Like other professions today, medicine faces the opportunities and challenges of an increasingly digital world. Professionalism challenges for medicine have recently been highlighted, from the discovery of potentially unprofessional content on health professionals' weblogs1 and medical trainees' social networking pages2 to deans' reports of unprofessional online content by medical students.3 Many U.S. medical school deans have reported incidents of unprofessional online postings by students, a few resulting in dismissal. However, only a minority of schools have Internet-specific policies in place. While some schools are in the process of creating new policy and guidelines, there are no national consensus guidelines for physician or medical student posting.3

Defining what constitutes professional versus unprofessional online behavior is difficult. While some behaviors clearly are unacceptable (e.g., patient privacy violations), others fall into a subjective continuum of acceptableness. Finding balance in expression of free speech and upholding medicine's social contract with society may require consensus gathering among all stakeholders: the public, practicing physicians, medical educators, and students.

Medical students' perspectives on online professionalism have not been well explored. Students have a unique perspective, many having grown up using Web 2.0 technologies. Better understanding of how students define unprofessional content and how students feel schools should handle these issues could help inform policy-creation efforts as well as approaches to teach online professionalism. We conducted a focus group study of medical students to understand and incorporate student perspectives into online professionalism discussions.

Method

We conducted six focus groups in November 2009 with medical students from George Washington University (GWU). Because views of preclinical students might differ from clinical students, we grouped first and second years separately from third and fourth years, with a goal of three groups each, 8 to 12 students per group.4 Recruitment included e-mail and verbal announcements, flyers, and snowball referrals. Participating students were provided dinner and entered into a drawing to win medical books. Groups were completed within a two-week period to minimize group cross-contamination. The GWU institutional review board approved the study.

To ensure triangulation in data collection, three moderators conducted the groups. None taught or evaluated medical students.

Moderator guide topics stemmed from questions raised by existing literature.3 Open-ended questions asked about general online habits, nature of students' postings, what would constitute inappropriate posted material, and thoughts about institutional guidelines. On arrival to the session, students completed anonymous surveys to collect demographic data. One of three student observers attended each focus group. At each session's conclusion, moderators summarized and paraphrased students' discussion points as a form of member checking. Moderators and observers recorded what they thought were the major findings discussed during the sessions.

Two authors (K.C.C., T.K.) independently read, reviewed, and coded the transcripts for themes using content analysis methods. Findings were compared with those recorded by moderators and observers, and no differences were found.

GWU School of Medicine and Health Sciences does not have formal guidelines or specific policy for student online posting. Starting in 2008, the dean has included remarks regarding responsible social networking use during new class orientation.

Results

Sixty-four students participated in six focus groups, with 8 to 12 participants per group. The average age in the preclinical groups was 23.7 years and, for the clinical groups, 27.1. Forty-four percent (28/64) were male. There were 8 (13%) first-year, 22 (34%) second-year, 27 (42%) third-year, and 7 (11%) fourth-year students. Each group lasted approximately 90 minutes.

Findings fell into four main categories: general Web 2.0 habits, online professionalism, concerns, and guidelines. With the exception of differences in general Web 2.0 habits, no differences were found between preclinical and clinical groups.

General Web 2.0 habits

Students' self-reported Web 2.0 usage varied on the basis of amount of free time, medical school coursework, and exams, with a range of multiple times an hour to rarely or never. Students in years 3 and 4 reported accessing social networking sites less often compared with their preclinical years. The vast majority of students used Facebook. They reported passive Web 2.0 behaviors (reading, observing, having pictures of themselves posted by others) more often than active behaviors. The majority of students were identified online by name as well as by institution.

Students reported using social networking sites for social updates and distraction.

I think for us we have such a hard time keeping in touch with people because of how busy we are, [so] this is the one way where we can let our friends know we're still alive and we care about you.

Postings by students generally involved personal matters and medical school. They often posted about novel experiences in medical school or in response to specific classes, exams, or rotations.

[A classmate] posted, “I lost my first patient.” I think for a lot of people it's not that he needs people to know he did, but it just happened. I think sometimes we post things just because we're frustrated and need somebody else who understands to see it.

Online professionalism Beyond HIPAA violations and illegal activity, inappropriate postings not clear cut.

Students uniformly expressed that respect for patient confidentiality laws online was critical.

Anything that's even remotely related to a HIPAA infraction should be stayed as far away from as humanly possible … it's completely, completely illegal; not just inappropriate, it's illegal.

Beyond privacy violations, students had differing views on what they considered inappropriate to post online. Many students considered posting pictures depicting intoxication and sexually suggestive material inappropriate. References to alcohol, specifically, generated energized discussion. Some students felt that speaking poorly about attending physicians, their medical school, and specific classmates was also inappropriate. Yet, others felt nothing was inappropriate.

I don't think anything is inappropriate per se. I mean it's only inappropriate to the point that it really impacts your own personal relationship with your clients or your group.

Students experience online identity conflicts.

Students noted the distinction between one's professional and social identities, and how these could be blurred online.

You have a professional personality and you have a social personality and those two things are often very, very different. I don't … really want people knowing about different parts of my life.

I think your professional network and social network are just one on Facebook…. I added one of the residents I work with [as a “friend”]…. I want to make sure that I don't look like a complete idiot—because she could say something.

They also recognized how their online “footprint” might not reflect who they actually were or wanted to be.

I think we're all trying to just draw the line between showing who we are and sort of hiding the bad, if you want to call it that. I personally am going to take down pictures from college because that was a while ago and that's not who I am really anymore.

Just because we happen to be entering this profession, we can't completely cut off the person that we are, but we can just present it in a better way.

Some students felt that their online behaviors only had repercussions for themselves; a minority recognized their behaviors could reflect on their institutions or the medical profession.

Different professional standards for medical professionals debated.

Some students felt that medical professionals were held to a higher standard.

I think we're held to a higher standard in some senses in terms of our professional behavior and even our personal behavior.

Others disagreed.

Concerns Many situations increased students' perceptions of online risks.

Students described many situations that raised their concern about the risks of online activity such as interviewing for medical school, starting the clinical years, and applying for jobs and residency.

My privacy settings were the same versus two years ago and now, but they will definitely change during rotations when I start seeing patients and they know me by name.

Hearing personal stories from friends and family, warnings by faculty/deans, and media stories also raised perceptions of risk. One student described the reaction from fellow students during orientation where a dean relayed an anecdote highlighting the need to be careful posting information online:

I helped with orientation for the first years this year, and after that talk, they were all really, really scared and lot of them went home and really went through their Facebook and changed a lot of stuff. They asked me … is this serious? What should we be doing? So I think it concerns people.

There was also a common feeling that just being a medical student caused them to be careful about what they posted online.

Many have taken precautionary behaviors.

Students described many actions taken to limit publicly available posted information about them. These included expunging material, untagging (removing name-indexing “tags”) photographs, deactivating their Facebook accounts, and increasing privacy settings.

Unless you are actually a friend of mine, you cannot see anything about me, and I don't think you can even search for me which was an important privacy setting for me.

I've started making a conscious decision not to take certain pictures like last night I was dodging cameras because I don't want to deal with it anymore. I don't need a million pictures of me taken.

As a result of these precautionary behaviors, some expressed feeling unfairly constrained.

I think it has started to become really limited for us because we can't really express ourselves fully. I think we're a good group of students, I mean we're in medical school, the little amount of fun that we can have, we can't really talk about it on Facebook.

Facebook ambivalence.

When talking about Facebook, students displayed ambivalence. On the one hand, Facebook is perceived as a vital social hub that is “so valuable to stay in touch with people.” Many students expressed that they felt they had to use Facebook since all their friends were on it.

Yet, they also saw it as an increasingly risky “forum that can get you into trouble.” Not all enjoy using Facebook, and some feel trapped by its role in their lives.

I have Facebook not by choice. I actually hate it, but I feel like you have to have Facebook these days.

I immediately shut down the idea [of getting rid of Facebook account] when I realized I would have no communication whatsoever.

Privacy setting skepticism and perceived lack of control.

Some students were wary of privacy settings on social networking sites, believing that one still had to be careful, even with the highest privacy settings in place. “I'm skeptical that if it's blocked then it's blocked because … people can hack into anything.”

Tied into this skepticism was a perceived lack of control of information posted about them online.

Facebook, the wall postings, and the picture postings are a lot like driving a car. You can control your own circumstances as much as you want, you can not post scandalous things or you can not put naked pictures of yourself online, but you can't control what your friends put on.

Some students felt resigned to this lack of control.

You obviously don't want really inappropriate things on the Internet with your name attached to them, but it's unavoidable.

Guidelines Medical student posting guided by general expectations of medical students, common sense.

The medical students did not know of any formal guidelines in place for what they posted online; instead, they were guided by their individual interpretations of what was expected from medical students and by the desire to limit personal risk.

It's what you envision that the profession would want or would expect of you, or what would prevent you from getting a job, or what would prevent you from getting into medical school, what you think society's norms are.

Some felt that these expectations of medical students were unreasonable.

Recommendations are welcome, but don't control.

Most students did not believe formal guidelines for posting online content were necessary or desirable. They felt medical students should know better, using their common sense: “If you think … it's appropriate to have yourself naked all over the Internet, maybe you shouldn't be a doctor.” Others thought that having institutional guidelines would be insulting:

I think I'd find it insulting if the medical school handed down a set of guidelines that said this is what you can't post on your [Facebook] profile but we expect you to use your judgment when it comes to this patient's life.

Students expressed concern that institutional guidelines would be too controlling; it was a personal risk.

I think it's your own risk, I mean, if you really want to put yourself out there, you should … if someone else down the road sees you and you get burned, and you don't get a job because of something on Facebook, that was your judgment at the time.

Those that were in favor for having guidelines felt that other students could benefit from having them:

I think yes … some of the younger students who are right out of college … may not have as much of a grasp at the idea of professionalism.

In addition, some students felt formal articulations of expectations were needed if schools were to take disciplinary actions for posted content.

While some students felt it would be acceptable for schools to have guidelines for online behavior during working hours, students' personal time was off-limits.

You can control the activities that we do from 8:00 in the morning until 5:00 pm but besides that—our own personal lives—you can't control that.

However, while having guidelines was often contested, the consensus was that recommendations on appropriate posting would be acceptable.

I think there should be … recommendations, not guidelines…. We feel that it's inappropriate to put X, Y, and Z on your Facebook page.

Suggest raising awareness through discussion, involve students.

Students felt that raising awareness of online professionalism issues was important but were against any kind of formal monitoring of their online activities.

I think it's nice to make medical students aware that people like physicians and attendings and even patients can find you and see you on Facebook … but [deans] shouldn't check [sites] regularly.

They suggested incorporating online professionalism into existing professionalism curricula.

I'm all for teaching people the tools to be able to figure out what is professional … it's such a gray area; it's such a judgment call for everyone.

In terms of consequences for unprofessional online posting, students felt that an honor council of peers was most appropriate.

Honor council people are students just like us; they have a better understanding of what we're going through. Let them judge.

Discussion

Students are avid users of Web 2.0, but feel conflicted about aspects of its use. They have concerns associated with their online presence; many have taken precautionary behaviors to minimize risks. They are sensitive to feeling controlled by institutional guidelines or policies, yet they desire guidance and recommendations that would allow them to take personal responsibility for their actions. Students suggested involving peer honor councils and incorporating online professionalism discussions into professionalism curricula to raise awareness.

Central to these findings was the concept of personal risk. Students seemed to view their online behaviors through a lens of personal risk—how they defined what was inappropriate depended on their comfort/discomfort with this risk. They expressed their concerns in terms of risks and risk-minimizing behaviors taken. The construct of “online professionalism” for students appears to hinge on the idea of personal risk and consequences for one's career, rather than how their individual behavior might negatively reflect on the medical profession. While we did not find differences in views between preclinical and clinical students, it is possible that there is a progressive professional identification not captured in this study.5 Further work might explore how students' professional identity construction is impacted by the blurring of professional and personal identities online.5

During focus group concluding remarks, some students commented that they were planning to increase their privacy settings as a result of the discussion and that the focus group discussions were helpful:

The whole issue here is based around your self-awareness and common sense and the only way to build common sense is by experiencing things, and so hearing all the different conversations really will help me in the future, definitely.

These students' perspectives on online professionalism provide an additional viewpoint to those of medical school educators.3,6,7 Perhaps the most concerning findings reported in other studies of online professionalism are incidents of patient privacy violations.1–3 It is reassuring to see how aware and concerned students are of safeguarding patient privacy.

This study has limitations. This was a single-institution study. As in all focus groups, it is possible that not all participants felt comfortable expressing their opinions if contrary to popular viewpoints. Preexisting relationships between group participants could have influenced participation. While data collection member checks were performed, postanalysis member checks were not formally conducted because of their impracticality; however, triangulation of data analysis was conducted to verify the findings.

As social media continues to shape medical education and the public's view of the medical profession, medical students need to be able to responsibly engage in these tools in ways that will best serve themselves and the profession at large. Medical educators are challenged with finding ways to support this expression while continuing to uphold our social contract with society and ethical obligations. Listening to, understanding, and incorporating student perspectives on online professionalism are critical to finding this balance of responsible engagement in social media.

Acknowledgments:

The authors thank the 64 students who participated in the focus groups, student assistants Timothy Amass and Avneet Sodhi, and focus group moderators Jennifer Halvaskz and Debra Herrmann.

Funding/Support:

The authors acknowledge funding support from the Dean's Office, George Washington University School of Medicine and Health Sciences.

Other disclosures:

None.

Ethical approval:

The George Washington University Institutional Review Board approved the study.