitals have billions in $$$, I'll start thinking about it being a "calling".

If someone is called, why can't docs seem to apologize and work out an answer as to what can be done to make things better? There is a reason "deny and defend" and gaslighting and blacklisting examples still go on. Is that all part of the "calling" to help sick people?

Vamsi Aribindi said...

Personally, I actually follow advice that suggested that a "good" social media profile can help you- by letting residencies and prospective employers/collaborators know more about you and signal that you're a normal, healthy, and well-adjusted person.

I keep my facebook profile entirely public- BUT I take care to delete anything that anyone might consider to be inappropriate. I happen to enjoy target shooting, but I never allow a picture of me and a gun in the same photo (though I have posted photos of me at a range with some friends). I have posted photos of me+friends in a hospital, but never with a patient. I don't drink anyway, but regardless I police my profile for any association with inappropriate alcohol use if I'm at a bar or party. The only "controversial" posts I might have are when I promote my blog posts- but I try to be professional, thoughtful, and discrete on said blog, in the hopes it too reflects well upon me.

Skeptical Scalpel said...

Interesting comments. I'm not sure I agree that tort reform has helped lawyers. I think they'd say it hasn't. I don't think everyone who goes to med school does it for the money. You could make a lot more money in investment banking or hedge funds.

pamchenko said...

Do people really fired from residency for sexually suggestive photos or pictures of binge drinking? I imagine people get fired under the heading of professionalism for HIPAA violations, working while under the influence of substances.
What I think is more interesting is the ability to fire residents. Since we can't unionize, is it okay to fire people for consistently violating any of the other core competencies? What if someone was consistently deficient in Systems Based Practice? A follow up thought is how do you become deficient in systems based practice? I can think of ways this would be deficient but never has such behavior been penalized.

Basically to me this study shows that we need more effective HIPAA compliance.

Hope said...

Luckily I'm #1) Far too lacking in self-control to self-regulate the time or energy I afford to facebook to have a functional life and #2) Really paranoid about having an online fingerprint for many reasons, including those mentioned above...so I canceled my Facebook account about 4.5 years ago. I have to say, life got immeasurably more simple. Yes it's sad not to see photos of family and get social invites via this social media tool...but honestly, I'm surviving without it and my mind is less cluttered as a result.

Skeptical Scalpel said...

I agree. I haven't closed my account but I only go on FB once every 2-3 days.

Anonymous said...


Skeptical Scalpel said...

Yes, very unprofessional and very criminal.

Carolyn Thomas said...

Sigh.... Yet another example that seems to prove the truism: just because you're brainy enough to get accepted into medical school, doesn't mean you can't be stupid.

"....Until stories about residents being rejected for jobs after training start emerging, there probably won't be a change in the way they use Facebook or other social media...."

There just may be that change if residents (and all med students) smarten up and start paying attention to real-life MDs out there who have been fired specifically for Facebook use. For example, 48 yr old Dr. Alexandra Tran was fired from her Emergency Medicine job at a Rhode Island hospital and also sanctioned by her State Medical Board after she decided to post information on her FB page about one of her trauma patients; she didn't name names, but investigators determined that she had violated the patient’s privacy rights by writing enough that others in the community could easily identify the patient.

Not specific to medical residents, but another ongoing scandal among 13 4th-year male members of the Dalhousie University Dental School in Canada might also be relevant to your post on unprofessional behaviour. The students started a Facebook page calling themselves "Class of DDS Gentlemen", and posted a series of rape-related hate posts, some aimed specifically at their female classmates (including "voting" by name for which classmate they'd like to "hate F**k"). All 13 male students - mere months before they were due to graduate - have now been suspended from clinical activities pending an external investigation.

Anonymous said...

Carolyn Thomas, I don't want to confuse brains or IQ in terms of school learning, with EQ or emotional quotient. Is the behavior you mentioned unacceptable? Yes. My question is what medicine/admin does to try and stop people from getting into med school who are like this in the first place.

Has there ever been any sort of ethics/professional interview with these people? Do hospitals and other groups put stuff like this (and other things on the internet) out to teach these kids in the first year that this behavior isn't tolerated?

Skeptical Scalpel said...

Carolyn, good points. You might be interested in reading this woman's different prospective on the Dalhousie dental students http://news.nationalpost.com/2015/01/12/christie-blatchford-dalhousie-dentistry-students-paying-a-heavy-price-for-victimless-thoughtcrimes/#__federated=1.

Regarding interviews to try to assess professionalism. I think that would be as hard to do as assessing "grit." [see: http://skepticalscalpel.blogspot.com/2014/08/true-grit.html] What people say and what they actually do can be quite different.

Emma Watson said...
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