Medical students take liberties online

According to new study published in JAMA, a majority of medical schools surveyed report that their students have posted unprofessional material online. The authors (Drs. Katherine C. Chretien, S. Ryan Greysen, Jean-Paul Chretien, and Terry Kind) write:

In the past year, 13 percent (6/47) of these had no incidents, 78 percent (36/47) had fewer than 5 incidents, 7 percent (3/47) had 5 to 15 incidents, and 2 percent (1/47) had some incidents but did not know how many. Incidents involving violation of patient confidentiality in the past year were reported by 13 percent (6/46). Student use of profanity, frankly discriminatory language, depiction of intoxication, and sexually suggestive material were more commonly reported. Issues of conflict of interest were rare.

According to the authors, most of the material fell into one of four categories:

Sexual-Relational Content. Ten open-ended text examples detailed sexually suggestive or explicit content or inappropriate relationships. Examples in this category included sexually provocative photographs of students, requesting inappropriate friendships with patients on Facebook, and sexually suggestive comments.

Affiliation With School. Nine open-ended text examples detailed negative comments pertaining to specific medical school experiences. Examples included using profanity or other disparaging language in reference to specific faculty, courses or rotations, classmates, or medical school. Some examples were reported as discriminatory in nature.

Intoxication or Substance Use. Seven open-ended text examples detailed content suggesting intoxication or illicit substance use. Examples involved photographs (illicit substance paraphernalia, depiction of intoxication, students holding alcoholic beverages), video, and comments.

Threats to Patient Confidentiality. Four open-ended text examples detailed references to patients in which patient privacy was at risk. The majority of examples involved blogs that described clinical experiences with enough detail that patients could potentially be identified. One example was related to posting patient details on Facebook.

The authors recommend that the professionalism curriculum include a “digital media component,” as “may not be aware of how online posting can reflect negatively on medical professionalism or jeopardize their careers.”

Agreed. But isn’t the problem bigger than that? What would compel a medical student to post confidential information about a patient? Career or professionalism aside, why so little respect for privacy?

This may be an overlap of several conditions: the sheer volume of personal and suggestive material online (“everybody does it”), the market for confession and sensationalism beyond the Internet (talk shows provide a good clue to this), and the social habits of young adults who, especially in school, tend to mix with others their own age.

The vast majority of medical students probably don’t post inappropriate material online–and some of the material may be only borderline inappropriate. But the problem extends beyond isolated incidents, beyond ignorance or indiscretion. It takes a certain muscle to keep things to oneself, and maybe we have forgotten to exercise it.


  1. “It takes a certain muscle to keep things to oneself, and maybe we have forgotten to exercise it.”

    Do we have such a muscle? Humans are very social beings.

  2. Diana Senechal says:

    Humans are social, yes, but we also have many traditions of secrets and privacy. The locked-up diary, the confidant, the confidentiality rules, the family secrets, the silent wish, thought, or prayer, the bathroom, the whispered conversation, the secret meeting, the spy, the encoded message, the cryptic poem, the drawn curtains, the retreat in the woods, the life lessons that show that telling everybody everything is not such a great idea.

    To a degree it is an individual choice: what to disclose and what to keep private. But insofar as the choice affects others, affects our own lives in ways we can’t see, and affects the general culture, we need guidance in making these choices. Young people should learn early on why some things should be kept private–and should practice doing it. And adults should set a good example.

    When I was in high school we had a peer counseling (or, rather, peer listening) program. Those who took part would be available to listen to our classmates–not to give advice–if they were having a difficult time. One of the most important rules was confidentiality. (Of course we would report an emergency to an adult, but we would not go around telling our classmates.) I am sure it was broken now and then, but we understood and practiced the principle.

  3. I know a med student who posts critical things about the curriculum and administration of parts of her school… because it’s administered by incompetents.

    It’s only “unprofessional” to complain in public if private complaints haven’t been tried; otherwise there’s little chance to organize other students to complain en-masse, which is the only plausible way to force reform.

    Or I suppose one could claim that a “professional” always covers up for institutional incompetence, but that’s not a definition I endorse.

    (Now, many of the other things listed above really are unprofessional, but…)

  4. Diana Senechal says:

    Good point, Sigivald. I agree. There must be room in any profession for criticism, both private and public. When criticizing a specific school, it is probably best to make private complaints first–but if that doesn’t work, then yes, public complaints are often appropriate, within reason. It depends largely on the tone and spirit, the nature of the complaint, and other things.

  5. Bill Leonard says:

    It certainly is legitimate to criticize perceived incompetence at work at your college or university medical school; after all, the student — or his family, or someone — is shelling out a lot of money for the student to be there.

    But most of the material cited strikes me as typical of student behavior most everywhere: potential medical doctors or not, we’re still talking about a lot of relatively immature people who still have a lot of growing up to do.

  6. Granted, some of the conduct here is clearly inappropriate (patient confidentiality, asking patients out, etc.) and even illegal which will get one in trouble at work. And certainly young people should be asked to focus on exactly what are the costs to speaking one’s mind in a public forum, online or off.

    Yet doctors (and medical students) don’t check their First Amendment rights at the door. I would love to see you argue with a lawyer about exactly what a medical student can and can’t say online about their school or professors. “Indiscretion” sounds like a very vague, squishy charge to lay at a student’s feet, and sounds like action taken therein could very well open up an institution to a lawsuit.

    This is still a free country, Diana, and I am more afraid of clumsy, arrogant school administrators than I am of student rants.

  7. I don’t think much of this study. Violation of patient confidentiality is in an entirely different categories from things like criticism of school administrators or sexually suggestive photos of oneself…lumping them all together in a single category of “unprofessional behavior” seems very unhelpful.

  8. I didn’t follow the link to read the study, but it wouldn’t surprise me at all if the parts that violated (or almost violated) patient confidentiality were things like blogs or facebook/myspace entries along the lines of “OMG, it was SO cool today! We had this patient come in suffering from….”

    That type of thing could easily be addressed by adding a digital media component to the curriculum, or including it in an existing course or whtaever. Students of any age/discipline need to be reminded that the Internet is a public, worldwide forum, and that postings thereon CAN be detrimental to careers.

  9. Also, when did permitting yourself to be photographed holding an alcoholic beverage become unprofessional behaviour?
    It sounds to me like one of those set of alarmist statistics where you start off with something that is genuinely unprofessional (eg breaching patient confidentiality) and then expand your definition to cover numerous things that the average person doesn’t regard as that bad.

  10. Diana Senechal says:

    I agree–a lot of things are lumped together, and some are not necessarily unprofessional at all.

    From the study:

    “Although some of the incidents identified in this survey appear to be clear-cut lapses in professionalism (eg, violation of patient privacy and photos involving illicit drug use), others fall into more ambiguous categories (eg, using profanity and being sexually suggestive). Certain examples, such as negative comments about a student’s institution or profession, might not be considered unprofessional. The line separating protected First Amendment rights and inappropriate postings may be unclear. The categories of unprofessional incidents used in this survey were based on prior studies on Internet professionalism, but are subject to disagreement. Notably, examples of students’ public behaviors that fall into many of these categories have been documented long before the advent of the Internet.17,18 Some, such as socially inappropriate medical student shows (in which medical students write and perform satirical comedy skits), may serve important coping and stress-release functions during difficult training; however, when disseminated on media-sharing sites such as YouTube or Google Video, they carry the potential for significant public impact and viral spread of content.”

    The concerns raised in the study are valid, but some of the categories and examples are indeed questionable, as are the stats.

  11. I don’t have JAMA access at the house, so I can’t read the underlying article, but this looks pretty far out there. Are they seriously suggesting that the dignity of the profession requires that physicians and medical students should never – NEVER – use profanity or drink alcohol? Seriously? Or talk negatively about their experiences? Or make a sexual joke to a friend? Really?

  12. Diana Senechal says:

    I don’t think they’re suggesting anything of the sort. I agree with other commenters that the study is problematic if not downright weak. But to the researchers’ credit, they make an important distinction (explicitly, in the study) between what one does offline with peers and what one posts on the Internet.

    That said, I don’t see anything wrong a picture of a medical school student holding a beer or a glass of wine. Alcohol is legal, and it is part of professional gatherings as well as private lives. On the other hand, if they posted a video of themselves ranting in a thoroughly drunken state, that could be problematic.

    As for profanity, offline it is said and forgotten. Once posted online, it stays. Someone else may quote it and keep it, even if the author deletes the original post. Medical students (and others) should be aware of this difference.


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