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The increased use of social media, cloud computing, and mobile devices has led to the emergence of guidelines and novel teaching efforts to guide students toward the appropriate use of technology. Despite this, violations of professional conduct are common.
We sought to explore professional behaviors specific to appropriate use of technology by looking at changes in third-year medical students’ attitudes and behaviors at the beginning and conclusion of their clinical clerkships.
After formal teaching about digital professionalism, we administered a survey to medical students that described 35 technology-related behaviors and queried students about professionalism of the behavior (on a 5-point Likert scale), observation of others engaging in the behavior (yes or no), as well as personal participation in the behavior (yes or no). Students were resurveyed at the end of the academic year.
Over the year, perceptions of what is considered acceptable behavior regarding privacy, data security, communications, and social media boundaries changed, despite formal teaching sessions to reinforce professional behavior. Furthermore, medical students who observed unprofessional behaviors were more likely to participate in such behaviors.
Although technology is a useful tool to enhance teaching and learning, our results reflect an erosion of professionalism related to information security that occurred despite medical school and hospital-based teaching sessions to promote digital professionalism. True alteration of trainee behavior will require a cultural shift that includes continual education, better role models, and frequent reminders for faculty, house staff, students, and staff.
The increasing use of social media, cloud computing, and mobile devices challenges medical schools and teaching hospitals to guide students toward the appropriate use of technology [
Despite teaching efforts and the emergence of guidelines [
In addition to formal instruction, studies show that components of the “hidden curriculum [
To assess the changes in medical student attitudes and behaviors about digital professionalism, we modeled the approach of Reddy et al [
Our survey (
Immediately before their initial clinical clerkship, all students received two 45-min educational sessions on digital professionalism (
We administered the survey to students embarking on their clinical clerkships at our hospital (n=51) before the local session on digital professionalism; students had already attended the central session as described above. We surveyed students again at the end of their clerkship in April 2013. Data were maintained anonymously and without linking to protect student identity and facilitate truthful reporting.
Responses were dichotomized to unprofessional (1,2) or professional (3,4,5), with neutral being considered professional for the purposes of analysis. Fisher test was used to determine significance of differences between pre- and post-clerkship surveys. All data were analyzed using SAS 9.3 (SAS Institute, Cary, NC). The primary outcome was participants’ change in opinions. Secondary outcomes included the observation of, and participation in, technology-related unprofessional behaviors.
In addition, for a subset of unprofessional behaviors where prevalence of participation was ≥30% (ie, medical record lookup outside of care and explicit instruction, use of third-party services with patient data, taking images of physical findings, conducting Web searches on patients), we analyzed post surveys to determine whether there was any correlation between observing behaviors and participating in behaviors. Where possible, we calculated relative risks (RR) and 95% CI.
We conducted a sensitivity analysis to determine how missing surveys would affect our results as not all students submitted end-of-the-year surveys, and we had avoided asking for linking information to preserve anonymity. This conservative analysis imputed answers for participants who did not return a post-clerkship survey, or who skipped a particular question, and biased responses toward the null.
The response rates for the pre- and post-clerkship surveys were 96% (49/51) and 86% (42/49), respectively. Changes in perceptions regarding each behavior (pre- vs post-clerkship survey responses) and the post-clerkship observation and participation in each behavior are shown in
When asked post-clerkship whether a medical student should access the record of a patient not under his or her care without explicit instruction to do so, respondents were less likely to consider the behavior as unprofessional (98-71%,
Fewer students perceived the use of third-party services (eg, Dropbox, Google Drive) for patient data to be unprofessional at the end of the year, reaching borderline statistical significance (94-80%,
By the end of their clinical clerkship year, students were less likely to consider ignoring pages from nurses to be unprofessional (100-82%,
Other behaviors that students considered significantly less unprofessional after their clerkship year included conducting Web searches on patients (“Googling” patients, 57-29%,
Significantly fewer students considered the following types of online posts to be unprofessional: negative comments about patients (100-89%,
Our conservative sensitivity analysis resulted in the loss of statistical significance for many results where we observed a change in perceptions over the course of a clinical year. Notable exceptions included looking up medical records of patients outside of ongoing patient care or formal educational context (98-71%,
Perceptions of professionalism of technology-related behaviors pre- and post-clerkship.
Behavior | Preclerkship | Postclerkship | Observation and participation | ||||||||
n |
n (%) |
n |
n (%) |
n (%) |
n (%) |
||||||
Looking up the medical record of a patient who is not under your care without explicit instruction to do so | 49 | 48 (98.0) | 38 | 23 (60.5) | <.001 | 19 (46.3) | 13 (31.7) | ||||
Taking a photo or video of a patient’s physical findings | 49 | 19 (38.8) | 39 | 17 (43.6) | .67 | 34 (87.2) | 13 (33.3) | ||||
Sharing a photo or video of a patient’s physical findings | 49 | 36 (73.5) | 38 | 28 (73.7) | >.99 | 28 (71.8) | 7 (17.9) | ||||
Saving work that contains patient data to a 3rd party service | 49 | 46 (93.9) | 39 | 31 (79.5) | .06 | 22 (57.9) | 13 (34.2) | ||||
Not passcode protecting a personal device used for work | 49 | 47 (95.9) | 38 | 30 (78.9) | .02 | 10 (26.3) | 3 (7.9) | ||||
Downloading non-work related programs onto a work computer | 49 | 38 (77.6) | 37 | 25 (67.6) | .33 | 7 (18.9) | 4 (10.8) | ||||
Using a personal email address for professional communication | 49 | 36 (73.5) | 38 | 21 (55.3) | .11 | 22 (59.5) | 15 (40.5) | ||||
Using a professional email address for personal communication | 49 | 13 (26.5) | 37 | 10 (27.0) | >.99 | 30 (83.3) | 27 (75.0) | ||||
Playing online games at work | 48 | 45 (93.8) | 40 | 31 (77.5) | .03 | 17 (43.6) | 2 (5.1) | ||||
Not returning a page from a nurse | 49 | 49 (100.0) | 38 | 31 (81.6) | .002 | 19 (50.0) | 0 (0.0) | ||||
Not returning a page from a colleague | 49 | 49 (100.0) | 37 | 34 (91.9) | .08 | 14 (36.8) | 1 (2.6) | ||||
Not returning a phone call or page from a patient | 49 | 48 (98.0) | 36 | 34 (94.4) | .57 | 12 (31.6) | 2 (5.3) | ||||
Not replying to an email requesting a response | 49 | 48 (98.0) | 39 | 34 (87.2) | .08 | 19 (50.0) | 13 (35.1) | ||||
Not replying to an email from a professor that requests a response | 49 | 45 (91.8) | 37 | 34 (91.9) | >.99 | 9 (25.0) | 6 (16.7) | ||||
Not replying to an email from a class administrator that requests a response | 49 | 48 (98.0) | 37 | 34 (91.9) | .31 | 12 (33.3) | 9 (25.0) | ||||
Answering a mobile phone while in a patient’s room | 49 | 45 (91.8) | 39 | 34 (87.2) | .50 | 31 (79.5) | 2 (5.1) | ||||
Using a mobile device for non-work related matters while on rounds | 49 | 46 (93.9) | 40 | 35 (87.5) | .46 | 28 (71.8) | 8 (20.5) | ||||
Using a mobile device for non-work related matters while in a patient’s company | 49 | 49 (100.0) | 40 | 36 (90.0) | .04 | 17 (43.6) | 1 (2.6) | ||||
Using Facebook at work | 49 | 42 (85.7) | 40 | 31 (77.5) | .41 | 35 (89.7) | 15 (38.5) | ||||
Watching non-work related videos at work | 49 | 39 (79.6) | 40 | 28 (70.0) | .33 | 34 (87.2) | 16 (41.0) | ||||
“Friending” a patient online | 49 | 49 (100.0) | 42 | 38 (90.5) | .04 | 2 (4.9) | 0 (0.0) | ||||
Accepting an “online friend request” from a patient | 48 | 44 (91.7) | 42 | 36 (85.7) | .51 | 2 (4.9) | 0 (0.0) | ||||
“Googling” a patient | 49 | 28 (57.1) | 42 | 12 (28.6) | .01 | 26 (63.4) | 22 (53.7) | ||||
“Friending” a resident online | 49 | 5 (10.2) | 39 | 7 (17.9) | .36 | 31 (77.5) | 13 (32.5) | ||||
“Googling” a resident | 48 | 7 (14.6) | 40 | 6 (15.0) | >.99 | 28 (68.3) | 26 (65.0) | ||||
“Friending” an attending online | 49 | 24 (49.0) | 41 | 18 (43.9) | .68 | 9 (22.0) | 4 (9.8) | ||||
“Googling” a physician | 49 | 0 (0.0) | 42 | 5 (11.9) | .02 | 34 (82.9) | 36 (87.8) | ||||
Making negative comments about patients in online posts | 49 | 49 (100.0) | 37 | 33 (89.2) | .03 | 12 (33.3) | 0 (0.0) | ||||
Making derogatory comments about nurses or hospital staff in online posts | 49 | 49 (100.0) | 37 | 33 (89.2) | .03 | 15 (41.7) | 0 (0.0) | ||||
Making derogatory comments about residents or attendings in online posts | 49 | 49 (100.0) | 36 | 31 (86.1) | .01 | 13 (36.1) | 0 (0.0) | ||||
Making derogatory comments about peers in online posts | 49 | 48 (98.0) | 37 | 33 (89.2) | .16 | 15 (41.7) | 0 (0.0) | ||||
Not giving feedback to other students about inappropriate online behavior | 49 | 36 (73.5) | 36 | 21 (58.3) | .17 | 13 (36.1) | 6 (16.7) | ||||
Not giving feedback to residents about inappropriate online behavior | 49 | 31 (63.3) | 36 | 17 (47.2) | .19 | 10 (27.8) | 7 (19.4) | ||||
Not giving feedback to faculty about inappropriate online behavior | 49 | 28 (57.1) | 36 | 19 (52.8) | .83 | 9 (25.0) | 4 (11.1) | ||||
Not giving feedback to nurses about inappropriate online behavior | 49 | 29 (59.2) | 36 | 17 (47.2) | .38 | 11 (30.6) | 6 (16.7) |
Clinical clerkships are a critical time in the formation of medical students’ professional identities. Students constantly compare what they have been taught with what they see, and the influence of this “hidden curriculum” of medical school is thought to play an important role in the acculturation of students into the profession [
Students encounter new risks for unprofessional and unethical behaviors with the use of electronic medical records and social media; these risks are rarely discussed or taught explicitly. Unfortunately, several of the behaviors we assessed have critical legal and regulatory implications, exposing trainees and medical centers to substantial ethical, legal, and financial risk. Snooping in charts, for instance, violates the privacy rule of HIPAA (Health Insurance Portability and Accountability Act of 1996) and subjects the individual and institution to fines, along with a loss of patient trust; students may be dismissed from school at the first occurrence of such a violation. Allowing data to “leak” from secure environments onto third-party cloud servers violates the Security Rule of HIPAA; third-party services should not be used, unless they are sanctioned by the organization, encrypted, and have signed business associate agreements ensuring compliance with regulations.
Given that policy tends to lag behind technology, educators and hospital leadership need to proactively assess and monitor behaviors of their students, and assess risk and compliance with expectations and existing regulations. Medical educators must understand the basis for unprofessional behaviors and provide education, support, and resources to make it easy for medical students to act professionally and ethically, even in these pressured environments. Organizations are beginning to create agreements with cloud-based providers that do ensure the security and auditability of protected health information while meeting the needs of users. This development is encouraging that health care entities are making it easy for users, including students, to do the right thing all the time.
Patients trust that medical providers, including students, will safeguard their information, upholding a central tenet of medical professionalism. Students also have an obligation to their patients and society to use their time in medical school most effectively to become competent clinicians. This sets up an ethical dilemma where a student feels that the use of a new but unsanctioned technology, like a third-party cloud service for preparing case presentations, outweighs the low but not negligible risk of a data breach. The law is clear in this case that data must be secured; in some cases, however, the law and policy are less clear.
Should students be allowed to look up the medical record of a patient not under their care for educational purposes? Electronic health records allow students the opportunity to see and follow different cases that they may not encounter on their own during medical school. Students may also follow patients longitudinally with the electronic health record, after their formal role in the patient’s care has ended, to learn the outcome [
Recognizing digital professionalism as an important component of medical education will allow integration into the classroom, the clinic, and simulation-based training, with competencies that are tested throughout medical training. However, integration of digital professionalism training must be done in a manner that truly instills students with the tangible tools and resources they need to act professionally. Professionalism training for students, faculty, and staff must shift from abstract descriptions such as “keep data private” to behaviorally oriented definitions, such as “encrypt mobile devices.” These definitions can be taught and refined as technology continues to evolve.
Although the introduction of a formal curriculum similar to the one we offer in our study may be a first step, our findings suggest that isolated sessions on professionalism are not sufficient to sustain perceptions and behaviors of professionalism [
A critical step in improving students’ performance and professional development is for faculty and staff to take a closer look at their own behaviors and expectations. Whereas the ultimate responsibility for unprofessional actions lies with the students themselves, faculty must hold themselves to a high standard. The more complex a setting and task, the bigger the discrepancy between what is explicitly taught in formal curricula and what is learned by students [
We conducted our study at a single site with a limited number of students. Our results may not be generalizable to other settings. We administered the survey anonymously to promote honest responses. However, this design limited our ability to perform paired analysis of pre- and post-clerkship surveys that might detect subtle differences. We performed a sensitivity analysis to conservatively account for missing responses. We did not formally pretest these questions with students and could not exclude differences in interpretation for some questions. However, questions from pre and posttest were kept identical with the same population, making it less likely to influence responses.
Although technology is a useful tool to enhance teaching and learning, the ethical dilemmas and legal ramifications of its potential misuse require enhanced attention to learners’ beliefs and behaviors. True alteration of trainee behavior will require a cultural shift that includes continual education, better role models, and frequent reminders for faculty, house staff, students, and staff. Future studies should assess and compare various educational strategies for promoting professionalism.
Survey questions administered at the beginning and end of the clinical clerkship year.
Curriculum delivered during educational sessions at the beginning of the clinical clerkship year.
electronic protected health information
The authors thank Dr Warner Slack for his insightful contributions and Jeanne Tyszka for her assistance in manuscript preparation. BHC was supported by Institutional National Research Service Award # T32HP12706 and by the Division of General Medicine Beth Israel Deaconess Medical Center. SKB thanks the Arnold P. Gold Foundation for a career development award through a Gold Professorship. BHC was supported by an Institutional National Research Service Award # T32HP12706 and by the Division of General Medicine Beth Israel Deaconess Medical Center. SKB was supported by Arnold P. Gold Foundation for a career development award through a Gold Professorship.
Dr Crotty serves on the Advisory Board of Buoy Inc.