Number of Citations: 2

Submitted: 8 February 2020
Accepted: 9 April 2020
Published online: 1 September, TAPS 2020, 5(3), 71-82
https://doi.org/10.29060/TAPS.2020-5-3/OA2226

May Eng Loo¹, Brenda Wong², Yee Mun Lee³

¹Health Outcomes and Medical Education Research (HOMER), National Healthcare Group, Singapore; ²Group Education, National Healthcare Group, Singapore; ³Department of Urology, Tan Tock Seng Hospital, Singapore

Abstract

In order to understand what constitutes unprofessional online behaviour from the perspectives of stakeholders, there have been studies that examine the perceptions of doctors and the public on hypothetical online postings. However, the considerations and reasoning of the participants when they evaluate online posts have not been explored in-depth. This project aimed to examine the main considerations and possible conflicting considerations of faculty and residents when they evaluate the appropriateness of Facebook posts, and how they might negotiate any conflicts. Faculty and residents from the National Healthcare Group – Alexandra Health Pte Ltd Residency in Singapore were randomly presented Facebooks posts as part of an online questionnaire, rated their appropriateness, and provided explanations for their ratings. Responses were coded for main considerations and responses with 2 or more conflicting considerations were further analysed to describe the conflict and the way they were negotiated. 182 faculty and residents rated the appropriateness of three out of six Facebook posts and explained their evaluation. Except for one post which was evaluated as ‘Neither appropriate nor inappropriate’ by the majority (37%) of the respondents, all other posts were rated as either ‘Very inappropriate’ or ‘Inappropriate’ by the majority of respondents (34%-69%). Despite similar evaluation of inappropriateness, faculty and residents take into account a wide range of considerations. These considerations tend to conflict with one another when the respondents considered freedom of expression of the poster and the educational purpose of a post. Understanding physicians’ negotiation of conflicting considerations provides insight into their outworking of professionalism in social media context.

Keywords:           Professionalism, Social Media, Postgraduate Education

Practice Highlights

• Doctors within the same Residency do not necessarily have a uniform set of professional priorities regarding social media.
• They may also have to manage conflicting professional and personal values in different contexts.
• Educators of professional values could recognise the complexity of such conflicts and be sensitive to this in their teaching.
• We recommend creating platforms for doctors to have conversations on social media use.

I. INTRODUCTION

In June 2017, Mark Zuckerberg announced that the Facebook community was officially two billion people. While seeking to understand how social media can be maximised for good, Chief Product Officer Chris Cox was conscious of Facebook’s responsibility to ‘curtail any way that it can be misused or turned into something sad’ (Constine, 2017). In healthcare education and practice, social media has both the potential to be maximised for good (e.g. facilitating communication and improving knowledge) as well as the potential to be misused, compromising patient confidentiality and eroding public confidence in the medical profession (Greysen, Kind, & Chretien, 2010; Hamm et al., 2013). In their commentary, Chretien and Kind (2014) propose that in order to reap the benefits of social media use for healthcare, physicians need to be first aware of the risks of using social media and address concerns of unprofessional online behaviour.

In order to understand what constitutes unprofessional online behaviour from the perspectives of stakeholders, there have been studies that examine the perceptions of doctors and the public on hypothetical online postings (Chretien, Farnan, Greysen, & Kind, 2011; Dawkins, King, Boateng, Nichols, & Desselle, 2017; Greysen et al., 2013; Jain et al., 2014; Kesselheim, Batra, Belmonte, Boland, & McGregor, 2014; Kind, Greysen, & Chretien, 2012; Rocha & de Castro, 2014). These studies found that online behaviour that participants judged as unprofessional include patient privacy violations, patient content in general and negative comments about faculty and staff.  However, the considerations and reasoning of the participants when they evaluate online posts have not been explored in-depth, and especially for posts that may be inappropriate but may not appear obviously unprofessional.  Such ‘grey posts’ may include patient storytelling posts where, for example, a patient’s identity is not revealed but details are shared to encourage reflection or request support through social media (Wells, Lehavot, & Isaac, 2015).  Professional or personal values may sometimes come into conflict when they seem equally important in such situations. However, not much is known about what these conflicting considerations are when doctors evaluate such online posts and how these conflicting considerations are resolved or negotiated.

In response to concerns about unprofessional behaviour on social media, guidelines have been published by medical associations in various countries like the USA, UK, Canada, Australia, New Zealand as well as Singapore (American College of Physicians Ethics, Professionalism, and Human Rights Committee, 2012; Australian Medical Association, 2010; Canadian Medical Association, 2011; General Medical Council, 2013; Singapore Medical Council, 2016). These existing guidelines are generally comprehensive, providing principles for social media use and examples of unprofessional behaviour to avoid. Regarding posting online, concerns about patient confidentiality, professionalism, collegiality and preserving patients’ and the public trust in the medical profession are key issues raised by the guidelines. In particular, the Singapore Medical Council gives a list of inappropriate posts, examples include ‘speaking and writing in an indiscreet, bigoted, rude, and obscene or profane manner’ and ‘posting personal or derogatory comments about patients or colleagues’ (Singapore Medical Council, 2016).

Our study seeks to explore the considerations and possible competing or conflicting considerations of faculty and residents in the National Healthcare Group – Alexandra Health Pte Ltd (NHG-AHPL) Residency program when they evaluate online postings, especially grey posts. This study also aims to examine how the participants resolve or negotiate these conflicting considerations. Identifying the considerations of faculty and residents when they evaluate the posts sheds light on what constitutes unprofessional online posts and provides a platform for further discussion on existing social media use guidelines. Furthermore, understanding how doctors negotiate at times conflicting norms and obligations also provides insight into how they perceive the outworking of professionalism in the social media context.

II. METHODS

Six Facebook posts deemed inappropriate were identified from an online search. One author (L.M.E.) searched Google News on 30th June 2016 using a Boolean search: (social media OR Facebook OR twitter OR blog OR online OR internet OR web) AND (doctor OR physician OR medical student OR hospital OR clinic OR ward) AND (inappropriate OR unprofessional OR wrong OR unethical). The search was restricted to the first 20 pages of results (10 hits/page) and four posts (Posts 1, 2, 4 and 5) that appeared inappropriate but were not clearly unprofessional were selected. The remaining two posts (Post 3 and 6) were re-used from a pilot phase of the study. The characteristics of the posts are described in Table 1 and the screenshots of the six posts can be found in Appendix A.

Table 1. Characteristics of posts

As part of an online questionnaire administered between 8^th September and 30^th October 2016 on social media use, faculty and residents from the NHG-AHPL Residency program in Singapore were asked to rate the appropriateness of three of these posts and to explain their evaluation. All respondents provided informed consent at the start of the questionnaire. Considerations were identified using structural coding which is a question-based code that acts as a labelling and indexing device (Saldana, 2012). For example, the following response was coded ‘Purpose’, ‘Language’ and ‘Respect’ based on the question “What do respondents consider when they evaluate posts?”

Someone has just died. Instead of showing empathy to the family of the deceased who had just lost a loved one, she uses swear words in a callous, insensitive way. Even though her intentions might have been good to ask people to wear a crash helmet, the way she said it was offensive and highly inappropriate given the circumstances. (F5.3)

In the first round of coding, two authors (L.M.E, B.W.) coded each response independently and resolved coding discrepancies through discussions. Using a codebook developed from the first round of coding as a guide, each response was revisited and coded. Coding discrepancies were resolved through more extensive discussions. The second round of coding added new codes to the codebook. Responses with two or more conflicting considerations were further analysed to describe the conflict and the way they were negotiated.  Conflicting considerations were identified based on the plain reading of the response, prompted by the use of conjunctions such as ‘but’, ‘even though’ and ‘while’. Appendix B gives a full description of the codes used. Ethics approval was obtained from the institution’s Domain Specific Review Board. 

III. RESULTS

A total of 182 respondents (36.8%)–64 faculty and 118 residents–rated the appropriateness of three out of six Facebook posts. 463 responses–169 responses from faculty and 294 responses from residents–were analysed. Table 2 provides a summary of the results for each post.

Table 2. Summary of results for Posts 1-6

A. Evaluation and Considerations

Except for Post 4 which was evaluated as ‘Neither appropriate nor inappropriate’ by the majority (37%) of the respondents, all other posts were rated as either ‘Very inappropriate’ or ‘Inappropriate’ by the majority of respondents (34%-69%). In particular, Post 5 has a relatively high proportion of respondents (10%) rating it as either ‘Appropriate’ or ‘Very appropriate’. Respondents have a broad range of considerations with ‘Professionalism’, ‘Language’, ‘Behaviour’ and ‘Platform’ repeated across all six posts.

‘Platform’ was the main consideration for Post 2 and Post 6. Respondents considered the inappropriateness of posting on a public platform what should only be said or done in private, “FB is a public forum. People should settle personal grievances NOT online but privately” (R2.57; Post 2); “Publicly criticizing a colleague is inappropriate. Feedback should always be given in a private setting” (R6.33; Post 6).

For the other posts, the main considerations were ‘Consent’ (Post 1), ‘Professionalism’ (Post 3), ‘Freedom’ (Post 4) and ‘Confidentiality’ (Post 5). More than half of the respondents (55%) for Post 1 considered whether consent or permission was obtained before posting. For Post 3, more than half of the respondents (59%) considered professionalism generally or more specifically in terms of attitude. For Post 4, 42% of the respondents considered the freedom of speech of the poster including the freedom of the poster to post personal matters in a personal capacity, with personal accountability. Confidentiality and privacy of patients was considered by 24% of respondents on Post 5.

B. Negotiation of Conflicting Considerations

Among the six posts, Post 5 had the most number of respondents with conflicting considerations (n=15), followed by Post 4 (n=13).

For Post 5, fourteen respondents considered that the poster has an educational purpose versus other considerations and one respondent considered freedom of expression versus language.  To negotiate the conflicting considerations for Post 5, six respondents reasoned that the educational message of the post and the poster’s good intentions need to be subjected to (or at least seen in the light of) considerations of confidentiality, language, professionalism and respect. For example, two faculty members, F5.3 and F5.5, thought that although the poster had good intentions and the message was educational, her language and tone were inappropriate.

Someone has just died. Instead of showing empathy to the family of the deceased who had just lost a loved one, she uses swear words in a callous, insensitive way. Even though her intentions might have been good to ask people to wear a crash helmet, the way she said it was offensive and highly inappropriate given the circumstances (F5.3).

F5.5 also considered the possible identification of the victim, “although message was ‘correct’ strong language including expletives used which is inappropriate timing and location of post may allow identification of victim” (F5.5).

However, there were nine respondents for Post 5 who considered educational purpose and freedom of expression at the same level of importance as other considerations. Rating Post 5 as ‘Neither inappropriate nor appropriate’, F5.6 reasoned that the possible breach in Professionalism/Confidentiality may be justified by educational purpose, “I don’t think it’s appropriate to talk about patient experiences on Facebook but I believe she has done so with the intention of encouraging others to wear helmets” while R5.39 reasoned that the inappropriate language use may also be justified by the freedom of the poster to say what she wants as long as there were no patient identifiers, “While her choice of words may not be the best, there were no patient identifiers. Again, she can say what she wants”.

For Post 4 which had 13 respondents with conflicting considerations, 12 respondents considered that the poster should have the freedom to express his personal opinion versus a variety of other considerations, including that of ‘Professionalism’,’ Language’, ‘Audience’,’ Behaviour’, ‘Context’, ‘Platform’ and ‘Consequences’. One respondent considered norms on social media versus the harsh language used.

To negotiate the conflicting considerations for Post 4, six respondents prioritised professionalism and other considerations like audience and consequences over freedom of expression.  For example, a resident reasoned that while medical professionals can have their own political views, the poster should consider the possible consequences of such a post being seen by a wider audience and being used against him, “Everyone is entitled to his own view, medical professionals can have their own political views, but caution needs to be exercised if this information is used against him. might need to restrict to close friends only” (R4.43).

Seven respondents, however, considered freedom of expression and norms on social media at the same level of importance as other considerations. For example, respondents R4.51 and R4.60 rated Post 4 as ‘Neither inappropriate nor appropriate’. They reasoned that the harsh language used or the negative consequences of the post may be justified by the poster’s entitlement to freedom of expression, “He is entitled to his beliefs and freedom of speech about political and religious issues. Even though these comments are harsh and mean, we can’t possibly control how everyone speaks” (R 4.51); “Everyone is entitled to free speech and he has every right to say what he wants. But again this does not look good on his reputation” (R 4.60).

The number of respondents with conflicting considerations for the other posts ranged from 1 to 6. In general, respondents negotiated the conflicting considerations mainly by prioritising professionalism over and above the other considerations.

IV. DISCUSSION

A total of 182 faculty and residents (36.8%) from the NHG-AHPL Residency program in Singapore rated the appropriateness of Facebook posts and 463 evaluation responses were analysed. One of three postgraduate medical education programs in Singapore, the NHG-AHPL Residency comprises 27 residency programs within a few institutions including hospitals and nine polyclinics. Faculty and residents who explained their evaluation took into account a wide range of considerations and these considerations tended to conflict with one another when the respondents considered freedom of expression of the poster and the educational purpose of a post. These findings suggest that doctors within the same Residency do not necessarily have a uniform set of professional priorities and may have to manage conflicting professional and personal values in different contexts.  The teaching and evaluation of professionalism should thus increasingly take conflict and context into consideration (Ginsburg et al., 2000). Educators of professional values could recognise the complexity of such conflicts and be sensitive to this in their teaching, whether formally or informally.

Freedom of speech or expression appears to be a recurrent consideration for posts not just in the personal domain (Posts 2 and 4) but also those in the work-related domain as well (Posts 3 and 5). Given that freedom of expression is not commonly encouraged or emphasised in Asian cultures (Kim & Sherman, 2007), it may be somewhat surprising that this was a recurrent consideration for doctors in Singapore. This consideration thus deserves more attention from developers of social media use guidelines and online professionalism course facilitators who can seek to start addressing these considerations by first recognising and acknowledging them. While existing social media guidelines could and should be tempered by recognising doctors’ right to free speech, doctors and medical students would also need to exercise critical judgment to consider whether their freedom of expression is appropriate in view of the guidelines (Farnan et al., 2009).

This study found that the post that elicited the most number of conflicting considerations was Post 5. This post by a junior doctor contained insensitive language and patient-related content but had an educational purpose. It is unclear whether if the post had been written more sensitively, it would elicit even more conflicting considerations. This may be a valid cause for concern given the potential negative consequences of such posts (Wells et al., 2015). Although the victim was not named, it is still possible that enough details are given for him to be identified. Such a post may also violate family members’ expectations of privacy. Public trust could also possibly be undermined because of the insensitivity and lack of empathy displayed by a doctor. It may be helpful for faculty to engage residents or students with such issues informally or formally during relevant courses and to explore alternative avenues for patient storytelling.

Based on the findings of our study, we recommend creating platforms for conversations on social media use to take place among faculty and residents. Using existing social media use guidelines and relevant findings from studies as material for discussion, faculty and residents could consider various perspectives, discuss how guidelines may moderate some considerations and explore further considerations arising from the conversation. Discussions like these require doctors to exercise critical judgments on ethical dilemmas and arrive at possible ways to negotiate conflicting considerations in various circumstances within the social media context. In her commentary on social media and medical professionalism, Fenwick (2014) discusses how doctors in contemporary practice must deal with conflicting priorities and urges a more pluralistic approach to understanding the notion of professionalism while thinking critically about social media’s current and future implications for practice.  Such conversations can provide opportunities for the doctors to do so and perhaps more crucially, to consider how social media can be used creatively for better patient and health outcomes.

In a recent systematic review on the use of social media in graduate medical education, the authors found ten studies pertaining to resident professionalism (Sterling, Leung, Wright, & Bishop, 2017). However, most were exploratory, surveying residents about their social network behaviour and exploring how program directors use social media to monitor unprofessional behaviour of residents. Although our study was limited to the faculty and residents in one Residency in Singapore, to our knowledge, this is the first study to shed light on how residents as well as faculty negotiate conflicting considerations when evaluating online posts. Instead of hypothetical Facebook posts (whereby it would be possible to address potential biases by varying factors like the age or gender of the poster), we used authentic posts (except Post 6) which respondents might find more relevant and might be more motivated to evaluate and discuss them. Another limitation of the study was that we did not consider how factors like the respondents’ age, type of residency program or their actual usage of social media may influence their evaluation of the posts. However, we followed a systematic, transparent process for coding the written responses and we achieved a high interrater reliability through extensive discussions.

Future work should focus on understanding the complexities of how doctors negotiate conflicting professional values. In this study, respondents were asked to explain their evaluation after rating the appropriateness of the posts and the length of responses varied from one word to several sentences. Due to the limitation of such a study design, the reasoning process of some respondents could not be examined. Conducting interviews or focus groups could enable more in-depth analysis of how participants negotiate conflicting values. Research in moral psychology has shed light on how a person makes moral judgments.  According to cognitive developmentalists a person may spontaneously have a new intuition that contradicts the initial intuitive judgment during the course of thinking about a situation (Kohlberg, 1969; Piaget, 1965). He/she comes to see a dilemma from more than one perspective and experiences competing intuitions. In particular, focus-group discussions could shed light on how the moral judgments of participants in the group might influence one another (Haidt, 2001). Studies designed to focus on examining how doctors resolve conflicting professional values can deepen our understanding of medical professionalism and what it constitutes, within the social media context and beyond.

V. CONCLUSION

This study aimed to explore the considerations and possible competing or conflicting considerations of faculty and residents in the NHG-AHPL Residency program when they evaluate online postings, especially grey posts. Faculty and residents who explained their evaluation took into account a wide range of considerations and these considerations tended to conflict with one another when the respondents considered freedom of expression of the poster and the educational purpose of a post. These findings suggest that doctors within the same Residency do not necessarily have a uniform set of professional priorities and may have to manage conflicting professional and personal values in different contexts. Educators of professional values could recognise the complexity of such conflicts and be sensitive to this in their teaching, whether formally or informally. We recommend creating platforms for conversations on social media use to take place among faculty and residents.

Notes on Contributors

Ms Loo May Eng is Research Analyst at Health Outcomes and Medical Education Research (HOMER), National Healthcare Group. She is the primary author of this manuscript and was involved in the study design, data collection and analysis of this project.

Dr Lee Yee Mun is Senior Consultant at the Department of Urology, Tan Tock Seng Hospital. He was involved in the conceptualisation of this project.                                

Ms Brenda Wong is Program Coordinator at Group Education, National Healthcare Group. She was involved in data collection and analysis.

Ethical Approval

Ethics approval was obtained from the institution’s Domain Specific Review Board (NHG DSRB Ref: 2015/00584).

Acknowledgements

The authors would like to thank all residents and faculty who participated in the questionnaire.

Funding

The research did not receive any specific grant from funding agencies.

Declaration of Interest

There is no conflict of interest to declare.

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*Loo May Eng
Health Outcomes and Medical Education Research,
National Healthcare Group
Tel: (65) 6359 6362
Email: may_eng_loo@nhg.com.sg