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Chapter 7: Electronic Professionalism

Chapter Authors: Nicholas C. Kuzma, MD & Nancy D. Spector, MD

Advances in technology have revolutionized medical education and expanded the reach of communication both within and outside of the medical community. While these advances have led to numerous benefits in medicine, they have also created new challenges in professional behavior for medical trainees and faculty. The use of e-mail, text messaging, smart phones, social networking sites and mobile applications have accelerated communication among health care providers, but also have the potential to create conflicts not previously encountered. Most hospitals, medical schools and graduate medical education programs now have social media guidelines.  Despite the presence of these institutional standards, both medical educators and trainees believe that they frequently view inappropriate posts, created by their colleagues, on commonly utilized social networking sites1,2.

The three responsibilities outlined in the Physician Charter that are most relevant to this area of professionalism are:

  • Commitment to patient confidentiality
    • New electronic communication technologies, including social networking sites, have transformed the way people communicate and share information. While these technologies can aid in the care of patients (e.g., sharing a photo of a rash with a dermatologist), physicians must protect this information as they would any other confidential documents.  It goes without saying that it is never appropriate to share patient-identifiable information on any unsecured social networking sites. For other types of professional communication, there are HIPAA compliant technologies available and physicians, with the assistance of IT specialists within the institution, should utilize those technologies in order to assure patient confidentiality.
  • Commitment to maintaining appropriate relations with patients
    • The rise of social networking sites has blurred traditional patient-physician boundaries.  As physicians, we are taught to keep an appropriate separation with our patients.  Becoming “friends” with patients can result in a sharing of many, more private, aspects of our lives with our patients.  Almost all guidelines relating to electronic professionalism discourage physicians from “friending” patients or families on social networking sites. 3-5  In contrast, physician practices have developed social media presences to share information and enhance access for patients and their families. Patients “friending” professional social media sources does not interfere with maintaining appropriate relations.   
  • Commitment to professional responsibilities
    • The loosening of social inhibitions in the online environment often allows people to behave differently than they would in person, a phenomenon known as the online disinhibition effect6. Negative comments written on social networking sites by physicians, even when posted anonymously, can damage the doctor-patient relationship. Physicians need to avoid online disinhibition by respecting social media guidelines and participating in the processes of self-regulation.

Medical professionalism underpins the trust the public has in physicians.  Electronic communication and social media may facilitate the ability of physicians to meet their professional responsibilities to society by ensuring effective communication with the public at large. However, physicians must be cognizant of the “three P’s” of electronic professionalism: public, permanent and powerful7.

  • Public 
    • While social networking sites contain purposefully public communications, “private” e-mail and text messages may inadvertently become public as well. Copies of e-mails and text messages are kept by e-mail service providers and telecommunication companies and are discoverable in a lawsuit. There have been numerous instances in which confidential information and unprofessional behavior became public in this fashion.
  • Permanent
    • An inappropriate statement or photograph can exist forever in an electronic medium (be it an e-mail, text message, or social networking site posting) and eventually make its way into the public realm, leading to embarrassing disclosures of unprofessional behavior.
  • Powerful
    • The permanence of electronic media and the potential for public disclosure make these communications quite powerful. For example, sending identifying patient information electronically without the use hospital-approved encryption can jeopardize patient confidentiality and privacy.  Additionally, inappropriate use of technologies poses a threat to workplace professionalism, especially within the inequitable relationships common in medical education (e.g., resident-medical student, or faculty-resident). 

The Pediatric Competencies that are most relevant to this area of professionalism are:

  • Patient Care
    • Provide effective health maintenance and anticipatory guidance
  • Practice-based Learning and Improvement
    • Use information technology to optimize learning and care delivery
    • Develop the necessary skills to be an effective teacher
  • Interpersonal and Communication Skills
    • Communicates effectively with patients, families, and the public, as appropriate, across a broad range of socioeconomic and cultural backgrounds
  • Professionalism
    • Professionalization
    • Professional Conduct
    • Cultural Competence
  • Systems-based Practice
    • Know how to advocate for the promotion of health and the prevention of disease and injury in populations

Behavioral Statements

The components of electronic professionalism listed above provide general goals. It may be helpful to identify specific behaviors or practices that would exemplify professional conduct and some that would represent lapses of professionalism.

Examples of Exemplary Professional Conduct:

  • Separates professional and personal content online
  • Maintains a professional decorum in personal content
  • Does not use publicly accessible social media to discuss individual patients or their care
  • Treats colleagues fairly and with respect in all forms of interaction and communication
  • When posting material online, declares any conflicts of interest transparently
  • Maintains appropriate physician-patient boundaries
  • Notifies a colleague if his or her electronic communications appear inappropriate 

Examples of Lapses in Professional Conduct:

  • Consistently uses electronic media during educational activities for unrelated purposes
  • Sends communications to colleagues that are harassing or intimidating in nature or include disrespectful language or tone
  • Does not obtain consent for patient photographs
  • Uses non-encrypted technology when sending confidential patient information
  • Violates institutional human resource policies or federal privacy laws
  • Displays social media content that discriminates against an individual or group on the basis of culture, beliefs, race, gender, sexual orientation or religion
  • Routinely uses the internet or social networking sites to gather personal information about patients 

Teaching Professionalism

Learning Objectives for the Trainees:

  • Describe how electronic communication technologies have effected medical practice and professionalism
  • List examples of information that are inappropriate to post online
  • Describe the risks and potential consequences of sending unencrypted e-mails or text messages that contain protected health information 
  • Discuss the impact of social networking on the professional boundaries between physicians and patients
  • Identify situations when the use of electronic communication may become a disruption in a hospital or doctor’s office
  • Discuss the impact of social networking on the inequitable relationships inherent to a teaching hospital or medical education environment
  • Ascertain that multiple perspectives and opinions exist regarding social networking site content
  • Rate the risks and benefits of commonly used modes of interpersonal communication within the hospital
  • Discern when it is acceptable to use the internet or social media to gather information about a patient 

Teaching Methods

Reflective Exercises

These reflective exercises can be used for individual reflection on professionalism issues or can be modified and discussed as part of a larger group meeting:

  • Have trainees review your hospital’s social media policies. Following the review, ask the trainees to discuss examples of social media content they have encountered that has violated these guidelines. In addition, ask the trainees to describe what next steps they take after viewing inappropriate content.
  • Many trainees believe that electronic professionalism guidelines impede individualism. Have a group of residents discuss this perception. What are the best ways to balance personal and professional content online?  Following initial discussion, ask trainees to identify examples of physician generated social media content that is professional and allows for individual expression.
  • Have trainees brainstorm ways that physicians can professionally use social media to help meet their responsibilities to patients and society.
  • After holding a focused discussion on the disruptions encountered by use of electronic communication during educational forums or patient encounters, ask trainees to discuss an incident in which they found the use of electronic communication distracting either to themselves or to others.  Ask how each handled the situation.  Discuss if silence promotes, condones and improves disruptive behaviors.
  • Discuss how electronic health records affect the doctor-patient relationship.

Using any of the vignettes below, ask trainees to describe a similar real-life situation. Ask them to identify the conflicting values and what they learned from the situation. 

Vignettes

Chapter 7 Vignettes - Electronic Professionalism

Vignette 1 - Facebook crowd sourcing

Points to consider during discussion:

  • Identify any potential patient privacy concerns.
  • What would you do after reading this message?

Vignette 2 - Fax or text?

You are on call overnight and obtain an ECG on a child who presented with syncope. You think the ECG is abnormal and call the on-call cardiologist. Instead of faxing the ECG, she asks you to text a photograph because she will receive it faster and the ECG will be easier to read.  

Points to consider during discussion:

  • Identify any potential patient privacy concerns.
  • What would you do next?
  • If protected health information is not included, is consent needed to send the ECG?
  • What can you do to ensure that this communication is more secure?

Vignette 3 - Personal info via text

Points to consider during discussion:

  • Identify any potential patient privacy concerns.
  • Does it matter if it’s a work phone or your private phone?
  • What medical information is OK to text on an unsecured network?
  • What can you do to ensure that this communication is more secure?

Vignette 4 - YouTube post

One of your colleagues places your intern "class video" on YouTube. The video is a humorous depiction of the intern class' first year of training.  It contains no protected health information.

Points to consider during discussion:

  • Does placing this video on YouTube create any professionalism issues?
  • How might your opinion of the video change if you were a hospital administrator or the parent of a patient?

Vignette 5 - Tweeting complaints

Points to consider during discussion:

  • What professionalism issues are highlighted in this vignette?
  • What would you do after reading this message?

Vignette 6 - Tweeting about personal opinions

Points to consider during discussion:

  • Many people will disagree with this post, but does it create any professionalism issues? 
  • Is there a difference between sending this message using an anonymous versus identifiable account?  
  • What would you do after reading this message, knowing it came from a colleague?

Vignette 7 - Neophyte doc 

A well respected, older physician, an expert in his field, tells you he is proud that he has never used Twitter, Facebook or any other social networking site.  He isn’t even sure if information about him can be found online. 

Points to consider during discussion:

  • What are the downsides to ignoring social media and electronic communication technologies? 
  • How can web 2.0 technologies be used to advance a physician’s role as a professional?  
  • Is this doctor correct in believing that he doesn’t have an online footprint? 

Vignette 8 - Message board post

Points to consider during discussion:

  • Does commenting in this situation violate any electronic professionalism guidelines? Is commenting beneficial? 
  • When giving medical advice online, should you state that you are a physician (or a medical student)? Is it better to use your real name or post anonymously? Should you mention the name of the hospital (or medical school) where you work?

Vignette 9 - Advice for a friend

Points to consider during discussion:

  • Who should you give medical advice too? 
  • What conflicts exist in this situation?
  • What medical-legal issues should be considered?
  • Does giving advice electronically instead of face-to-face change any of these issues? 

Vignette 10 - Searching for info

The day before your continuity clinic, you always search for information about your adolescent patients on Google and Facebook to identify any risk taking behaviors that you want to discuss with them.

Points to consider during discussion:

  • How can the internet affect the doctor-patient relationship?
  • What professionalism issues are highlighted in this vignette?
  • Is it OK to routinely use the internet or social networking sites to gather information about your patients or only in certain circumstances?
  • Is there a difference between searching social media sites about patients and searching about residency or fellowship applicants? 

Vignette 11 - Broadcasting complaints

Points to consider during discussion:

  • What professionalism issues are highlighted in this vignette?
  • How would you give feedback to your colleague?
  • What are potential solutions to help resolve the problem between your colleague and the senior resident?

Vignette 12 - Inapropriate posts

While in the ED one evening, a teenager arrives after being stabbed in the abdomen.  The knife is still protruding from the abdomen.  The PEM fellow wishes to get a picture of the wound/knife for teaching purposes, but he has forgotten his camera.  After obtaining patient/parent consent, he asks you to take a picture using your cell phone and e-mail it to him, which you do.  Later that week, while looking at a different colleague's Facebook profile, you see that she posted the image with the caption, “You never know what will walk in off the streets.”  Several residents have left comments about the image on her Facebook page.

Points to consider during discussion:

  • Under what circumstances is it appropriate to take educational medical photographs?
  • Is it appropriate to use an internet-connected cell phone to take such images?
  • What are the risks of transmitting medical images electronically?
  • Who has behaved unprofessionally here?  You?  The PEM fellow?  The resident who posted the image on Facebook?
  • What medical legal issues should be considered?

Vignette 13 - Embarrassing post

Points to consider during discussion:

  • Does this post create any professionalism issues? 
  • What would you do after seeing this post about yourself?

Vignette 14 - To friend or not to friend?

Points to consider during discussion:

  • Inequitable relationships are inherent to teaching hospitals and the medical education environment (e.g., resident-medical student, or faculty-resident). How can social media affect these dynamics? 
  • Does this request create any professionalism issues?
  • Would you “confirm” this request? What if it was your Senior Resident? Chief Resident? Program Director?

Vignette 15 - Talking about tests

Points to consider during discussion:

  • Does this message create any professionalism issues?
  • Does this message constitute irregular exam behavior that can be investigated and have action taken?

 

Assessment Tools

There are no published tools to assess a trainee’s electronic professionalism.

References

  1. Kesselheim JC, Schwartz A, Belmonte F, et al. A National Survey of Pediatric Residents' Professionalism and Social Networking: Implications for Curriculum Development. Acad Pediatr. 2016;16(2):110-4.
  2. Kesselheim JC, Batra M, Belmonte F, Boland KA, Mcgregor RS. New professionalism challenges in medical training: an exploration of social networking. J Grad Med Educ. 2014;6(1):100-5.
  3. Shore R, Halsey J, Shah K, Crigger BJ, Douglas SP. Report of the AMA Council on Ethical and Judicial Affairs: professionalism in the use of social media. J Clin Ethics. 2011;22(2):165-72.
  4. Federation of State Medical Boards. Model policy guidelines for the appropriate use of social media and social networking in medical practice. http://www.fsmb.org/Media/Default/PDF/FSMB/Advocacy/pub-social-media-guidelines.pdf. Accessed March 1, 2015.
  5. Farnan JM, Snyder Sulmasy L, Worster BK, et al. Online medical professionalism: patient and public relationships: policy statement from the American College of Physicians and the Federation of State Medical Boards. Ann Intern Med. 2013;158(8):620-7.
  6. Suler J. The online disinhibition effect. Cyberpsychol Behav. 2004;7(3):321-6.
  7. Spector ND. e-Professionalism: Challenges in the Age of Information. J Peds 2010: 156(3): 345-346.

Acknowledgements

We would like to acknowledge the following colleagues for their contributions to the development of some of the concepts included in this chapter:  Paul S. Matz, MD, Katherine Gargiulo, MD, Robert McGregor, MD, Matthew McDonald, MD and Leonard Levine, MD.  

Index of Pediatric Competencies addressed by learning activities

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