Miss Manners for social networking: a new role for medical librarians

Conjure up in your mind the picture we all abhor, the image of the stereotypical librarian. The bun, the thin tight lips ready to display their disapproval at the slightest provocation, that knowingly superior look in her eye. Now think of Miss Manners. It is that knowingly superior exterior she presents to the world that reminds me of the stereotype. Maybe librarians are something like Miss Manners; we do so like to tell others what to do and how to do it.

We are indeed known for always telling people what to do, mostly to be quiet. So maybe one of the things we ought now to be telling our patrons how to do is how to behave in the online social networking environment. Librarians have acted as arbiters of social mores for generations in our roles as collection development agents. We make available to our public that which we deem appropriate and useful for them. While we loathe outside censorship, we have always indulged in self-censorship in making our selections [1]. That is, we librarians have always felt that we know what is best for others. As such, I believe we may be ideally suited to help students and educational institutions deal with the professionalism issues arising from the use of social networking media.

Today's medical school students and residents are Millennials, members of Generation Y. As children of the Internet Generation, they claim high-speed, broadband web access as their birthright and assert that they were born with all the knowledge needed to exploit the content and conveniences of the web. According to the Pew Research Center's Internet and American Life Project, they see their early adoption of new technologies as “a badge of generational identity…as what distinguishes them from other generations” [2].

My local newspaper's technology columnist says, “Social networking is the new drug” [3]. It may be, but social network sites really do not represent a new concept. They are really just another form of public gathering space. Their characteristics of persistence, searchability, replicability, and invisible audiences are what differentiate them from more familiar physical public spaces, like malls and gyms [4]. Facebook, online since 2004, with more than 845 million active users, is the best known and most popular social networking site [5]. It has created an international virtual community. But this community does not have the physical context that provides the clues that ordinarily help us determine what is appropriate or inappropriate in any space.

Many feel that the Internet presents a particular threat to professionalism because the desire and the ability to make personal contributions to the collective media is pervasive and occurs in the absence of rules for digital behavior [6]. It has been suggested that in virtual communities the essentials of responsibility, accountability, and social trust that build traditional communities are eroded [7]. Online threats to professionalism include violations of confidentiality, with “the ubiquitous presence of cell phone and personal digital assistants with recording devices creat[ing] the risk of patients becoming digital ‘content’” and the amplification of “already unprofessional behavior by enabling public consumption of such acts” via web technology [8]. While many of today's students may feel they are the masters of their virtual communities, they have not demonstrated that they are masters of etiquette in the use of new social networking tools or that they can use these tools in an appropriate, mature, responsible manner.

Social networking in the health professions

The Facebook habits of medical school students and residents in the United States and abroad have been studied [9–14]. The overwhelming majority of those surveyed have Facebook accounts; they use their own names; most accounts are not made private; and they contain personally identifying information, including sexual orientation, religious views, relationship status, and many display photographs showing alcohol consumption and intoxication. Disturbing content in many online student profiles has been found, even though many users report that they recognize that what they do in medical school is not separate from what they do on Facebook and understand that what they do outside of their educational environment can have repercussions in their future careers.

A survey of French residents and fellows in 2009 revealed a higher level of sophistication in their use of Facebook: While 73% had Facebook accounts, 61% changed default privacy settings, and 85% automatically declined requests from patients to “friend” them [14]. Almost all believed that doctors should not be forbidden from registering on Facebook, but that they should limit their profiles to Facebook friends. Almost half believed that the doctor-patient relationship changes when patients know that their physicians are on Facebook.

Responses to social networking by school administrators

Chretien et al. surveyed the deans of student affairs of US medical schools in 2009 about unprofessional content posted online by medical students [15]. An astonishing 64% of respondents reported awareness of incidents involving students posting unprofessional content, including use of profanity, racist language, and depiction of inappropriate sexual and alcohol-related content. Violations of patient confidentiality and conflict of interest were rare. Most incidents resulted in informal warnings; however, some were serious enough to result in dismissal.* Interestingly, only 38% reported that their schools had policies in place that broadly covered student online postings. Of these policies, the overwhelming majority did not explicitly mention Internet use.

In 2010, Kind et al. found that while almost all US medical schools had a Facebook presence, only 13 of 128 medical schools with publicly available online student handbooks, guidelines, or policies had guidelines or policies that dealt specifically with online social networking behavior. They said that “Those schools that have policies are defining the balance between what are forbidden, discouraged, and appropriate social media behaviors, in order to help students navigate their online interactions” [16].

School administrators are concerned about any appearance of their school names or logos in an online posting. They fear it may be misunderstood as an endorsement of the posting's content [11, 17]. Many professionals fear that what may just be “a momentary lapse in judgment by an individual physician to create unprofessional content online can reflect poorly on the entire profession, that the public perception and image of the profession will be damaged.” Greysen et al. say, “each individual physician should develop a greater consciousness of the potential impact of their online actions for the entire profession” [18].

Life on Facebook

Medical students are adults with full rights and privileges of all citizens, including the right to free speech as protected by the First Amendment. The right of self-expression and communication in the school environment was confirmed by the Supreme Court. In a Vietnam War–era case involving high school protesters, “the Court held that school officials cannot censor student speech unless school officials reasonably forecast that the speech will cause a material and substantial disruption of school activities or collide with the rights of others. Mere apprehension of disturbance or an offense given is not enough”† [19]. So the fear that students might behave inappropriately on the web is not sufficient grounds to restrict their use. The line between free speech and inappropriate or unprofessional speech is, however, increasingly fuzzy. Librarians hold our rights to free speech and free expression especially dear. Librarians with their long history of support for intellectual freedom could provide significant assistance to schools and individuals in helping to clarify this line in the Internet environment.

Lack of awareness, naiveté, and inappropriate, often immature, attitudes all contribute to students' poorly chosen online postings. Millennial medical students feel special and confident [20] and may, therefore, not feel the need to be concerned about what others think. Employers, including residency program admissions staff, are using Facebook in addition to traditional references to find out about candidates. According to a 2009 survey by CareerBuilder.com, 45% of hiring managers use social networking sites to research job candidates [21–23].

This represents a serious disconnect between how Facebook was intended to be used, as a vehicle for social networking, and how it is used in the real world. As part of our responsibility to provide students with the skills they need to manage the world of online information, librarians can help students make that connection. Educating students is the best way to try to change their behavior. Librarians have a long history of educating users, and many would be excited to share their knowledge and interest in this topic.

As early adopters of most new technologies, librarians are very comfortable online. Librarians taught a generation how to search the web and use word processing, presentation, and citation management software. Indeed, librarians have blossomed online. Just check out all the new and exciting librarian sites on the web that show librarians in an entirely new, fresh, amazing, even epic light.‡

And I can't help but wonder…

Is there any relationship between medical students' lack of concern about online images and the problem of misrepresenting publishing credits in applications for residency programs [24–27]? The inability to understand and handle the differences between what is mine and what is yours is directly related, in my mind, to an inability to distinguish between what is private and what is public. The general feeling that anything online is open to everyone and not owned by anyone may feed the sense that claiming something that is not really yours is not such a bad thing. Librarians would be the ideal purveyors of information about publishing and the ethical issues involved.

Should we be concerned about the behavior of undergraduate medical students? Does it have anything to do with their performance as physicians in the future? The answer, according to Papadakis et al., is yes [28]. In a case-control study, they found that disciplinary action by a medical board was strongly associated with prior unprofessional behavior in medical school. Unprofessional behavior was associated with an increase by a factor of three in the risk of future disciplinary action.

Is the medical profession being overly sensitive about its public image? Public trust is seen as essential to the profession, and public image is seen as essential to public trust [29, 30]. Jain notes that “It is clear that there is no longer a professional remove between many clinicians and their patients” when they come together on social networking sites [31]. The implication is that this is bad thing. Is it really a bad thing? He continues, “During medical training, the importance of maintaining professional distance…is taught by educators and reinforced by the use of beepers and paging services meant to shield physicians from their patients.” Is that a good thing? I don't think so.

Many prominent personalities have been exposed using social networking systems inappropriately and unprofessionally. The electronic environment in which our current crop of students has grown up definitely has its dark side where people expose themselves (both literally and figuratively). I cannot help but wonder if and how influences like these affect their use of social networking.

In response to one such recent scandal, my local newspaper noted, “If you would be embarrassed if the public could see a particular photo of yourself or read something you wrote, do not put it into cyberspace. Really, if you wouldn't put it on a highway billboard, don't make it available to anyone with a computer or a smartphone” [32]. And since that includes just about everybody these days, you would think that most people would have the simple common sense not to do that. Many, many articles have also appeared in medical journals with advice for health professionals [33–43]. With so much advice around, how is it that so many seemed to have missed it?

And finally, I have to wonder if the online offenses (the surgical team laughing as a foreign body is removed from a patient's rectum, which did not even occur in the United States [44]; the medical school comedy skits [45]) cited over and over as examples of why Internet use should be restricted are isolated incidences or are truly representative of widespread unprofessional and disrespectful behavior by the upcoming generation of health professionals? Janssen and Klein “caution against implicating an entire student body, or the national population of medical students, based on actual or perceived errors of a few” [46].

Conclusion

There should no question of the role and value of social networking applications in medical education [8, 47]. Brown even suggests using social media to teach professionalism [29]. At the same time, there should be no question about the need for e-professionalism to be included in the contemporary curriculum on ethics and professionalism at our nation's health education institutions. “As educators, we are charged with making students aware of their rights and encouraging safe practices and professional behavior on social networking sites,” said Farnan et al. [6]. This should cover all areas of currently available social media, and any and all new digital media yet to be invented. Librarians are the educators most in the vanguard in adopting new media.

The American Medical Association's Council on Ethical and Judicial Affairs' policy on “Professionalism in the Use of Social Media” contains recommendations that could constitute the core of what should be taught to students [48]. But almost nothing has been written on teaching the use of social media to health professionals. A continuing education class was taught by the Department of the Humanities at Penn State Hershey Medical Center [49]. So this is an open arena just ready for medical librarians to handle.

Medical librarians often have difficulty attracting and maintaining the interest of students. Students, however, should recognize the expertise of librarians in relation to publishing and the ethics involved in that area. The journal articles they read online are managed by librarians, so it should not be a far leap to suggest they might pay attention to librarians addressing them on the ethics of other online activities.

And what does Miss Manners herself have to say about social networking? “Miss Manners is afraid that people are only just beginning to realize that what is made available online stays available. And is often passed around and sometimes appropriated by others. What may seem acceptable, or even charming, to one's peers of the moment could look very different to a prospective employer, for example, and later even to oneself” [50].