A surge of interest in debating the uses of social networking media—blogs and microblogs (Twitter), social networking sites (Facebook, Myspace), and content sharing sites (YouTube, Flickr)—is occurring among medical associations, medical educators, and researchers.1 Despite emerging studies that suggest benefits of social media to enhance medical practice, the published literature remains dominated by strong concerns about its perceived abuses. These social media risks are typically framed in worries about medical professionalism, and social media use is discussed as a matter of professional ethics. Two examples of this framing are the new teaching modules focusing on avoiding risky behavior2 and the codes of “e-professionalism”3 that are proliferating in medical schools and hospitals.

This emphasis on risk avoidance, although important, can foreclose experimentation and the new possibilities afforded by social media. What may be helpful is to reconsider the dynamics at stake in the guidelines that regulate online behavior and to rethink online professionalism. Toward this aim, in this Perspective, I outline three areas for critical rethinking by educators and students, as well as by administrators, professional associations, and researchers. First I highlight concerns reported through recent reviews of social media use. Then I turn to a discussion of professionalism, outlining the current scholarly debates about its changing nature and the contexts that challenge notions of medical professionalism in social media. The online terrain itself and social media’s built-in codes have also generated critical debates in digital research that are relevant here, and I have summarized this literature briefly. Next, I revisit the potential benefits of social media, including their potential to signal new forms of professionalism. Finally, the Perspective ends with specific suggestions for further research that can move the debate forward.

Examining the Evidence: Reviewing the Use of Social Media

The potential risks of using social media in medical practice are widely described.4–6 Uppermost are concerns about compromising patient confidentiality and eroding public confidence in the medical profession through posting content that contains profanity, discriminatory language, and/or depictions of intoxication or sexually explicit behavior.7 Some authors have warned that professionals’ personal messages to friends via electronic media can be scrutinized according to codes of professionalism. Charges of unprofessionalism are also linked to blogs and tweets perceived to criticize employers.6 There is general concern that a sense of disinhibition and anonymity in online environments may produce inappropriate postings, amplified immediately by the wide reach of the media.4

Responding to such concerns, some have argued for “e-professionalism”3,8 as a distinct new paradigm requiring particular training and practice. Following this recent trend, new policies have explicitly set forth prescriptions for normative behavior to regulate and reduce social media use.9 The General Medical Council of the United Kingdom, for example, released a national social media policy in April 201310 that emphasizes the prohibitive: Do not share identifiable information about patients anywhere, do not mix social and professional relations, and do not post anonymous material on any site if you identify yourself as a doctor. This “thou shalt not” orientation chimes with similar guidelines published by the American Medical Association in 2011. Medical education has responded with instruction aimed to prevent students from encountering social media hazards.2

Meanwhile, studies are now appearing that show how social media can enhance medical practice and how an online presence can foster collegiality and extend professional development and national/international linkages.11–13 A range of social media experiments are creating professional–patient support groups and discussion forums, typically to facilitate self-care14 or to disseminate public health information.15 In their scoping review of this literature, Hamm and colleagues11 conclude that while positive results tend to be reported, there is not yet much evaluation showing significant effectiveness. This lack of evidence may be one reason why social media hazards attract far greater attention than do its benefits.

Clearly, despite the proliferating studies of social media and medical professionalism, more research is needed—as is the case with any new area of practice. However, a broader problem exists: what some have called the “good and evil” framing of social media use.16 Is the rush to regulation fully warranted? Are restrictions the most useful way to respond to problematic content posted online? Greysen and colleagues17 conclude that physician postings of problematic content still constitute only a relatively small percentage of the total number of professional violations, and that these postings may be online manifestations of serious offline violations. That is, as a community, we might look more closely at whether problematic behaviors are a consequence of social media (and therefore best ad dressed through policing online activity and teaching medical students about online professionalism) or if, perhaps, the online environment simply makes more visible—and more public—some deeper problems in conceptualizing and actualizing medical professionalism.

Reconsidering Professionalism(s)

What is understood to be medical “online professionalism”? The emphasis in the social media literature falls on inappropriate individual postings. Here we see a view of professionalism as a matter of individuals making ethical decisions. The decisions are assumed to be rational, drawn from particular professional values that can be developed through education and disciplined through ethical codes.

Increasingly, this long-standing assumption is being critically reconsidered. Traditionally, professionalism has been represented as a normative value system, associated with trust, specialized knowledge, and the discretion needed to manage risk in public service.18 However, critics argue that professionalism is not a way of being; rather, it is an ideological discourse used to ensure occupational containment and control.19 For example, Lewis20 highlights the fundamental conflict between the discourses of institutionalized medicine (the “profession”) and of “professionalism” (which still tends to focus on the values and behaviors of individual clinicians). The profession emphasizes expert-driven, high-tech, high-cost interventions—sometimes at the expense of humanistic patient care, social justice, and democratic inquiry. However, professionalism makes the individual responsible for both altruistic care and duty to multiple authorities. The professionalism discourse works well as rhetoric to contain deep systemic conflicts by controlling individual practitioners and making these individuals primarily accountable for navigating the system to meet conflicting demands.

Furthermore, recent debates in medical professionalism have shown the inadequacy of singular frames of professionalism. These traditional frameworks simply cannot respond to multiple regulators, fast-changing evidence, and new forms of practice.21 Growing research points to the pluralism of medical professionals’ responsibilities.22 Professionals must juggle obligations to institutional rules and efficiencies, to patients and families, to broad social needs, to medical science, to professional standards and regulatory codes, and to their own personal values. This “web of commitments” often necessitates what May23 has called “legitimate compromises.” Doctors navigate a path of action that simultaneously balances concerns for different stakeholders without necessarily meeting the full expectations of any one. For example, in social media, a junior doctor may regularly blog about incidents from his anesthesia practice to illustrate common dilemmas for students and educators. The postings may cover effective strategies but may also reveal problems: entrenched routines, conflicting protocols, ineffectual hospital processes of organizing and resourcing, questionable staff competence, family issues. Even if all the material is anonymized and responses from colleagues and the public are overwhelmingly positive (both for making visible—and interesting—the complex dynamics of medical practice and for launching lengthy debates about best practices where there are conflicting priorities), such a blog can easily be dismissed as “unprofessional.” Blog readers may be able to discover the identities of patients, providers, staff, or others; the physician may potentially contravene an employer’s contract; blog postings may flout professional codes of ethics respecting colleagues; and blog content may compromise some patients’ confidentiality.

Some experts have argued that entirely new understandings of professionalism are called for by these conflicts. For example, critical studies24 show that universal lists of professional virtues are not fit for the contradictory demands of contemporary practice. Evetts,25 a sociologist of professions, draws attention to new realities of professionalism being produced through the infiltration of markets into public institutions such as hospitals; that is, she shows how the conventional self-regulation and altruistic commitments defining a professional community (“occupational” professionalism) are being displaced and overridden by employers’ demands and output measures (“organizational” professionalism). Increasingly, researchers are studying professionalism as a collective endeavor embedded within complex systems. For example, Martimianakis and colleagues26 show how a simple direction to a clinical clerk from her emergency department supervisor that she conduct a quick internal vaginal examination of a pregnant patient in a busy hallway integrates multiple conflicts of professionalism: patient-centered care, resource constraints, historic institutional conflicts and practice, hierarchies, gender and race, and the different roles demanded of doctors (problem solver, humanist, teacher, colleague, advocate, cooperative employee).

All of these issues speak to a more systemic, relational, and even pluralist approach to understanding professionalism. Certainly, the networked context of social media in itself challenges an isolated focus on the behaviors of individual professionals. Additionally, this fluid online context deserves a more critical examination before the medical community tackles the question of how to balance pluralist understandings of professionalism with important responsibilities of professional conduct.

Thinking More Critically About Social Media

Technology becomes valuable, meaningful, and consequential only when people actually engage with it in practice, according to digital work specialist Orlikowski.27 The operation and outcomes of technologies such as new social media are not fixed or determining. They are always emergent through interaction with humans in practice: what Orlikowksi27 calls the contingent intermingling of virtual spaces. In health care, the various online users interacting through social media—professionals, students and colleagues, patients, families, and other stakeholders—are not easily separated. Yet research in online medical professionalism does not often account for these interrelations.

Furthermore, there are important dynamics to consider critically, such as the algorithms and technological affordances built into the software itself. These create digital infrastructures that govern everyday practice: what Kitchin and Dodge28 call “codespace.” Existing histories of social media are already shaping particular forms of participation. Facebook algorithms and routines shape the content and style of exchange, as well as what is taken for knowledge. Van Dijk’s29 in-depth study of social media use shows how patterns of “friending,” “favoriting,” linking, trending, and following have come to shape broader cultural expectations for relationships. Notions of privacy itself are being reconfigured through online norms. These changing ideas of relationship, privacy, and knowledge are bound to affect how patients and professionals engage online.

Those of us in the medical community also need to be more critical of assumptions that “openness,” blurred boundaries, and connectivity are inherently good things. Users donate free labor to generate content that creates commercial profits for digital corporations, and user connectivity feeds corporate data mining.30 From this perspective, social media participants can simultaneously be viewed as empowered agents and targets for exploitation. Further, the “digital divide” continues to complicate genuine online outreach to aging, low-income, or rural populations. These are broader issues that would be well worth examining with medical students. This sort of instruction can help develop their deeper critical thinking about what is really happening when they engage with patients and colleagues through social media platforms.

Despite these very real, often-unexamined issues, the virtual environment generated through social media affords unique benefits for communication. Common practices of content reiteration and remixing (combining content and even techniques of different media types) connect participants in unique ways while producing new hybrid forms of knowledge. Virtual tagging practices (tags generated dynamically to sort, group, and display items) continually reconfigure knowledge while remixing past and present.31 The phenomenon of our “traces” or digital footprints in virtual environments (photos, Web pages, posts, even our patterns of clicks and selections, etc.) creates resources that can be harvested in useful ways. Instead of promoting anxiety and control-seeking, we educators might help students think more in terms of distributed agency, emerging human–nonhuman interactions, and surprising new forms of practice.32

Issues for Further Research

More studies are needed—a common refrain among medical researchers publishing about social media. We need robust, comparative accounts of how physicians and students in different clinical contexts actually use social media in their everyday practice. Nuanced empirical examinations in situ can trace practitioners’ dilemmas and how they negotiate these, showing the conflicting norms and obligations at play. How do professional identities shift and adapt through social media? What identities are constructed online? What forms of professional–patient communication are evolving online?

We also need studies providing evidence about the effectiveness of using social media to engage the public, provide service, and disseminate useful information. How can physicians communicate better with the public online? What innovative uses of evolving social media can improve outreach, involve patients and families more meaningfully in health decisions, promote public debate about health, and disseminate up-to-date information? Cross-professional studies in the public service sector can be useful here, as social media use is generating broad experiments in policing, nursing, pharmacy, teaching, and social care.12,33,34 Research also needs to examine not just the behavior of professionals but also their online interaction with the public.

This sort of research could help identify new guidelines for and issues regarding professionalism in social media that avoid the ideological closure or simple restricting of e-professionalism. Further, this approach challenges the prevailing focus on how single individual practitioners use social media tools for certain predetermined objectives. Instead, we need to acknowledge how clinicians are continually configuring and being reconfigured in their professionalism as they engage online. Studies need to track these dynamics against the changing capacities and applications of technology and its changing norms of use. Such studies turn from preoccupation with behaviors of the individual medical professional to professionals-in-relation: with patients and families, with colleagues from one’s own profession and other allied occupations, with stakeholders and advocates, and with the social media tools themselves.

In Sum

The growing literature about online medical professionalism is highlighting important problems. Some of it, however, may be reinforcing old discourses of professionalism as containment and control. I suggest that we physicians look more deeply at what constitutes professionalism. Regulations and instruction in online behavior can help address some immediate issues but may not develop students’ capacity to think critically about their engagements in digital worlds. Nor can such restrictive, didactic approaches to professionalism help students to navigate the larger issues at stake in their practice: central conflicts between profession and professionalism, and contradictory demands among stakeholders. New social media are continually appearing, often in response to what users do, with profound effects on both social norms and the meaning of professionalism. These media need broad critical examination by educators as well as students to appreciate how they influence interactions, relationship structures, the meaning of privacy, and the value of certain types and bodies of knowledge.

The approach I advocate does not rush to govern “bad” social media practices but, rather, looks more closely—and more critically—at its current and future implications for practice beyond the simplistic, dualistic good/evil framing. We need more empirical research examining professionals’ and students’ everyday experiences and strategies in working through dilemmas, as well as the implications of these strategies and experiences. We need to foster new understandings of how using social media affects professional boundary issues, online identities, relations with patients and other stakeholders, and professional learning. As we study these questions, we are likely both to witness new guidelines governing professionalism and to develop new understandings of the notion of professionalism. Given the widespread shift to treat professionalism as a pluralistic range of practices rather than as a singular set of virtues or state of being, we might focus on tracing the new forms of professionalism that are emerging through various online experiments. The most important question may not be how to protect professionals online but, rather, how social media can open new debates about medical professionalism for better patient care and healthier societies.

Acknowledgments: The author gratefully acknowledges the comments of three anonymous reviewers whose suggestions have helped strengthen this Perspective.

References 1. Hamm MP, Chisholm A, Shulhan J, et al. Social media use by health care professionals and trainees: A scoping review. Acad Med. 2013;88:1376–1383 2. Lie D, Trial J, Schaff P, Wallace R, Elliott D. “Being the best we can be”: Medical students’ reflections on physician responsibility in the social media era. Acad Med. 2013;88:240–245 3. Spector ND, Matz PS, Levine LJ, Gargiulo KA, McDonald MB 3rd, McGregor RS. e-Professionalism: Challenges in the age of information. J Pediatr. 2010;156:345–346 4. Greysen SR, Kind T, Chretien KC. Online professionalism and the mirror of social media. J Gen Intern Med. 2010;25:1227–1229 5. Mostaghimi A, Crotty BH. Professionalism in the digital age. Ann Intern Med. 2011;154:560–562 6. Mansfield SJ, Morrison SG, Stephens HO, et al. Social media and the medical profession. Med J Aust. 2011;194:642–644 7. Chretien KC, Greysen SR, Chretien JP, Kind T. Online posting of unprofessional content by medical students. JAMA. 2009;302:1309–1315 8. Cain J, Romanelli F. E-professionalism: A new paradigm for a digital age. Curr Pharm Teach Learn. 2009;2:66–70 9. Kind T, Genrich G, Sodhi A, Chretien KC. Social media policies at US medical schools. Med Educ Online. September 15, 2010;15 10. General Medical Council. Doctors’ Use of Social Media. 2012 http://www.gmc-uk.org/guidance/10900.asp. Accessed June 17, 2014 11. Hamm MP, Chisholm A, Shulhan J, et al. Social media use among patients and caregivers: A scoping review. BMJ Open. May 9, 2013;3 12. Hawn C. Take two aspirin and tweet me in the morning: How Twitter, Facebook, and other social media are reshaping health care. Health Aff (Millwood). 2009;28:361–368 13. Omurtag K, Turek P. Incorporating social media into practice: A blueprint for reproductive health providers. Clin Obstet Gynecol. 2013;56:463–470 14. Berntsen E, Babic A. Cherry: Mobile application for children with cancer. Stud Health Technol Inform. 2013;192:1168 15. Cameron AM, Massie AB, Alexander CE, et al. Social media and organ donor registration: The Facebook effect. Am J Transplant. 2013;13:2059–2065 16. George DR, Green MJ. Beyond good and evil: Exploring medical trainee use of social media. Teach Learn Med. 2012;24:155–157 17. Greysen SR, Chretien KC, Kind T, Young A, Gross CP. Physician violations of online professionalism and disciplinary actions: A national survey of state medical boards. JAMA. 2012;307:1141–1142 18. Freidson E Professionalism: The Third Logic. 2001 Cambridge, UK Polity Press 19. Fournier V. The appeal to “professionalism” as a disciplinary mechanism. Soc Rev. 1999;47:280–307 20. Lewis BWear D, Aultman JM. Medical professionals and the discourse of professionalism: Teaching implications. Professionalism in Medicine: Critical Perspectives. 2006 New York, NY Springer:149–161 In: 21. Christmas S, Millward L New Medical Professionalism: A Scoping Report for the Health Foundation. London, UK Health Foundation October 2011. http://www.health.org.uk/public/cms/75/76/313/2733/New%20medical%20professionalism.pdf?realName=JOGEKF.pdf. Accessed June 17, 2014 22. Zukas M, Kilminster SHager P, Lee A, Reich A. Learning to practise, practising to learn: Doctors’ transitions to new levels of responsibility. Practice, Learning and Change: Practice-Theory Perspective on Professional Learning. 2012 New York, NY Springer:199–213 In: 23. May L The Socially Responsive Self: Social Theory and Professional Ethics. 1996 Chicago, Ill University of Chicago Press 24. Stronach I, Corbin B, McNamara O, Stark S, Warne T. Towards an uncertain politics of professionalism. J Educ Policy. 2002;17:109–138 25. Evetts J. Sociological analysis of professionalism: Past, present, future. Comp Sociol. 2011;10:1–37 26. Martimianakis MA, Maniate JM, Hodges BD. Sociological interpretations of professionalism. Med Educ. 2009;43:829–837 27. Orlikowski WJ. Sociomaterial practices: Exploring technology at work. Org Stud. 2007;28:1435–1448 28. Kitchin R, Dodge M Code/Space: Software and Everyday Life. 2011 Cambridge, Mass MIT Press 29. Van Dijk J The Culture of Connectivity: A Critical History of Social Media. 2013 Oxford, UK Oxford University Press 30. Curran J, Fenton N, Freedman D Misunderstanding the Internet. 2012 London, UK Routledge 31. Deuze J. Participation, remediation, bricolage: Considering principal components of a digital culture. Inf Soc. 2006;22:63–75 32. Bayne S. Academetron, automaton, phantom: Uncanny digital pedagogies London Rev Educ. 2010;8:5–13 33. Green B, Hope A. Promoting clinical competence using social media. Nurse Educ. 2010;35:127–129 34. Schmitt TL, Lilly K. Social media use among nurses. J Dermatol Nurses. 2012;4:181–187