Preserving Surgical Professionalism in Social Media; Long Live the Media, But Let Live the Surgeon

Abstract

The positive impact of social media in surgery is ever increasing, although they present some challenging aspects, as preservation of medical professionalism. Physicians should respect patient privacy and integrity through their online presence. However, their personal expression also deserves respect, not being labeled “unprofessional” just for conveying private attitudes and beliefs.

The role of social media in surgical research and education has been growing exponentially in the last decades; one can now prepare for surgery through YouTube and follow debates among world-renowned experts on Twitter.¹ Online published research reaches a wider public than the printed version of any journal, and young professionals have digital access to job interviews and residency programs as Medical Faculties have turned from dusty, century-old institutions, to modern, Instagram-friendly environments.² Social media offer a great potential to surgeons to evolve making the most of modern technological affordances, which keep improving with an unprecedented speed. However, what happens when the surgeon him/herself becomes a by-product of the profession’s social media?

THE SURGEON’S ONLINE PROFILE AS A RESEARCH SUBJECT

As physicians have been traditionally role models for their contemporaries, wide exposure in the digital era may further amplify these expectations. But how sovereign is actually the social media presence of today’s doctors? Several research projects dealt with the prevalence of “unprofessional behavior” of young surgeons on social media.^3–6 Each time, the researchers created a neutral, “predator” account, through which available personal profiles of young surgeons were assessed for unprofessional or “potentially unprofessional” content. A recent article in the Journal of Vascular Surgery (August 2020) concluded that young surgeons’ social media content “might have consequences upon employee and patient trust… and undermine the profession as a whole.” To the Journal’s credit, the article was immediately retracted on the following grounds: (a) the directory of surgical trainees was used without permission by the Association of Program Directors in Vascular Surgery; (b) major methodological bias was present, as definition of “potentially unprofessional behavior” was overtly subjective and judgmental (ie, potentially sexually suggestive attire in off-hours, or individuals holding alcohol). On this occasion, the Editorial team regretted the “conscious and unconscious biases plaguing the methodology, and the peer review process’ failure.” However, the exact same biases plague several previously published studies, which still occupy the shelves of medical research.^3–6 In 2014, hundreds of surgical residents’ Facebook profiles were scrutinized to find that 14% had “potentially unprofessional,” and 12% clearly unprofessional content.⁴ The same authors also asserted that unprofessional content was “unacceptably high” among resident surgeons.³ Another team in 2017 obtained a list of Urology graduates from the American Urology Association,⁵ analyzed their Facebook profiles for unprofessional or “potentially objectionable” content but also followed up with these graduates 1 year later to see how their online behavior evolved.⁶

After careful consideration of the aforementioned studies, some points deserve further reflection.

• (i) Research based on personal data is not an issue of “minor risk”

Good practice in research recommendations require informed consent to conduct any type of scientific study (https://www.gmc-uk.org). In the above studies, ethical approval was simplified as a “minor risk” project just because analyzed data were publicly available. However, internet-mediated research is regulated by the same ethical principles as any other type of medical or sociologic research: respect of the privacy, dignity of individuals and communities, valid consent, right to withdrawal, scientific integrity and social responsibility, maximizing benefits, and minimizing harm (“Ethics Guidelines for Internet-Mediated research,” available through https://www.bps.org.uk).

Although this kind of research is legally acceptable in the United States, in Europe, the General Data Protection Regulation provides a framework for transparent handling of personal data (https://gdpr-info.eu). The rights of the data subject (in this case, surgical residents) on processing and reuse of their personal information should be safeguarded under any circumstances. As outlined in Chapter 3 of the European General Data Protection Regulation, study subjects should be informed in a transparent manner on the aims and methodology of the project but also maintain the right to rectification, erasure, and objection when it comes to processing their personal data. The above-mentioned projects, all United States based, did not step outside legal grounds, but what about research ethics? Providers of the participants’ list (ie, professional organizations) did not ensure that their members were informed about the ongoing research or that the provided list would not be stored and linked to potentially sensitive data. On 1 occasion, the study cohort was clearly retraceable, as included profiles made the object of a later “follow-up” publication about the evolution of social media profile after residency.⁶ Thus, content posted by a junior resident may resurface later, even if erased in the meantime. While everyone needs to be conscious of the lifetime risk of misuse of his/her own social media content, medical research should lead the way in data protection. In this case, acquiescing to the scrutiny of personal data to draw hasty conclusions about the profession hardly seems to help evolve research, patient care, or medical professionalism for that matter.

• (ii) Medical professionalism as the backbone of patient care

In 2002, the landmark essay “Medical Professionalism in the new Millennium” sought to define good medical practice.⁷ Three fundamental principles stand out as follows:

• (a) Primacy of patient welfare, placing the patient’s needs above everything;

• (b) Respect of patient autonomy, empowering patients to make well-informed decisions about their treatment options; and

• (c) Social justice, abolishing discrimination and providing care to all those in need.

Consequently, unprofessional behavior is defined as a direct or indirect violation of these ethical standards, which is inexcusable or even unlawful. The American Accreditation Council for Graduate Medical Education has rightfully included professionalism among the 6 core competencies for residents (https://knowledgeplus.nejm.org/blog/acgme-core-competencies-professionalism/). Through this broader definition, residents (as all health care professionals) are committed to be conscientious, compassionate, nonjudgmental, and avoid any kind of compromise of patients’ well-being. Of very important notice, all the above-mentioned principles relate to conduct in the professional environment and not the physicians’ personal space or expression off-hours. Although these 2 facets (professional and personal) are inevitably interlaced, reflecting the same human being, care should be taken to not impose to the physician’s personal life expectations meant for the workplace. Thus, leisure-time activities can hardly qualify as “(potentially) unprofessional” if they do not collide with patient (or colleague) welfare, autonomy, or social justice. The previously cited articles^3–6 actually provided no evidence that surgeons’ off-hours attitude influenced their quality of work or relationship with patients. Most of all, they confused unprofessional, that is, legally punishable acts, with potentially unprofessional conduct, even if this only describes human behavior subject to personal judgment and unrelated to patient care. The researchers may disagree with their subjects upon personal opinions or attitude, choice of lifestyle and attire, since such matters are highly subjective, but to label, a behavior as unprofessional is an entirely different matter.

• (iii) Surgeons as part of the social net

Surgeons are exposed to a stressful, physically and emotionally challenging environment and may be subject to depression, anxiety, and altered quality of life. They are expected to manage life-threatening situations and deal with distress that affects patients, families, peers, and themselves. They need to practice for years, often loosing balance between personal life and work. It has been suggested that up to 69% of surgical residents may suffer from burnout, depression, or suicidal behavior at some point in their career.⁸ As these young professionals are expected to honor the human nature and privacy of patients, it seems irrational to deprive them of their own human character in personal expression. Imposing to this already strained population a purely professional and censored lifestyle might increase the risk of social isolation and personal failure, resulting in an adverse impact on their performance and ability to prioritize patient welfare. In this sense, considering surgeons’ social media as part of their professional space might add unnecessary strain to their already thin work-life balance.

The gross absence of proof that the personal lifestyle and choices of young surgeons had any impact on their professional quality cannot be over-emphasized. A first step would be to question the aims of such sensationalist research, which should not be encouraged by academic and scientific publications. On the contrary, the medical community could focus more on rewarding the diversity, strength, and resilience of young doctors, helping them grow into solid and positive elements in the social net. Importantly, in the aforementioned studies,^3–6 no indication was given as to the incidence of unprofessional behavior in the general population of the same age. There is a certain possibility that the young doctors targeted in these publications may actually be respectful, well-behaved, and even too conservative compared to their peers.

Well-established professionals and hierarchical superiors have a key role in changing this judgmental and discriminatory trend. They can set the example by creating a culture where the professional, but also personal, skills, and individual expression are valued, where the thin line that divides professional and private life is respected.

THE SURGEON’S RESPONSIBILITY IN THE SOCIAL MEDIA

Nowadays, social media have become an integral part of the surgical profession; they provide a sense of community, make the world seem smaller, and allow sharing experiences and knowledge among individuals who might never meet otherwise. For example, #SoMe4Surgery (Social Media for Surgery) assembles more than 4800 surgeons to a digital Twitter community, sharing scientific knowledge and experiences with diverse peers all over the world.⁹ Several similar networks exist and will further develop in the future, having a complementary role to the traditional professional associations. It is the responsibility of surgeons to use social media in a positive manner; to convey human values, professional culture and knowledge, and help the old inaccessible surgical stereotype evolve into the ideal surgeon of modern times.

At the same time, some notorious aspects of social media need to be kept in mind. Online users, under cover of anonymity, can be allowed to express abusive and disrespectful behavior, with little sense of unease and consequences. There is a risk for doctors to be drawn into this “arena,” using their professional details to boost their public image, forgetting that the content they share might be a potential source of distress for patients or colleagues. An insightful recent publication illustrates the multifaceted threat social media might represent for medical professionalism.¹⁰ Breach of patients’ or colleagues’ confidentiality may occur, even unintentionally, and 1 hasty upload may threaten medical secrecy, entailing serious consequences. Finally, it is widely known that patients and employers screen doctors’ social media profiles when choosing a physician or employee. Surgeons must be aware that professional interaction through their personal social media may be a slippery ground and that barriers may be hard to re-establish thereafter. In this sense, when a surgeon engages with social media as “Dr X” rather than “Mr/Mrs X,” he/she has consciously chosen to represent the profession. This may lead to increased visibility, scrutiny, and judgment, making it more challenging to maintain personal space and expression.

As a conclusion, although the positive impact of social media in surgery is increasing, everybody should be aware of their potential adverse effects. Physicians ought to respect human life and integrity inside and outside social media. Remember that personal expression deserves respect and understanding, for healthcare professionals, as for anyone else.

ACKNOWLEDGMENTS

The authors would like to thank Dr Despoina Mantziari, PhD, Lecturer and Research Ethics Officer at the School of Media, Arts and Humanities, University of Sussex, United Kingdom, for her valuable input on the article’s content and revision of the English language.