Writing on the Wall: Crude behavior online can jeopardize a student’s future

Titled “For Doctors, Social Media a Tricky Case,” an article in The Boston Globe in April told of an emergency physician who was fired by a Rhode Island hospital and reprimanded by the state’s medical board for commenting online about a trauma patient, even though the post did not mention the patient’s name. The medical board determined that the physician included enough details to enable others in the community to identify the patient.

The article has been widely disseminated at osteopathic medical schools, a number of which are urging students and faculty to exercise caution and be more professional when communicating through social media, blogs and other Web-based platforms. Although violations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) pose the greatest concern, other signs of questionable judgment, such as using profanity online and posting photos of oneself drinking alcohol, also invite trouble.

“When people communicate online, as opposed to face-to-face, they seem to lose all of their inhibitions,” observes John R. Gimpel, DO, the president and chief executive officer of the National Board of Osteopathic Medical Examiners (NBOME), noting that students have even used foul language in the comment field of the computer-based Comprehensive Osteopathic Medical Licensing Examination—USA.

Not only can posting inappropriate content reflect poorly on physicians and medical students, but also “friending” the wrong people on Facebook and other social networking sites can be unprofessional, asserts Dr. Gimpel, who edits the Medical Professionalism newsletter of the American Association of Colleges of Osteopathic Medicine (AACOM). Physicians shouldn’t communicate with patients and faculty shouldn’t communicate with students using personal online accounts, he believes.

Residency directors and faculty frequently keep an eye on students’ online behavior, points out Bruce D. Dubin, DO, JD, the dean of the Rocky Vista University College of Osteopathic Medicine in Parker, Colo. Dr. Dubin says he is shocked by what some students say online about patients and their school. “They are posting comments and photos that could prevent them from getting residencies,” he notes. “Students need to recognize that the things you post online are there forever.”

Scope of problem

In December 2009, JAMA: The Journal of the American Medical Association published a survey on unprofessional online behavior among allopathic medical students. Of the 78 schools that responded, 60% cited incidents of unprofessional postings. While 13% of the responding deans of student affairs reported violations of patient confidentiality, 53% cited incidents of student profanity, 48% cited frankly discriminatory language, 39% cited depictions of intoxication, and 38% cited sexually suggestive material.

The survey participants provided many examples of such incidents in response to open-ended questions, including the following:

• Sexually suggestive or explicit content, such as students posting sexually provocative photographs of themselves or requesting inappropriate friendships with patients on Facebook.
• Negative remarks about medical school experiences, including the use of profanity and other disparaging language to criticize faculty members, courses and the school as a whole.
• Content indicating intoxication or illicit substance abuse, such as photographs of students drinking alcoholic beverages or photographs of illicit drug paraphernalia.
• References to patients that jeopardized patient confidentiality.

Inspired by the JAMA article, AACOM supported a similar study on how students and faculty use social networking and other Web applications. The preliminary results of the research, which has not yet been published, indicate that use of profanity is the most common example of unprofessional conduct online, followed by depictions of intoxication and sexually provocative behavior and violations of patient confidentiality, notes the study’s lead investigator, India L. Broyles, EdD, an associate professor of medical education at the University of New England College of Osteopathic Medicine (UNECOM) in Biddeford, Maine.

But while almost 80% of the responding deans of student services are reporting incidents of inappropriate postings, most cite only a few incidents, according to Dr. Broyles. “The study actually indicates that unprofessional online incidents have declined because now more people know what they can and cannot do in social networking,” she points out. “Three years ago, there was too much blurring of the boundaries between faculty and students. They are not ‘friending’ each other as much today.”

Professionalism training

“Social networking is a large professionalism issue that needs to be addressed at both the school and hospital level,” says Elizabeth Varadian, OMS V, the 2011-12 national chairman of AACOM’s Council of Osteopathic Student Government Presidents (COSGP). Varadian, who studies at the New York College of Osteopathic Medicine of New York Institute of Technology (NYCOM) in Old Westbury, underwent leadership and professionalism training during her first career as a high school biology teacher. But students who enter medical school right after earning their baccalaureate degrees are sometimes unaware of what constitutes professional behavior, Varadian says. Medical students need guidance on the high standards physicians-in-training are expected to uphold, she maintains.

As the 2010-11 chairman of COSGP’s Leadership Development Committee, Varadian coordinated a survey of student government presidents on the intensity and integration of professionalism training at their schools, as well as the most common offenses brought before school ethics and judiciary committees. Many of the respondents reported that their schools have codes of professionalism or conduct but nothing specific to social networking, Varadian notes. Some student government presidents reported offenses involving third-year students posting inappropriate photographs from their rotations and making comments on how annoying or how obese particular patients are. “Somehow these students didn’t realize that updating Facebook with patient information could be a violation of HIPAA,” Varadian observes.

Medical school is extremely intense and stressful, with students, especially those on rotation, continually finding themselves in sometimes bizarre situations they’ve never previously encountered, such as observing a patient who has a large foreign object lodged in a bodily cavity or a patient experiencing hallucinations. While it is understandable for students to want to discuss their experiences, they should do so discreetly and privately over a cup of coffee, not on the Web, Varadian says.

Encouraging COSGP members to lead professionalism sessions at their schools, Varadian has developed professionalism and social networking scenarios, which she has presented to NYCOM students and demonstrated at COSGP’s national meetings. In one such scenario, students are asked to imagine that they are a fourth-year medical student interviewing for a residency position at a prominent city hospital.

“You have put a lot of hard work into your studies and rotations over four years and are eager to share your experiences with the residency director,” the scenario begins. “Unfortunately, during the interview, the director mentions that she saw several ‘unprofessional’ photos and videos of you on Facebook because other students on rotation from your school were showing them to each other in the hospital lounge area. She informs you that although you have a promising application, she cannot offer you a position due to her concerns about your professionalism.”

After being presented the scenario, students are asked to discuss several questions, such as “Why do you think the residency director made this decision?” and “Would you be comfortable allowing a residency director to browse through your Facebook profile or search for you on the Web?” The questions encourage students to reach their own conclusions about professionalism, Varadian says.

The dean and chief academic officer of the Pacific Northwest University of Health Sciences College of Osteopathic Medicine (PNWU-COM) in Yakima, Wash., Robyn Phillips-Madson, DO, MPH, notes that when students and residents give talks on social media and professionalism, other students are more apt to listen than they do when “old fogey” administrators and faculty lecture on the topic.

Thus, Dr. Phillips-Madson tries to involve trainees in the presentations and workshops addressing online communication that are held during freshman orientation, as well as right before students begin their third-year rotations and during the college’s “Community Doctoring” course. She points out that PNWU-COM students attending an emergency medicine conference took notice when a resident spoke to them about how residency personnel look at trainees’ Facebook pages.

Posting profanity and questionable party photos are the main problems with the conduct of medical students online, Dr. Phillips-Madson says. She observes that students swear more casually today than in the past, so they need to be told directly that such behavior isn’t professional. “Profanity may be acceptable among peers their age, but they shouldn’t use it in public or online,” she says. Students should also refrain from posting photos of themselves drinking alcohol and from making comments such as “I got so smashed this weekend.”

In the small city of Yakima, members of the community occasionally contact PNWU-COM to report what they consider to be students’ unprofessional behavior online or in town. Osteopathic medical schools and health centers in close-knit communities need to adhere to particularly high standards of professionalism, Dr. Phillips-Madson notes, especially given that it is easier to inadvertently share patient-identifying information in a town in which everyone knows everybody else.

In this video from The DO’s archive, Marc Lawrence, MD, prescribes do’s and don’ts for promoting your practice and communicating with other physicians online. “You’ll be surprised how many referrals you’re going to get,” he says.

Dr. Phillips-Madson advises students to use the strictest privacy settings on Facebook and other social networking sites but warns that these settings can be breached. “Friends” can show Facebook pages to other people, so students can never be sure who will see their profiles, comments and photos, she warns. What’s more, students need to monitor what their Facebook friends post online. Dr. Phillips-Madson notes that she has had to “defriend” people who posted inappropriate material on their own Facebook pages, as well as on her Facebook wall. She tries to do this tactfully, explaining that “In my profession, I have to be very careful,” she says.

The president-elect of the Association of Osteopathic Directors and Medical Educators (AODME), Richard LaBaere II, DO, MPH, confirms that residency directors do commonly google and search on Facebook for the names of residency candidates. Unlike the case with physicians, no national database reports disciplinary actions taken against medical students. Research has shown that medical students who act unprofessionally are more likely to get in trouble as residents and as practicing physicians, he says.

A particular problem among some trainees is their proclivity to post photographs and videos of themselves on social networking sites, notes Dr. LaBaere, the director of medical education for Genesys Regional Medical Center in Grand Blanc, Mich. Even if a trainee doesn’t intend to record and transmit a patient’s image, HIPAA violations can result from showing any part of a patient in a snapshot or video. When such photos and videos are forwarded to hundreds of people, as often happens online, the likelihood increases that someone will recognize that patient, Dr. LaBaere says.

It is essential for residency directors and other clinical faculty to spell out to trainees what is and isn’t appropriate, Dr. LaBaere says, noting that the AODME puts on workshops to teach clinical educators how to address deficiencies in professionalism.

Social media policies

Even as they emphasize the importance of discretion online, more and more organizations and institutions in the profession are using Facebook and similar tools to share information with students, faculty, staff, alumni, association members and the public. “We must remember that there are positive aspects to using social media,” says Dr. Broyles, who uses Facebook to promote UNECOM’s online master’s program in medical education leadership, which she directs.

Many osteopathic medical schools are interested in developing social media policies for faculty as well as students, but only a few have such policies in place, Dr. Broyles notes. UNECOM, for example, requires departments and programs with Facebook pages to have two administrators monitor any postings. “If someone clicks that they ‘like’ my program’s page, I google the person’s name to determine whether they likely have a legitimate interest in the program,” she says. Sometimes Facebook fans only want to post advertisements, which Dr. Broyles promptly takes down.

The Western University of Health Sciences College of Osteopathic Medicine of the Pacific (WesternU/COMP) in Pomona, Calif., is among those osteopathic medical schools in the early stages of developing social media policies for students, faculty and staff. “We recently formed a small working group on social media because the issues are so numerous and varied,” says Gail Singer-Chang, PsyD, WesternU/COMP’s assistant dean for interdisciplinary professional education. “Our group has discussed topics ranging from using social media within education to better speak the language of students to managing inappropriate and unprofessional behavior. Some individuals in the group have suggested caution, however, because a social media policy that is too narrow may not be applicable to future technologies.”

Faculty members increasingly use image- and video-sharing platforms, such as SlideShare and YouTube, to teach students. One concern is that the clinical cases used for instructional purposes, which are based on real patients but do not contain identifying information, could still potentially be problematic if made available to a national public audience, Dr. Singer-Chang points out. “Patients who discover online that their physicians are teaching with patient case material could become unduly concerned about their own privacy,” she says.

Regarding students’ online professionalism, Dr. Singer-Chang recounts an incident in which a professor told students to stop checking their Facebook pages in class. “This caused an uproar,” she says. “The students said, ‘We can’t stop because we are addicted.’ ” In developing a policy, the work group needs to weigh the potential harmfulness of this dependency.

At the Midwestern University/Chicago College of Osteopathic Medicine (MWU/CCOM) in Downers Grove, Ill., online behavior is addressed as part of the college’s overall commitment to professionalism, says Bernadette B. Gniadecki, DO, appointed two years ago to chair the college’s new professionalism committee. “When you speak about social media, there is a big generational difference in understanding what’s right and what’s wrong,” says Dr. Gniadecki, an emergency physician who is a clinical assistant professor at MWU/CCOM.

In addressing problems related to social media, schools need to show respect for new technologies and students’ technology skills while helping students understand the need for professionalism, privacy and decorum in the culture of medicine, she notes. The goal is to “bridge the generation gap,” not alienate students, Dr. Gniadecki says.

MWU/CCOM’s Lisa Marie Piwoszkin, OMS IV, says she appreciates her school’s emphasis on professionalism, which she believes helps prevent egregiously unprofessional postings by students, such as violations of patient confidentiality. But she observes that her classmates do post comments about their classes and teachers online, which she doesn’t consider appropriate.

“Facebook is definitely used as an outlet for venting,” says Piwoszkin, who is the vice president of the Student Osteopathic Medical Association. “You should use common sense when you post something,” she notes. Even when you use privacy settings, you never know who is going to gain access to your comments and photos.”

COSGP’s 2010-11 chairman, Robert Schneidewend, DO, who graduated from MWU/CCOM in May, points out that the college urges students to “untag” themselves from any comments or photos related to drinking alcohol. Students are also encouraged to use LinkedIn for their professional profiles and reserve Facebook for personal communication but only under the most restrictive privacy settings. Some students will use nicknames or alter the spelling of their names on Facebook to make themselves difficult to find by faculty and potential residency directors and employers, Dr. Schneidewend adds.

Practicing DOs, as well as trainees, sometimes comport themselves irresponsibly online, Dr. Gimpel points out. For example, medical and osteopathic licensing boards have disciplined physicians for misrepresenting their credentials on their websites and other Internet venues.

In November 2010, the American Medical Association adopted a policy on professionalism in social media. The policy presents the following guidelines for physicians:

• Maintain standards of patient privacy and confidentiality.
• When using social networking websites, use privacy settings to safeguard personal information but realize that these settings “are not absolute” and that once posted on the Internet “content is likely there permanently.”
• If interacting with patients online, “maintain appropriate boundaries of the patient-physician relationship.”
• To ensure appropriate professional boundaries, consider separating personal and professional content online.
• When noticing unprofessional content posted by another physician, bring that content to the attention of the offender so that he or she can remove it. If the behavior “significantly violates professional norms” or isn’t adequately resolved, it should be reported to appropriate authorities.

Preserving public trust

“The digital revolution of the past 25 years has just begun to influence medicine,” write Arash Mostaghimi, MD, MPA, and Bradley H. Crotty, MD, in “Professionalism in the Digital Age,” an opinion piece published in Annals of Internal Medicine in April. “As a profession, we must seek to identify common standards and develop resources to teach current physicians and trainees a basic set of principles to guide electronic interactions now and in the future,” they emphasize.

The NBOME’s Dr. Gimpel, for one, believes in erring on the side of caution. “What you put online can jeopardize your ability to care for patients,” he says. “It’s a matter of preserving public trust.”