The Influence of the Residency Application Process on the Online Social Networking Behavior of Medical Students: A Single Institutional Study

Online social networks (OSNs) have become a major method of communication since their introduction just over a decade ago. The growth in the use of these networks, especially among college-aged individuals, has been dramatic. Facebook is the largest OSN, and it reports over one billion active worldwide users.1 The use of these networks among adults has risen dramatically over the past several years.1,2 The Pew Internet and American Life Project has demonstrated that the use of social network sites among those aged 18 or greater has increased from 8% of Internet users in 2005 to 69% in 2012.3 Among Internet users aged 18 to 24 years, 75% have profiles on social networking sites.3 The rate of Facebook use by college students is staggering, increasing from 85% of students in 2005 to 96% in 2011, according to recent studies.4,5

Recent studies have shown that 45% to 70% of employers are now screening OSN profiles to examine job candidates.6,7 In the medical residency application process, it appears that OSN screening is progressing more slowly. A survey of medical schools and residency programs in 2009 revealed that 9% of respondents looked at applicants’ OSN profiles as part of the evaluation process.8 A 2010 study demonstrated that only 4% of pharmacy residency directors were using social media information for the process of selection.9 However, 90% of them felt that students should be accountable for unprofessional behavior on OSN Web sites. Of the residency directors that did screen applicants, 28% of these program directors reported a negative outcome for the applicant. In the same study, of those residency directors who hadn’t used OSN screening, most reported that the information on these sites would influence their decision. Unlike program directors, only 55% of pharmacy students thought they should be held accountable for their OSN content, stating they didn’t believe that online social media should be used to judge their professional attitudes or ability.10 A similar study of otolaryngology residency directors in 2012 found that 11% of Facebook accounts screened had questionable content.11 However, this did not have an effect on these students’ Match outcomes. In another study, 17% of surgery program directors were using social media Web sites to screen their applicants in 2012.12 In their results, this screening led applicants to be ranked lower one-third of the time.

Medical schools have also begun to more heavily screen and regulate the use of OSNs by their students. In 2009, a study by Chretien and colleagues13 demonstrated that 60% of all U.S. medical schools had reported incidents of students posting unprofessional content through online social media, such as classified patient information, inappropriate language, depictions of intoxication, or sexually suggestive material. Qualitative evaluations have found a mix of opinions regarding what students believed was appropriate to post on OSN Web sites; some students were concerned about possible outcomes from online posts, and some had begun to change the privacy settings on their profiles in reaction to a greater stress placed on the topic at their school.13 Lie and colleagues15 found that after attending a session regarding professional use of OSNs while in medical school, 40% of responding students reported editing or changing their Web presence, and 24% reported spending less time on OSN Web sites. To our knowledge, no literature to date has quantitatively evaluated the direct effects of the residency application process on the social media behavior of medical students.

As students become more aware of the potential use of OSN screening by residency program directors, we hypothesize they may adjust their behavior within OSNs in preparation for the residency application process. This study was designed to determine the extent to which this is the case and to quantify the extent to which the residency application process has altered medical students’ online behavior.

Method Study sample

We conducted an e-mail survey of all third- and fourth-year medical students from Indiana University School of Medicine. The source population list was obtained using the third- and fourth-year medical student master e-mail lists, totaling 608 potential respondents. On the basis of previously published data regarding response rates to e-mail surveys among the general public, and of physicians, we expected a 35% response rate.14 This study was approved by the joint Indiana University–Purdue University Indianapolis institutional review board.

Survey

The survey was designed by the study team to provide answers to the study hypothesis. The survey was created after a thorough review of existing literature on this topic. The survey instrument was then piloted among 10 first- and second-year medical students at Indiana University School of Medicine and underwent iterative revisions by members of the study team. The survey instrument examined four content areas: use patterns of social networking sites; whether or not respondents altered their social media accounts in preparation for the National Residency Matching Program (NRMP) process and strategies used to do so; respondents’ beliefs regarding the frequency with which their online profiles are used in the residency application process and whether or not such use is ethical; and demographic data (see Supplemental Digital Appendix 1, https://links.lww.com/ACADMED/A159, for the full survey).

Most response options were categorical. A five-point Likert scale (strongly disagree, disagree, neither agree nor disagree, agree, strongly agree) was used to assess students’ perceptions of their online profiles as well as the ethicality of using their profiles in the candidate selection process. Demographic data collected included year of birth, year of medical school, primary specialty of interest, and gender. Utilization data included whether or not the respondent was using or had ever used OSNs, the frequency of use, which OSNs were used, type of use (personal versus professional), and privacy settings of respondents’ own personal OSN profiles.

Data collection

The survey questionnaire was sent to study subjects via e-mail using an initial invitation message and two reminder e-mails. Surveys were completed anonymously using the online survey tool Survey Monkey. Data collection took place over a four-week period in the month of May 2012. No incentives were offered for survey completion.

Statistical analyses

Simple descriptive statistics were performed on all Likert scale responses and epidemiological data from respondents. Response data were treated as ordinal and analyzed using nonparametric statistical tests. The Mann–Whitney rank sum test was employed for comparisons between third- and fourth-year students, and the Kruskal–Wallis test was used when groups were analyzed on the basis of specialty competitiveness. A P value of < .05 was considered statistically significant. The following statistics program was used to make these calculations: Primer of Biostatistics, Version 6.0 (McGraw-Hill, New York, New York).

Results

Our findings are reported as an aggregate for all respondents. There were no statistically significant differences between the third- and fourth-year students in any of the measures.

Respondent characteristics

There was a 30.1% (183/608) response rate to our survey. Respondents’ demographic data consisted of 53.0% (97/183) third-year medical students and 47.0% (86/183) fourth-year medical students. The students were 48.1% (88/183) male and 51.9% (95/183) female. The average age of the respondents was 26.9 years (range 24–37). These demographic data are consistent with the student population of Indiana University School of Medicine as a whole (49% male, 51% female).15 The OSN use patterns for respondents are reported in Table 1. Overall, respondents had an OSN use rate of 98.9% (181/183). More than half, or 62.8% (115/183), of OSN users reported that they used OSNs more than once daily. A total of 83.1% (152/183) reported personal OSN use only, whereas 12.6% (23/183) reported use of their accounts for personal and professional reasons. The majority, 63.4% (116/183), of respondents reported that access to their profile was completely private; only 1.6% (3/183) reported that access to their profile was completely public, and the rest of respondents had varying gradations of privacy protection.

Table 1Table 1:

Use Patterns of Online Social Networks for 183 Third- and Fourth-Year Medical Students, Indiana University School of Medicine, 2012

Effect of residency selection process on social media behavior

Survey respondents were asked questions about the effect of the residency selection process on their social media habits (see Table 2). More than half, or 60.1% (110/183), of respondents had altered or planned to alter their OSN profiles before applying to residency. Of the 37.2% (68/183) of respondents who did not change the content of their profiles, 47.1% (33/70) reported they didn’t because their OSN profiles only contained information that was appropriate for use in the residency application process, and 35.7% (25/70) didn’t because their profiles were privacy protected.

Table 2Table 2:

Effect of Residency Selection Process on Social Media Behavior for 183 Third- and Fourth-Year Medical Students, Indiana University School of Medicine, 2012

Of those who did change (or planned on changing) their OSN profiles before the residency application process, 46.4% (51/110) altered the content of their accounts in some way (deleting pictures, deleting wall posts, altering profile information, etc.), 12.7% (14/110) deleted their profiles entirely, and 28.2% (31/110) altered their privacy settings. Only 8.2% (9/110) of individuals wrote in that they planned on changing their names within their OSN profiles prior to applying to residency programs, and 1.8% (2/110) reported that they would both change their names and alter their privacy settings. The majority, 60.0% (66/110), of those respondents who changed their profiles stated that they were doing so because they felt they did not want to be judged professionally by the content on their social networking profiles, and 30.9% (34/110) did so because they didn’t think it appropriate for residency program directors to view their personal profiles.

Attitudes toward use of social media in the residency selection process

Table 3 outlines the attitudes of respondents regarding the use of social media in the residency selection process. Most, or 70.5% (129/183), of respondents believed that residency program directors are currently using social media accounts to screen applicants applying for residency positions. Less than half, or 43.7% (80/183), believed that it is ethically acceptable for residency pro gram directors to do so, whereas 38.8% (71/183) did not think this is ethical. Likewise, 30.7% (56/183) thought the content on their online profile was an accurate representation of their pro fessional persona, whereas 42.1% (77/183) did not. The majority, or 70.5% (129/183), of students felt that the content of their online profiles should not be used to judge their professional attitudes or abilities. When asked whether their OSN profiles contained only information that they would be willing to share with residency directors, 40.4% (74/183) disagreed and 42.1% (77/183) agreed.

Table 3Table 3:

Attitudes of 183 Third- and Fourth-Year Medical Students’ Toward Online Social Networks and the Residency Application Process, Indiana University School of Medicine, 2012

Discussion

Our findings demonstrate the effects of the residency application process on the social media behavior of third- and fourth-year medical students at Indiana University School of Medicine. Specifically, the majority of respondents altered or planned on altering their OSN behavior in some way in preparation for the NRMP process. Additionally, most respondents felt that residency directors used OSN sites for the application process, and they were mixed as to whether or not this was an ethically acceptable action. Most did not feel as though their OSN profiles should be used to judge their professional abilities. To our knowledge, this is the first study to quantify the effect of the residency match process on the OSN behaviors of medical students. Although these survey data had a low response rate and are from a single institution, they provide novel insights into the OSN behaviors of medical students.

Most respondents changed their OSN profiles or settings in some way (altering content or privacy protection, deleting their accounts, changing their names) in anticipation of the residency application process. This could be for several reasons. First, this may herald an increasing awareness of the potential consequences that OSN profiles may have on their careers, either from the maturation process that takes place during medical school training or from the increasing literature on the negative effects of OSNs on medical professionalism published in the past several years.16,17 It could also be awareness due to the proliferation and promulgation of guidelines and use statements for medical professionals by institutions and societies.18,19 Lastly, this could be a local phenomenon at Indiana University, where we have had formalized guidelines on social media use for several years20 and also have interactive learning sessions in the first and third years of medical school regarding acceptable use of social media and its effect on professionalism.

Some changes in OSN use at our institution surprised the authors. For example, over 8% of respondents wrote in that they planned to change their OSN profile names before the application process. The most likely reason for an OSN profile name change is to prevent profile recognition in a routine OSN name search. The desire to have OSN profiles hidden in this way from residency directors could represent students’ desire to separate their personal and professional online networks. This supports the fact that over 70% of respondents did not feel that their online profiles should be used to judge them professionally.

Respondents’ attitudes toward the use of social media in the residency selection process seem to be mixed. Our findings demonstrate that the majority of respondents believe that residency program directors use student’s OSN accounts to screen applicants for residency positions. Recent data, however, demonstrate that the number of residency directors who actually use OSNs to screen applicants is likely quite low.8,9,12 Irrespective of the descriptive reality, only a minority of respondents felt that screening OSN profiles for this purpose was ethically acceptable. In fact, most respondents did not feel as though the content of their online profiles was an accurate representation of their professional persona, and were split when asked whether their OSN profiles contained only information that they would be willing to share with residency directors. In addition, the majority of respondents believe that the content of their online profiles should not be used to judge their professional attitudes and abilities. These data are similar to findings reported by Cain and colleagues,10 which showed that a majority of pharmacy students didn’t believe that OSNs should be used to judge their professional attitudes or ability. Our findings underscore the fact that there are a wide variety of opinions among students on the use of OSNs for the evaluation of potential residency candidates, although most felt as though OSN profiles should not be used as a screening tool for the Match. The actual ethicality of the screening process of residency applicants is not well defined, although this is a ripe area of academic inquiry.

There were several limitations to this study. First, although it is common that surveys of physicians yield low response rates,14 the response rate in this study poses the potential for selection bias and limits the generalizability of the study findings. However, the OSN use rate of medical students in our study is consistent with data from other recent studies.2123 Because this is a study of students at a single medical school, the results may not be widely generalizable and may instead represent trends in local culture or responses to unique local attitudes toward OSN use as noted above. Additionally, the lack of literature and previous studies of this topic meant that a validated survey tool did not previously exist and had to be created in order to study this topic in this population.

This study generates questions that are worthy of further evaluation. First, replication of these findings by a study with a more robust response rate, or among several institutions, would help to justify a generalization of the results. Additionally, understanding more fully the actual behavior of program directors and how program directors feel about the appropriateness of using of OSNs in screening residency applicants would complement these findings.

In summary, our findings demonstrate that medical students seem to be conflicted on their opinions of the use of social media screening in the selection of residency candidates, although the majority of students have altered their OSN profiles in some way in anticipation of the NRMP. This implies that students have an understanding of the potential role of social networks in the residency selection process and are taking measures to mitigate any negative effects that information on their OSN profiles may have on their digital footprint. The implications of this study on the academic community are numerous. We believe that residency program directors will find this information helpful when deciding whether to use OSN profiles as a screening method in the future. This study provides further information for students regarding tangible and immediate potential effects of OSNs on their future careers. As more data regarding the use of OSNs as a screening tool in the residency application process emerge, we predict there will be a shift in the way both residency directors and students adapt to the use of OSNs as a form of communication.

Acknowledgments: The authors thank Marie Ann Brunsman and Marti LaChance for their help with the design and implementation of the survey tool.

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