CHAPTER 2

PRIVACY, PROFESSIONALISM, AND SOCIAL MEDIA IN MEDICINE

JOANNA MACDONALD, MB.CHB., FRANZCP, PHD

The advent of the technologies known collectively as Web 2.0 has allowed the medical profession’s “secrets” to be aired in a public arena. Whereas previously jokes told by medical staff, student skits, disparaging comments about patients, and bona fide discussions of challenging patients took place behind closed doors [as did wild partying, the misuse of drugs, debriefing after challenging experiences, and seeking support], the widespread dissemination online of material created by doctors or medical students has opened those doors. Further, it has allowed such material to spread and be archived in ways unimaginable even 30 years ago. Before the widespread use of faxing, society relied on its members to communicate in person, on paper, or by telephone. While gossip has always spread, the speed and geographical extent of its spread were limited by the technology available. In the space of three decades, we have seen a shift to a limitless capacity to communicate text, visual images, and videos instantly worldwide. This has led to calls for greater regulation or guidelines for doctors concerning the dangers of indiscriminate use of these modalities (Gorrindo & Gorrindo, 2008). In this chapter, I shall briefly explain what is meant by Web 2.0 technologies and review what little is known of its use by doctors and medical students. I shall then turn to professionalism, initially extracting the key elements of professionalism and examining those that are particularly pertinent to the use of Web 2.0. Finally, I shall discuss whether regulation and guidelines are the most appropriate way of addressing these issues, concluding that, instead, the basic principles underlying professionalism already allow the profession to address the potential adverse consequences of these and future technologies.

WHAT IS WEB 2.0 ?

Web 2.0 is a term used to describe the web-based technologies that “allow users to contribute to websites” (McGee & Begg, 2008). Examples include YouTube which allows sharing of movies; Flickr on which users share photos; and the various social networking sites (SNSs) e.g., Facebook, MySpace, and Bebo, and “sexting,” the transmission of sexually explicit photographs of oneself by cellphone (Muscari, 2010). In considering these phenomena and their effect on medicine and professionalism, one of the most challenging aspects is their speed of change and development.

Facebook, for example, was established in 2004 (Facebook Fact-sheet, n.d.), and currently has over 500 million users, with an average of 130 “friends” each (Facebook Statistics, n.d.). While it was originally developed for users affiliated with colleges or universities in the United States (U.S.), access is now universal, with 70% of users outside the U. S. (Facebook Statistics, n.d.). Registered users can choose one or more “networks” to join, and by mutual agreement become “friends” with other members. A “friend” is a user who has been allowed access to another user’s postings by that user. Facebook users can use their site to “post” photos of themselves or others; search for “friends”; keep in contact with friends, acquaintances, and classmates; chat and comment on their activities, thoughts, plans, and emotions; and join a myriad of groups of like-minded users. The average user creates 90 pieces of content each month and is involved with 80 groups. Fifty percent (50%) of users log on daily (Facebook Statistics, n.d.). Such activity is replicated, although perhaps not in the same volume, by innumerable other SNSs and Web 2.0 technologies. The result is an inconceivable quantity of personal information, written, photographic, and cinematic, circulating globally.

Facebook has changed its privacy settings on a number of occasions since its inception, seemingly attempting to find a balance between its wish to maximize the spread of its network and its users’ concern to maintain some control over their information (Facebook, Information We Receive, n.d.). Currently the user’s “name, profile picture, gender and networks are visible to everyone” (Facebook, Company Timeline, n.d.). Using any applications or websites, including search engines, allows those applications to access that information as well as the user’s list of “friends”. There are websites available that allow users to compare the privacy settings and policies of the various Web 2.0 technologies (Digizen, 2011) but there is no evidence that people use these data in deciding which communication sites to join.

All SNSs share four unique characteristics: “ Persistence … Searchability… Replicability… Invisible audiences….” (Boyd, 2007). These features, combined with the ease of searching and storing digital information, mean a “digital dossier” can be compiled with ease (Gross & Acquisti, 2006). This information is then available to be viewed and further copied, modified, and disseminated by unknown viewers, out of context, and into the future. Even if the SNS user has deleted the material or deactivated their account, such material can persist on the sites of other users. For instance, an image or comment could be copied by a “friend”, sent to others of their “friends”, and so become widely available beyond the control of the member who “posted” it.

THE USE OF WEB 2.0 TECHNOLOGIES BY DOCTORS AND MEDICAL STUDENTS

SOCIAL NETWORKING

Given the recent development of Web 2.0 technologies, there is limited information in the peer-reviewed literature regarding their use or misuse by doctors. As might be expected, however, there are numerous reports online largely documenting the unwanted consequences of indiscriminate use of these networks (Du, 2007; Read, 2006). The first reports attempting to quantify the use of SNSs by medical students and postgraduate trainees were published in 2008 (Ferdig, Dawson, Black, Black, & Thompson, 2008; Thompson, Dawson, & Ferdig, 2008). They described a study that was limited by its failure to note the ages of the participants, and only reported details of the material posted for 10 of the participants, with no indication of the grounds upon which these data were analyzed. The authors suggested that there was a decline in Facebook usage as the users aged, but as this was a cross-sectional sample, an alternative explanation, that this was a cohort effect, is equally plausible. Despite these shortcomings, the study gave cause for concern in that there was some unprofessional material displayed (e.g., violations of patient privacy and use of foul language) (Thompson et al., 2008).

Another study published to examine directly the use of SNSs by young doctors was that of MacDonald, Sohn, and Ellis (2010). This study described the content of Facebook postings over three months in 2008-2009 of all (338) doctors from the graduating classes of 2006 and 2007 from the University of Otago School of Medicine, the larger of the two medical schools in New Zealand. At that time Facebook was the most commonly used SNS in New Zealand (Swan, 2008). The study found that 65% (220) of the graduates had Facebook accounts of which 63% (138) had adjusted the privacy options available at that time to restrict the information available on their pages to “friends”. The pages of the remaining 82 accounts were readily visible at that time to any of the 8364 members of the Otago network, and by extension to many of their “friends”. These pages were examined in detail. The users’ sexual orientation was revealed in 30 (37%) of these pages, their religious views in 13 (16%), and their relationship status in 38 (46%). Photographs of members obviously intoxicated were displayed by 8 (10%), and 18 (22%) belonged to groups that were of concern, e.g., “Perverts united” or F*** medicine-I want to be a ninja”. Conversely, some 37(45%) showed photographs of themselves engaging in healthy behavior, raising the possibility of this being an opportunity for positive role modeling. These young doctors were actively using their accounts, 66% in the preceding week, suggesting that they were active users of Facebook despite having graduated up to two years previously. This gives further grounds to challenge the conclusion of Thompson, Dawson, and Ferdig ( 2008) that the use of SNSs decreases with age.

Other studies in the field have relied on reports of the use of these media, either self-reports or reports by administrators at medical schools. Thus, Garner and O’Sullivan (2010) reported on a voluntary online survey about the use of Facebook. The conclusions that can be drawn from this study are limited by the response rate of 31% (56 students), and the fact that participation was voluntary and self-reported. Given that, 52% of the respondents admitted to having photographs of themselves that they considered embarrassing on their Facebook sites and 54% reported that they had witnessed colleagues posting unprofessional material, e.g., discussion of experiences with patients. An anonymous questionnaire e-mailed to 405 postgraduate doctors, residents and fellows, in France similarly had a low response rate of 50%, of whom 147 (74%) (36% of the full sample) had a Facebook profile (Moubarak et al., 2011). Of those who used Facebook, their relationship status was available for 93 (63%) respondents, their sexual orientation for 39 (27%) and religious views for 13 (9%), although the extent to which this information was widely available was not clear.

Using a different approach, Chretien,...