Ethical responsibilities of leaders of tweetchats?

That way by justinbaeder
Over a year a go, Natalie Lafferty and I hosted the first #meded chat on Twitter. Ours was between 9-10pm UK time, and 5 hours later a similar chat was held for participants in the US.

We had some really great and very wide-ranging discussions. In the UK we had a lot of participation from students and doctors in training. This made for particularly rich and informative debates, for example on portfolios and competency. Over the summer we wound the chats down and didn't get them started again, although the US chat has kept running. But thanks to some calls on Twitter we have got some momentum building again and it looks as if our first session will be announced soon.

In advance of this I wanted to clarify what someone who participates in these chats could expect. I am not so interested in etiquette. We didn't really have any problems before, and participants seemed to be relatively sophisticated users of Twitter, so saying 'be nice' would seem to be a bit superfluous, and a little prissy.

But there are some other issues that I think we should address. The first is the issue of archiving. Anyone can archive anything on Twitter, but I think we should be clear with users that we ourselves will be archiving tweets and the implications of that. Up to now we had been using Symplur's archiving tool but we need to check whether individual tweets can be removed if they breached the confidentiality of patients or others. Again this did not arise before, but it is a serious enough governance issue that I think we should draw attention to it.

Next is the issue of research. As we are forming a community with the participants we would not consider researching the community without making participants aware. However, others outside our community might make us an object of research without making us aware. We can not do anything to stop that but we can make participants aware at least.

So given all that, here is a first draft. It is a fully editable document so please leave a comment here or directly on the document. What else do you think we need to add?

Case discussion on Twitter: how can we make best practice explicit?

Image by quinn.anya

It's great to see the growth of discussion in medical education on Twitter. Recently I have seen a few really interesting cases being discussed (and a lot being learned), but there have also been some questions about how we together can think about what is best practice in leading these discussions.

Case discussions have always been a very important way of learning in medicine. And as one doctor said, junior staff are still encouraged to submit cases to journals, but it can take many months for a case submitted to a journal to reach publication. In the meantime, social media removes those barriers to publication. We can all self-publish. But we have to be responsible too. I think that all of the people currently involved in leading discussions are being responsible, but how do we make clear to others what best practices we are following? I think that it is important to consider this for a few reasons. First, we have an obligation to all patients to make these discussions safe. Second, we are modelling how to share these cases to other students and professionals.

We also need to think about whether the existing guidance, which in the UK is from the GMC, is sufficient to guide us.

So a few questions....

What should we tell patients about sharing their story? Do we need their consent if the story is not recognisable to others?
When the GMC discuss confidentiality the emphasis is on not sharing information (without consent) that would allow another to recognise a patient or someone close to them. In the new draft guidance on social media the only additional emphasis is on the impact of embedded information such as GPS co-ordinates that would allow us to know from where a tweet was made, or an image taken. 

My own practice is that if I want to share a story about a patient that might allow them to recognise themselves then I ask permission, and I record that when sharing the story. So far this has only happened once and it was in a blog post. How could it be conveyed that a patient was aware and happy that their story was being shared on Twitter? If this is done in a separate tweet then those following the tweets may miss it and wonder if permission has been given. Is this something we need to be concerned about?

What about sharing images routinely made as part of care?


In 2011 the GMC gave additional guidance on the audio-visual recordings. For some images made as part of routine care, such as pathology slides, internal images of organs, and xrays,  then no specific consent to take the images is needed. It is presumed that if the patient gives consent to the procedure then they give consent to the image being recorded. The guidances says that attempts should be made to make patients aware that they may be shared in an anonymised form, but there is no need to ask permission before doing this. This includes for publication in widely-accessible media such as press, print and internet. We can presume this includes Twitter!  

The draft social media guidance makes no additional comment on this so sharing an anonymised image on Twitter for teaching purposes seems acceptable. But images are rarely of much value without an accompanying story. So we are back to the situation above. How much permission is it good practice to obtain before sharing a story? And we have to remember that the real-time nature of social media means that a story about a patient might be shared as it is happening, rather than six months later, so that it is more likely that people may recognise themselves or others.

Other images that are made as part of routine care, but are not part of a procedure, such as an image of the outside of the body, do need specific consent to be given. And again patients should be made aware that these images may be used for teaching or research, but specific consent does not have to be given for them to be shared for this purpose as long as they are anonymised and all identifying details are removed. However, the guidance states that if the image is to be shared in widely accessible media (eg Twitter or a blog) then if the image is identifiable consent must be obtained. If the image has been anonymised then good practice is that consent should also be obtained but," if it is not practicable to do so, you may publish the recording, bearing in mind that it may be difficult to ensure that all features of a recording that could identify the patient to any member of the public have been removed."

What about recording an image to share in an educational discussion on social media?


The GMC guidance which applies here is the section on "recordings for use in widely accessible public media". Here, even if the patient is not identifiable, and has been anonymised, consent must be given explicitly. Paragraph 37 states:
"You must get the patient's consent, which should usually be in writing, to make a recording that will be used in widely accessible public media, whether or not you consider the patient will be identifiable from the recording"
We are also obliged to check with our employers what their policies are. Some trusts prohibit the use of mobile phone cameras by staff to protect patient confidentiality.

If consent has been obtained from patients to share their non-identifiable images online, how can we share that information in a tweet? Can we presume that if we see an image shared on Twitter then the person sharing it has followed the correct policies, just as when we see an image in a journal we might presume that the correct policies have been followed? Should those leading case discussions develop their own policies and make these accessible from their Twitter profile?

Medical education on Twitter is fantastic. There are no professional or geopgraphic boundaries to discussions. And no boundaries to patients participating either! I want to see all that is happening already continue and also for more people to get involved. I think that by considering these issues and showing how we can be safe and transparent we can take these discussions to a new level of participation.

Are medical schools abusing 'fitness to practice'?

In 2005 the GMC introduced guidance on 'Professional values and fitness to practice' for medical students. Some have said the notion that a student could be 'fit to practice' is nonsensical....as they aren't licensed until after graduation. But the case has been made that medical students are placed in a position of trust with regards to patients and public as students so they should be held to higher standards than other students.

However, a conversation on Twitter today suggests that some medical students feel that medical schools are abusing their responsibility to ensure students 'fitness to practice' by threatening to carry out FTP procedures for what students perceive as minor misdemeanours  such as missing a day on placement.

You can find the fitness to practice guidance of many medical schools online. They specify serious and severe health and professional issues, but often have a line which says 'and any other matter which may call into question a student's fitness to practice'. This ambiguity is retained in a lot of professional guidance because it is impossible to specify every single circumstance that may mean that concerns would be justified, but it may be that this alarms students as they feel that the guidance then leaves too much leeway to the medical school and potential for abuse as suggested.

So do you think that medical schools are becoming unnecessarily disciplinarian? If so what is driving them to do this? Or are standards slipping? Were higher standards expected of medical students 'in your day'?

UPDATE: Thanks to @jomciver for this link to a very helpful blog post from senior staff in Birmingham medical school on what Fitness to Practice means (and what it doesn't)  and how they are trying to make the process clearer.

Would you block your patient on Twitter?

Road Block, a photo by PSP Photos on Flickr.

@amcunningham I see the logic of not being friends on FB, but if a pt. follows you on Twitter, should you block them?#DifferentPlatform
— WelshGasDoc (@welsh_gas_doc) February 6, 2012

This question came about because I had tweeted a link to some research which had shown that 1/3 of practicising physicians, who responded to a survey (with a 14% response rate)  and said they used Facebook , had been issued with a friend request by a patient or their carer. This was much higher than the level reported in more junior doctors and medical students.

So should doctors refuse friend requests from patients? I have never had a Facebook request from a patient but if I had I would explain that I keep that account for close friends and family. A Facebook request can just be ignored which is an essentially passive act.

But I wouldn't block a patient from following me on Twitter. My Twitter presence is not orientated towards patients but I don't think that they would find anything shocking or surprising in my tweets. It would give them an insight into what I do when I am not in the practice. I consider that patients, or colleagues or students might read everything that I write here or on Twitter or anywhere else publicly online so I wouldn't worry about that.

A few people did think that patients should be blocked however. We discussed that this wouldn't necessarily stop them accessing the tweets as one only has to look at the profile instead. And blocking someone on Twitter is quite a hostile and aggressive act. I think I would find it hard to explain why I was doing that. One doctor said that he had blocked a young, female patient from his Twitter account because he wanted to set clear boundaries.

Another option, as the BMA guidance on the use of social media suggests, is to consider protecting your Twitter account and only allowing approved followers to see Tweets. In my experience the vast majority of doctors in the UK do have public accounts and I don't know if patients accessing tweets is a factor for those who choose to protect their accounts.

And how would I respond to a patient asking me for information on Twitter? Say they asked me where was the best place to find information about diabetes? Well, I would reply and point them to some good sources of information. And what if they were to ask me about their medical condition? If they were following me I would send them a DM advising that I can't give medical advice on Twitter but to get in contact with me in the surgery. I'd also advise them that their tweets are public and that that they might want to be careful about sharing sensitive information so it might be best to delete them. Normally I wouldn't send a DM to someone who I was not following as they would not be able to reply. But I think that in this case it might be the easiest way to deal with the situation. I wouldn't feel comfortable talking to a patient about a medical problem in 140 chtrs even if they were private messages. Essentially, I would treat a patient no differently to any other person I meet on Twitter. And since many people do not use real names on Twitter, and I have no way of remembering the names of all the patients registered with our practice it would be an impossible task to block all patients anyway.

I wouldn't follow my patients on Twitter. But perhaps I will change my mind about this. Perhaps following people from the area could give me better insights into what it is like living in the area and how I might be a better advocate for the community. Have no doubt however that the digital divide is real. A few weeks ago we were having a #nhssm (NHS social media) discussion on using video services such as Skype with patients when Evan Hilton, the executive director of Gofal, the Welsh mental health charity tweeted about the issue of digital in/exlusion in the South Wales valleys. He followed it up with this statistic:

@buzzumi @amcunningham in context of community based mental health services @gofal_ less than 10% of service users on line at home
— Ewan Hilton (@EwanHilton) January 18, 2012

Our patients face many challenges (often beyond their control) in staying health or living with illness. We haven't yet figured out how social media can be best used to help them but perhaps there is a case for not putting more blocks in the road. What do you think?

Doctors getting people back to work

The YouTube video above was shared by the GMC as part of their pre-consultation on updating the guidance on Good Medical Practice(GMP).


Reward to doctors for getting patients back to work is not mentioned in the draft version of Good Medical Practice.  However, for the first time the GMC guidance to doctors includes specific mention of encouraging patients to stay in or to return to employment. I am not aware of the reason why this has been included at this time. The wording is


"51 You must support patients in caring for themselves to empower them to improve and maintain their health. This may include encouraging patients, including those with long-term conditions, to stay in or return to employment or other purposeful activity. You may also advise patients on the effects of their life choices on their health and well-being and the possible outcomes of their treatments."
(my emphasis)


This is specifically raised in the consultation questionnaire:

"At paragraph 51 of this section, we advise doctors that they must support patients in caring for themselves to empower them to improve and maintain their health. This is essentially the same as GMP 2006. But we also now say that such support may include ‘encouraging patients, including those with long term conditions, to stay in or return to employment or other purposeful activity’. 
30 Do you agree this is a reasonable expectation of doctors "


What do you think of this guidance to doctors? The consultation closes on Friday 10th February 2012. Any member of the public can take part.  Find out more here including the link to the e-consultation.



"Doctors to encourage long-term sick to return to work" Daily Mail 1/11/2011
"Who is in charge of doctors and consultants- the DWP?" Twisted News 1/11/2011

"New section of the Department of Health" Jobbing Doctor 1/11/2011

"Work guidance for long-term sick" Guardian 1/11/2011 

More thoughts on doctors' morals

Moral Compass by psd


I wanted to write a quick post to follow-up last week's discussion on the GMC consultation on Good Medical Practice. Several doctors commented that they were concerned that the line which said that they should act "at all times" in a manner that would not reduce trust in themselves or other doctors left them open to possible persecution over lifestyle choices.
For example Ditzy wrote:
"Most of us are up in arms over the ambiguity of what activities, in their private lives, the GMC felt was appropriate for them to regulate. A one off drunken dancing on the tables at the village pub? An affair with a married person? Multiple sexual partners? Frequenting the bookmakers? Falling out of nightclubs every Friday night? There simply is no guidance and any of these actions could, potentially, be said to bring the doctor and the profession into disrepute although none of them are illegal. "


I decided to go back and find out what the reaction was to the introduction of this clause in to the 2006 version of Good Medical Practice. The results of the official consultation are available here. This includes feedback from doctors and the wider public on the 2005 draft document (which unfortunately I can not locate). They note that:
"While honesty and trustworthiness within the doctor-patient relationship are perceived as important by the public, most people no longer appear to expect doctors to demonstrate moral excellence in all aspects of their lives, and it is widely recognised that they are ‘only human’. Some doctors also felt that expectations of probity, as set out in the draft document, are no longer appropriate."


So the GMC recognised in 2006 that the public did not expect 'moral excellence' of doctors. 


But when the guidance was published it was reported in the Guardian, by Sarah Bosely, as being a "tougher ethical code". Why was this? Jane O'Brien, Head of Standards and Ethics for the GMC, is reported as saying that the GMC had been criticised for not giving clear enough guidance to doctors in the past, for example, about how long after a professional relationship ends would it be appropriate to start a sexual relationship with a patient. But Good Medical Practice was not intended to be a rule-book.
"The guidance encourages doctors to think through their behaviour, and is not a set of rigid rules by which they can be judged - which may leave the GMC open to criticism. "We don't think there is a way of making guidance that would provide that absolute boundary," Ms O'Brien said."


An article by the writer Dea Birkett in the Health Services journal, commenting on the 2005 draft policy was very clear that she did not want to know what doctors got up to when they were not at work. Her suspicion was that the guidance had been updated to make it more 'politically correct'.


But what has the reality been? Are doctors being sanctioned for legal sexual activity that might be frowned upon by the public? I haven't reviewed all the Fitness to Practice procedures which are published on the GMC website but there are some accounts in the press. A trainee anaesthetist was suspended for 9 months after accessing (legal) hardcore porn on a hospital computer. Another doctor who had an 'inappropriate' relationship with a patient for several years, and who was cautioned for kerb-crawling, was not suspended.


In the past year, 43 doctors were referred to a GMC hearing  for 'indecent behaviour' but the outcomes are not described. Having reviewed some fitness to practice proceedings it seems likely that these are serious events such as the sexual assault of patients. It seems that it would be very unlikely that having an affair would be deemed 'indecent behaviour'.


In summary, when the current version of Good Medical Practice was introduced there were concerns from the doctors and public that it would involve holding doctors to an exceptional moral standard. However, there is no evidence that doctors are being reprimanded for the types of behaviour which Ditzy has raised in her comment.


Does this reassure anyone? 

"at all times..."

 
The Passage of Time by TonyVC


The GMC, the body which regulates doctors in the UK,  is consulting on the next version of Good Medical Practice. The consultation ends on Friday, 10th February, 2012 and you can learn more here. Since 2005 Good Medical Practice has been the core guidance for doctors on how they should act professionally. In a previous post written almost exactly 2 years ago I discussed the fact that  the guidance states "You must make sure that your conduct at all times justifies your patients' trust in you and the public's trust in the profession." but does not make clear what kind of conduct might be expected to reduce confidence in a doctor or doctors as a whole. It is perhaps deliberately vague.


The last version of Good Medical Practice was issued in 2006. Times have changed since 2006 and in this consultation the GMC have started using social media to spread the word about the consultation and get some informal feedback. They have started a Facebook page and a twitter account, @gooddoctoruk. 


There has been a lot of discussion of the consultation on Twitter, primarily around how much doctor's lives outside their hours working as a doctor should be regulated. Do we have to be professional "at all times"?


To get the debate going Shree Datta, co-chair of the British Medical Association's Junior Doctor's Committee wrote a piece on her thoughts around the current guidance on conduct outside of work. She thinks that in the current guidance there  is "little reassuring detail" about what might be considered appropriate or inappropriate. She says: "The simple fact is that people make mistakes and it is unrealistic to expect doctors alone to remain flawless at all times in every aspect of life. Yet the current guidance suggests that that is what is expected of doctors and arguably does not ringfence our privacy or allow for our personal autonomy."


The GMC then asked the question "Do you think the GMC should regulate doctors lives outside medicine?" This was the response from 1167 people. 94% said No.

The GMC have responded to this saying:

"Most commonly fitness to practise cases citing this paragraph arise where doctors are convicted of criminal offences, accept cautions or equivalent sanctions across the UK. But occasionally we also take action on doctors’ registration as a result of doctors’ behaviour in the public sphere, which while not illegal, may undermine patients’ or public trust in the profession.

The rationale for this has always been that patients need to trust their doctors absolutely. Many patients will be vulnerable when they seek medical care and need to be able to trust doctors implicitly.

For the doctor/patient relationship to be successful, patients must trust doctors to be honest and to act with integrity in their patients’ interests. Patients do not want their doctors to have criminal convictions, particularly for violent or sexual offences, and they may not want to be treated by a doctor whose conduct they find morally repugnant or unacceptable. For example, many people would not want to confide in, or agree to be examined by, a doctor found guilty of crimes relating to child abuse or child pornography, even though there was no evidence that the doctor was clinically incompetent."

The comments that the GMC have shared from people who said No in the poll suggest that they thought that there were being asked about the regulation of activities which would usually be considered legal. But by their response it seems that the GMC think that this question also relates to taking action if a doctor is convicted of illegal activity.

Now we have gotten to the stage of the official consultation. Here is the question that doctors  and others are asked to respond to:

"In September 2011, 1,167 people responded to our online poll asking how far the GMC should go in regulating doctors’ behaviour outside medicine. The vast majority (94%) thought the GMC should not take action against doctors for their conduct outside medical practice. We think that if a doctors’ conduct undermines trust in the profession. It should, in some cases, lead to action on their right to practise medicine. (This approach is also taken by other health regulators in the UK). We therefore think it is important to make this clear in Good Medical Practice (see paragraphs 67–8 of the consultation draft).

Do you agree that the guidance achieves a fair balance in terms of the GMC’s role and remit?

Yes      No      Not sure"

This is section 67-68

67 You must be honest and trustworthy in your professional practice.

68 You must make sure that your conduct at all times justifies your patients’ trust in you and the public’s trust in the profession.

This wording is actually very similar to the current version which can be seen here. 

On Twitter some have suggested that since the GMC "did not get the answer they wanted" in the pre-consultation they have simply asked the question again. The GMC have responded through twitter that the pre-consultation activity was just that; a full consultation was still needed. But it is interesting that the strength of feeling about the question above has made it into the official consultation documents.

So are we experiencing a shift in how doctors think they should be regulated? Do we think that as long as we conduct ourselves appropriately during the working day then it does not matter what we do out of hours?  Should the GMC take any action against those who receive a criminal conviction? What does it mean to be professional in the 21st century? 

It's certain that this topic is going to be discussed for a long time.


By the way, if you look at my old post you'll see that whether patients trust doctors seems to be based on their interactions with them as a professional. We don't know what impact other factors have.


EDIT: Initially this post stated that the poll was of 1167 doctors. This was wrong. The poll was open to anyone and it is not known how many respondents were doctors.

On being public : How social media reshapes professional identity.

This was my presentation at ALT-C (conference of the Association for Learning Technology) earlier this year. It sums up in 20 minutes a lot of the thoughts and ideas that are covered in this blog. But of course it raises more questions than answers- I hope!

Governmentality and Professionalism

This is an essay that I wrote last year on changing concepts of professionalism for a module on the Cardiff EdD. The ideas need a lot more work but there may be some parts that are of wider interest including a history of medical professionalism in the UK.
Governmentality refers to a Foucauldian concept of the "art of governing". If you have any thought on what I have written then please leave a comment. I'm publishing it today as a follow-up to some discussion with Cl are Gerada. Governmentality and Medical Professionalism

Social media, black humour and professionals...

Last week I presented at #altc2011 (the Association for Learning Technology Conference). My topic was "On being public.... how social media reshapes professional identity". One of my main points was that social media almost necessitates a reflexivity which we can get by without in face to face encounters. The pace of interaction is fast, we're dealing with people we may not otherwise come across, and norms are still being established. In fact we may never even get to the stage of having 'social norms'. Probably the only way to operate in these spaces is by having internalised your own values, but also being able to step outside of those values and to see what has shaped who you are and what you think, and to afford the same courtesy to others.


A few days later I came across a discussion between several male doctors on twitter which caused me to reflect on this very topic. The doctors were using slang, which I have not come across before, to refer to the wards in which they might have been working. The terms used were 'labia ward' and 'birthing sheds' to refer to the delivery suite where women give birth, and "cabbage patch" to refer to the intensive care ward where many patients are unconscious. 


I was shocked at this and angry and did query the doctors about some of the other things they said, but I felt I couldn't challenge them directly at that time about this language. One of the doctors referred to midwifes as 'madwives' and was challenged by a medical student to justify this position. In the meantime I pulled together the tweets using a curation tool and informed the doctors involved that I had done this. I did not tweet the link publicly and did not endeavour to have a conversation in public about this. However I did feel the need to check with others how they felt about this exchange so I sent them a link to the collated tweets by private message. I wanted to find out if my own shock and revulsion was  typical and also to gain some advice on what to do about this.  


Almost all replies stated that they found the discussion insensitive. Doctors seemed to be as likely to be offended as non-doctors. Some thought that this was risky behaviour because regulators may take action. I personally think this is very unlikely and do not consider these tweets a disciplinary offence.

But what happened in public? A few others (mainly other doctors) did challenge the use of this language. The protagonists explained that they thought their tweets should be interpreted as a conversation between medical professionals. One expressed that he did not want to cause offence and that he perhaps had misjudged sending the tweet.


How did I feel?
I was surprised at the strength of my reaction to this. I wanted to let it pass but I also felt that this was not appropriate. I felt that the language objectified women and was misogynistic. I privately told one of the doctors this and asked that he removed the tweets but he refused to do so and suggested that my feelings of offence were my problem.


Some doctors have thought that I am concerned that this kind of talk will 'bring the profession into disrepute'.  But I am not. I believe that patients make assessments of us as individuals. I don't believe that the public will think less of doctors after this. As has been pointed out, programmes like "Cardiac Arrest" have portrayed doctors as cold and callous individuals. But there has been no corresponding fall in trust in the "profession". 


The doctors involved in the initial discussion have suggested that my views to their use of slang are atypical. Only a very small number of their followers have raised any kind of objection to their use of this language. Perhaps inside more women are offended but they feel that they can not speak up because to have your views dismissed publicly is humiliating. I don't know. But I don't think that this is an issue of numbers. 


My account of this episode, so far,  has been very personal. But I also want to place this story  in a wider context within the medical education literature on professionalism and black humour.  Is the use of derogatory humour or slang by medical professionals inappropriate? Berk thinks that ;
"Simply put, derogatory and cynical humour as displayed by medical personnel are forms of verbal abuse, disrespect and the dehumanisation of their patients and themselves. Those individuals who are the most vulnerable and powerlessin the clinical environment – students, patients and patients’ families – have become the targets of the abuse. Such humour is indefensible, whether the target is within hearing range or not; it cannot be justified as a socially acceptable release valve or as a coping mechanism for stress and exhaustion."


Berk was writing this in response to research by Wear and colleagues on medical students and residents attitudes to this kind of humour. It is interesting to note that usually  it is referred to as being performed behind closed doors. Some accounts suggest that it is about establishing insider and outsider groups if performed in public. 


Wear suggests that doctors "throughout academic medicine might begin candid discussions of derogatory and cynical humour in their particular cultures in order to become better aware of their participation in it and their responses to it when they overhear it from others". 


And so I am writing this. Social media- blogs and twitter- are my culture. I want to raise this topic here- in this public space- so that I can think about how I respond to it in the future when I 'overhear' it. The next time I may choose to ignore it. Despite Wear's suggestion that incidents like this  provide 'teachable moments', and should be challenged,  the spaces of social media are much more exposed than a hospital corridor. 


But at the same time my blog is also a relatively safe place for me. I await your thoughts. 

My #altc2011 presentation.

View more presentations from Anne Marie Cunningham

If you view this directly on slideshare the speaker notes might make my points much clearer I hope. When the video of the presentation becomes available I will upload that too.
Enjoy and any questions/comments please post them here!

Social media, organisations, identity and anonymity- an interview

Steve Wheeler interviewed me at the ALT-C conference on Wednesday just after my presentation on social media and professional identity. I will blog that shortly but here is the interview in the meantime.
Watch live video from jamesclay on Justin.tv

Digital professionalism... if only it were that easy

Image: Doctor reading articles by rosefirerising

The longer I am online and the more I become immersed in being online the more complex this existence seems.

I want to talk about some principles for "Digital Professionalism" which have been put forward by Rachel Ellaway in the journal Medical Teacher last year. The journal is paywalled so I am going to give the principles here.
The 7 principles are:

Principle #1: establish and sustain an on online professional presence that befits your responsibilities while representing your interests. Be selective in which channels and places you establish a profile.

Principle #2: use privacy controls to manage more personal aspects of your online profile and do not make anything public that you would not be comfortable defending as professionally appropriate in a court of law.

Principle #3: think carefully and critically about how what you say or do will be perceived by others and act with appropriate restraint in online communications.

Principle #4: think carefully and critically about how what you say or do reflects on others, both individuals and organizations, and act accordingly.

Principle #5: think carefully and critically about how what you say or do will be perceived in years to come; consider every action online as permanent.

Principle #6: be aware of the potential for attack or impersonation, and know how to protect your online reputation and what steps to take when it is under attack.

Principle #7: an online community is still a community and you are still a professional within it. The call for ‘is there a doctor. . .’ may come online as well as on a ‘plane or in a theatre’.

 To me these are good starting points, but as someone active in the space, I can see that these principles only take me so far. I'll write more in my next post but I wonder what you think of them now. Please comment.

What is more important: behaving badly or being seen to behave badly?

Doctors behaving badly
Yesterday, CNN carried a story ("Photos of drinking, grinning aid mission doctors cause uproar")
that doctors from Puerto Rico, volunteers in Haiti, may be disciplined because pictures of them holding soldiers' guns, drinking alcohol and with patients (possibly without their consent) have been posted on Facebook. The comments on the story are interesting, as some say the doctors are being treated too harshly. They may be traumatised by events and should be allowed to relax. Others who have seen all of the photos are in no doubt that the activities of the doctors are unprofessional. But in nearly all cases, commenters are talking about the act of taking the photo, rather than the sharing of the photo in social media.I have not read all 1411 comments but there does not seem to be anyone advocating that the photos could be OK in private, but inappropriate in public.


Medical students behaving badly
The conduct of medical students in social networking sites has been recieving increasing press. In September 2009,  Chrieten et al. published the reults of a survey in JAMA which found that the majority of US medical schools has had to take disciplinary action against some students because of their activities on social networking sites. And in November 2009, Farnen et al. described a case where first-year medical students posted a sketch from a medical talent show on YouTube. The sketch was of a hip-hop song accompanied by medical students playing  with plastic skeletons and  body bags. It was removed when a more senior student complained that it portrayed the medical school poorly, although there was student resistance to that action as the video had been very popular with students. The author's state:
" Our students' video has become our digital liaison. Prospective medical school applicants often comment on viewing it before their interview day. Alumni and senior faculty responded with significant concerns about the video's representation of the medical profession and how patients may react to this depiction of physicians' training. " (my emphasis) Students do not seem to have been disciplined for any unprofessional conduct in the production of the video,instead it is the sharing of the activity through social media which is the focus of the article. This seems to suggest that activities may be acceptable in private but not in public. In a further response to letters on their work, Chrieten et al. state "the medical profession is responsible for maintaining the public's trust. It is necessary to understand how online behavior is viewed by the public and how that affects trust in the medical profession."
Hayter (2006) has wrote about the medical student show. He says that it has various functions including "the collective ventilation of emotional reactions to the process of becoming a doctor". There are links to some of the skits from these shows in this Slate article. What we do not know is how the general public views these shows. Did they know of them? Did they think the conduct was appropriate? Since medical faculty often participate, and attend, they may be seen to approve of the content. If this is the case then why is it not appropriate to share the content publicly.


What does it mean to bring the profession into disrepute?
In the UK, both nursing ("You must uphold the reputation of the profession at all times") and pharmacy (where one should report any circumstances that may "bring the pharmacy professions into disrepute") bodies imply that not upholding the reputation of the profession is in itself something that a member may be disciplined for. For UK doctors, the GMC document "Good Medical Practice", states that "You must make sure that your conduct at all times justifies your patients' trust in you and the public's trust in the profession." But it is not clearly stated what conduct may contravene that trust. Older GMC guidance, prior to the first publication of Good Medical Practice in 2005, states that "convictions for drunkenness or other offences arising from misuse of alcohol (such as driving a motor car when under the influence of drink) indicate habits which are discreditable to the profession". Although this terminology is no longer used in Good Medical Practice, when discussing the case of a doctor convicted of driving with a blood alcohol level three times above the upper legal limit, it is stated that, "Public confidence in the medical profession is likely to be undermined by such conduct." The doctor was suspended for three months, in order to "send the right message to the public". In the case of medical students, GMC guidance states that drunk driving and "alcohol consumption that affects clinical work or the work environment" is unacceptable.There is no mention of drunkenness away from patients.


What do patients think?
Research conducted by Mori for the Royal College of Physicians in the UK consistently shows that doctors are the profession thought most likely to be telling the truth. This is routinely reported as "Public Still Trust Doctors". Smith (2001) distinguishes between trust, which exists at the level of individual interaction, and confidence, which relates to abstract systems.  Boudreau et al (2008) asked members of the public about the attributes of the ideal physician. They were reformulating the medical curriculum and wanted patient input. Patients wanted doctors who listened to them and didn't treat them as a 'number'. When asked "If I said to you that a doctor was very professional, what would that mean to you?", some patients responded negatively suggesting that it might mean someone 'stuffy-nosed' or who didn't want to bother with 'menial things'. But generally being professional was associated with behaviours that concerned individual interaction with the patient: bedside manner and interpersonal skills. 
But what of trust (or confidence) in the wider medical profession?  It is understudied. Hall et al.(2002) found, using a new scale, that trust in one's own physician is higher than trust in the physicians generally. They say that might not be a surprise as one might settle with a doctor one trusts, after experience of others who are less good. Calnan and Sanford (2004) in the UK, sudied general trust in the healthcare system rather that trust in the 'medical profession', and found that trust that patients would be provided with patient-centred care, was strongly associated with trust in the system. 


Conclusions
Professional bodies still talk about individuals conducting themselves at all times in a way that does not reduce trust in the profession. But the very limited studies which look at how the public view the medical profession suggest that it is the interactions with individual doctors in the healthcare setting which determine trust. Patients value patient-centred doctors.
Pattison and Wainright (2010) suggest that the ethics of a profession should be determined in conjunction with the wider public. It is not something that a profession can do alone. But I think that after that  behaviour is either unacceptable because it is unprofessional, and therefore should be disciplined, or it is acceptable. If it is acceptable it can be shared through social media.The use of social media is a secondary consideration.


Questions
But what do you think?

1. How do you feel about medical student shows?
2. Are medical student shows appropriate to share online?
3. Would seeing photos or videos of doctors, nurses or pharmacists in a state of drunkenness on Facebook affect your view of the profession as a whole?
4. Would it affect your view of the individuals involved as professionals?
5. What determines your trust of the medical profession as a whole?

Feel free to answer these questions or leave any other comments.


(This post resulted from a rather long discussion with @psweetman, @bitethedust, @drmarcustan and @mtnmd earlier today. I am currently studying for a module on Changing Modes of Professionalism for my EdD course, and writing an essay on deprofessionalisation in medicine. This writing is only tangentially related... as yet!)




References
Boudreau JD, Jagosh J, Slee R, Macdonald ME, & Steinert Y (2008). Patients' perspectives on physicians' roles: implications for curricular reform. Academic medicine : journal of the Association of American Medical Colleges, 83 (8), 744-53 PMID: 18667888
Calnan MW, & Sanford E (2004). Public trust in health care: the system or the doctor? Quality & safety in health care, 13 (2), 92-7 PMID: 15069214
Checkland K, Marshall M, & Harrison S (2004). Re-thinking accountability: trust versus confidence in medical practice. Quality & safety in health care, 13 (2), 130-5 PMID: 15069221
Chretien KC, Greysen SR, Chretien JP,  Kind T (2009). Online posting of unprofessional content by medical students. JAMA : the journal of the American Medical Association, 302 (12), 1309-15 PMID: 19773566
Chretien KC, Greysen SR,  Kind T (2010). Medical Students and Unprofessional Online Content—Reply JAMA : the journal of the American Medical Association, 303 (4) 329
Farnan JM, Paro JA, Higa JT, Reddy ST, Humphrey HJ,  Arora VM (2009). Commentary: The relationship status of digital media and professionalism: it's complicated. Academic medicine : journal of the Association of American Medical Colleges, 84 (11), 1479-81 PMID: 19858794
Hall MA, Camacho F, Dugan E, & Balkrishnan R (2002). Trust in the medical profession: conceptual and measurement issues. Health services research, 37 (5), 1419-39 PMID: 12479504
Hayter CR (2006). Medicine's moment of misrule: the medical student show. The Journal of medical humanities, 27 (4), 215-29 PMID: 17123173
Pattison, S., Wainwright, P. (2010). Is the 2008 NMC Code ethical? Nursing Ethics, 17 (1), 9-18 DOI: 10.1177/0969733009349991
Smith, C. (2001). Trust and confidence: possibilities for social work in 'high modernity' British Journal of Social Work, 31 (2), 287-305 DOI: 10.1093/bjsw/31.2.287