Ethical Quandaries and Facebook Use: How Do Medical Students Think They (and Their Peers) Should...

AJOB Empirical Bioethics, 5(2): 68–79, 2014Copyright c© Taylor & Francis Group, LLCISSN: 2329-4515 print / 2329-4523 onlineDOI: 10.1080/23294515.2013.864344

Article

Ethical Quandaries and Facebook Use:How Do Medical Students Think They(and Their Peers) Should (and Would)

Act?Daniel R. George, Penn State College of Medicine

Anita M. Navarro, Association of American Medical CollegesKelly K. Stazyk, Association of American Medical Colleges

Melissa A. Clark, School of Public Health and Warren Alpert Medical Schoolat Brown University

Michael J. Green, Penn State College of Medicine

Background: Despite widespread use of Facebook among medical trainees, little is known about how students regard the ethicalquandaries that arise from its use. Methods: In 2011–2012, Penn State College of Medicine and the Association of AmericanMedical Colleges (AAMC) conducted a national survey to explore how students were engaging with social media, includingtheir beliefs about handling ethically challenging situations that can arise with Facebook use. Results: The response rate was30% (2,109/7,144). Students expressed pragmatism about Facebook use and were mindful of ethical perils and professionalresponsibilities. They recognized the sensitivity of personal health information and expressed intent to proactively addressproblematic situations with peers. While “friending” patients was largely perceived as problematic, students suggested strategiesto safely integrate Facebook into future practice. Conclusions: Our study confirms previous research demonstrating ubiquitoususe of Facebook among students, while suggesting that students are aware of potential ethical pitfalls of Facebook misuse.

Keywords: social media, professionalism, ethics, Facebook, medical education, social networks

Over the past decade, social media tools such as Face-book, Twitter, and YouTube have become routine modes ofcommunication. Because these tools foster user-generatedcontent, social interaction, and real-time collaboration,they have the potential to fundamentally change howpeople interact with one another. These technologiesare pervasive—Facebook has surpassed a billion usersworldwide, or nearly one-seventh of humanity (Facebook2013)—and are actively influencing professional environ-ments. Within health care, the emergence of social media hasraised profound questions about patient and provider con-fidentiality, informed consent, public/private boundaries,professionalism, and other issues of ethical import.

How these technologies will be integrated into the ca-reers of current physicians-in-training is not yet known, butthis question has been an area of concern as a new genera-tion of students brings a set of experiences and facility withsocial media to medical school. Recent studies have estab-

Address correspondence to Michael J. Green, MD, MS, FACP, Department of Humanities, Penn State College of Medicine, 500 UniversityDrive, Hershey, PA 17033, USA. E-mail: [email protected]

lished that rates of social media use are above 90% for medi-cal students (Bosslet et al. 2011). Despite the near-ubiquitousadoption of social media among current medical trainees,some suggest that students are naive about the potentialhazards resulting from their forays with social networkingsites such as Facebook, as well as the negative impact thatimproprieties may have on the doctor–patient relationshipand future employment opportunities (Peluchette and Karl2008). Other studies have found that medical students be-lieve strongly in maintaining professional demeanor whenusing social media and are aware that their behavior onsocial media can impact peers, patients, and supervisors(Farnan et al. 2010).

Researchers have only recently begun to explore therange of student engagement with existing social mediatools (Cheston, Flickinger, and Chisholm 2013; Chretienet al. 2010). Furthermore, few have considered the positivepotential of social media for self-directed lifelong learning,

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Ethical Quandaries and Facebook Use

Opinion 9.124 - Professionalism in the Use of Social Media

… Physicians should weigh a number of considerations when maintaining a presence online:

(a) Physicians should be cognizant of standards of patient privacy and confidentiality that must be maintained in all environments, including online, and must refrain from posting identifiable patient information online.

(b) When using the Internet for social networking, physicians should use privacy settings to safeguard personal information and content to the extent possible, but should realize that privacy settings are not absolute and that once on the Internet, content is likely there permanently. Thus, physicians should routinely monitor their own Internet presence to ensure that the personal and professional information on their own sites and, to the extent possible, content posted about them by others, is accurate and appropriate.

(c) If they interact with patients on the Internet, physicians must maintain appropriate boundaries of the patient-physician relationship in accordance with professional ethical guidelines just, as they would in any other context.

(d) To maintain appropriate professional boundaries physicians should consider separating personal and professional content online.

(e) When physicians see content posted by colleagues that appears unprofessional they have a responsibility to bring that content to the attention of the individual, so that he or she can remove it and/or take other appropriate actions. If the behavior significantly violates professional norms and the individual does not take appropriate action to resolve the situation, the physician should report the matter to appropriate authorities.

(f) Physicians must recognize that actions online and content posted may negatively affect their reputations among patients and colleagues, may have consequences for their medical careers (particularly for physicians-in-training and medical students), and can undermine public trust in the medical profession.

Figure 1. AMA Code of Medical Ethics.Excerpted from the AMA Code of Medical Ethics(AMA 2011). Used with permission. Copyright 1995-2013.American Medical Association. All Rights Reserved.

professional networking, and self-expression by students(Mostaghimi and Crotty 2011), as well as for increasedawareness of general health information and improvedaccess to care. It is not known, for example, how futuredoctors envision integrating social media into their profes-sional lives (Atherton and Majeed 2011) and what socialmedia tools might have the greatest potential in the de-livery of health care (Mansfield et al. 2011). Professionalorganizations, such as the American College of Physicians,Federation of State Medical Boards, and American MedicalAssociation (AMA), have published guidelines for physi-cians’ ethical use of social media (see Figure 1) (Farnan et al.2013; Shore et al. 2011), but their tone and content suggestan expectation of misuse rather than consideration of howthese technologies might be applied in a positive manner(George and Green 2011; 2013).

As such, there exists a valuable opportunity to learnmore not only about how students who have come of agewith different norms of privacy use popular social network-ing tools such as Facebook, but also how they regard the eth-ical quandaries that arise on these platforms. Such knowl-edge would add nuance to existing efforts (Farnan et al.2013; General Medical Council 2006; Guseh, Brendel, andBrendel 2009; Shore et al. 2011; Snyder and the AmericanCollege of Physicians Ethics Professionalism, and HumanRights Committee 2012) to formulate professional guide-lines and would assist institutions in developing relevantcurricula to help health professionals use social media ap-

propriately. Since medical trainees often approach socialnetworking as “native speakers” (Gorrindo and Groves2011; Prensky 2001) and have already begun navigating theunique professional and ethical dilemmas posed by Face-book, their views and practices may represent a bellwetherfor future trends in medicine. With this background in mind,the purpose of this study was to explore how current stu-dents use Facebook, with a particular emphasis on howthey think they and their peers should (and would) act inresponse to salient ethical dilemmas.

METHODS

As part of a larger study of social media use among medicalstudents, Penn State College of Medicine collaborated withthe Association of American Medical Colleges (AAMC) in2011–2012 to design a national survey to address the fol-lowing research questions:

• How would medical students handle ethically challeng-ing situations involving social media?

• What positive role can social media play in improvingcommunication with patients and peers?

Due to the high prevalence of Facebook use among med-ical students (and its ubiquity worldwide), Facebook wasselected over other popular applications, such as Twitter orGoogle+, as the central focus of the survey.

We developed a set of scenarios and questions designedto ascertain how participants would handle various ethi-cal dilemmas that may occur when medical students useFacebook. The scenarios were based on the user interface ofFacebook at the time of the survey’s development, recentlyreleased AMA guidelines for professionalism and the useof social media (Shore et al. 2011), and an exploratory focus-group study conducted by the staff of the AAMC’s medi-cal student career-planning program, Careers in Medicine(Stazyk and Navarro 2011).

For each scenario (see Figures 2–8, shown later), weprovided a range of possible options and asked students:(1) how they thought they would respond to the situation;(2) how they thought they should respond; and (3) how theythought their fellow students would respond. Using this gen-eral format, we explored three key domains: privacy, thepatient–physician relationship, and students’ relationshipswith peers and colleagues. We also included two open-ended questions about “friending” patients: (1) “In youropinion, what could be the positive aspects of ‘friending’a patient?” and (2) “In your opinion, what could be thenegative aspects of ‘friending’ a patient?”

The survey was pilot tested for face validity and claritywith focus groups consisting of eight first- and fourth-yearmedical students at Penn State College of Medicine whoprovided verbal and written feedback. We refined severaldrafts before finalizing the scenarios and questions. Thesurvey was constructed using Vovici 6 survey software, re-viewed by the AAMC’s Organization of Student Represen-tatives, and then distributed online. Overall, there were 53

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questions in the survey, and it took students approximately10–20 minutes to complete it.

Sample

A national random sample of 7,560 medical students wasdrawn. This sample represented approximately 10% of thepopulation of active MD students enrolled in U.S. medicalschools at the time the survey was distributed (n = 75,603).The AAMC maintains a complete database of all medicalstudents (n = 78,770), including students enrolled in jointMD programs as well as inactive students.

Data Collection

The research protocol was submitted to institutional reviewboards at Penn State College of Medicine and the AAMCand was determined to meet criteria for exemption. To re-cruit students, the AAMC sent an invitation to students’school e-mail addresses to direct them to the questionnairewebsite. The invitation contained a unique URL that wouldonly allow the invited student to participate once. The firstmessage was sent in November 2011, and four monthlyfollow-up messages were sent, with the final mailing occur-ring in March 2012. In each e-mail, students were provideda secure link to an introductory page that explained the na-ture and purpose of the study, and stated that completionof the survey implied informed consent. As incentive toparticipate, those who completed the survey were offeredentry into a drawing to receive an iPad 2. Those who didnot complete the survey could still enter the drawing bysending their e-mail address as a reply to the invitation.

Data Analysis

Quantitative AnalysisDescriptive statistics were computed for demographics andclosed-ended survey questions. Chi-squared statistics wereused to analyze differences between survey participants andthe eligible population.

Qualitative AnalysisResponses to the two open-ended questions about thepros and cons of “friending” patients were independentlyread by two of the investigators (DRG, MJG) to groupinto common themes and to identify illustrative exam-ples. The investigators coded responses, compared perti-nent quotations, and discussed the meaning of the quo-tations until agreement was reached on the suitability ofeach quotation for inclusion. Several illustrative quotes areincluded in this article to add nuance to the quantitativedata.

RESULTS

Of the 7,560 email invitations that were sent, 193 recipi-ents were deemed ineligible because they were enrolled injoint programs or had requested to be unsubscribed from

AAMC surveys. Another 223 invitations were undeliver-able or bounced back. In total, 2,109 individuals answered atleast one question in the survey; using as a denominator the7,144 who received the invitation and were eligible to par-ticipate, we calculated a response rate of 30% (2,109/7,144).

Demographics

Demographic data describing the population of medicalstudents overall and respondents specifically are shown inTable 1. We used chi-squared analysis to compare the demo-graphic characteristics of respondents with the populationof all medical students and found that the sample closelyresembled the larger population with regard to type of med-ical school and regional representation of medical schools.However, study participants were younger and more likelyto be female, white, and in their first year of medical school.

Facebook Use Patterns and Preferences

Ninety-two percent of students in our sample reported thatthey currently have a Facebook account, and of those, 97%reported that they currently use their account. More thanhalf (53%) indicated that they connect to Facebook severaltimes per day. Most students were not new to Facebook,with 73% reporting that they had a Facebook account formore than 5 years. Students tended not to separate theirprofessional and personal identities on Facebook: 72% saidthey used the same profile for their personal life and medi-cal/professional life, while 27% used separate profiles.

Responses to Scenarios

Each scenario presented an ethical dilemma, and partici-pants were asked (1) what they thought was the most appro-priate response in the given situation, (2) what they thoughtthey would actually do, and (3) what they thought theirpeers would actually do.

Scenario 1 asked participants how they thought theyshould and would respond if they observed another medi-cal student posting private health information on Facebookabout a local weatherman who was a patient. Students mostfrequently responded (55%) they should “call, text or in-stant message the student and suggest that he/she removethe post.” While almost half of students (46%) also reportedthis was the course of action they would actually take, fewer(29%) believed this is how their peers would respond, and31% indicated their peers would most likely “do nothing”(see Figure 2).

Scenario 2 asked students how they thought they shouldand would respond if an undergraduate Facebook “friend”posted inappropriate/offensive comments on his or herown profile. Students most frequently responded (37%) thatthey should “ask undergrad friend to stop posting offensivecontent,” while 28% indicated they would actually do so,and 27% believed this is how their peers would most likelyrespond. However, 29% said they would be most likely to

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Table 1. Characteristics of participants compared to medical student population

All medical students,∗ Respondents,Variable, n (%) n = 75,603 n = 1,859 p Value

Age (years) n = 75,307 n = 1,853 <.00121–25 32,457 (43.1%) 1,062 (57.3%)26–30 37,051 (49.2%) 645 (34.8%)31–35 4,443 (5.9%) 111 (6%)36–40 1,506 (2%) 35 (2%)

Gender n = 78,770 n = 1,848 <.001Female 37,179 (47.2%) 966 (52.3%)Male 41,590 (52.8%) 882 (47.7%)

Race/ethnicity n = 78,770 n = 1,831 <.001White 47,025 (59.7%) 1256 (68.6%)Asian 17,329 (22%) 359 (19.6%)Black or African-American 5,435 (6.9%) 127 (6.9%)Hispanic, Latino, or of Spanish origin 6,144 (7.8%) 119 (6.5%)American Indian or Alaskan Native 630 (0.8%) 17 (0.9%)Native Hawaiian or Pacific Islander 158 (0.2%) 9 (0.5%)Other 788 (1%) 67 (3.7%)

Year in medical school n = 79,938 n = 1,850 <.001First year 20,544 (25.7%) 562 (30.4%)Second year 20,224 (25.3%) 458 (24.8%)Third year 20,224 (25.3%) 357 (19.3%)Fourth year 18,865 (23.6%) 475 (25.7%)

Type of medical school n = 78,770 n = 1,854 .810Public 46,474 (59%) 1099 (59.3%)Private 32,295 (41%) 755 (41%)

Regional representation of medical school n = 79,938 n = 1,853 .550Southern 25,580 (32.8%) 615 (33.2%)Northeastern 23,501 (29.4%) 539 (29.1%)Central 20,783 (26.4%) 506 (27.3%)Western 8,793 (11.4%) 193 (10.4%)

∗The total number of “All medical students” was derived from several AAMC databases, hence the variability in the “n” for each category.

“change privacy settings to customize who can read thecontent others post to [one’s] wall” (see Figure 3).

Scenario 3 asked students how they thought they shouldand would respond if a fellow student posted cell-phonepictures of his or her public drunkenness at a downtownbar and added captions with foul and borderline racistlanguage. Students most frequently responded (39%) theyshould “suggest to the student that they remove the con-tent.” However, 41% indicated they would actually do noth-ing, which they also believed was how their peers wouldmost likely respond (41%) (see Figure 4).

Scenario 4 asked students how they thought they shouldand would react if they received a friend request fromone of their patients who had asthma. Students most fre-quently responded (40%) that they should “decline the in-vitation and send a Facebook message with a privacy state-ment that accepting friend requests from patients is not al-lowed.” However, 35% indicated that they would actuallyjust “decline the invitation and do nothing else,” which is

how 42% believed their peers would most likely respond(see Figure 5).

Students who indicated they would accept the friendrequest in this scenario (7%) were asked additional ques-tions. One probe asked how students thought they shouldand would respond if they noticed the patient regularlyposting Facebook status updates about her health situa-tion, including pictures of the patient with a cat whosepresence was likely to exacerbate her diagnosed asthmaticsymptoms. Students most frequently responded (28%) thatthey should “inform the attending physician of what waslearned,” while 33% indicated that they would actuallyjust “wait until next visit to discuss further.” Students be-lieved their peers were most likely (34%) to do nothing (seeFigure 6).

Another follow-up question asked students how theythought they should and would react if the patient soughttheir medical advice via Facebook. Students most frequentlyresponded (60%) that they should “explain in person that



Figure 2. Responses to Scenario 1.Scenario 1: Imagine you are a 3rd-year medical student on your internal medicine inpatient rotation. Your team admitsa prominent local weatherman who gives televised weather reports every weekday. That night, you log in to yourFacebook account and notice in your newsfeed that a fellow medical student who had been rounding with you hasposted the following status update: “Just did an EKG on Channel 8 weatherman – awesome.”

interacting with the patient in this manner is not accept-able,” and 44% indicated that this is what they wouldactually do. However, students most frequently believed(30%) that their peers would provide a single brief responsethrough Facebook (see Figure 7).

The final follow-up question asked students how theythought they should and would respond if the patientsought to initiate a personal (i.e., non-medical) correspon-dence via a Facebook message. Students most frequentlyresponded (61%) they should “explain in person that you

Figure 3. Responses to Scenario 2.Scenario 2: Over lunch, a fellow medical student remarks that several of your Facebook friends from undergrad haveposted multiple comments on your page the last several weeks using sexist and obnoxious language. She says thatother medical students who are “friends” of yours on Facebook have noticed the posts and believe they reflect badly onyou. She encourages you to do something about your undergrad friends since she doesn’t want to see your reputationsuffer.



Figure 4. Responses to Scenario 3.Scenario 3: Early one Saturday morning, you log onto Facebook and see in your newsfeed that a fellow student hasposted cell-phone pictures of their public drunkenness at a downtown bar and added captions with foul and borderlineracist language (presumably while in an inebriated state).

cannot interact in this manner,” which was also the most fre-quently cited response (42%) for what they said they wouldactually do. However, only 30% of students felt that othertrainees would respond in this manner, believing (34%) thattheir peers would “provide a single brief response throughFacebook” (see Figure 8).

Students were also given an opportunity to respondto two open-ended questions about the pros and cons ofinviting a patient into their social network via “friending,”

and more than 1,000 comments were received. Opinions onthe issue varied. Students largely expressed resistance to“friending” patients (indeed, only 7% indicated they wouldaccept a friend request from the patient who had asthma inScenario 4). Some open-ended responses illustrating suchresistance included the following:

“I will not friend a patient—it seems like a recipe for disasterto me. I could see how friending a patient could enhance the

Figure 5. Responses to Scenario 4.Scenario 4: During your outpatient primary care rotation, you have been following a 24-year-old patient who has severeasthma, and, over several visits, you develop a good rapport. One evening, you discover that the patient has sent youa friend request on Facebook to your personal account.



Figure 6. Responses to Scenario 4 (continued).Scenario 4 (continued): You have accepted the “friend” invitation from the patient with asthma and you notice thatyour patient regularly posts status updates about her health situation on her Facebook profile. You see that she hasbeen having frequent and relatively severe breathing problems lately. You also note that she has posted several recentphotos of herself cuddling with her beloved pet cat, which you know is likely to make her asthma much worse. She isnot scheduled for a follow-up doctor appointment until 4 months from now.

doctor-patient bond and open lines of communication aboutthe patient’s health, but I definitely feel that there are betterways of making those connections.”

“I don’t really see the point. I can understand the use of emailcorrespondence with patients, which is kept confidential, how-ever, social networking is anything but confidential, and it is

public. Furthermore, I see it as a potentially dangerous mediumif a patient becomes upset about some aspect of your profes-sional relationship or is having difficulties with their health. Inthe circumstance that you always have a perfect professionalrelationship with your patient, it just seems like a way to getfree advertising? I have not come to see the benefit of the pro-fessional use of Facebook yet.”

Figure 7. Responses to Scenario 4 (continued).Scenario 4 (continued): If this same patient sought medical advice from you via a Facebook message. . .



Figure 8. Responses to Scenario 4 (continued).Scenario 4 (continued): If this same patient sought to initiate a personal (i.e., non-medical) correspondence with youvia a Facebook message.

At the same time, some students acknowledged thepotential usefulness of social media in medical practice,if applied in a safe and responsible manner in the realmsof patient education, health promotion, and interpersonalcommunication. As several students reported, a technologysuch as Facebook potentially could play a role in educatingone’s patient base:

“In the future, it might be a good way to remind patients ofupcoming appointments and for the staff to check in when apatient gets a new prescription. Also, I intend on being veryinvolved with the community as a practicing physician andFacebook is a great vehicle to get the word out about upcomingevents and things of interest.”

Students also endorsed the belief that Facebook couldpromote healthy living:

“You could potentially use your Facebook to promote healthyliving, post articles related to health that are accessible to thepublic, encourage people to eat healthy and exercise by simplyposting about the things that you are doing to stay healthy.You can post articles about stress, or smoking cessation. Youcan help create an environment and culture that encourageshealth. You can also continue to have a rapport with a patienteven when they are not visiting your office, provided that yourFacebook page is at least somewhat professional and does notcontain offensive language or photos.”

Indeed, many noted that an active presence on Facebookcould potentially result in better patient–physician relation-ships and could enhance communication:

“I really like the idea of being highly accessible to patientsin a variety of ways (phone, email, Facebook). On Facebook,patients could ask simple questions and get answers quicklywith minimal effort.”

“If I had a professional account, [patients] could stay up-dated on things like schedule changes, get [appointment]reminders, join fundraisers like a group for Run for theCure, or find out if we had to unexpectedly close the prac-tice due to weather, flooding, hurricane, find out when wegot flu shots in or stay up to date on public health typeinformation.”

“[Patients] might be more uninhibited with information whennot face-to-face and more likely to share pertinent informationon Facebook; they might feel more comfortable with the physi-cian and view them as more of a person with whom that theycan speak candidly and honestly instead of telling them whatthey think the physician wants to hear. [With Facebook], youcan glimpse into a patient’s personal life and have a better un-derstanding. For example, if [you] notice several posts aboutbeing depressed or other similar feelings, you may be able totalk about it during the patient’s next visit.”

The prospect of having an active professional presenceon Facebook had particular resonance for students thinkingof practicing in smaller, rural communities:

“In rural medicine I think this could be a great way to es-tablish rapport with your patients, especially if you see themday-to-day anyway. Also I think communicating with them viaFacebook once in a while, even if it’s about their medical con-dition might be acceptable. I think some patients would see itas above and beyond if a doctor messaged them to see howthey were doing, in this day and age I think a lot of patientsmight actually appreciate that kind of personal contact fromtheir doctor.”

“It would help me remember who patients are. I’m consideringeventually working [in] a rural area where I may have a largepatient base that would easily recognize me on the street. It



might be good to have a point of reference to help me learnand remember individuals between clinic visits.”

The potential adverse consequences of using Facebookwith patients were clear to students, who expressed thatany interaction with patients must be undertaken with a fullunderstanding of how to use privacy controls to maintainpatient confidentiality:

“Facebook’s current privacy settings make it simple and easyto maintain communication with a patient without ‘friending’them, or to have them as a ‘friend’ while granting them noaccess to your non-professional (as in, personal, not as in, un-professional; there is no obligation to keep your personal worldprofessional if you can effectively keep it compartmentalizedfrom your professional world) content.”

“Becoming Facebook friends with a patient, in and of itselfis not unethical. This is similar to providing them with yourcontact information, business card, or telephone number. It issimply another form of widely used communication. However,you will be inadvertently making personal content available tothem. Depending on the scope and nature of the content, thismay or may not be inappropriate. However, if the content islimited, then Facebook is merely another form of communica-tion between patient and physician, and can be effective if usedin a responsible way with privacy controls.”

Thus, as these illustrative quotes indicate, students gen-erally felt they should avoid “friending” patients, but sawvalue in using Facebook in other ways that might enhancetheir professional practice.

DISCUSSION

The use of Facebook is a pervasive part of modern lifefor many people, including medical students. This studyconfirms previous research findings that >90% of medicalstudents use Facebook, but challenges the perception thattrainees are naive about the potential consequences of itsmisuse. On the contrary, students in our study express astrong pragmatism about social media platforms, and ap-pear to be savvy users, mindful of ethical perils. Studentsgenerally appear to recognize the sensitivity of personalhealth information, and when faced with peers who violatepatient privacy, their most frequently expressed responsewould be to proactively address the situation with thatpeer. Students also recognize a moral responsibility to bringsuch content to the attention of the individual and even totheir supervising physicians in the event that peers do nottake appropriate action to resolve the situation (although asubstantial number of students expressed hesitation at theprospect of confronting a colleague).

While such results underscore an awareness of patientprivacy and confidentiality standards that must be main-tained in all environments (including Facebook), they alsosuggest opportunities for medical educators to help stu-dents explore the ethical implications of online quandariesthey may encounter. Further, the results suggest an expla-nation for why previous research examining online content

for violations of professional ethics (Farnan et al. 2010; Laguet al. 2008; Thompson et al. 2008) has found relatively fewviolations: Health care professionals and students are gen-erally adept at avoiding egregious mistakes on social mediaplatforms.

Students also seem to be well aware of the responsibil-ity to routinely monitor their presence on social networkingsites to ensure that content posted about or to them by othersis appropriate, and to take action to prevent inflammatorycontent from appearing in their profiles. Both their closed-and open-ended responses demonstrated an aptitude forusing privacy settings and current Facebook functionalityto preempt or mitigate potentially awkward or ethicallyproblematic situations. This suggests a sophisticated un-derstanding of the boundaries between professional andprivate use of Facebook while providing insight into howstudents actively negotiate norms of appropriate conducton Facebook to protect themselves and respect patient pri-vacy.

While “friending” a patient on Facebook is largelyseen by students as problematic, they provided compellingsuggestions for how Facebook could be safely integratedinto future practice to improve communication, enhancepatient–physician relationships, and promote public health.Such findings suggest that the AMA and other professionalorganizations might consider qualifying their guidelines toaccommodate the nuanced usage patterns of current and fu-ture trainees. For instance, rather than an injunction against“friending patients,” future guidelines might advise thatprofessionals should never friend patients if they are unsureof how to keep personal and professional data separate.

It is notable that respondents in our study occasion-ally reported a disconnect between what they thought theywould do versus what they thought they should do. Suchcognitive dissonance suggests that while students are oftenable to identify the most ethically appropriate action in agiven scenario, their anticipated behaviors are not alwaysconsistent with their moral reasoning. There are a numberof possible explanations for this observation, ranging fromlack of moral courage, to lack of self-awareness, or the ex-istence of external constraints that prohibit one from takingaction. Such dissonance is consistent with research demon-strating that people tend to misconstrue how they are likelyto behave in morally challenging situations, with a tendencyto predict they will act in more socially acceptable ways thanthey actually do (Epley and Dunning 2000). Future inquiryshould delve more deeply into the reasons for this moraldissonance, and medical educators developing profession-alism curricula are encouraged to use creative strategies tohelp students reflect on the reasons why their anticipatedactions may not always match their moral beliefs.

Another interesting pattern that emerged is that in mostof the scenarios, students indicated that their peers wouldbe inclined to act less morally than they themselves would.Though this perception would seem to reflect a general com-petiveness of medical school environments and a cynicismstudents hold about peers, that is not likely to be the main



explanation. As Epley and Dunning so aptly demonstratedin their series of studies on the “holier than thou” phe-nomenon (Epley and Dunning 2000), people generally ex-press overly charitable views of themselves with regard totheir expected moral actions, even though their less flatter-ing predictions about the behaviors of others are consider-ably more consistent with their own actual behaviors. Thisinteresting area of inquiry deserves further attention.

Limitations

There are several limitations to our study. The 30% responserate was low, and our sample was not representative withregard to the overall medical student ethnicities and yearsof training. However, response rates for surveys of healthpractitioners are notoriously low (typically <25%) (Scottet al. 2011; Wiebe 2012), and response rates for online sur-veys have been steadily declining since the 1980s (Sheehanand McMillan 1999). Despite these limitations, our samplewas representative with regard to type of medical schooland regional representation, making our findings general-izable with regard to these important features (Dillman,Smyth, and Christian 2009). Not surprisingly, participantswere somewhat younger than the national sample of medi-cal students, which may reflect that generation’s interest insocial media relative to older cohorts, as well as the biasesof students who have had less experience in clinical settingscompared to students in their third and fourth years.

Relatedly, those who answered the survey may havebeen savvier with technology or have a propensity to useFacebook more than others, thus biasing the results in favorof pro-Facebook use. Even though the survey was anony-mous, there may be a social desirability bias whereby re-spondents answered in ways they felt would reflect betteron them or on their medical schools. Further, the interpreta-tion of complex questions and scenarios in the survey mayhave led to some misinterpretation.

The nature of the survey lends itself to some subjectiv-ity in the interpretation of results, and different members ofthe research team may have arrived at varying conclusionsabout the data. That said, measures were taken in this studyto limit bias by having multiple researchers undertake inde-pendent data analysis, with disagreements in interpretationresolved through discussion and consensus. Moreover, thisstudy did not directly observe students handling challeng-ing ethical situations, but rather asked for a self-report onwhat they thought they would do, what they thought theyshould do, and what they thought their peers would do.It is well established that people are susceptible to behav-ioral forecasting errors, such as the tendency to mispredicttheir future moral actions in self-inflating ways (Epley andDunning 2000). Thus, there are inherent limitations in theinterpretation of our data as being reflective of the actualfuture actions of medical students. Lastly, our survey wasbased on the user interface of Facebook in 2011–2012, whichpotentially limits the interpretation of our data should sitefunctionality shift in coming years.

Implications

Despite these limitations, our data provide valuable in-formation about how students use Facebook, how theyperceive ways to integrate social media into their profes-sional lives, and how they believe they would deal with re-lated ethical complexities. This study offers insights abouta group of students who are coming of age as medical pro-fessionals during the social media boom and are activelygrappling with ethical challenges presented by emergingtechnologies as they relate to future practice. Such insightscan be instructive as social media pervade and alter profes-sional settings such as health care.

Given the signals from our study that students per-ceive value in tools such as Facebook for improving pa-tient care (if used safely and responsibly), medical schoolsand professional organizations might consider developingpedagogical approaches and guidelines that are not sim-ply punitive in their nature. Instructors of courses on ethicsand professionalism could include relevant content on theethical quandaries created by social media while also fos-tering student reflection about the positive application ofthese technologies in medicine and public health. Teachinghospitals could also involve students in the development ofpolicy guidelines around social media as well as profession-alism course content, and other formal documentation (e.g.,boilerplate responses that students and faculty could sendpatients if approached on social media platforms such asFacebook). As observed in our study, trainees may indeedprovide important insights not only into the proactive rolesocial media can play in the delivery of more effective andpatient-centered health care in coming decades, but also intohow norms of professionalism are adapting to technologicalinnovations.

In light of the varied clinical applications of Facebookthat were identified by students, it would behoove thosewho develop professional and institutional guidelines torecognize both positive and negative aspects of this tech-nology. Administrators might even entertain the notion ofhow to compensate medical professionals who use socialnetworking for the benefit of their patients, particularly forthose who amass large networks of patient (and colleague)followers.

Additionally, given that >90% of students report hav-ing a Facebook account, institutional policies that promoteignoring or abstaining from social media are not viable, andrisk contributing to a generation of doctors disconnectedfrom patients and colleagues who are increasingly presenton social media platforms. Future generations of medicaltrainees will be true “digital natives”—having used Face-book and other social media for most of their lives—andinstitutions would benefit from adapting to this culturaltrend so as not to contribute to a generational bias.

How future physicians will integrate social media intotheir careers remains to be seen, and the stakes are high.Further research might explore how medical professionalsand trainees are adjusting to evolutions in this technology,



and in particular, how they can successfully use these me-dia to enhance their practice and professional development.The social contract between the medical profession andsociety requires physicians to embody altruism, integrity,and trustworthiness (ABIM Foundation, ACP-ASIM Foun-dation, and the European Federation of Internal Medicine2002; Cruess and Cruess 2008), and we should think nowabout how these values will be maintained in an era ofwidespread social media use.

ACKNOWLEDGMENTS

We thank Erik Lehman from the Department of PublicHealth Sciences at Penn State College of Medicine for hisinput on the statistical analysis undertaken in this study.

AUTHOR CONTRIBUTIONS

All authors had a substantial role in conceptualizing, writ-ing, and finalizing the article.

FUNDING

None.

COMPETING INTERESTS

None declared.

ETHICAL APPROVAL

This study was approved by the institutional review boardsat Penn State College of Medicine and the Association ofAmerican Medical Colleges (AAMC).

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