Editor's Note: The online version of this article contains a table with questions/scenarios about social networking site use and program director responses to them.

Introduction

The definition and measurement of professionalism, both elusive concepts in medical education, have become even more challenging as online social networking sites (SNS) have increased exponentially in popularity and use. Numerous consensus-driven practice guidelines have been published to guide physicians' behavior on SNS,1–4 and many publications have examined the impact SNS may have on trainee professionalism.5–7 The latter concern derives from the increased prevalence of SNS engagement among medical students and residents as compared to the faculty who oversees their training.8–11 Although SNS can yield invaluable opportunities for learning and patient care, unprofessional behaviors have been reported in this context as well.12–14 Owing to the relationship between unprofessional behavior among physicians-in-training and subsequent state medical board disciplinary action,15–17 medical educators must take seriously trainee lapses in professionalism related to SNS.3

Despite an emerging literature, investigation of SNS use in pediatrics residency training remains limited. This training setting poses unique challenges and warrants deliberate study for several reasons. First, pediatrics residents care for adolescent and young adult patients and work closely with the parents of these young patients, all of whom have come of age in the era of SNS. The pervasiveness of SNS in the pediatrics practice setting necessitates explicit attention to the concomitant potential for unprofessionalism online. Although pediatrics program directors have been previously surveyed,9 program directors' direct accountability for professionalism education makes this group of medical educators a particularly robust population for study.18 The personal and professional stressors inherent to the residency experience are known to conspire against professionalism19; therefore, unprofessional behavior online may be more problematic in graduate medical education.

There are few studies regarding interactions between physicians and their patients on SNS. One publication from the psychiatry literature addresses this topic,7 yet psychiatrists already receive robust training related to professional boundaries. On the other hand, pediatricians' training on this subject may be inadequate, especially in the face of high SNS use among pediatrics patients and their family members. The potential for lapses in professionalism resulting from pediatrics trainees' interactions with patients on SNS remains understudied.

Pediatrics program directors (PDs) have been tasked with educating our trainees in the 6 core competencies, including professionalism. Recent studies indicate that formal curricula in ethics and professionalism are uncommon in pediatrics residency training.20,21 We hypothesized that pediatrics residency PDs agree on the online behaviors that are unprofessional, and that they have encountered pediatrics residents' unprofessional use of SNS. We also hypothesized that pediatrics PDs are relatively unfamiliar with SNS, and that few programs or institutions offer formal curricula addressing online professionalism. To test these hypotheses, we conducted a survey of pediatrics residency PDs and associate program directors (APDs) to ascertain their baseline familiarity with SNS, experiences with trainee unprofessionalism on SNS, perceptions of appropriate use of SNS, and strategies for teaching their trainees about online professionalism.

Methods

Results

Demographics

Our survey response rate was 33% (162 of 497). Respondents represented 50% (99 of 197) of all pediatrics residency programs in the nation. The sample includes 95 women (66%) and has a median age of 44 years (interquartile range, 37–53 years). Other demographic information on respondents is presented in table 1.

TABLE 1 Demographic Characteristics of Responding Program Directors^a

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Program Directors' Perceptions of Residents' Social Networking Site Use

Respondents were asked to rate the appropriateness of different resident activities on SNS (table 2). Most respondents gave ratings of “somewhat appropriate” or “completely appropriate” to 4 online activities: friending peers at the same training level (136, 88%); friending former supervisors or teachers (111, 72%); friending former supervisees or learners (107, 71%); and friending other hospital staff (92, 61%). On the other hand, most PDs gave ratings of “somewhat inappropriate” or “completely inappropriate” to the remaining 6 activities included in our survey: accessing SNS while at work (109, 72%); connecting with friends via SNS while at work (111, 73%); friending current supervisors or teachers (90, 59%); friending current supervisees or learners (93, 61%); friending current patients or their families (151, 99%); and friending former patients or their families (145, 94%). Indeed, PDs expressed nearly uniform disapproval of the latter 2 activities.

TABLE 2 Program Directors' Ratings of the Appropriateness of Various Resident Activities on Social Networking Sites^a

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Discussion

Our national study of pediatrics residency PDs and APDs demonstrates that online unprofessionalism among pediatrics residents is fairly common, with more than half of our sample having encountered inappropriate online content posted by residents in the last year. This finding corroborates data from other specialties about the incidence of inappropriate behaviors on SNS.12,22 Given the less frequent use of SNS by PDs and APDs than trainees, we suspect that these results likely underestimate the actual incidence of such lapses.23

Interestingly, despite the prevalence of SNS use, less than half of our sample has adopted any of the 6 educational strategies we asked about in our survey, and a quarter of our sample did not know if their institution has a policy to guide online behavior. Research done in another setting has uncovered inadequate educational interventions and hospital policies,12 which may derive from educators' unfamiliarity with SNS as compared to their learners. Because millennial learners' experience with SNS surpass that of their teachers, PDs and faculty may struggle to devise curricula and policy in this area. Therefore, the process of designing these interventions must be a collaborative one, blending input from both medical educators and trainees.

Our study revealed that the PDs and APDs in our sample were infrequent users of SNS. This unfamiliarity may yield an overly restrictive approach to this technology. Given the prevalence of SNS use among trainees, medical educators may move beyond simply saying “no” and may need to define and role model professionalism on SNS for their trainees.24 This is of particular importance in pediatric training owing to the high prevalence of SNS use among pediatrics patients and their parents. In addition, as the use of “patient portals” and “e-visits” increase to meet the needs of “meaningful use,”25,26 it will become essential to train physicians in appropriate electronic communication with patients, some of which may occur via SNS.

Our study found high levels of consensus about what constitutes unprofessionalism online. PDs and APDs voiced unequivocal disapproval of certain online activities, such as the friending of patients or family members or using SNS to post comments or observations about the workplace, unbecoming photos, unprofessional language, or patient information or images.

The subject of professional interactions between pediatricians, patients, and family members has been understudied. We demonstrated that PDs in our sample are overwhelmingly opposed to the friending of patients or family members. Do residents agree with their PDs about what constitutes professional conduct on SNS? To date, no studies have explored how pediatrics residents define professionalism using SNS and what online behaviors they deem inappropriate. Data from some specialties demonstrate that residents may hold diverse opinions on key issues such as how SNS may alter the physician-patient relationship and professional boundaries.7,27 Future work should be done to collect data across specialties to inform the graduate medical education community of trainees' perspectives. A more thorough understanding of whether and how trainees' views are concordant with that of medical educators will be needed to engage in effective curriculum development about SNS.

Limitations to this study include the fact that we surveyed only pediatrics PDs and the findings may not be generalizable to other specialties. Also, the lack of availability of demographic data about nonresponding PDs reduces the ability to generalize within pediatrics. We invited PDs and APDs to complete an anonymous survey and may have multiple respondents from the same institution/program, which affects the interpretation of some data, such as the number of programs having policies or curricula about online professionalism.

Conclusion

We found that pediatrics PDs are encountering lapses of professionalism involving residents' activity on SNS, and that curricular offerings aimed at guiding residents' behavior online are currently uncommon. The lack of familiarity with SNS on the part of PDs and others responsible for educational programs may hinder the development of effective curricula on this subject. Future work is needed to measure how residents define professionalism on SNS, and to identify useful and beneficial ways in which SNS can augment medical education. Finally, finding agreement on the definition of unprofessionalism in the use of SNS that rings true across specialties would facilitate the development of policies and curricula that can be applied throughout the graduate medical education community.

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