Lie, Désirée MD, MSED; Trial, Janet EdD; Schaff, Pamela MD; Wallace, Robert MD, MBA; Elliott, Donna MD, EdD
In 2011, the American Medical Association (AMA) published six guidelines for physicians entitled “Professionalism in the Use of Social Media.”1 Much has been written on the need for such guidelines,2,3 given recent media attention to physicians’ presence online4 and reports of unprofessional conduct on Web 2.0 platforms open to the public among practicing physicians, residents, and medical students.5–7 Medical students exhibit a high rate of social media use even before arriving at medical school8 and may not be aware of the implications of their social media use for their future careers.9 Few U.S. medical schools currently have or enforce policies about monitoring their students’ online presence,10,11 and the boundary in this area of professionalism between respecting privacy and intruding into students’ personal lives remains to be established. Medical students have been surveyed and found to lack awareness about the need for privacy settings and vigilance in monitoring their own online presence because of the impact it could have on their future practice.12 Nevertheless, these surveys also have indicated that students recognize their personal responsibility in maintaining their online presence.13 Given that patients are now able to research their physicians online (which includes finding information on social media sites) and the continuing challenges associated with permanently erasing Web data, we need to educate students early about the risks to their future professional personae based on their current online behaviors.14–17
There is scarce literature on a curriculum to address this emerging need in professionalism education. Importantly, little is known about whether and how students respond to such curriculum and how effective it may be at changing personal online behaviors. We therefore conducted a mixed-method study with first-year medical students to examine whether a brief, required, two-hour intervention embedded within a professionalism course was associated with a change in students’ attitudes and use of online social media. We hypothesized that the intervention would be associated with increased awareness and action among students to change their online presence to reflect their new professional roles.
Setting, participants, and curriculum
We conducted this study at the Keck School of Medicine of the University of Southern California and included all medical students (n = 180) entering their first semester of medical school in the fall of 2011.
During the Professionalism and the Practice of Medicine (PPM) course, we introduced this new curriculum. PPM is a 200-hour required course that spans the first two years of medical school.18 Two faculty mentors teach the course weekly in groups of 24 to 30 students using a standardized, case-based curriculum that includes professionalism, bioethics, narrative medicine, cultural competence, integrative medicine, community health, health policy, and the business of medicine. In 2011, we added a two-hour session that covered the 2011 AMA social media use guidelines.1
The new session, “Online Social Media and Professionalism,” was presented in the second week of the course and included a large-group, didactic presentation on the role of reflection in practice, followed by a 30-minute interactive lecture on maintaining a professional presence online, using content from recently published literature, media clippings, and videos.5,6 This session was followed by an hour-long, small-group discussion led by faculty mentors who had received prior training and who followed a standardized script with prompts. Each group of 24 to 30 students discussed their current online presence and social networking habits and the professional implications of those behaviors, and reviewed a patient scenario. The faculty mentors provided trigger questions (e.g., “How, if at all, do you see your online presence changing in future?”), acknowledged students’ opinions or comments (e.g., “It looks like there are two different opinions among the group about the need for privacy settings”), and summarized the discussion (e.g., “Most of you seem to agree that you will maintain a separate online social presence for your family or friends only and will not give your future patients access to this identity. Is there anyone who thinks differently?”).
Within one week of the small-group session, students were required to submit electronically to their faculty mentors a written reflection. The assignment prompt was, “In two paragraphs, reflect on your current Web presence and how this might or might not change after today’s session, to reflect your new role as a student physician.” The assignment had no word or page count limit. The course overall is graded as pass/fail with formative feedback provided twice during each year; the course pass rate over the past three years has averaged 98%.
Outcome measures and data analysis
The primary outcome measures that we analyzed in our study were the themes that emerged from our narrative analysis of students’ written reflections. First, we, with experience in narrative coding, deidentified the student reflections, organized them into a single document, and qualitatively analyzed them in sets of 24 to 30 reflections, using a previously validated method.19,20 All five of us initially reviewed 48 student reflections as a working group, constructed categories of themes, and agreed on the categorization of themes into domains, using an iterative process of discussion, refining and revision of the coding schema, and consensus. We achieved interrater agreement at 100% for this sample before proceeding to the next stage.
Because no one reflection yielded more than four themes in the initial sample, we coded the remaining reflections for a maximum of four themes per reflection. Using the agreed-on coding scheme (with definitions for each theme and domain), each of us then independently reviewed 48 to 60 reflections. At least two of us independently read and coded each reflection. At the end of the individual coding process, we met in pairs in a round-robin arrangement to derive consensus for each set of 24 to 30 reflections. We documented the number of themes per student and the total number and frequency of themes. Finally, we determined the distribution of themes within each domain.
The secondary outcome measures that we analyzed were aggregated standard course evaluations of the session and aggregated results of a follow-up survey asking students about changes in their online presence and activity since the session. Session evaluations included standard questions with five-point Likert scale responses and were administered electronically three weeks after the session. We administered the follow-up survey four months after the session, also electronically. We collected survey data using Qualtrics Labs, Inc. software (Survey Research Version of the Qualtrics Research Suite, Provo, Utah). We collected both datasets anonymously.
The four-month follow-up survey asked students about their current and planned future online social networking activities with single-option responses. One question asked, “Since submission of the reflection on your online social networking, what further action have you taken relative to your online presence?” Following the question were four possible responses and prompts based on findings from our qualitative analysis of the written reflections: (1) No review and no action taken, (2) I reviewed and no action was taken (i.e., online presence deemed appropriate), (3) I reviewed and edited my presence (e.g., detagging of photos, change in privacy settings), or (4) I reviewed with significant change in my Web presence (e.g., removal of a profile or creating a new online presence, such as LinkedIn). In other questions, we asked students about their social media use, including current trends and intentions—for instance, “Since the session addressing online social media, has your use of social media …” and “Do you anticipate your use of online social media to …,” with three possible responses of “stay/ed the same,” “decrease/d,” and “increase/d.” We also asked students for their opinions about curricula addressing social media and professionalism. We used descriptive statistics—frequency, means, and standard deviations (SDs)—to analyze the data we collected from the session evaluations and the four-month survey.
The institutional review board at the Keck School of Medicine of the University of Southern California approved our study.
Of the 180 first-year students in the PPM course, 97 (54%) were male, and the mean age at admission was 23.85 years (range 20–45 years). Just over 50% were white (86 white, 51 Asian, 20 Hispanic, 6 African American, 1 Native Hawaiian, and 16 no response).
Primary outcome measure
All students (180/180; 100%) submitted written reflections. Reflections varied in length from 200 to 1,000 words. We identified a total of 539 themes within three domains for the 180 reflections through our coding process. The number of themes that we identified for each reflection ranged from 2 to 4 (average 2.9 themes per reflection). In their reflections, over 90% (162/180) of students reported current or past use of Facebook, MySpace, Twitter, LinkedIn, or other online media, with a minority (4/180; less than 3%) describing no online social presence other than the use of e-mail.
Our initial coding of the first 48 reflections produced 10 separate themes in the three domain categories (see Table 1): immediate action (four themes), intended future action (four themes), and value change (two themes). In the domain of immediate action, the four themes were no action taken (i.e., did nothing); reviewed Web presence and found no problems, therefore no action taken; reviewed Web presence, found problems, and edited presence (e.g., Googled self, removed photos, or changed privacy settings); and reviewed Web presence and made major change (e.g., deleted Facebook account). The domain of intended future action contained four similar themes: no future action will be taken; will review but not change Web presence; will review and edit Web presence (e.g., remove photos or change privacy settings); and will review and make major change in future Web presence (e.g., delete Facebook account or create a separate, professional Web account). The domain of value change included two themes: patient-centeredness (i.e., aware that patients’ perceptions should be considered) and role awareness. No additional themes emerged when we applied our coding scheme to the remaining reflections; in other words, we reached a saturation of themes within the first sample of 48 reflections.
In aggregate (see Figure 1), 34% (182/539) of themes fell in the domain of immediate action, 35% (190/539) in the domain of intended future action, and 31% (167/539) in the domain of value change. Within the domain of immediate action, most “did nothing” (94/182 themes). Within the intended future action domain, most students expressed an intention to review and edit their Web presence (84/190 themes). Within the domain of value change, the majority of students expressed a new awareness of the link between their online social networking activity and their professional representation as future physicians—that is, role awareness (144/167 themes). We provide representative quotations linked to each domain and theme in Table 1.
Students’ reflections demonstrated thoughtful attention to the issues raised in the introductory interactive lecture about online professional presence. Many reflected on how, when, and why they had developed their MySpace or Facebook accounts, and philosophized about the role of social media in their lives. Although it was clear that a majority of students had considered the nature of their Web presence before coming to medical school, many of their responses reflected awareness that, as new members of the profession of medicine, they might be perceived differently and/or more closely scrutinized by peers, faculty, and patients. Some expressed regret over the possibility of losing the digital record of a particular time in their lives; for example, there were many comments about the need to delete photographs and/or chat logs or blogs that represented archival evidence (“memorabilia”) of their college or high school years. Students spoke about feeling that they had a “right” to a personal online presence and about the value of connecting with family and friends through social media. They simultaneously reflected that their new professional identities demanded some modification of their previous online behavior. The awareness that their online presence could have an effect on the patient–doctor relationship was a common thread in their reflections.
Another frequently noted theme was role awareness within the domain of value change, demonstrating students’ acute awareness of their new professional role and the implications of their current online presence for future patient–doctor interactions. One student wrote:
I’ve never been particularly interested in social network sites—I was never even particularly active on Facebook, except when it became possible to post photos on the site…. However … I realized how unprofessional some of those photos would look to my peers, superiors, and patients. I ended up untagging/deleting about 150 photos…. I see now how different it is to be seen as a professional versus a student…. The contrast is stark. People expect students to have fun, experience new things, and maybe even get a little crazy from time to time. However, a professional is … someone who cares for the lives of other humans. When I first started untagging photos I thought, this is not fair. Why should I have to wipe away these memories?… But then I quickly came around to the conclusion that fairness is not the issue. This is about being the best we can be. I eventually realized I’m not losing any part of my identity at all. It’s not like polishing my online presence is changing who I am and the things I care about. I’m still me, and I am responsible for presenting myself as a young professional.
Secondary outcome measures
All students (180/180; 100%) submitted a postsession evaluation. Session evaluation questions asked students about the overall session quality and the effectiveness of the teaching and session exercises. On a scale of 1 to 5, with 1 as needs improvement and 5 as excellent, students rated overall session quality at 3.92 (SD 0.28), session effectiveness “for realizing importance of a professional Web presence” at 3.89 (SD 0.26), and effectiveness of session exercises at 3.63 (SD 0.32). These ratings were comparable to (i.e., not statistically significantly different from) other PPM course session ratings (range 3.04–4.56; SD 0.13–0.50).
Four-month follow-up survey.
Sixty four percent of students (115/180) responded to the online follow-up survey. Of these, 64% (74/115) reported spending an average of 1 to 10 hours weekly on online social networking, 27% (31/115) reported spending 0 hours, and 9% (10/115) reported spending more than 10 hours. Seventy-three percent (84/115) reported no planned change in their behavior, and 24% (28/115) reported an intention to reduce the amount of time they spend on online social networking. In response to the question addressing action taken since the session, 41% (47/115) chose the option “I reviewed and no action was taken,” 19% (22/115) chose “No review and no action taken,” 34% (39/115) chose “I reviewed and edited my presence,” and 6% (7/115) chose “I reviewed with significant change in Web presence.” Forty percent of respondents (46/115) then had reviewed and edited or made a significant change in their online presence after the session. When asked about future curricula, 59% (68/115) chose “there should be no discussion beyond years 1 and 2 of medical school,” 23% (26/115) chose “updates every year,” and 18% (21/115) chose “it is the faculty’s decision.”
We conducted a mixed-method study using qualitative and quantitative approaches to capture students’ responses to a brief, integrated curriculum designed to raise awareness of the potential impact of online social networking on their future professional identity. Our data also provide a snapshot of students’ online social networking behaviors at medical school matriculation. Our session was well received, as the high session evaluation ratings indicate. We used our qualitative analysis of students’ written reflections as a primary measure of curricular effectiveness. Students’ reflections confirm the universality of online social media use and its central role in students’ lives before their entry into medical school, affirming prior observations.7,12,13,21 Significantly, students’ reflections, submitted within one week of the session, indicated that although most students considered their online presence to be benign and within the bounds of their current roles as medical students, they also reported intent to monitor, edit, and change their online presence in the future. They described this intent with specific behaviors, such as “Googling self,” “editing photos,” “detagging photos,” “defriending,” and “increasing privacy settings.”
Some students reported critically examining how their online presence might be interpreted by future patients and whether proactive editing and censoring of their current activities may be needed. They demonstrated a willingness to change their online presence, while acknowledging a need to maintain a social presence separate from their professional presence. In fact, several students commented that they would consider creating a separate, professional Web presence. To quote one student: “I would advocate for different personal and professional pages. Any time we are accountable for patient health and privacy there should be no gray areas, and any online communication should be only through professional-style pages.”
Four months after the session and written reflection, many students reported that they continued to monitor and edit their online presence, although their reported time spent using social media, an average of 1 to 10 hours weekly, did not substantially change. A majority of students expressed the opinion that they did not need reminders of what they learned beyond year 2 of the curriculum, indicating that they felt that they could independently address the issue and maintain vigilance about their online activities.
On the basis of our findings, we propose a theoretical framework for integrating discussion on social media use into an existing professionalism or doctoring course, using a learner-centered approach advocated by the most recent Carnegie report, which emphasized more supportive learning environments.22 Our findings suggest that students are astute and insightful observers with respect to their social networking behaviors and that facilitated group discussion with peer exchange and debate stimulates further self-reflection in the context of their new roles as future health professionals. Such nonjudgmental discourse can generate thoughtful reflection on the intersection of social media use and professional roles, with the desired educational outcome of future vigilance. In other words, giving permission to students to discuss this otherwise private and personal aspect of their lives by creating a safe space for conversation, with explicit recognition and acceptance of the central role of online engagement in their social lives, can lead to planned future self-monitoring and a greater capacity for lifelong learning. We suggest that the framework of a facilitated group discussion followed by individual written reflection may naturally bridge the generation gap23 between faculty and students (who demonstrate a differing reliance on Web-based social media), thus increasing faculty members’ understanding of students’ reliance on social personal identity and building toward future mentoring relationships. Further, the exercise of writing the reflection may itself reinforce (or increase the likelihood of) future prudent behaviors. Students’ narrative feedback in the session evaluations (data not shown) suggests that they value being included as partners in the conversation about their online presence. We speculate that such integrated, student-centered curriculum may reduce the need for a prescriptive institutional policy that requires enforcement and the monitoring of individual students’ online presence during medical school.17,24
It remains to be determined whether students entering medical school are more receptive to this educational model than students further along in training. We also acknowledge that the question of who should teach and lead these discussions about appropriate and responsible use of online social media remains unanswered. Residents’ use of online social media more closely aligns with that of medical students than that of faculty, and they may be perceived as more credible teachers capable of bridging the digital divide.25 The findings from a recent study surveying faculty, residents, and medical students at one institution suggested that residents were more confident than faculty that they had the knowledge to teach about this aspect of professionalism but that they needed to learn additional mentoring skills to be able to do so effectively.26 The importance of faculty development and training to effectively teach and facilitate thoughtful conversation about this topic cannot be overstated.
Our study has several strengths. The mixed quantitative and qualitative measures allowed us to explore different student perspectives. For the written reflection and the postsession evaluation, we had a 100% response rate. We used a systematic, validated process for narrative coding that yielded high interrater reliability and reached theme saturation. We verified actual behavior change and intent to change using a four-month follow-up survey. In the interim between the session and the follow-up survey, no other curriculum on the topic was presented. We used a standardized yet simple curricular intervention requiring few course hours that is easily reproducible at other schools or programs.
Our study also has some limitations. We conducted it at a single institution, so our results may not be generalizable to other institutions. We inferred students’ online presence and intent to change through self-report and did not seek outside verification. However, because the PPM course is pass/fail with no penalty or reward for the content of assignments, and the range of narrative responses included the option “no action will be taken,” we believe that students’ responses were not skewed toward socially desirable responses, especially as there was no established norm for social desirability. Because we collected responses anonymously, we could not link intended actions from students’ written reflections with their corresponding responses to the four-month follow-up survey.
In an era when the public and patients can easily access physicians’ personal and professional information online,27–29 and physicians may be (rightly or wrongly) judged by their online social media presence,24–29 educating medical students early about the implications of their online presence will be integral to professionalism teaching. Our study suggests that students already have a strong Web presence and engage in online social networking when they enter medical school, are open to discussing this presence, and, more important, are ready and able to edit and monitor their presence during the course of their training. Early education has the potential to make students partners and peers in the construction of meaningful guidelines and policy about appropriate social media use, both for educators and for institutions.28,30,31 It remains to be determined whether further curricula spread throughout training are needed to refresh students’ awareness of the need to monitor their online presence. Future studies should examine whether reinforcement throughout training is needed, whether the inclusion of more complex ethical and policy issues that involve patients in the curricula would reinforce learning, and whether curricula presented at different developmental stages by different instructors or mentors have different effects on students’ behaviors and attitudes.
Acknowledgments: The authors thank the Class of 2015 at the Keck School of Medicine of the University of Southern California for their active participation in the project. The authors also are grateful to Pradip D. Patel, MD, professor of pediatrics, University of Louisville School of Medicine, for his thoughtful review of the manuscript and to Christopher Forest, MSHS, PA-C, Keck School of Medicine of the University of Southern California, for his technical expertise and assistance.
Other disclosures: None.
Ethical approval: This project received exempt status (HS-11-00570) from the institutional review board at the Keck School of Medicine of the University of Southern California.
Previous presentations: An abstract was presented at the Western Group on Educational Affairs meeting in Asilomar, California, in April 2012.
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