Monday 13 January 2014

Social media and medical professionalism : Commentary in Medicial Education February 2014

This is a pre-publication version of the following paperCunningham, A. (2014), Social media and medical professionalism. Medical Education, 48: 110–112. doi: 10.1111/medu.12404 

In this issue, Jain et al. (1) are undoubtedly correct when they suggest that the focus on social media in the medical education literature to date has been a worry about threats to professionalism. In conducting their study, they set out to explore how students, faculty and university staff (presumed to represent the public) view the posting of certain materials to public Facebook profiles. They found agreement on the most serious transgressions such as breaching patient confidentiality. There was more disagreement, however, about other issues such as appearing in photographs with alcohol, or as part of what the authors described as ‘same sex couples’.  In general, students were more tolerant than their faculty or the public.


The focus on social media in the medical education literature has concerned threats to professionalism

What does this research on online professionalism tell us about our deeper uncertainties about what it means to be a doctor in the 21st century?  Hafferty has described the confusion between the various conceptions of professionalism (2), indicating that to some professionalism is an identity and set of values, whereas to others it is a set of attitudes and behaviours. Medical students also employ different discourses when considering professionalism with some focussing on more superficial aspects such as how they act or appear, whilst other students have more complex and embodied understandings(3)

To some professionalism is an identity and set of values, whereas to others it is a set of attitudes and behaviours

Let us consider the portrayal of alcohol consumption by medical students in social media. We know that excessive alcohol consumption has a long history in the culture of medical schools.  The Pithotomy Club, a  John Hopkins Medical School student society formed in Sir William Osler’s time(4), had a cherub on a beer keg as its emblem, and an annual revue, the Pithotomy Show, which ended in a ‘beer slide’(5).  (Forthcoming) research by Black and Monrouxe (6) finds that some medical students in the UK feel compelled or coerced by their fellow students to drink alcohol or take more than they had intended. Although there are concerns about the alcohol consumption of medical students and doctors (7-9), the culture in medical schools which facilitates this is rarely examined.  An online survey of medical students in the UK in 2012(10) found that only 22% thought that their medical school promoted a healthy attitude to alcohol. Is it surprising that some of the students thought that medical schools were more concerned about image than student well-being given the preponderance of messages about not sharing images of alcohol consumption through social media combined with a tacit acceptance of a pro-alcohol culture?  Students sensed that being seen to behave badly may be considered worse than actually behaving badly.  That is, the portrayal of a ‘professional demeanour’(11) was seen as more important that the actual behaviours of medical students. So when we consider the portrayal of alcohol by students in social media, might students have a more complex understanding of this than the restricted discourses often promulgated by their schools?

Is it surprising that some students think that medical schools are more concerned about image than about student well-being?

Next let us consider whether we should be concerned that personal information, not usually revealed in the consultation, may be self-disclosed through social media profiles. Thompson et el. (12) in their 2008 study of the Facebook profiles of medical students and residents in Florida were the first to postulate that the revealing of sexual orientation and political views through social media could be construed as unprofessional.   Professional boundaries are normally seen as either crossed (when no harm is done to the patient) or violated (where harm does occur), but we have no evidence that online self-disclosure through social media profiles affects subsequent consultations (13).  Still, the warnings persist.  In the study reported this month, Jain et al. (1) looked at perceptions of the expression of sexual orientation. We know that homophobia exists within medical cultures (14, 15) and that young people use social media to form networks to support them in dealing with the homophobia they meet in offline life (16). It would, therefore, be quite concerning if we were to recommend without good reason that medical students should be cautious about expressing their sexual identity online.

We have no evidence that online self-disclosure through social media profiles affects subsequent consultations


More generally,  discomfort over the disclosure of personal information is in keeping  with the tensions Frost and Regehr (17) describe between the discourses of standardisation and diversity in medical professional identity.  Is concern over releasing one’s sexual orientation or other personal information evidence that those leading medical schools, implicitly or otherwise, believe we can (or desire to) produce ‘neutral doctors’ (18) or ‘vanilla physicians’(19) who are able to leave behind their own personal values and socio-cultural backgrounds?  If so, then it is no wonder that social media is seen as a threat to a process of socialisation which Beagan (18) describes as in part involving isolation from all wider networks who might remind students of their previous identities. 

Discomfort over the disclosure of personal information is in keeping with tensions between the discourses of standardisation and diversity in medical professional identity

When we are online, just as when we are offline, we must always respect the dignity of our patients and colleagues. Beyond this, regulating and advising on behaviour in social media risks appearing, as Lerner states, ‘alarmist’(20). There are alternatives. McCartney suggests that ‘doctors, like other citizens, are entitled to express opinions online and one effect of the undoing of the medical god-complex has been to humanise medicine and populate it with doctors who are fallible but professional’(21).  Ballick describes such an approach as ‘rather thoughtful and subtle’ and acknowledging of ‘the complexity of online life’ (22).
If we recognise that ‘becoming a professional is an interpersonal and complex activity’(3) then we should aspire to research and guidance on social media and professionalism which reflects this.

Key quotes:
So when we consider the portrayal of alcohol by students in social media, might students have a more complex understanding of this than the restricted discourses often promulgated by their schools?
It would, therefore, be quite concerning if we were to recommend without good reason that medical students should be cautious about expressing their sexual identity online.
Is concern over releasing one’s sexual orientation or other personal information evidence that those leading medical schools, implicitly or otherwise, believe we can (or desire to) produce ‘neutral doctors’ (18) or ‘vanilla physicians’(19) who are able to leave behind their own personal values and socio-cultural backgrounds? 
When we are online, just as when we are offline, we must always respect the dignity of our patients and colleagues.
If we recognise that ‘becoming a professional is an interpersonal and complex activity’(3) then we should aspire to research and guidance on social media and professionalism which reflects this.






Thursday 9 January 2014

I'm proud to be hacking the NHS. Come and help me.

In a few weeks James Morgan and I are hosting NHS Hack Day in Cardiff. Over 100 'geeks who love the NHS' will be coming together on January 25th and 26th  to come up with tech solutions to the problems facing NHS patients and staff.  Whoever you are, if you care about making the NHS better then you can help at NHS Hack Day. Sign up here.

Hacking the NHS? Isn't that a bad thing to do?

No! Hacking is a good thing. It's about making things better and solving problems.Back in the day people at MIT  started using the  word hack: "When one did something ingenious and clever and unthought of with some technology, it was known as a good hack." Hacking is NOT about breaking into databases and stealing your information (that's 'cracking'  not hacking). We will be using databases of information at NHS Hack Day. But the databases will have been made freely available to all of us because people know that when you set data free then people can do great things with it. The databases won't be health records of individuals, but information about services so that we can figure out ways to solve problems. This is called "civic hacking"- and you can learn more about it in this short video and this article.


What is NHS Hack Day? 

First of all, NHS Hack Days are two days- a Saturday and a Sunday. They happen 3 times a year. So far there have been hack days in London, Liverpool, Oxford and Cambridge. We are very proud that this is the first NHS Hack Day in Wales. NHS Hack Days are non-profit events. The people who attend are all giving up their time for free because they love the NHS and want to make things better for all of us who use the NHS.

Who should come to an NHS Hack Day?

Two kinds of people are needed. First of all we need people with IT skills- techies- people who can write computer programmes and make different computer programmes work together. You will hear these people being called coders or developers. We need people who can design. Designers make it easier for us to use things whether services or software.
But we also need people who know what kinds of problems we need to solve- people who understand the systems of the NHS. These people are 'domain experts'. Some of these people will be health professionals- nurses, physios, health care assistants, doctors, students. But there are other people who understand the systems of the NHS- the people who have to use it, patients and the public. We need you too. You are also a 'domain expert. You can tell us what problems we need to solve. And you can help to solve them as well.

What  happens at NHS Hack Day?
There are three stages:

Pitches What do you think we could do better? What problem would you like us to solve in less than 2 days?  You have 1 minute to tell others about it. So no slides. Just stand up and tell everyone what you want to do. Does that sound nerve-wracking? What happens if you are not sure if your idea might be achievable, or if someone has done it already (they might have- but that means you might be able to make their solution even better)?

All the people who come to NHS Hack Days are very nice and friendly but I think it can be a little bit scary to stand up in front of everyone and ask them to work on your idea so if you think you have an idea and you want to chat it over with some other people first why don't you come along to our 'Library Meeting'. It's in Canton Library at 7pm on Wednesday 22nd January. If you would like to come to this please sign up here
After the meeting we will be going to Chapter cafe bar at 8.30pm so you can come and join us there if 7pm is too early. We will  be organising a pre-meet in London as well.

You can also join the email list and write about your idea or solution there.

The Hacking
From about 11am on Saturday until 3pm on Sunday people will be trying to solve these problems sitting around tables with laptops in front of them and chatting with each other. We will form teams - those who know what the problem is and those who can help to solve it- working together. This is a form of co-production. 

The Presentations
From 3-5pm on Sunday teams will present the solutions to the problems they have been working on. This session is amazing because it is incredible what smart people can achieve in just over a day when they put their mind to it.

Below is a video made at the NHS Hack Day in Liverpool in 2012 that shows you what all of this looks like together. If you think that NHS Hack Day might be for you then you should come. Sign up here.



Any questions? Just ask!