Concerns about medicine’s status as a profession have been growing for the past 80 years. By the late 1990s, many experts felt that medicine had become self-serving and insular, had violated its social trust, and was in danger of losing its vaunted professional status. The slowness of medicine’s awakenings notwithstanding, the inaugural decade of the twenty-first century was marked by a flurry of actions deigned to define, assess, and institutionalize professionalism within the classrooms of medical education and hallways of clinical practice. By 2000, for example, virtually every medical school and residency program had implemented some type of formal professionalism curriculum.

Medical professionalism faces a number of challenges. Perhaps the most important is the need to reconcile professionalism being taught in the “classroom” (which includes the professionalism embedded in the codes, charters, competencies, and curricula) with professionalism being observed by learners in the clinical settings modeled on a day-to-day basis by more senior clinicians and faculty. At root is a classic hidden curriculum problem of the gap between efforts to formalize professionalism instruction and the day-to-day or moment-to-moment lived experience of trainees. In some cases, the gap has been great enough to cause some trainees to “push back” against and disavow the formal professionalism curriculum. Successfully developing and implementing approaches to teaching professionalism that integrate elements of the formal and informal or hidden curriculum remain elusive.

Competency-based medical education has further defined, benchmarked, and assessed professionalism. The Accreditation Council for Graduate Medical Education (ACGME) professionalism competency emphasizes the development of professional character, high standards of accountability, humanism in all dealings with others, and altruism—putting the interests of the patient before self-interest. There are now a large number of readily available formal professionalism curricula, assessment tools, and literature (see web links and Suggested Readings). Although the challenge of formal versus informal curricula remain, these resources identify important aspects of professionalism and point to areas for further curricular development.

Professionalism requires attention to several domains of physician behavior, including truth-telling, confidentiality, disruptive behavior, assuming responsibility, respectful communication with patients and colleagues, giving and receiving feedback, bullying, sexual harassment, personal appearance and attire, and others. In this chapter, we focus on three major professionalism issues: inappropriate use of social media, plagiarism, and boundary violations. We first define each challenge, then illustrate each with one or more cases. We end the discussion of each challenge with commentary regarding educational and institutional implications in four areas: (1) formal/informal curriculum; (2) faculty development; (3) institutional response; and (4) remediation.

Social Media

The explosive growth in information technology, especially the adoption of social media, presents a new challenge to professionalism. Concerns about sharing confidential patient information on public social media web sites, posting of inappropriate personal information, using social media at inappropriate times such as on rounds or during lectures and other educational activities, and failure to maintain good professional boundaries by, for example, “friending” patients on social media sites are among the problematic behaviors that have been noted among recent cohorts of medical students and residents. “Millennials,” or Generation Y (those born between 1980 and 1994), which includes medical students, residents, and to some degree fellows and junior faculty are almost constantly engaged in using social media. It is estimated that in the United States alone there are over 120 million users of Facebook, and that number is growing rapidly. This method of communication has supplanted other forms of interaction, including the telephone and even e-mail, which is more commonly used by older faculty. In the area of social media, faculty are what Prensky has termed “digital immigrants,” whereas their younger charges who grew up with digital technology are “digital natives.” Capitalizing on the benefits and understanding the risks inherent in social media remains a challenge for undergraduate and graduate training programs.

Educational and Institutional Implications

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   Formal/Informal Curriculum

   
   
   
   
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     Many students and residents are unaware of the risks of using social media. For example, a study of online posting by medical students and residents found that only 37.5% made their Facebook pages private.

     
     
     
     
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       Education can be effective. One school that developed an educational intervention around Internet privacy saw an 85% drop in publicly available Facebook pages.

     
     
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     Modeling professional behavior in the informal curriculum

     
     
     
     
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       Engaging students in respectful dialogue and discovery about how and why they use social media can be helpful in bringing about behavior and culture change.

       
       
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       Enlisting student leaders who may have had experiences with professionalism issues relating to Internet usage may also help students recognize that the issue is serious and affects their peers and colleagues.

   
   
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   Faculty Development

   
   
   
   
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     Inappropriate use of social media among faculty has increased as evidenced by a recent flurry of articles in the popular press and a study of the actions of state medical boards dealing with this issue.

     
     
     
     
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       Faculty development programs focusing on the use and abuse of social media by students and colleagues can be helpful in raising awareness of the risks involved.

       
       
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       Encouraging faculty to lead by example in the use of smart phones and other handheld devices can also be effective in addressing inappropriate usage.

   
   
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   Institutional Response

   
   
   
   
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     The use of social media by medical trainees is growing.

     
     
     
     
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       Surveys by school administrators to determine the extent of social media use and its appropriateness/inappropriateness can help give the school a sense of the extent of social media practices among students, residents, and faculty, and help shape institutional policy.

     
     
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     Few schools have written policies that specifically deal with social networking, but schools with any written policies about unprofessional behavior are better able to handle violations than schools without written policies.

     
     
     
     
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       Developing written policies that take into account school size and the range of problem behaviors can be helpful in crafting institutional responses that are targeted and appropriate.

       
       
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       Collaborative engagement of students, residents, and junior faculty in policy development facilitates implementation of the policies in question.

   
   
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   Remediation

   
   
   
   
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     There are currently no national standards for remediation of unprofessional behavior involving social media among medical students and residents. It falls to individual deans, course and clerkship directors, and faculty to come up with remediation procedures that are fair and fit the questionable behavior.

     
     
     
     
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       Apart from dismissal from school, remediation is best accomplished in the spirit of improvement and increased awareness of the risks associated with social media use. Personal research by students who have violated social media standards into what is known about millennials and their status as “digital natives” along with journaling and reflection are often useful.

     
     
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     Recruitment of student leaders who have had professionalism lapses and who share messages about the risks of inappropriate use of social media can be an effective method of “spreading the word” about expectations and appropriate behaviors.

Plagiarism

Another challenge in educating for professionalism is plagiarism. This problem may, in part, derive from the “digital divide” between generations and their knowledge and understanding of the rules that govern electronic, print, and written media. For example, evidence of plagiarism was found in 5.2% of the personal statements of residency applicants to a single institution by comparing them with readily available Internet sources. Likewise, in their undergraduate coursework some medical students believe that citing Internet sources such as Wikipedia or other websites is unnecessary because of the “open source” nature of these sites. Equally concerning is the trend among some faculty and trainees to “cut and paste” medical records in clinical care. Residents may observe their attending physicians engaging in this practice or get the message that it is okay to “cut and paste” a patient’s history from day to day or from previous hospital admissions. Medical students, for whom there is typically no formal instruction in this area, learn to follow suit. The result is an “epidemic” of behavior that is a threat to both professionalism and quality of care.