As users have become more permanently connected to the Web, there has been a corresponding increase in individuals posting personal material to widely available electronic venues. The immediacy of digital media technologies not only offers a wealth of information at the click of a button but also now enables users to append individual contributions to the vast electronic ether in a few keystrokes. The effect of such digital media use on undergraduate and graduate medical education is only beginning to be realized, and we have chosen to explore this topic after an inciting personal experience at our own institution. We began to examine digital media use amongst our medical trainees after a group of our students created a hip-hop music video set in the anatomy laboratory as part of the 2006 annual first-year talent show.1 This video, which depicted students dancing with plastic skeletons and lying in body bags, received rave reviews from student participants. Students subsequently requested that the video be made available electronically to be shared with family and friends. After discussion with the medical school administration, the video was posted on YouTube and received numerous views. Following the posting, a fourth-year Pritzker medical student raised concerns regarding the representation of the medical school and its students in the video, and the administration agreed to remove the video. In the absence of established institutional policy, the removal of the video and subsequent actions prompted a closer look at the general “digital behavior” of our students and medical trainees. The positive implications that Web-based applications share (e.g., flexibility, collaboration, and interactivity) must be weighed against the negative implications, including potential misuse, violations of confidentiality, and threats to professionalism. In this commentary, we explore the salient issues that arise with the wide use of digital media, including the interaction between public access to digital information and professionalism, individual and institutional representation, and potential strategies for medical educators to address this growing trend.

The “New” Professionalism and Public Consumption

The issues of professionalism and digital media must be considered within the appropriate context. Is digital content posted by trainees the personal behavior of an individual who happens to be a medical trainee, or of an individual in the role of a medical trainee? The issues of digital representation and professionalism have largely been explored in reference to the former—the posting of personal exploits of individuals who also happen to be physicians or student physicians; however, there are an increasing number of in vivo medical training postings, students and trainees posting material while in their roles as health care providers.

Although the Health Insurance Portability and Accountability Act (HIPAA) protects patients' privacy, the ubiquitous presence of cell phones and personal digital assistants with recording devices creates the risk of patients becoming digital “content.” Despite HIPAA regulations, cases such as the YouTube debacle in which surgeons posted an unauthorized video from the operating room while removing a foreign body from a patient's rectum2 are growing more common. This scenario is just one example of how Web technology can amplify already unprofessional behavior by enabling public consumption of such acts. However, these digital tools can also be used to further the education of trainees and patients. Surgeons at Henry Ford Hospital, for example, used the microblogging technology of Twitter to “tweet” during surgery, giving real-time updates about a robotic partial nephrectomy.3 Social networking tools, when used in a professional manner, may help to address, not create, communication barriers.

There are few training programs that do not have an end-of-the-year show with skits directed and performed by students and residents, often roasting each other, faculty, and the occasional patient. Recent work supports such events and their underlying function of using brevity and humor in response to the intensity of medical training.4 However, until now the medical show was exactly that—a show produced and performed for a closed audience who share the medical training experience. The digital age has brought these shows out of the lecture halls and onto the monitors of anyone who chooses to access them, including potential patients. While many alumni and senior faculty agreed that our students' video was well made and amusing, this humor was not likely to be appreciated by those who have little understanding of the true nature of undergraduate medical education. It is the issue of public consumption that argues for education on appropriate digital behavior.1

Professionalism curricula have largely been taught in the context of the physician–patient relationship, which has not been immune to the effects of digital media. As patients become increasingly Web savvy, they are experiencing an entirely new accessibility to their physicians. There have been reports of patients attempting to “friend” their physicians on social networking sites, such as Facebook and MySpace, and also posting public messages regarding their satisfaction, or dissatisfaction, with their physicians' performance. Questionable “friendings” between patients and physicians, or even physicians at varying levels of training (e.g., residents and attendings), are occurring with alarming frequency.

Free Speech and Representation

There are few legal precedents to inform the regulation of “digital images” posted by students and residents. As Thompson et al5 have previously demonstrated, the use of social networking sites, such as Facebook, is common among trainees; close to 45% of those surveyed reported membership on such sites. Widespread use of and transparency of access to such digital media highlight the need for increased awareness of the ramifications of posted content. Regulation must, however, be tempered by sensitivity to students' right to free speech.

The historical underpinnings of this argument date back to the 1960s, when three public school students in Des Moines, Iowa were suspended for their protest of the Vietnam War. In his ruling on that case, Justice Abe Fortas writes that “[s]tudents in school, as well as out of school, are ‘persons’ under our Constitution [and] are entitled to freedom of expression of their views.”6 An important caveat and precedent established by this ruling was the “material disruption” clause, which states that any conduct that “materially disrupts class work or involves substantial disorder or invasion of the rights of others is not immunized by the constitutional guarantee of freedom of speech.”6

In examining our seminal event, a crucial question is whether our students' video created substantial disruption or invasion of the rights of others. There is a wide array of medical-student-created material currently available on the Web raising issues so incendiary as to potentially generate a disruption in the classroom. In fact, our students responded to the removal of the video by circulating a petition for its reposting, which could have been construed as disruptive to our learning environment. As we consider policy implications, we must keep in mind that freedom of speech and expression of one individual cannot be to the detriment of the learning environment of the institution.

In addition to representing an individual's viewpoint, digital media postings may contain subliminal content, such as the use of a school name, property, or logos, which may be misconstrued as implicit institutional endorsement of the content of the information. 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. Although a significant proportion of professionalism curricula address physician conduct while in the company of patients, few have explored the ramifications of trainees or physicians' actions outside the work environment.

Finally, trainees may personally experience repercussions of their behavior, as prospective employers, such as residency directors, colleagues, and patients, have open access to potentially compromising depictions of the trainees on publicly available sites. In one case, a patient's family member requested a change in resident physician because of questionable behavior exhibited on a resident's personal MySpace page. Such anecdotal reports continue to increase in frequency.

How individuals represent themselves in the electronic realm will become an increasingly important issue as the use of these sites increases. For the class of 2012, Facebook has been available and increasingly popular throughout their higher education experience. Increasing numbers of junior faculty and residents are present and active on these sites as well, suggesting that education and instruction on role modeling of professional behaviors and appropriate content must occur at multiple levels.

Future Strategies

Although the implementation of digital technologies in the classroom could lend a cutting-edge advantage to students, the liberal use of Internet media may pose a compromise to professionalism. We propose potential solutions to safeguard both institutional and individual representation, and we hope to initiate an open dialogue about how to address these impending challenges to undergraduate and graduate medical training. Establishing faculty familiarity with theses applications and their capabilities is a logical first step in an effort to educate about and patrol for negative material. Ensuring students' understanding of the potential risk of their behavior is also essential. Education on the ramifications of posting negative material is likely a more effective approach than instituting blanket institutional policy aimed at strictly regulating trainees' online contributions. Providing trainees with commonsense suggestions for preserving a professional “digital image,” such as maintaining strict privacy settings on social networking sites and espousing a “think-before-you-post” attitude, are simple initial steps. We encourage our trainees to routinely perform searches for their names online and to identify material posted without their consent. These solutions are the first steps in protecting trainees' “digital reputations.”

Educators must also develop and enforce policy aimed at protecting the representation of both their institution and the medical profession. Trainees must realize and acknowledge that the digital intersection of their personal and professional lives can be blurred in light of the medical profession's accountability to society. As a result of our personal experience, we have developed a policy which requires that material occurring in the context of the individual's role as a medical trainee, or containing institution-identifying content, be reviewed by faculty for appropriateness before posting. Institutional approaches to monitoring trainees' “digital professionalism” are certain to become a ripe field of research, as trainees' and physicians' perceptions of such policies are largely unexplored.

In addition to educating trainees on the potential consequences of their digital behavior, we must also consider modifying existing professionalism curricula to reflect the evolving physician–patient relationship. Answering such questions as whom to “friend” on social networking sites and what constitutes inappropriate contact between a trainee and a patient, colleague, or superior are a few of the issues we have addressed in a “Medical Professionalism in the 21st Century” curriculum implemented this past fall. This course is informed by the open discussion that occurred between faculty and students as we collectively reflected on these new and challenging issues.

Finally, there is the need to address the impact of digital media in the context of trainee behavior in the company of actual and standardized patients (SPs). Prohibiting the use of electronic devices with recording capability during any patient care may be the first step. However, additional protections are certainly warranted. A group of students at our institution, for example, approached a course director with the idea of creating a compilation of “SP Bloopers” that occurred during their first-year doctor–patient interview course. However, institutions like ours that tape and review student SP experiences as part of the learning process must ensure the strict protection of these videos for the sake of both the SPs and the educational rights of the trainees. In the context of actual patient care, ensuring that trainees receive sound professionalism training and recognize the real and digital boundaries of the physician–patient relationship is the primary safeguard against digital indiscretion.

The impact of electronic technology in medical education is only beginning to be realized. Medical educators should familiarize themselves with these advances, not only to take advantage of their opportunities but also to guide students as they navigate a new digital terrain. A sound initial approach based on education and primary prevention will assist educators in addressing these new digital challenges. Ultimately, we must impart to students the primary importance of “connectivity,” maintaining a dynamic of trust and respect between doctor and patient.

References 1 Lerner BH. Future doctors behaving badly: Dancing with skeletons and mocking dermatologists in medical-student comedy shows. Available at: (http://www.slate.com/id/2204108). Accessed July 30, 2009. 2 Associated Press. YouTube surgery video spells trouble for docs. Available at: (http://www.msnbc.msn.com/id/24157772). Accessed July 30, 2009. 3 Cohen E. Surgeons send “tweets” from operating room. Available at: (http://www.cnn.com/2009/TECH/02/17/twitter.surgery). Accessed July 30, 2009. 4 Hayter CR. Medicine's moment of misrule: The medical student show. J Med Humanit. 2006;27:215–229. 5 Thompson L, Dawson K, Ferdig R, et al. The intersection of online social networking and medical professionalism. J Gen Intern Med. 2008;23:954–957. 6 Tinker v. Des Moines School Dist., 393 U.S. 503 (1969).