‘Doctors can’t be doctors all of the time’: a qualitative study of how general practitioners and medical students negotiate public-professional and private-personal realms using social media

Abstract

Objective

The objective of this study is to explore the experiences and perspectives of general practitioners’ and medical students’ use of, and behaviour on, social media and to understand how they negotiate threats to professional and personal life on social media.

Design

A two-phase qualitative design was used, consisting of semistructured interviews and follow-up vignettes, where participants were asked to respond to vignettes that involved varying degrees of unprofessional behaviour. Data were analysed using template analysis.

Setting and participants

Participants were general practitioner tutors and third year medical students who had just completed placement on the University of Limerick longitudinal integrated clerkship. Five students and three general practitioners affiliated with the medical school were invited to participate in one-to-one interviews.

Results

Three overarching themes, each containing subthemes were reported. ‘Staying in contact and up to date’ outlines how social media platforms provide useful resources and illustrates the potential risks of social media. ‘Online persona’ considers how social media has contributed to changing the nature of interpersonal relationships. ‘Towards standards and safety’ raises the matter of how to protect patients, doctors and the medical profession.

Conclusion

Guidance is required for students and medical practitioners on how to establish reasonable boundaries between their personal and professional presence on social media and in their private life so that poorly judged use of social media does not negatively affect career prospects and professional efficacy.

Strengths and limitations of this study.

• The sampling method facilitated balance of gender, age and nationality of participants.

• The conceptual lens, communities of learning, situated the data in terms of accepted theory and evidence.

• The use of vignettes provided rich data on participants’ experience of social media use and behaviour.

• The study was limited to one cohort of participants in a single medical school.

• The number of participants was relatively small (n=8).

Introduction

Social media is defined as ‘a group of internet-based applications that build on the ideological and technological foundations of Web 2.0, and that allow the creation and exchange of user generated content’.¹ It has become an effective communication tool for public health to convey information to populations in ‘real-time’ during the COVID-19 pandemic.² While social media can improve communication in some instances, the associated environment is fraught with the danger of suboptimal communication.³ A comprehensive review warned that, for health professionals and patients, social media can negatively impact mental health, privacy and information quality.⁴ The concept of ‘online professionalism’, rooted in the traditional values of medicine, has evolved in the past decade in response to the challenges of the constantly changing social media sphere.⁵

Unprofessional online behaviour resulting in disciplinary action for medical students and doctors is concerning⁶; one international study reported that almost one-fifth of the medical students surveyed admitted to sharing clinical images inappropriately.⁷ Similarly, surveys of medical students in Australia,⁸ England⁹ and the USA¹⁰ reported that unprofessional social media posting was common. While regulatory guidelines are available, inappropriate behaviour on social media remains problematic,¹¹ with the majority of residents in one study admitting to having posted inappropriate photographs of medical colleagues intoxicated on social media.¹² In this context, the findings of cross-sectional survey of the public are relevant; it reported that inappropriate use of social media by physicians, including images of intoxication, would cause patients to trust them less.¹³ Such implications have been highlighted by medical ethicists.¹⁴ The phenomenon is not restricted to doctors—over half of the respondents in a survey of registered nurses said that they had witnessed inappropriate online behaviour among colleagues.¹⁵ Furthermore, postgraduate programme directors frequently check the social media profiles of residency applicants for inappropriate behaviour.¹⁶

Recent research surveys of medical students, residents and consultants reported that almost one-third of students had posted inappropriate photographs of themselves on social media; the findings among residents and consultants were significantly lower.¹⁷ This raises the question of whether there is an effect for age in the use of social media; a systematic review examining the impact of social media on medical professionals encouraged intergenerational dialogue.¹⁸

Physicians and students may be unsure of the full medical, professional and personal reputational consequences of the new social media age.^{19 20} Ethical concerns also include the public-professional and private-personal spheres. Few qualitative studies examining the views of medical students and those of their clinical supervisors on this topic exist. The aim of this study was to explore general practitioners’ (GPs) and medical students’ perspectives on and experience of social media. Specific objectives were to investigate how students and their GP tutors use social media, what challenges they encounter in keeping boundaries between professional and personal identities and private and public realms, and how they negotiate these challenges and conduct themselves professionally when using online platforms.

Conceptual framework

‘Communities of practice’ is a popular theory for conceptualising the development of medical professional identity,²¹ whereby the medical profession is understood as both a ‘collegial profession and community of practice’.²¹ The theory states that successful identity formation depends on a dynamic interplay between members of the medical community at different stages of the medical continuum. To this end, social media can supplement but not replace ‘meaningful contact with members of the community’, which is considered in this framework to be the most important factor in professional identity formation.²¹

A qualitative epistemic approach leads to a methodology that teases out the subjective experience of a research participant, and that is why interviews and responding to short vignettes were selected for this study. Given that we are not trying to make an invariant real-world truth claim, such as with large sample size quantitative studies, we chose a conceptual-methodological approach that investigated the depth and breadth of how medical doctors and students experience social media in their personal and professional lives. Thus, the theoretical contribution of our article is to say that social media is not merely a communication tool but is a fluid medium in which people posit varying identities and often negotiate these with themselves, their colleagues, patients and those in the social media sphere, and that it is particularly difficult for doctors as they expect so much from themselves and have so much expected from them by others.

Methodology

Study design

The study adhered to the COnsolidated criteria for REporting Qualitative research principles for reporting qualitative research (online supplemental material 1).²² Participants were contacted by email sent from a research administrator who was not involved in course teaching and assessment, thus ensuring no power dynamic or coercion. This study used a hybrid methodology whereby an in-depth, semistructured interview based on a topic guide designed by the research team was followed, for some participants, by a second interview structured using short ethical dilemmas on social media described here as vignettes.

Setting and participants

Participants were GP tutors and third year medical students who had just completed a longitudinal integrated clerkship.²³ Five medical students and three GPs participated in the study. Purposive, non-probabilistic sampling was used to ensure that a balance was achieved between students from Europe and North America and that both males and females were selected to be as representative as possible of the student population. The characteristics of the participants are outlined in table 1. As judgemental sampling involves the judgement of the researchers based, for example, on their expertise and knowledge of previous research, it was decided to base the sample size on a previous qualitative study on medical student mobile phone usage.²⁴ The interview process worked through the eight participants until no new themes were emerging. This is known as data saturation—the ‘stopping criterion’²⁵ for the data collection being met as those being interviewed are repeating themes mentioned by others or are not suggesting new themes.

Table 1.

Participant characteristics

GPs/ final year medical student	Gender (M/F)	Age category (20–30) (30–40) (40+)	Style of interview (face-to-face, phone, Skype)
Interview 1: GP	F	30–40	Phone
Interview 2: GP	M	30–40	Phone
Interview 3: Medical student	M	20–30	Skype
Interview 4: Medical student	M	20–30	Face-to-face
Interview 5: Medical student	M	20–30	Face-to-face
Interview 6: Medical student	F	30–40	Face-to-face
Interview 7: GP	M	40+	Face-to-face
Interview 8: Medical student	F	20–30	Face-to-face

GP, general practitioner.

Public and patient involvement

No patients were involved in the study, but the research question was derived from classroom discussions and interactions with medical students and GP tutors.

Data collection

The interview guide was developed by an interdisciplinary team, and vignettes were developed by two members of the research team (ES, AOR) with the purpose of exploring students’ and clinicians’ responses to examples of unprofessional behaviour online by healthcare workers (online supplemental material 2). These vignettes were designed so that doctors and medical students could give ethical and professional perspectives not simply on themselves but also on those with whom they work and will be working in their medical careers. Participants were asked to respond to three separate scenarios that required them to consider the ethical dilemmas and professional practice challenges of using social media personally and professionally. Where the themes explored in the vignettes were addressed by the participants in their initial interview, they were not interviewed again with the aid of the vignettes.

Interviews were conducted by a trained female researcher (MM) who would have known some of the participants and lasted between 15 and 30 min. These were conducted by telephone, Skype or in person and were digitally recorded, with the explicit consent of those participating. Where participants were invited to a second interview, if their first interview had not addressed the themes in the vignettes, they were shown or read short vignettes about the use of social media, and their opinions were elicited.

Data analysis

The methodology used was template analysis. A coding template based on representative parts of the data is developed and, subsequently, is revised and refined.²⁶ It facilitates the use of a priori themes that can later be modified or excluded as the data analysis evolves, as the researchers read and re-read the data. The identification of templates is thus iterative in nature—some are established initially as more important and then, after thorough reading and re-reading of the data transcripts, may be seen as less important or more important. This helps to compare perspectives between different categories of participant, in this case, GPs and medical students. It is a practical method that is well suited to a team involving multiple coders as it gives the freedom to the team to collaborate on the direction and content of the coding. The process involved over six meetings of the coders (AOR, VN, JOD).

Initially, the coders read the full interview texts to familiarise themselves with the raw data. Preliminary data coding was conducted independently with the use of a priori themes that the researchers expected to appear in the data; only a priori themes related to the research question were chosen. These included benefits of social media, personal and professional use, and potential pitfalls. The initial codes and themes were used to define a coding template; this facilitated the researchers to understand the relationship between codes and themes while maintaining flexibility so that more codes and themes could be added as the hierarchical analysis developed. Coders discussed personal experiences with social media and attitudes towards the scenarios in the vignettes, a process known as ‘active-acknowledgement’ for overcoming researcher bias.²⁷ Discrepancies were resolved by personal reflection and ongoing dialogue between the data analysis team.

Findings

The analysis produced three overarching themes, each with subthemes that were often interconnected and, in some cases, had overlapping ideas.

Staying in contact and up to date

This theme refers to the practical, day-to-day applications of social media for medical students and GPs. Social media has undoubted social and networking benefits, and these were highlighted by participants, as well as the challenging nature of the information available—which can help participants stay up to date, but which can waste time also. This theme has been divided into two subthemes: ‘staying connected’ and ‘educational tool’.

Staying connected

Maintaining friendships and staying in touch with others was the primary stated use of social media platforms. One student said how helpful Facebook was in keeping touch with family throughout the world and with a network of friends from a previous course, whereas another felt that the speed and ease of access may come at the cost of maintaining meaningful relationships:

Perhaps they are superficial relationships, but you know I feel like if I didn’t have ‘Facebook’, particularly I would absolutely lose contact with these people. (Student, male)

Social media was perceived as very useful for staying in touch, but there appeared to be an awareness of the link between social media abuse when interviewing for jobs or being publicly castigated for holding the ‘wrong’ view on a contentious topic:

I am very conscious about putting up things like my date of birth, things about politics … of not giving away too much about myself. (Student, female)

In this quote, there is both the appreciation of confidential personal details such as ‘date of birth’ and the sense that there are areas which are personal and private, such as political views. This raised the idea that students and GPs alike were aware of the importance of boundary setting, and so social media must be approached carefully.

‘Educational tool’

This subtheme describes how, on one hand, social media platforms have significantly enhanced learning but, on the other, must be handled with care. Concerns about social media being a distraction for learning were evident for GPs and students:

You can spend hours and hours just scrolling going from Twitter to Facebook to LinkedIn. (GP, male)

99% of the time it is just for killing time. (Student, male)

Some medical experts post clinical pictures and scenarios and invite students to suggest differential diagnoses, often giving the correct answer and an explanation at a later point. While this was appreciated by one student in the interview, in the follow-up vignette discussion he then questioned the professional ethics of posting patient information in a publicly accessible forum, and the concepts of consent and confidentiality were raised. When asked about professional concerns relating to one vignette (on online sharing of clinical educational material), all participants acknowledged the importance of confidentiality:

I think you need to be careful about what you post. Personally, for myself, as a rule of thumb, I don’t think you should post anything about clinical … a clinical scenario or anything because that could get you into trouble. (Student, female)

Most noticeable in this last statement is the tension between a very useful medical pedagogical tool, which may benefit medical students, and the ethicality of referring to identifiable patient case studies.

Online persona

This theme analyses the process whereby learners at all stages of the medical continuum negotiate an online image and attempt to balance personal and professional dimensions. There are three subthemes: ‘crafting an image’, ‘societal expectations’ and ‘boundaries are blurring’.

Crafting an image

Participants agreed that care had to be taken with how medical students/clinicians present themselves online. Students and GPs were aware that various platforms serve very different purposes. Both groups indicated a degree of embarrassment with self-promotion on social media. All participants were conscious of how they would be perceived by the public. Several felt it was important to be selective with what gets posted to craft a positive image:

You can hold an image of yourself … put up the photos where you look good are having a wonderful time …. I suppose also, some people open their hearts a bit too much … it probably doesn’t cast them in the best light even if that is not their intention. (Student, male)

Another student explained this concept further, detailing how he restricted what he posted to paint an almost superhuman version of himself:

The image you are trying to maintain could be what you identify with or what you want to identify with, but you are not really that, so kind of detachment is potentially harmful particularly with young people …. There is a culture of social media that is centred around vanity and around what you want to identify with vs what you actually identify with. (Student, male)

This quote strongly points to the tensions and pressures in emotional self-regulation involved in using such impression management strategies. It also highlights the danger, when using social media, of a cognitive dissonance between the image medical students and doctors wish to project and the extent to which this image accurately reflects who they are.

Societal expectations

This theme considers how participants think society might view them when using social media. An experienced GP participant felt strongly that society expects something more from medical students compared with other students as they are ‘future doctors’. This question as to whether society should expect a higher standard from doctors permeated most of the interviews:

Maybe somebody looking on would say … ‘I don’t care if my plumber has 20 pints at the weekend … or I see them on ‘Facebook’ running … with no clothes on’—but I don’t want to see a GP on Monday morning who has been doing that. (GP, male)

The fear of reputation damage was balanced with the realisation that we cannot all be perfect all the time. One student described this succinctly but still advised utmost caution when using social media:

We are only human. I mean, God forbid, Watson and Crick who discovered DNA, I am sure they were mad for their lush [alcohol] every once in a while, but who cares? (Student, male)

Other students took an opposing view and expressed in both interview and follow-up vignette the need to maintain professional conduct on and off duty:

They have a reputation to maintain and here they are not representing themselves in a professional manner. (Student, male)

In some instances, there was dissonance between the view expressed by a participant in the interview and that of the same participant in the follow-up vignettes. One student, when asked about societal expectations, cited the example of a picture shared on a social media platform of a doctor smoking a cigarette, saying that it made no sense for that doctor then to tell patients not to smoke. When asked to comment on the vignette where a patient expressed concern about doctors who were potentially going to operate on her had appeared drunk on a social media platform, she responded,

I would tell her that doctors can’t be doctors all of the time. (Student, female)

A very striking example of this is the extent to which doctors now have to demarcate their public and private life, which is revealed in the remark from one GP about how they had been told to circumvent their social media behaviour at a wedding:

I suppose you can try to make it as private as you can, but I don't know if people entirely understand the rules of it, you know when pictures go up I don’t think you're even able to take them down or that kind of thing. I think people are kind of wary of that you know when pictures are being taken on a night out or something you know people might say ‘don't put them on Facebook’. I was at a wedding recently of a doctor and there was a request on the invite not to put any pictures up on social media. (GP, female)

Aside from doctors not being allowed to have a personal life or having to be aware that parts of it may be captured inadvertently on social media such that they must take steps to prevent this, there is also the sense that the rules for social media usage are evolving, but that this GP and others are not clear what those rules are and who is deciding on them.

Boundaries are blurring

This subtheme refers to the changing dynamic between doctors and patients to which social media is contributing. GP participants agreed that it was not unusual to have friends who might be taken on as patients or to have social interaction in the community with existing patients. However, the introduction of social media has the potential to destroy privacy and to blur the boundary between personal and professional.

Friend requests on ‘Facebook’ were cited by many students and GPs as a potential source of compromise, with all viewing it as an inappropriate relationship, fraught with possibilities of doctors’ personal information being inappropriately viewed and the potential for medical advice being requested online. The risk to patient safety brought about by casual contact and giving advice in a non-clinical and more relaxed social media environment was pointed out. One GP emphasised maintaining a division between personal and professional life:

It is about keeping things separate. Your personal life and your professional life. (GP, male)

This points, once again, to the need for individual doctors to decide where they are going to draw their boundary lines with their patients online. Many participants talked about withdrawing from social media interaction or making it difficult for the public to find them. Given that we are all fallible, one GP highlighted the need for doctors to be careful about how they use social media:

I would try and avoid it. I think the importance of being a good doctor is to limit yourself. So, for example you would, you can't be good 24–7. You can't be empathic 24–7. We are all human, we have moods, we say the wrong thing, we do the wrong thing. I can only imagine someone Facebook messaging me that they have a bit of indigestion or a bit of headache or something along those lines and me not responding or me responding in an off-handed way in a less than professional manner and then the inevitable happens, they have pneumonia, they have meningitis, they have cardiac issues or something and of course they have contacted me and I have contacted them and it has been unprofessional and that means that I am partly responsible for what happened. So, I am very wary of patients using social media to contact me. (GP, male)

This ties into the final theme of what exactly is the proper use of social media by doctors.

Towards standards and safety

This final theme illustrates the current uncertainty regarding what it means to be a medical professional on social media. There are two subthemes: ‘clarifying the standard’ and ‘safe navigation’.

Clarifying the standard

While the data show that there is awareness among all participants of some ethical dimensions and legal ramifications of poor conduct on social media, there was no clear consensus on what is acceptable. One GP, while aware of the limitations of his own experience with social media, expressed concern for medical students:

People who have spent all their waking hours for the last ten years stuck in a room swotting, most of them don’t have life experience and are not worldly-wise and therefore are very innocent … they are just not aware of the huge implications this can have on their future so I think that needs to be spelled out very clearly and explicitly. (GP, male)

GPs and students appeared to disagree on whether clinical experiences could be shared online for teaching and reflective purposes. The vignettes magnified this uncertainty and were useful in presenting examples of where such social media dilemmas might occur. Most of the GPs believed that there was insufficient guidance provided for them and for students. They agreed that a clear set of guidelines that would uphold good professional conduct while protecting individuals who, in their leisure time, were trying to unwind was necessary:

It is a stressful enough job. You would hate to think that people would be told that you can never let your hair down, you can never do this or that. I think there has to be a balance somewhere. (GP, female)

This quote underlines the imperative of educating future and current physicians in the use of social media to achieve a private social life.

Safe navigation

This final subtheme connects the perceptions found throughout the data on how students and GPs might successfully and safely navigate social media platforms, accessing education and connecting with others while at the same time keeping themselves plus their current and future patients safe. GPs were very clear on what type of information should not be divulged on social media platforms:

Any info. that you think could harm you, your family or your patients. (GP, female)

The follow-up vignettes revealed that for three of the students, there was a high level of awareness of risks with sharing information online. They recognised the potential for litigation and damaged career opportunities as consequences of inappropriate use of social media platforms. However, a fourth student did not appear to have this level of awareness and was actively engaging in broadcasting her own clinical experiences seemingly without awareness of the dangers:

I have a [You Tube] channel that I just started, and I am just uploading some videos about my life … about medicine

[Interviewer] Do you think there are any risks with that?

No, not really. (Student, female)

There was no evidence among participants of any level of participation in formal education on engaging in social media, and for most, awareness seemed to come from life experience. One student told how lessons learnt about life as a younger girl influenced her behaviour on social media platforms:

My dad used to always give us lectures about pictures which I totally understand so I do have certain settings on ‘Facebook’ which only allows … not even all my friends to see my photos. (Student, female)

There was a notable lack of awareness of the existence of guidelines among both groups of participants. All agreed that, in general, social media can be a positive thing, but most urged caution and showed awareness of risk:

I think overall, social media is great but just be careful with it. That is the long and the short of it. (GP, male)

Discussion

The analysis has provided new insights into the research question exploring GPs’ and medical students’ experience of and perspectives on social media use and behaviour. While educational and networking benefits to the profession exist, most expressed unease about boundary setting and staying safe on these platforms. GPs and medical students appeared to agree that there was a line between professional and personal realms that needed to be maintained, but for medical students, defining where that boundary lies was difficult to conclude.

The scenario that caused the most disagreement among participants related to a video of doctors behaving unprofessionally during their time off, with some defending them and others saying it was unacceptable to behave in a certain way at any time. The statement in our study that ‘doctors can’t be doctors all of the time’ is a dominant theme. An important point in our study is the discordance between what participants think and what they say, as illustrated by the follow-up interview seeking their reactions to vignettes. Other research has reported similar inconsistencies, where respondents acknowledged that inappropriate social media use was common but was far more likely to interpret the behaviour as being inappropriate when it was reported among colleagues rather than themselves.¹⁷ Establishing boundaries in a social media age is difficult for all citizens but especially for doctors as they are expected to practise to the highest level. The quote regarding Crick and Watson was very apposite in this respect.

The theme of ‘crafting an image’ refers to the efforts of medical students and physicians to portray themselves favourably on social media. This phenomenon has been described as an online ‘identity crisis’ for medical professionals.²⁸ Researchers have warned of the problem of conflating ‘self-expression, self-promotion and self-communication’.²⁹ Research with healthcare professionals on the subject of ‘digital identity’ formation identified the potential for conflict when professional, personal, public and private identities did not align.³⁰ The ‘communities of practice’ theory of identity formation addresses how personal and professional identities should be congruent. To this end, role-modelling, mentoring, experiential learning, reflection and support from medical educators are important.

The concept of dual relationships, whereby professionals and the public interact formally at times and informally at other times, is brought to a greater level of acuity by social media where ‘context collapses’—a point emphasised in our data.³¹ Formal education at medical school in digital professional identity formation in medical school curricula is thus important as is subsequent professional accreditation.³² Some of the participants in our study were aware of which social media platforms to use for various purposes and how to use privacy settings to ensure safety. Scholars have called for systematic approaches to the instruction of e-professionalism so that it can be incorporated into existing curricula.³³

The generational difference between the two groups of participants—students and GPs—is another important consideration. The so-called ‘generation Z’ or millennials who have grown up with social media are thought to be more aware of its use for personal branding and career promotion.³⁴ This raises the matter of how these generations may have experienced social media differently and how it may be an important effect—the ‘cohort effect’ as it is known in research on depression, for example, where younger generations report greater incidence of depression.³⁵ Without negating the cohort effect theory, the participants’ responses on social media were striking in that they raised similar themes to the GPs, for example, of the effect posting intemperate remarks or ill-advised images would have on a medical practitioner’s career. This suggests a ‘trans-generational’ appreciation of the gravitas associated with medical practice, which may be affected by the increasing presence of social media in our personal and private lives.

Guidance from medical educators in the USA advised reflection on social media identity and with who and how they will interact.³⁶ The seriousness of inappropriate social media use is recognised by training bodies,³⁷ and early reports of pilot interventions designed to teach social media professionalism have met with success.³⁸

Strengths and weaknesses

The ‘two-stage’ nature of the study, involving in-depth interviews followed up by a phone call soliciting views on hypothetical scenarios, was a particular strength as it allowed participants to reflect on their views. A useful cross-cultural element was the participation of GPs and medical students from Ireland and North America. The use of a theoretical framework facilitated understanding of the data in terms of prior knowledge and theory while allowing flexibility to incorporate new themes. Limitations of the study were its location in a single medical school in Ireland and the small sample size. The results may not be transferable to other countries and may not be reflective of younger medical students and older clinicians. The interviewer was known to most of the participants, which, on one hand, may exaggerate the propensity of participants to give socially desirable answers in the context of behaviour—a phenomenon known as social desirability bias³⁹; on the other hand, it may produce richer data due to the easy establishment of rapport and trust.⁴⁰

Implications for further research and practice

Research is warranted to identify how best to teach safe practices for engaging with social media. Clear and dynamic guidelines for medical students and GPs are needed for ethical social media use in the medical profession due to the rapidly changing speed and scope of social media.

We have outlined operational guidance based on the study findings for professional practice:

• Medical educators should support students to use social media as a means of engaging in communities of practice with peers and senior colleagues.

• Existing medical curricula must incorporate social media policies and formal instruction on e-professionalism.

• Educators should acknowledge the tensions between personal and professional identities.

• Specific guidance is needed for students on what is appropriate to post and where and with whom it is appropriate to interact.

• We have identified a need for skills teaching on how identities are developed and the setting of boundaries, and this may extend beyond social media use.

Conclusion

Students and GPs view social media as a positive resource for the medical profession. Guidance is required for students and medical practitioners on how to establish reasonable boundaries between their personal and professional presence on social media and in their right to a private life in which ineffective use of social media does not negatively affect career prospects.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

Ethics statements

Patient consent for publication

Not applicable.

Ethics approval

Ethics approval was provided by University of Limerick Department of Education and Health Sciences Research Ethics Committee (2017_05_17_EHS).