MEDICAL STUDENTS AND FACEBOOK: THREATENED...

Faculdade de Medicina da Universidade do Porto – 2011/2012

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MEDICAL STUDENTS AND

FACEBOOK: THREATENED

PROFESSIONALISM?

Abstract BACKGROUND The increasing use of social networks is common to all professional areas,

including Health Care Service. OBJECTIVES Our main goal is to consider potential patients’, medical students’ opinion about

the role of Facebook in healthcare, based on their personal experiences and knowledge, in order to compare them, regarding their similarities and differences and compared those opinions with the actual Portuguese Law.

METHODS This is an observational, cross-sectional study since data was collected from a series of two different questionnaires with three common groups of questions and a specific question to each target population group. The questions were closed item or scaled item ones. We inquired 82 medical students from both 2nd and 5th years of “Faculdade de Medicina da Universidade do Porto” and 44 people who were at “Hospital São João” in Oporto and were not busy or sick at the moment we asked them to fill our questionnaire. We used IBM® SPSS® Statistics Version 19 to obtain adequate descriptive measures of all questions and compare them by gender within the same group and generally between study groups.

RESULTS The results were presented in form of tables, one for the comparison between genders within both study groups and another one for the comparison between study groups.

CONCLUSIONS There weren’t great discrepancies on answers given by both sexes on each study group. Both study groups didn’t have a concrete idea of Portuguese Laws on such polemic matter as the impact of Facebook on Medical Professionalism. Both medical students and general populations reasonably think Medical Professionalism is threatened by the overuse of Facebook. This social network is considered by the majority of medical students not to be a useful instrument to promote their academic success.


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Introduction

It is widely known that this world is not what it was twenty years ago. Year after year, worldwide citizens suddenly faced themselves with a technological advance that knows no boundaries. They started to substitute one-on-one for virtual contact in order to meet new people in a easier way, through social networks like Facebook, Hi5, Orkut, etc., fact supported by Ellison NB et al. when he claim “social networking allow people to present themselves and establish or maintain connections with others”(1). These changed not only people’s personal lives but also their professional behavior, merging both into one. Zur et al. upheld this sentence claiming “Internet blurs the line between what is personal and what is professional, as well as between self-disclosure and transparency.” (2). The increasing use of social networks was common to all professional areas, including Health Care Service.

Despite the facts mentioned above, medical students and young doctors are also citizens of

this globalised world and therefore have the right to use social networks (3)as long as they have measured the consequences of exposing themselves on the internet. If they don’t use privacy settings they carry the risk of being seen (4)“behaving in ways that are not consistent with a professional demeanor or in ways that indicate disrespect for patients”.

Due to these facts, the current use of social networks by new generations of doctors is

beginning to create concerns in such way that it has become a subject for scientific papers in several countries, such as France(5) and UK(3). Nowadays, medical students and young doctors are coming out of medical schools and medicine internship to face a labor market furrowed by modifications on its values.

The social networking amongst medical students and young doctors is out of control because

they don’t think about the potential consequences of their attitudes when facing a society that primes for accuracy and professionalism on the services it requests. This lack of conscience comes from the fact that, like any other people, medical professionals become absorbed in this “wave” of new technology and despise the medical principles they will indirectly vow as they graduate(5):

1. The principle of primacy welfare, which dates from ancient times, is based on a

dedication to serving the interest of the patient. Those interests must be above those of the physician;

2. The principle of patient autonomy states that doctors must be honest and empower patients to make informed decisions about their treatment, always respecting their privacy;

3. The principle of social justice, which promotes a fair distribution of health care resources and eliminates discrimination in health care.

The physician-patient relations, based on the principles mentioned above, strictly forbids a

physician to disclose information on the personal life of the patient as his/her relation to his/her patient should be ethical and professionally correct, instilling trust and a privacy feeling on the patient.

David Brendel et al. state that (6)the majority of medical students and young doctors choose

to keep their Facebook profiles widely open to the general public with their personal information available to all potential patients and propose that there should be guidelines for a responsible and professional use of social networks by doctors.


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Furthermore, a (7)2009 USA study published that 60% of the respondent deans of medical schools admitted that their students had online information that can affect their professional lives in the future. Meanwhile, newly graduate medical students also reveal (4)“personal information that might cause distress to patients or alter the professional boundary between patient and practitioner, as well as information that could bring the profession into disrepute”. These two conjugate facts don’t foretell anything praiseworthy to young doctors that on a ”brief moment” of their lives had irresponsible attitudes and that “brief moment” had irreversible effects on their future careers, creating reports on the media informing that students have been disciplined or dismissed as result of posts on Facebook and that (4)“job applicants are being vetted for and declined positions because of information sourced from” the same site. Those moments of irresponsibility can provoke chaotic effects on the public trust in health care service and physicians due to the permanent nature of the postings people make on social networks. Supporting these facts, David Brendel et al. stated that (6)“medical students’ behaviour at any circumstance can have an impact on their fitness to practise.” and Jane Garner et al. claimed that (3)“The information and other material that students place in these social networking sites is in the public domain and could influence the way patients see health professionals.”.

Besides the contact with physicians’ personal habits by their potential patients, (8)information disclosed by physicians on social networks may threaten the patient confidentiality as that information may uncover sufficient details to allow a doctor or a patient to be identified.

All those mentioned facts are supported by many already done studies. Amongst those studies, there is one we would like to withstand – the study of David Brendel et al. (6)already quoted above, whose results were quite interesting and relevant and helped to build our background. The results of that study stated that the use of Facebook amongst medical students and residents is very common, as the medical students use that social network more often (64,3%) than the residents (12,8%). The majority of the studied individuals had at least one identifiable piece of information and only one third of them had privacy settings on. One great part of these students and residents belonged to social groups where we could find offensive language, racism and sexist comments. Besides that, they often showed unprofessional behaviors on pictures of themselves or other colleagues, drinking or having some other behaviors that were not morally correct. Moreover, the majority of those medical students choose to keep their profiles widely open to the general public.

This study shown, as written above, that the use of Facebook by residents was less frequent

than by medical students, what may show a decline in the use of Facebook as students approach graduation(9). However, that conclusion should not be base on this study because of its static characteristics. The investigators should have followed the same medical students until they graduate to allow such a conclusion. Other explanation for those results could have been a generational effect(4).

Another relevant study in this area was made by Chretien et al. (7)who surveyed the deans of

American medical schools regarding accidents of unprofessional posting on social networks and whose results we have already mentioned above.

Finally, a Jane Garner et al.’s study came out very important for our background(5). This study

was carried on in the medical school of University of Liverpool and consisted on an anonymous survey e-mailed to the students of that institution. Only 56 from 180 students answered the survey, so the percentage of response was 31%, due to its voluntary character. The most important conclusions took by this study were that the majority of the surveyed claimed to have seen pictures of colleagues showing less correct habits posted on Facebook; and 36 % of the students inquired believe that what happens on Facebook is separated from what happens on college. This study ended with a very interesting sentence: (5)“Although the sample size of the study is small, the findings are certainly interesting enough to warrant further investigation.”.


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In addition to the quoted studies, other studies, like judicial files and media reports, show how physicians and patients might somehow be injured by the incorrect use of social networks.

We believe that our study is of the greatest importance in spite of all studies made in this area, focus the fact that none of those were about Facebook habits amongst medical students in Portugal, namely in our University. Some questions as “How they see those social networking habits?” and “How they feel about them poisoning their future careers?” show what we propose to lead with our study.

In light of the above, we wished to study the tendency to use social networks incorrectly and what different groups of people think about that. If so or not, we would like to inform the medical community of these startling facts.

Research Question

What is potential patients’ and medical students’ opinion about the influence of Facebook on medical professionalism and if there are valid reasons to think that medical professionalism is threatened?

Objectives

To evidence the opinion of potential patients and medical students about the influence of

using Facebook amongst health care professionals and students on medical professionalism

through concrete questions based on the Portuguese Constitution. Then evaluate their

knowledge of laws about the concerning issue;

To study if the patients had already been in some cases of disclosure of personal information

about their clinical cases;

To compare the opinions of both populations in study and evidence their similarities and

differences, withstanding the last ones and conclude about them;

To evaluate the possible positive and/or negative aspects of its utilization on medicine

students’ academic itinerary.

To evaluate if there are differences between the opinions of both sexes of both samples

individually about this polemic issue.

Methods

Participants

There were two target-populations that were studied, which are:

Medical students of the “Faculdade de Medicina da Universidade do Porto”;

General population who were not busy or sick at “Hospital São João” in Oporto.


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Sampling Process

The middle years of the theoretical and clinic phases of the course were chosen as

the sample of medical students. Therefore, our sample consists only on medical students of 2nd and

5th years of the Integrated Master degree on Medicine of the “Faculdade de Medicina da

Universidade do Porto”. We found out the schedules of those year’s classes and used them to

randomly choose two classes of each year to participate in our study. Due to those facts, the process

of sampling was a Stratified Sampling Process because we divided the medical students in strata

according to a variable of interest (in this case, the year of course in which the students are

registered) and then, within those strata, we selected randomly the classes, and stratified the sample

again by gender;

In concern to general population, we also used a Stratified Sampling Process (dividing

the sample by gender). We were in different places at different times and dates (to make a more

heterogeneous sample) of “Hospital S. João” in Oporto to deliver 44 questionnaires (to 22 women

and 22 men who were not busy or sick).

Study Design Our study was an observational and cross-sectional study. We collected some data through

the application of a questionnaire to two population samples, one from each target population group. The questionnaires have a common and a specific group of questions that will allow us to make comparisons between the target populations and, at the same time, enable us to study specific points related to a target population, respectively.

Concerning our study goals, it is an analytical study because we will take conclusions after we have analyzed the data we will collect.

Data Collection Methods The questionnaires were delivered to our previously selected sample by different means,

because our inquired people have different availabilities. Before we deliver them, these questionnaires were tested by two persons of each group, in order to verify if its extension is the most appropriate.

So, in order to fulfill the objectives of our study, we delivered the questionnaires as followed:

For the medical students’ sample, we randomly selected two classes from the 2nd

year and two from the 5th. We delivered the questionnaires to one student of both 5th year classes

and also to 2nd year classes and asked them to be responsible for delivering and collecting the

questionnaires of their respective classmates.

Relatively to general people, the delivery of the questionnaires was made by us as

explained before in Sampling Processes and the inquired people were asked to handout the

questionnaire as soon as they finished it to one member of this study team that was permanently at

the place where the questionnaires were distributed . That person was relayed with others by shifts

until every people requested to fill the questionnaire have done it.

Variables Description

The study variables (independent) are the opinions of the two target populations about Facebook’s role on Medical Professionalism, with afterwards comparison between them, and their


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knowledge about the Portuguese Laws which are related to healthcare services’ professionalism. The first variable can be measured by the comparison of some questionnaires’ closed item answers in form of percentages and by the average value of the scaled answered questions of the same questionnaires. The second variable can be measured by comparing the answers of both target populations to the second group of questions (which is common to all questionnaires) with the Portuguese Laws previously researched by our work team.

Our first outcome variable (dependent) is the conclusion of the first variable of study: whether or not the two target populations think that the medical professionalism is at risk due to the Facebook. The second study variable will lead us to our second outcome variable which is the conclusion on the knowledge that both target populations have about the Portuguese Laws and if they think the overuse of Facebook by young doctors and medical students leads to the need of changing those Laws. We will also have a third outcome variable which is correlated with medical students only, as we intend to conclude about the Facebook’s role in their Academic Career. If both target populations think that medical professionalism is in danger, that specific question on medical student’s questionnaire will be an important question to further solutions.

Another variable that is of some relevance is if within both populations, there were significant differences between the answers given by the different genders. We also will study that variable, stratifying both samples from both target populations by gender.

Our measured variables precision is proportional to the significance of our samples. The latter had some biases which we could not entirely eliminate because of the chosen participants specificity. Due to deadline issues, we also couldn’t select them as randomly as we wished.

Statistical Analysis

For Statistical Analysis of our questionnaires, we used IBM® SPSS® Statistics Version 19 to calculate the valid n and percentage for closed item questions and for the scaled item questions, we verified if the variables followed a normal distribution with equal homoscedasticity, which they were not, and so, we presented the results in the form of median and range. Moreover, we used IBM® SPSS® Statistics Version 19 to obtain results for the following two comparisons:

Comparison between sexes: o For the closed item questions, the chi-square test was used when the expected

values lower than 5 for cells were less than 20%. When that did not happen, to analyze the relation between two categorical variables, Fisher's Exact Test was performed, considering the answers "I do not know" as missing values.

o For the scaled item questions, it was used Mann-Whitney test.

Comparison between both target populations. As our target populations were only two, we used the same tests that we used for the comparison between sexes.

For all hypothesis tests, it was used a significance level of 0.05.

Expected Results

Concerning the first outcome variable, we can expect anything since there are both possibilities of the inquired sample to think that medical professionalism is being degraded by the use of Facebook by medical students or not. If they do, we will propose some solutions based on some questions of our questionnaire. If they don’t, we will just inform the Medical Community that, at least here in Oporto, most people think that there are no motives for concern with medical professionalism.

Relatively to the second outcome variable, we are expecting that people will not know anything about what is written in Portuguese Laws about medical professionalism because most of the people never had time to think about that as deep as we wanted to. Meanwhile what is written in Portuguese Laws is based on common sense of quotidian life, so we are expecting that people should be able to answer unconsciously right to the questions placed by our questionnaire. By comparing the target-population’s answers about the Portuguese Laws, we will evaluate their ethics.


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In relation to our third outcome variable, we are expecting that the majority of medical students state that Facebook is useless for their academic success and, with that we could post a possible solution (amongst others of course) for the problem (if its existence is confirmed) based on the answers to that question.

It is important to withstand that the conclusions eventually taken by our study have limits, which are:

The geographically limited space where this study is being done limited the

significance of our sample;

The generalization of our conclusions must not be taken for granted because the

mentality and consequently, other people’s opinions could differ of those opinions on which our

conclusions will be based on. Differences on cultural and social status of distinct societies may

have some influence on the analyzed answers;

Our sample contains some biases of selection, as we can’t do any better with the

time we have to present our conclusions.


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Questions/Answers Medical Students General Population

Male (n = 23) Female (n = 59) p Male (n = 22) Female (n = 22) p

I know Facebook . Valid n (%) 23 (100) 58 (98) 1.000 18 (82) 18 (82) 1.000

I use Facebook. Valid n (%) 20 (87) 54 (93) 0.399 10 (56) 11 (61) 0.735

I use Facebook: Valid n (%)

1-10 times a week. 8 (44) 41 (77) 0.009

6 (60) 11 (100) 0.035

More than 10 times a week. 10 (56) 12 (23) 4 (40) 0 (0)

I use Facebook to: Valid n (%)

Talk with friends. 19 (95) 47 (87) 0.435 8 (80) 10 (91) 0.586

Watch photographs. 15 (75) 40 (74) 0.935 5 (50) 4 (36) 0.670

Meet new people. 2 (10) 1 (2) 0.176 2 (20) 0 (0) 0.214

Comment/see profiles. 15 (75) 41 (76) 1.000 7 (70) 5 (46) 0.387

Play games. 2 (10) 6 (11) 1.000 0 (0) 3 (27) 0.214

Other things. 3 (15) 5 (9) - 2 (9) 1 (9) -

Can/should a doctor be punished by law if he/she publishes a clinical case only using writting: Valid n (%)

Should. 14 (61) 33 (56) 0.685

9 (43) 7 (32) 0.454

Shouldn't. 9 (39) 26 (44) 12 (57) 15 (68)

Can. 16 (70) 40 (68) 0.877

15 (71) 11 (50) 0.151

Can't. 7 (30) 19 (32) 6 (29) 11 (50)

The doctor should be prosecuted for disclosing pictures without the patient showing his/her face on Facebook. Valid n (%)

11 (73) 30 (77) 1.000

8 (53) 4 (29) 0.176

I don't know. 8 (35) 20 (34) 7 (32) 8 (36)

The disclosure of pictures makes the attitude of the doctor ethically worse than if the case was expressed only by write.

Valid n (%)

It makes the attitude substantially worse. 12 (52) 32 (55)

-

9 (47) 10 (46)

0.108 It's the same. 10 (44) 22 (38) 7 (37) 3 (14)

It doesn't seem worse apparently. 1 (4) 4 (7) 3 (16) 9 (41)

Results


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The doctor should disclose information about a case of domestic violence to the respective authorities. Valid n (%)

16 (76) 41 (72) 0.707

17 (77) 19 (86) 0.698

I don't know. 2 (9) 2 (3) 0 (0) 0 (0)

This doctor should be prosecuted for disclosing that information. Valid n (%)

8 (40) 18 (35) 0.670

8 (50) 5 (25) 0.121

I don't know. 3 (13) 7 (12) 6 (27) 2 (9)

It is acceptable for a doctor to have a former patient as friend on Facebook. Valid n (%)

11 (65) 30 (68) 0.795

13 (77) 13 (72) 1.000

I don't know. 6 (26) 15 (25) 5 (23) 4 (18)

It is invasion of privacy to do research on people you know on Facebook. Valid n (%)

3 (13) 2 (4) 0.149

6 (29) 2 (11) 0.241

It depends. 0 (0) 4 (7) 1 (5) 3 (14)

The doctor should tell his best friend that his wife is secretly using contraceptive methods while the couple was trying to

have a baby. Valid n (%)

4 (19) 6 (12) 0.459

6 (32) 9 (50) 0.254

I don't know. 2 (9) 7 (12) 2 (9) 4 (18)

The doctor should advert the classmate of his/her son who is bullying his/her child on the bully's next appointment. Valid n (%)

17 (77) 34 (63) 0.229

19 (91) 18 (86) 1.000

I don't know. 1 (4) 5 (9) 1 (5) 1 (5)

I already had knowledge of clinical cases revealed by doctors on Facebook. Valid n (%)

0 (0) 7 (12) 0.183

0 (0) 0 (0) 1.000

I don't know. 0 (0) 1 (2) 1 (5) 0 (0)

There should be resctricted groups on Facebook for doctors to discuss clinical cases.Valid n (%)

11 (55) 31 (61) 0.656

17 (77) 15 (75) 1.000

I don't know. 3 (13) 8 (14) 0 (0) 2 (9)

The Portuguese Constitution allows the creation of those groups on Facebook (exclusive for doctors). Valid n (%)

3 (30) 7 (25) 1.000

4 (67) 6 (75) 1.000

I don't know. 13 (57) 31 (53) 16 (73) 14 (64)

Degree of agreement on the sentence: "Doctors are very influenced by Facebook". median (range)

1.5 (6) 2 (8) 0.667 3 (8) 4 (10) 0.320


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Degree of influence that sexual tendencies revealed by doctors on Facebook have on the physician-patient relationship. median

(range) 6 (10) 5 (10) 0.379 4 (10) 5 (10) 0.216

Religious feelings revealed on Facebook by a doctor can influence physician-patient relationship. Valid n (%)

15 (71) 37 (69) 0.806

7 (41) 6 (27) 0.361

I don't know. 2 (9) 5 (9) 5 (23) 0 (0)

It's right that doctors may be influenced by clinical cases posted by other doctors on Facebook to diagnose their patients'. Valid n

(%) 9 (53) 27 (56)

0.814 7 (41) 9 (45)

0.815

I don't know. 6 (26) 11 (19) 4 (19) 2 (9)

It's correct for a doctor to render health services to a patient that has access to his/her Facebook page. Valid n (%)

16 (80) 38 (83) 1.000

14 (70) 14 (74) 0.798

I don't know. 3 (13) 13 (22) 1 (5) 3 (14)

The frequent use of Facebook by people can lead to legislative changes concerning patient confidentiality. Valid n (%)

11 (61) 19 (42) 0.175

13 (77) 12 (67) 0.711

I don't know. 5 (22) 14 (24) 4 (19) 4 (18)

Degree of agreement on the sentence: "Health Care Professionalism is being threatened by the use of social

networks as Facebook". median (range)

2.5 (4) 2 (4) 0.074 2 (4) 3 (4) 0.541

I would consent a clinical case of mine to be posted on Facebook so it could be discussed by health care professionals. Valid n (%) **

9 (45) 9 (53) 0.630

I don't know. 2 (9) 5 (23)

Facebook is an instrument that promotes my academic success. Valid n (%)

7 (32) 16 (30) 0.889 **

I don't know. 1 (4) 4 (7)

Table 1 – Results obtained by the analysis of the questionnaires filled by the general population and by the medical students both divided by gender (comparison between sexes). In the data processed, we used the absolute valid frequency (n), the valid percentage (%) and median and range to “measure” the answers to all the questions. We presented the p value with a significance level of 0.05. Cells in green shown a strong similarity (p = 1.000) between the answers and red cells evidence great discrepancies (p equal or less

than 0.05) between them. ** means that the question was specific to one target population only. – means we couldn’t present p value because we didn’t had sufficient statistical knowledge to do that, since chi-square test was not valid.


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Questions/Answers Medical Students

(n = 82) General

Population (n = 44) p

I know Facebook . Valid n (%) 81 (99) 36 (82) 0.001

I use Facebook. Valid n (%) 74 (91) 21 (58) 0.000

I use Facebook: Valid n (%)

1-10 times a week. 49 (69) 14 (32) 0.286

More than 10 times a week. 22 (22) 30 (68)

I use Facebook to: Valid n (%)

Talk with friends. 66 (89) 18 (86) 0.703

Watch photographs. 55 (74) 9 (43) 0.007

Meet new people. 3 (4) 2 (10) 0.305

Comment/see profiles. 56 (76) 12 (57) 0.097

Play games. 8 (11) 3 (14) 0.703

Other things. 8 (11) 3 (14) -

Can/should a doctor be punished by law if he/she publishes a clinical case only using writting: Valid n (%)

Should. 47 (57) 16 (37) 0.033

Shouldn't. 35 (43) 27 (62)

Can. 56 (68) 26 (60) 0.381

Can't. 26 (32) 17 (40)

The doctor should be prosecuted for disclosing pictures without the patient showing his/her face on Facebook. Valid n (%)

41 (76) 12 (41) 0.002

I don't know. 28 (34) 15 (34)

The disclosure of pictures makes the attitude of the doctor ethically worse than if the case was expressed only by write: Valid n

(%)

It makes the attitude substantially worse. 44 (54) 19 (46)

0.002 It's the same. 32 (40) 10 (24)

It doesn't seem worse apparently. 5 (6) 12 (29)


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The doctor should disclose information about a case of domestic violence to the respective authorities. Valid n (%)

57 (73) 36 (82) 0.276

I don't know. 4 (5) 0 (0)

This doctor should be prosecuted for disclosing that information. Valid n (%)

26 (36) 13 (36) 1.000

I don't know. 10 (12) 8 (18)

It is acceptable for a doctor to have a former patient as friend on Facebook. Valid n (%)

41 (67) 26 (74) 0.468

I don't know. 21 (26) 9 (21)

It is invasion of privacy to do research on people you know on Facebook. Valid n (%)

5 (6)

8 (20) 0.033

It depends. 4 (5) 4 (9)

The doctor should tell his best friend that his wife is secretly using contraceptive methods while the couple was trying to have a

baby. Valid n (%)

10 (14) 15 (41) 0.002

I don't know. 9 (11) 6 (14)

The doctor should advert the classmate of his/her son who is bullying his/her child on the bully's next appointment. Valid n (%)

51 (67) 37 (88) 0.012

I don't know. 6 (7) 2 (5)

I already had knowledge of clinical cases revealed by doctors on Facebook. Valid n (%)

7 (9) 0 (0) 0.095

I don't know. 1 (1) 1 (2)

There should be resctricted groups on Facebook for doctors to discuss clinical cases. Valid n (%)

42 (59) 32 (76) 0.066

I don't know. 11 (13) 2 (5)

The Portuguese Constitution allows the creation of those groups on Facebook (exclusive for doctors). Valid n (%)

10 (26) 10 (71) 0.003

I don't know. (44) (54) 30 (68)

Degree of agreement on the sentence: "Doctors are very influenced by Facebook". median (range)

2 (8) 4 (10) 0.003


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Degree of influence that sexual tendencies revealed by doctors on Facebook have on the physician-patient relationship. median (range)

6 (10) 5 (10) 0.102

Religious feelings revealed on Facebook by a doctor can influence physician-patient relationship. Valid n (%)

52 (69) 13 (33) 0.000

I don't know. 7 (9) 5 (11)

It's right that doctors may be influenced by clinical cases posted by other doctors on Facebook to diagnose their patients'. Valid n (%)

36 (55) 16 (43) 0.238

I don't know. 17 (21) 6 (14)

It's correct for a doctor to render health services to a patient that has access to his/her Facebook page. Valid n (%)

54 (82) 28 (72) 0.230

I don't know. 16 (20) 4 (9)

The frequent use of Facebook by people can lead to legislative changes concerning patient confidentiality. Valid n (%)

30 (48) 25 (71) 0.023

I don't know. 19 (23) 8 (19)

Degree of agreement on the sentence: "Health Care Professionalism is being threatened by the use of social networks

as Facebook". median (range)

2 (4) 3 (4) 0.339

I would consent a clinical case of mine to be posted on Facebook so it could be discussed by health care professionals. Valid n (%) **

18 (49)

- I don't know. 7 (16)

Facebook is an instrument that promotes my academic success because: Valid n (%)

23 (31) **

I don't know. 5 (6)

Table 2 – Results obtained by the analysis of the questionnaires filled by the general population and by the medical students (comparison between study groups). In the data processed, we used the absolute valid frequency (n), the valid percentage (%) and median and range to “measure” the answers to all the questions. We presented the p value with a significance level of 0.05. Cells in

green shown a strong similarity (p = 1.000) between the answers and red cells evidence great discrepancies (p equal or less than 0.05) between them. ** means that the question was specific to one target population only. – means we couldn’t present p value because

we didn’t had sufficient statistical knowledge to do that.


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Discussion

Comparison Between Sexes

Medical Students

Knowing the existence of Facebook is almost general (100 % on male and 98% on female)

between genders of this group and the use of it is less general (87% on male and 93% on female).

When questioned about how many times they went to Facebook, men claimed to use it more than

10 times per week (56%) unlike the majority of women (77%) that claim they don’t use Facebook

more than 10 times per week, as this difference is statistically significant (p<0.05). Although, both of

them revealed that they use it to talk with friends, watch photographs and see profiles most of the

times.

The next part of the questionnaire revealed some similarities when both female and male

medical students generally (73% on males and 77% on females) thought that a doctor should be

prosecuted for disclosing pictures without the patient showing his/her face on Facebook. This was

the only question where we could highlight the strong similarity of answers given by both sexes as

there weren’t significant discrepancies on their opinions on the rest of the questions of this part of

our questionnaire. Despite this fact, we could see that the men’s group didn’t have knowledge of

clinical cases revealed by doctors on Facebook, but some women had, which is important for one of

this study’s outcomes.

On the third group of questions of our questionnaire, medical students of both sexes once

more shown a great homogeneity on their answers as we couldn’t find any statistically relevant

differences on the answers given, but we could find one strong similarity as both male and females

strongly thought (80% on males and 83% on women) that it is correct for a doctor to render health

services on his/her Facebook page.

On the specific question, we once again didn’t find significant discrepancies or homologies

between the answers given by both male and female medical students, as they generally thought

(32% on males and 30% on females) that Facebook was not an instrument that could promote their

academic success.

Whit these comparisons we can conclude that the opinion of medical students about this

issue is basically the same, because we don’t have any statistical differences between the answers by

both male and female individuals of this study group.

General Population

The analyzed population was in the hospital’s waiting room, which makes this sample not

random, since the chosen patients are probably older (have more probability of getting ill), have

certain characteristics and so may not be representative of the corresponding population.

Nevertheless, for the purpose of making conclusions relatively to the population and not only the

sample, it is going to be considered this sample as a representative one. Moreover, the sample has

an n=44 (reasonably small, which might establish more biases) and equally distributed between

genders, which represents a factor in favor of a non random sample.

As far as the use and knowledge of the tool is concerned, there are no differences between

genders. However, 82% of the inquired people knows what Facebook is, which gives us the possibility

of asking all the survey questions to almost all the selected people. Even so, within those who know

the tool, only 58% actually use it, which indicates popularity even amongst those who don’t have a


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direct contact with it. The purposes to use Facebook are similar between genders (talking to friends

with a special emphasis).

As to the amount of times people use Facebook, there is a significance difference between

genders (p=0,035). Concerning the results, women apparently have a more subtle Facebook’s use as

the majority of them use it is less than 10 times per week. On the other hand, males reveal

themselves as a more moderated gender. These outcomes may be explained by the differences

between the genders’ own nature, which is an interesting field for anthropology.

Regarding the rest of the questions, there were no statistical significant differences

between genders. Nonetheless, both genders in general think that a certain doctor shouldn’t be

punished just for exposing a written clinical case, which might imply that we live in a society which

does not feel very “threatened” by Facebook. One of the extremely relevant outcomes for our

investigation project which led to same conclusion mentioned above was the null observation of

cases by the inquired people in which doctors revealed clinical cases on Facebook; in addition, the

most part of the sample thinks the tool does not have much influence within doctors and the

exposure of the doctor’s sexual orientation is irrelevant. Moreover, the sample, in general, does not

believe the patient’s access to his/her doctor’s profile has any kind of ethical problem. All these

outcomes are coherent with the current sample’s opinion (nowadays medical professionalism is not

compromised by the use of this tool). Nevertheless, and very interestingly, the inquired people

believe that its frequent use, in a long term, may lead to changing the laws on professional secrecy.

These results suggest that the general population does not think of the Facebook as a current threat

on healthcare, although it might be in a long term, as mentioned above.

Moreover, accordingly to the sample’s opinion, a doctor should report to the authorities

domestic violence cases, which may reveal an ethical consciousness – violating confidentiality in

cases when the patient’s health is at risk does not break the medical code.

As long as the relationship between doctor/patient is concerned, the population believes it is

okay for a doctor to have his/her patient as a friend on Facebook, as well as dealing with his/her

personal life during an appointment (ex: bullying).

It looks like the population believes Facebook is a useful tool for doctors, given the answers

to the 1st question of the group 3. They also believe they would allow doctors to discuss on Facebook

their own clinical case as a means to improve clinical discussion.

Generally, there weren’t many discrepancies between the answers given by both males and

females of this study group, just like what happened on the other study group. Due to this fact, we

can conclude that eventual differences on the answers given by the study groups in general, is not

derived from differences in the gender of individuals.

Comparison Between Groups

Question Group 1 Analysing the results obtained on the question “Do you know Facebook?”, it can be

concluded that both the general population and medical students have knowledge about this social network. However, a greater part of the Medical students know Facebook (99%) when compared with the general population (86%). Although these results are statistically significant, there are some factors that may have influenced the outcome, such as different size of the sample. While medical students in the study were 82, sample of the general population has a number of 44 participants.

Regarding the question “Do you use Facebook?” the difference is significantly greater. It appears that 90% of students surveyed admitted that they use Facebook and only 53% of the population has the same behavior. This indicates a statistically significant difference (p <0.05)


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compared to Facebook usage habits between the two study groups. We highlight an important point: although medical students use Facebook more, they use it less often (less than 10 times a week) than general population do, when they use it (22% of medical students against 68% of general population).

When asked about why they resorted to Facebook, it appears that in both groups the intention of the majority (89% on medical students and 86% of general population) is "talking with friends". The most curious parameter is to confirm that students use Facebook a lot more to see and comment photos than the general population, this being the only parameter where there is a statistically significant variation (p<0.05).

Questions of Group 2 Regarding the questions of the second group and p values, it can be concluded that there are

significant differences between the analised groups. While both groups reveal a certain knowledge about the Portuguese legislation by stating a

doctor can indeed be punished for disclosing a clinical case by writing, only the medical students’ group considers that same legislation appropriate, believing, by their own ethical values, the same doctor should be punished (p = 0.033). Moreover, this difference between groups reveals itself concerning the publication of patients’ not-showing-faces photographs. This might suggest a greater ethical consciousness regarding future doctors, in comparison with the general population’s group, both because of the different educations, disciplines, graduations and the responsibility while doctors. Nevertheless, it also reveals a greater kindness by the general population. This significant differences lead us to explore the true meaning of is “right” and “wrong”, which is not a study object.

As far as the comparison between the written publication and photographed one, it was of mutual agreement that the latter is significantly worse, which is a more subjective opinion, since in both ways the deontological code is broken. However, there were significant differences (p = 0.002) regarding the answers “it’s the same” and “it doesn’t seem worse apparently”. The medical students’ group shows itself better decided concerning the subject as it answers more often “it’s the same”, while the general population’s group reveals itself more irresolute by answering “it doesn’t seem worse apparently”. Once more, the reason why may be based on the fact that the medical students may have already been faced with this issues, developing a greater certainty regarding their answer.

Concerning the reporting of domestic violence cases to the authorities, it is of mutual agreement both the doctor should report those to them, and that this same doctor shouldn’t be punished by doing it (p = 1). This data shows both groups have both a correct formulated concept about the legislation and an appropriate ethical judgment (this is a more subjective conclusion). The deontological principle which supports the first conclusion is “the right of need”, regarding the criminal justice administration: reasoned danger of repeating the practice of serious criminal offenses. In addition, both groups consider acceptable for a doctor to have a former patient as a friend on Facebook, which suggests both groups don’t believe this tool and the doctor/patient proximity to negatively influence medical professionalism.

Nonetheless, the general population group considered significantly more times (0.033) that it is invasion of privacy to search for people one knows on Facebook. This can be easily explained by the age of the inquired people: medical students are obviously younger and so, more used to work with this tool than the other group.

Another interesting unconformity was the fact that the general population’s group considered a lot more often that a doctor should tell his best friend his wife is secretly using contraceptive methods while the couple was trying to have a baby than the medical students’ group (p = 0.002). This suggests medical students already choose their professional duty over a good social conduct. As far as the general population’s group is concerned, it can be easily understood the supremacy of a good social behavior regarding their decision. For the same reason, it can be explained the medical students’ group believes more often (p = 0.012) a certain doctor shouldn’t deal with personal issues during an appointment (example: bullying of his/her own son/daughter).


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Furthermore, there were almost no observations of related clinical cases on Facebook, in both groups. This once more suggests Facebook does not have a very important role on the threatening of medical professionalism.

Questions of Group 3 Analysing the answers given on the third group, it is possible to conclude that a great part of

both study groups (54% of medical students and 68% of general population) does not know if the Portuguese Constitution allows the creation of Facebook groups (exclusive for doctors) in order to discuss clinical cases. This reveals an important lack of knowledge in what concerns to medical professionalism. On the other hand, general population who claimed to know that it was possible while medical students thought not to be possible. It can be concluded that medical students are right since the article number four of an official document published by Portuguese Government states that medical information can only be used by the National Health System, so it could not be used on Facebook (10).

Another interesting finding was that general population (in median 4 in a scale from 0 to 10) think that doctors are more influenced by Facebook than medical students think (in median 2 in a scale from 0 to 10), as this difference is statistically significant (p<0.05). Therefore people from the first sample group think that the increasing use of social networks by doctors can lead to legislative changes in this matter (71% from the sample of general population and 48% of medical students).

Medical Students seem to be more concerned about the possible influence of the information revealed by doctors on their Facebook page related to their sexual orientation (in median 6 in a scale from 0 to 10) and religious beliefs (69%) on physician-patient relationship. Despite that fact, general population also think that sexual orientation can influence physician-patient relationship (in median 5 in a scale from 0 to 10) but they don’t share the same opinion about the impact of religious beliefs on that same relationship (33%). Due to these facts, it seems that it’s general belief that sexual orientation revealed by a doctor can influence his/her relationship with his/her patient, which is certainly a verification of one of 21st century biggest stereotypes.

Finally, the two great conclusions that result from this analysis are that both sample groups think that it is correct for a doctor to render health services to a patient that has access to his or her Facebook page (82% of medical students and 72% of general population) when, by law, it should be impossible to a physician to do so (10) and that, although there is an increasing influence of social networks on provision of health care services, they are a reasonable threat to Medical Professionalism. This last conclusion is the main outcome of our first and biggest objective and is corroborated by the median answers given by medical students (2 in a scale from 0 to 5) and 3 by general population (3 in the same scale).

Question of Group 4 – Specific for each Study Group

Medical Students

Only 31% of respondent students cited Facebook as an important tool to their academic

success. When asked why they thought Facebook was an important tool, medical students of our sample answered that it is an important mean to trade information and clarify doubts that may surge during their study. Despite being frequent users of this page, they do not consider Facebook as something that can be related to their professional life. This conclusion is satisfactory, as it appears that the "relationship" that medical students have with Facebook is totally separated from their job as students and, someday, as future doctors. This leads us to believe that the trend will not be for future doctor use Facebook as a tool, exposing clinical cases. Meanwhile, it also leads us to conclude that if Medical Professionalism was at risk, one of the solutions for that problem would be to restrict the use of Facebook by medical students inside the University for example.


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General Population Half of the general population inquired (49%) would accept to publish their clinical case in

Facebook in order to be discussed by health professionals. It is surprising to note that there are still a large percentage of people who agree to see their pathological situation exposed on a social network. This raises the possibility of not having good sense of the danger and violation of privacy that it represents and, therefore, accept this exhibition because they think it will bring some benefits to their therapeutic process. On the other hand, it could be that general population of our sample shown solidarity and compassion for third ones and wished that their clinical case could be disclosed to help other people with the same problem that they once had.

Conclusions

Since there weren’t great discrepancies on answers given by both sexes on each study

group, we can conclude that the differences revealed by the comparison between the two study

groups was not dependent on the gender of the inquired individuals.

Generally, both study groups didn’t have a concrete idea of Portuguese Laws on such

polemic matter as the impact of Facebook on Medical Professionalism as most of the questions that

involved knowledge about those types of Laws, both medical students and general people revealed a

direct lack of knowledge (answering “I don’t know”) or an indirect one as they were mistaken on the

answers they gave, fact that was demonstrated throughout this article by comparing those answers

to the Portuguese Medical Association Code of Ethics and other official documents on this matter.

Regarding the knowledge our study groups had on cases of disclosure of clinical cases on

Facebook, general population didn’t had knowledge of any case and neither did male medical

students. Meanwhile, some female medical students (n=7) had knowledge of at least one clinical

case posted on Facebook by a physician. These facts reveal a low frequency of clinical cases posted

by doctors on Facebook, but reveal their existence and the actuality of that problem.

Both medical students and general populations reasonably think Medical Professionalism

is threatened by the overuse of Facebook, since this thought is in median more frequently on general

people.

Facebook is considered by the majority of medical students not to be a useful instrument

to promote their academic success, but students who answered differently, think that the social

network is useful to discuss and clarify some doubts that may arise during their study. However,

since both study groups (more the general population) revealed a moderate worry for Medical

Professionalism, it could be a possible prevention to restrict the use of Facebook by medical students

at least while they are at the University facilities. In addition, responsible authorities for Portuguese

Health as ERS (“Entidade Reguladora da Saúde” ) could intervene and separate or fuse these two

entities (Facebook and Medical Professionalism) to create a more cohesive and stable model of

Health Care Services.


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References

1 - Ellison NB, Steinfield C, Lampe C. The benefits of Facebook “friends:” social capital and college students’ use of online social network sites. J Comput-Mediated Commun 2007; 12(4): article 1

2 – Zur O, Williams MH, Levahot K, Knapp S. Psychotherapist self-disclosure and transparency

in the Internet age. Prof Psychol Res Pract 2009; 40 (1): 22-30 3 – Garner J, O’Sullivan H. Facebook and the Professional beahaviours of undergraduate

medical students. The Clinical Teacher 2010; 7:112-115 4 – MacDonald J, Sohn S, Ellis P. Privacy, professionalism and Facebook: a dilemma for young

doctors. Medical Education 2010; 44: 805-813. 5 – ABIM Foundation, ACP-ASIM Foundation, European Federation of Internal Medicine.

Medical Professionalism in the New Millenium: A Physician Charter. Annals of Internal Medicine 2002; 136(3):243-46

6 – GMC. Medical students: professional behaviour and fitness to practise. London: The

General Medical Council; 2007. 7 – Chretien KC, Greysen SR, Chretien J-P, Kind T. Online posting of unprofessional conduct by

medical students. JAMA 2009;301 (12):1309-15 8 – Lagu T, Kaufman EJ, Asch DA, Armstrong K. Content of weblogs written by health

professionals. J Gen Intern Med 2008;23 (10):1642-6 9 – Read B. Think Before You Share. Student’s online socialising can have unintended

consequences. Chron High Educ 2006;52 (20): 38-41 10 - DIÁRIO DA REPÚBLICA—I SÉRIE-A Nº 18—26 de Janeiro de 2005, Lei Nº 12/2005 de 26 de

Janeiro.

Attachments

The questionnaires are available on the following websites:

http://www.scribd.com/doc/76339540/Questionario-Estudantes-de-Medicina

http://www.scribd.com/doc/76339794/Questionario-Populacao-em-Geral

http://www.scribd.com/doc/76339851/Questionario-Profissionais-de-Bioetica

http://www.scribd.com/doc/76339931/Questionario-Profisionais-de-Saude

http://www.scribd.com/doc/76339794/Questionario-Populacao-em-Geral

http://www.scribd.com/doc/76339851/Questionario-Profissionais-de-Bioetica

MEDICAL STUDENTS AND FACEBOOK: THREATENED...

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