As medical schools celebrate Match Day and the conclusion of the residency selection process, a new rite of passage occurs for many fourth-year students: restoring their Facebook accounts so that the accounts reflect their real names. Students have become aware that their social media accounts may be assessed by residency selection committees (possibly, to their detriment), and some students have decided to effectively hide their accounts, or to remove themselves from social media completely, until safely matched. Is this a victory or a failure for online professionalism?

In her Perspective in this issue of Academic Medicine, Fenwick1 argues that the emphasis on social media risk avoidance that predominates the literature and medical school curricula may inhibit needed experimentation with(in) social media and, in turn, the discovery of positive uses for social media in health care. Fenwick urges critical rethinking of the medical community’s very notion of professionalism: singular frames may be inadequate given the pluralism of medical professionals’ responsibilities. She points to areas of future research for exploring the complexities of the medical profession’s use of social media.

We share Fenwick’s enthusiasm for the potential benefits that physicians’ social media use can bring for health care and the public.2 We believe that the trajectory the medical profession has taken to address initial concerns of unprofessional online behavior by trainees and physicians—from the growth in the literature in this nascent area, to the development of medical school education and policies, to the publication of national professional organization position statements and guidelines—has been affirming to physicians’ professional commitment to maintaining public trust in this new and sometimes challenging digital age. Certainly, there are additional unanswered research questions and as-yet-developed curricula that could enhance medicine’s understanding and use of social media for public good, but the field is headed in the right direction for future growth. However, focusing at this time solely on minimizing the risks of social media use may derail progress.

This Way to Discovery: Social Media in Medicine’s Hierarchy of Needs

Maslow’s psychological theory of a hierarchy of needs, often depicted as five levels in a pyramid, describes a taxonomy of human motivations. According to the theory, humans cannot reach the highest pinnacle of self-actualization unless their more basic needs are met first. For instance, physiological needs such as food, water, and sleep constitute the bottom, most essential need, followed by safety, then social relationships, and so on. We propose viewing physicians’ social media use as a modified hierarchy of needs (Figure 1). The bottom, most basic level is Security. Security allows us physicians to use social media while protecting patient privacy; we understand behaviors that would jeopardize our careers. The next level is Reflection. Once we are aware of the risks of using social media, we can be thoughtful about our place in the digital world: What is our online identity? How will we interact with patients, colleagues, and employers online? How do we embody our professional ideals and values in our online presence? Whom do we represent? And finally, the top aspirational level is Discovery: How can we use social media to innovate, to create a healthier society, to educate patients, to advance our careers and mentor others, and to otherwise contribute to research, public health, and medical practice?

Figure 1:

Social media in medicine hierarchy of needs pyramid.

The social media and medicine landscape is evolving rapidly. The earliest studies, which focused almost exclusively on Security, described potentially unprofessional online behaviors and reported on the development of medical school social media policies and educational interventions.3–5 Now, there are more educational efforts that involve critical reflection of trainees’ online presence; these explore issues such as professional identity development and personal/professional boundaries, and they acknowledge that in some situations there are no right or wrong answers.6,7 Newer policy statements and guidelines acknowledge the opportunities available through social media use,8 and more guides exist on how medical professionals can and should responsibly engage with social media.2,9

Vital to the social media needs hierarchy model we propose is respecting the essential need of Security in order to move towards Reflection and then into Discovery. Research has shown that medical trainees and practicing physicians have experienced serious ramifications, including expulsion from medical school and state board medical sanctions, as a result of their online behavior.3,10 It is important to keep in mind that the few incidents uncovered through research or exposed in the media are likely not exceptions but, rather, just the proverbial tip of the iceberg; connecting via social media or even just talking offline with medical trainees about their own and their peers’ habits can reveal the extent to which they are writing about their patient care experiences online in potentially identifiable, and hence inappropriate, ways. We physicians and medical educators can and should do more to earn the public’s trust.

The Foundation of the Pyramid: Public Trust

Wynia and colleagues11 recently proposed that professionalism should be broadly viewed as a way of organizing health care, with the overall objective being the maintenance of public trust. Leach,12 in his commentary on that article, wrote that “the profession finds itself at a crossroad: Trust will either be eroded or strengthened depending on which path we take forward.” We agree. How the medical community responds to challenges—including those stemming from social media’s transformation of the way we communicate—matters. How we as a profession have responded to past—and continue to respond to present and future—social media challenges to professionalism reveals what matters most: maintaining public trust and honoring our contract with society. Individual physicians may have multiple professional responsibilities, but not with the same valence. Our responsibilities converge towards the common goal of preserving the dignity of our patients.

The social media in medicine’s hierarchy of needs pyramid (Figure 1) rests on a foundation of public trust. Although few studies reveal patients’ perspectives as to what would affect their trust in their physicians based on online behavior, we can make some pretty safe assumptions. Violating patient privacy by posting identifiable health information about a patient online without permission would clearly lead to mistrust of the individuals involved, and likely the profession at large. There are other scenarios that fall into gray areas and are open to interpretation. What if a patient sees that his surgeon has posted a photograph of himself appearing intoxicated at a party? What if the patient has surgery scheduled with the surgeon the next day? How would the patient’s trust in that doctor be affected? What about all the other people who view that photograph? Public sentiment may vary from apathy to outrage or something more nuanced in between. A better understanding of what holds together the nucleus of public trust will help guide the way forward.

As privacy online continues to shrink, how will societal expectations of privacy, and in turn perceptions of trust worthiness, change? How will definitions of online professionalism evolve based on these expectations? Likely generational effects are at play13; “oversharing” may be simply “sharing” to younger generations. We as individuals and as a profession will need to be both sensitive and adaptable to cultural changes over time.

Victory for Online Professionalism

Ascending the social media hierarchy of needs is a process, with awareness of potential challenges and benefits increasing with each step (Figure 1). The fourth-year medical student who has assumed responsibility for her online identity during the period of residency applications has started the process of learning to use social media professionally; the student who has reflected on his role and relationships online, and has crafted his own ethical and professional principles for interacting in the online space, has climbed further. A victory for online professionalism would be providing trainees with the tools and guidance needed to move to Discovery, while first ensuring that their basic social media needs are met. To do this, we need to continue to increase trainees’ awareness through developing relevant curricula, encouraging reflection, and providing positive role modeling and effective mentorship. We need research exploring patient perspectives. We need to continue to hold public trust close and begin to dream big.

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