Can We Trust Medical Trainees with Social Media and Other Digital Dilemmas

18 04 2011

Last weekend, I was on a panel for internal medicine residents at the American College of Physicians Council of Associates forum in San Diego.  I was invited by Erin Dunnigan and Baligh Yehia, the Co-Chairs of the Council, a position that I have also held earlier in my career.  The topic – was about the debate on social media use among medical trainees and whether it was professional.  Fortunately, I was lucky enough to do it with my rock star colleague Darilyn Moyer, the program director at Temple, who also moderated last years panel on Mean Girls in Medicine with me.

The Temple chief resident, Brooke Worster, started us off by asking the much debated anathema in medical education – what is professionalism – and if it is in the digital domain, it’s even harder to describe.  Then she proceeded to show some videos of medical students that you could say exercise some creativity – from the harmlessly funny to incredibly poor taste and ranging from schools such as UT Southwestern to my own alma mater Washington University in St. Louis.

The questions from the residents were spot on and here were some of the Q&A that followed:

Medical trainees are people too – shouldn’t they able to express themselves in ways  using colorful medical humor either in a show or their profile?

The objection is not for class shows and parodies – those have existed since the very first class medical show that took place at the University of Michigan and called the Galen’s Smoker (this year’s name- “Spleen Girls”).  The issue is more complicated with public consumption of materials never meant to be seen by a public audience.  Then, when a video is seen by a patient, an employer, or another interested stakeholder, alumni, philanthropists, those that donate their body to science (to name a few), the meaning of the video is not clear and those individuals often lose faith in the medical system.  There have been cases where patients have refused care by a residency trainee after seeing their Facebook profile with images that don’t seem suitable for their doctor.  So, while medical trainees deserve the right to blow off some steam and exercise creativity, it should not compromise their ability to see patients or work in the future.

Shouldn’t we just trust students and residents to police themselves on social media?

The answer here is that while most students are capable of policing themselves, a breach of professionalism on the internet is like a NEVER event – especially if it relates to patient information or trainee information that could result in harm.  So, opting for a putting out fires approach will not be effective and it’s important for medical educators to teach students and residents about responsible use of social media.  The good news is that the more one uses social media, the more likely they are to be able to draw that line in the sand.  Our research shows that superusers, or more frequent users, are more likely to oppose regulation but are also more likely to believe that they are responsible for portraying a professional image.  So, by teaching people to use it appropriately, we may actually prevent violations and breaches.

Should schools screen social media as part of its application process?

Interestingly, some students and faculty in the audience advocated for ‘second chances’ and redemption if a student had a inappropriate picture posted since Facebook privacy settings are initially confusing and a student could be misguided initially. But, let’s face it… screening applications for admission to medical school or residency is hard and takes time.  People are looking for ANY red flag to set downgrade your application compared to others.  Don’t give them a reason.  Medicine is not unlike any other industry in which candidates are interviewed to see if they can get the job done and also represent that organization appropriately.  If a video is posted that showcases a student in a tasteless parody with your school logo or name in the background, a hospital or residency is not going to want to take that risk with you.

What can medical schools do to protect themselves?

Well, for starters, schools can have a social media policy that highlight that do’s and don’ts in this area.  Unfortunately, in a recent study by @kind4kids and @MotherinMedicine, most schools do not so we have room for improvement.   The second thing is that schools can also deliver education, not only on the negatives – or how NOT to use social media, but they can also encourage and role model proper use of social media through disseminating course materials, student press, recruitment and admissions, or communicating with their students.  A recent post on a new student blog actually has a Poll this week asking students if they would want to receive information via social media and the majority say yes.

What can students do to ensure that their digital image is safe?

This question actually came from a student that has the same problem as me – a person with another name who happens to be garnering attention for the wrong reasons – in my case, it’s someone with my same name who is an ophthalmologist and has been accused of blinding patients and has many negative patient testimonials.  So, what can I do – well I initially started on LinkedIn to try to distinguish myself from this person and I also took control of my own digital footprint using a Google Profile to highlight who I am and the links on the web that I want people to see.  (You’ll notice my Facebook profile is NOT on my Google Profile).

The same old adage about Vegas applies here- whatever happens on social media stays on social media.  Therefore, just like the national dialogue on health information technology, its important for medical educators and trainees to engage in a constructive dialogue and establish policies that both set standards and teach others how to meaningfully use social media.

–Vineet Arora, MD


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Categories : career advice, medical student, residency training, social media

Nature vs. Nurture in Medical Education: The Case of Student Bedside Manner

13 03 2011

Sir William Osler at the bedside

Believe it or not, it’s been a major news week about the soft stuff in medicine, bedside manner.   First, a Time magazine story about a new study showing that patients cared for by physicians with greater empathy had better diabetes control.  That study comes on the heels of an editorial in the New York Times written by a patient (who also happens to be a science journalist and an outstanding writer) with mitral valve prolapse who graciously volunteered herself to be examined by preclinical medical students learning to do the physical exam and lived to vividly document the experience for all of us.  As she eloquently describes, some students seemed like naturals, whereas others were awkward and clunky.   

These articles add more fuel to the fire for the most hotly contested question in medical education – Can you teach these behaviors?  One on side, you have the nature supporters, saying that the role of admissions committees is to screen these behaviors out.  The nurture supporters say that these behaviors can be taught and its medical schools responsibility to do so.  While it is true that some pathologic behaviors need to be screened in admissions, the question for most students is more refined—is it true that some students come in ‘empathetic’ and others are just hopeless oafs that can’t empathize with patients?  Well, it was refreshing to read Number Needed to Treat blog written by a medical student who says the NYT article was eating away at her soul…She nails it by saying the following:

“Almost every single med student I know is, in fact, an affable person. Yet it doesn’t always come through in the exam room.”

Why is this so hard?  Well, it is not easy to learn how to do a physical exam while also forming your bedside manner.  Our students have to pass a national standardized exam that requires doing the over 100 step “head to toe” physical exam.  As a ‘dinosaur’, I never had to take such a test. I’m not even sure what all the steps are but have asked my colleague, Dr. Farnan, who runs our Clinical Skills program for medical students who informed me of all the points and that they are to be memorized.  Let’s be honest- most of our faculty could not do this without referring to a cheat sheet.  If they had to memorize it for a test, they may even come across robotic and unempathetic at first. 

So, what does this mean for students’ bedside manners while they are learning?  Well, mental capacity is finite.  Workload has been well described as a construct that includes the mental and physical challenge of the work.  For complex tasks, it is important to consider how much ‘spare capacity’ one has after the ‘primary task’ is dealt with.  Elegant studies have shown that experienced physicians are BETTER at performing a secondary task than novice physicians when both are doing the same primary task.  Why?  The experienced physicians have more ‘spare capacity’ to deal with the second task.  

So what is the primary and secondary task in interviewing a patient?  Well, the primary task is learning the physical exam and how to take a history.  As we celebrate this week’s residency match, the job of medical school is to produce physicians that can perform these basic functions during residency training.  While our medical students acquire these skills, of course some will be naturals, and therefore have more spare capacity to key in on their bedside manner.  In contrast, others may struggle with basic skills and have difficulty with both.  The majority, however, will first initially put all their mental effort into learning how to do a history and physical, leaving little ‘spare capacity’ for bedside manner.  Is there hope?  Yes, as these students get better at taking a history and physical, they will be more at ease.  This will then free up the necessary spare capacity to be continuously cognizant of their bedside behaviors.  Consistent with this philosophy, one school has had success actively reinforcing bedside manner skills while prerounding during the third year clerkship.

This progression is important, and highlights the learned art of medicine.  This was articulated beautifully by our recent keynote speaker, Dr. Joel Schwab, for the Gold Humanism Society senior student honorees.   On the subject of being humanistic, he said that he THINKS about the landmark article on etiquette-based medicine every time he sees the patient and he follows the 6 steps –

  1. Knock on the Door (wait permission to enter)
  2. Introduce yourself (with name badge on display)
  3. Shake hands (wear glove if needed)
  4. Sit down (smile if appropriate)
  5. Briefly explain your role on the team
  6. Ask the patient how he or she is feeling 

While working at a free clinic last Saturday, I too thought about this article for every patient I saw.  The first year students I was working with came from a variety of medical schools in Chicago and were volunteering their Saturday to do this.  I had no doubt that they all cared about the patients.  But, I did notice that they were taking time to think very hard about the chief complaint, figure out the right questions to ask, and how to present it coherently.  So, the role of medical education is to make sure that doing a history and physical becomes second nature for our students, and that thinking about bedside manner becomes the primary task.

–Vineet Arora, MD


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Is Medical Education Oppressive? Expert Failure, Social Media & Other Lessons from AAMC 2010

15 11 2010

I spent the majority of last week at the Association of American Medical Colleges.  This was my first time attending the majority of the meeting and it did not disappoint.  While there is lore that some authors are not good speakers, this was definitely not the case with Malcolm Gladwell. Using vignettes ranging from the Civil War to the downfall of Bears Stern and recent financial crisis, he eloquently described what happens when ‘experts’ fail.  Experts fail due to miscalibration, not incompetence.  Miscalibration results from overconfidence when one perceives they have perfect information.  This is certainly true in medicine, in which overconfidence can lead to diagnostic error through early closure.  

While I was still mulling over expert failure, I attended a very interesting session titled “Flexner, Freedom, and the Way Forward” delivered by Steve Kanter, editor of Academic Medicine and Dean of the University of Pittsburgh. Drawing from the educational pedagogy of Brazilian Paulo Freire, he articulated the need to go from the traditional medical education that is fundamentally oppressive, inhibits critical thinking, and rewards conformity to one that promotes intellectual inquiry, the freedom to explore ideas, and imagination.  Unfortunately, the current “deficit” model focuses on students as the major problem, as opposed to environment or instructional practices, and is characterized by the famous “P=MD” promulgated in medical schools today. The increasing emphasis on student unprofessionalism, with little attention on altering the environment or examining the role models – positive or negative- that students interact with is another example of the deficit model. 

So, how do we move to a generative model, which encourages more imagination, creativity, and freedom?  Interestingly, one of Kanter’s answers was through the cultivation of scholarly projects, something that he has championed at the University of Pittsburgh.  This was particularly interesting given the explosive growth in schools that now offer scholarly concentrations, including our own.   During an early morning breakfast meeting of schools with ‘scholarly concentrations’,  I wondered if we would reach a Gladwell ‘a tipping point’ where medical school ‘majors’ would become commonplace or whether these would remain a niche for select schools.   

In addition to thinking about how to move forward, it’s also important to think about how we ended up with this model if it is not desirable?  Is it possible that expert medical educators failed to recognize the importance of critical thinking?  Well, a more plausible explanation is conformity is actually desirable.  After all, few patients are looking for ‘creative imaginative doctors’ (often synonymous with quackery).  Instead, doctors are rewarded for ‘standard of care’ and following ‘evidence-based standards.’  Although creativity and imagination are not rewarded in medical practice, it is certainly needed in medical education.  On this centennial of the Flexner report, there were plenty of reminders at AAMC that we still have the same problems that plagued medical educators 100 years ago.  Reasons for lack of progress in this area include inertia, lack of funding, and the perverse incentives academic health centers that detract from the teaching mission. 

But, this begs the question, is medical education ready for creativity and freedom?   Interestingly, while the “mHealth” or mobile health summit was showcasing the latest technological innovations and advances just down the road in DC, AAMC sessions on social media and medical education focused on the fears associated with increasing use of social media among medical trainees.  When full-scale institutional bans were mentioned, students highlighted how this may inadvertently result in a backlash, popularizing these technologies or the creation of an underground.  In the words of one student (per @MotherInMedicine) “You trust us to care for patients, but not to post on Facebook.” Interestingly, medical educators weren’t the only group thinking about social media and professionalism.  At the same time, the AMA issued its new guidelines for social media, aimed at helping physicians cultivate a positive professional online presence without jeopardizing the doctor-patient relationship.  While social media use in medical education continues to be debated, the meeting was a powerful reminder that we need to consider the future practice of medicine in training the physicians of tomorrow.  While we cannot ‘see’ exactly what the future holds, ignoring it entirely would certainly be oppressive and an expert failure.

–Vineet Arora, MD


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Categories : doctor, medical student, social media

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