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Global medical ethics
Facebook activity of residents and fellows and its impact on the doctor–patient relationship
  1. Ghassan Moubarak1,
  2. Aurélie Guiot2,
  3. Ygal Benhamou3,
  4. Alexandra Benhamou4,
  5. Sarah Hariri4
  1. 1Service de Cardiologie, Hôpital Lariboisière, Assistance Publique-Hôpitaux de Paris, Paris, France
  2. 2Service de Cardiologie, CHU de Rouen, Rouen Cedex, France
  3. 3Département de Médecine Interne, CHU de Rouen, Rouen Cedex, France
  4. 4Département d'Anesthésie-Réanimation, CHU de Rouen, Rouen Cedex, France
  1. Correspondence to Dr Ghassan Moubarak, Service de Cardiologie, Hôpital Lariboisière – Assistance Publique-Hôpitaux de Paris, 2, rue Ambroise Paré, 75010 Paris, France; ghassan.moubarak{at}gmail.com

Abstract

Aim Facebook is an increasingly popular online social networking site. The purpose of this study was to describe the Facebook activity of residents and fellows and their opinions regarding the impact of Facebook on the doctor–patient relationship.

Methods An anonymous questionnaire was emailed to 405 residents and fellows at the Rouen University Hospital, France, in October 2009.

Results Of the 202 participants who returned the questionnaire (50%), 147 (73%) had a Facebook profile. Among responders, 138 (99%) displayed their real name on their profile, 136 (97%) their birthdates, 128 (91%) a personal photograph, 83 (59%) their current university and 76 (55%) their current position. Default privacy settings were changed by 61% of users, more frequently if they were registered for >1 year (p=0.02). If a patient requested them as a ‘friend’, 152 (85%) participants would automatically decline the request, 26 (15%) would decide on an individual basis and none would automatically accept the request. Eighty-eight participants (48%) believed that the doctor–patient relationship would be altered if patients discovered that their doctor had a Facebook account, but 139 (76%) considered that it would change only if the patient had open access to their doctor's profile, independent of its content.

Conclusions Residents and fellows frequently use Facebook and display personal information on their profiles. Insufficient privacy protection might have an impact the doctor–patient relationship.

  • Internet
  • facebook
  • internship and residency
  • doctor-patient relationship
  • confidentiality/privacy

https://doi.org/10.1136/jme.2010.036293

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    Introduction

    Web 2.0 or participatory web refers to a new set of Internet applications allowing users to generate content, comment and evaluate others users' actions, and belong to various virtual communities.1 2 Blogs, wikis, social networks, file-sharing sites and information aggregators are some examples of tools that promote interactions between users and spread of information.1–4 Among these new media of communication, social networks allow individuals to create a user profile, upload personal information and establish connections with other registered users. Facebook (http://www.facebook.com/) was launched in 2004 and is currently the most popular social networking site worldwide, with more than 400 million users in March 2010.5

    Several studies have described the widespread use of Facebook among college students, including medicine and pharmacy under graduates.6–10 Some authors were concerned that students were sharing private information in public spaces without being fully aware of the potentially harmful consequences of such information reaching an audience that it was not intended for.6 8 11 Few studies have explored Facebook use by residents, fellows or physicians. In a survey conducted at the University of Florida, Thompson et al10 found that 12.8% of residents had a Facebook profile (vs 64.3% of medical students) and that only 32.5% had restricted access to their profile. Jain12 and Lacson et al13 reported receiving a ‘friend request’ (the term used on Facebook for a request to add a person to one's virtual circle of relationships) from a patient and acknowledged doctors' general unpreparedness to face such a new ethical dilemma.

    The objectives of our study were to examine the frequency and characteristics of Facebook use by residents and fellows, the amount and type of protection of personal information available on their profile, and their opinions regarding the consequences of Facebook use on the doctor–patient relationship.

    Methods

    Survey instrument

    A two-part questionnaire was developed to assess Facebook use by residents and fellows and their opinions on the effect on the doctor–patient relationship. The first part was intended to be completed by Facebook users and to collect information on their online profile: date of registration on Facebook, number and type of Facebook friends, frequency of connection and profile editing, personal information available and description of privacy settings. Facebook users were asked to report whether any patients had requested that they be added as a friend and if the user accepted the request. In the second part, all participants were asked to imagine their reaction if they received a friend request from a patient by choosing from a pre-established list of reasons for accepting the request and reasons for declining it. The list of reasons was derived from a focus group of residents and fellows and discussions between the authors. Participants were also asked to indicate their level of agreement with statements concerning the influence of Facebook on the doctor–patient relationship. The questionnaire was pilot-tested on a panel of residents and fellows to verify the clarity and acceptability of questions. Input from the panel was incorporated into the final version of the survey instrument.

    Study design

    The survey was created online using the web-based application http://www.surveymonkey.com, which ensures anonymous data collection. It was sent to all residents and fellows at the Rouen University Hospital, France, in October 2009. Two reminders were sent at 10-day intervals to all residents and fellows to increase the response rate. No financial compensation was given for participation.

    Statistical analysis

    Statistical analysis was performed with Statview software version 5.0 (SAS Institute Inc., Cary, NC, USA). For continuous variables, the mean±SD or median are reported as appropriate. For categorical variables the number of residents and fellows in each category and the corresponding percentage are given (the number of respondents to a particular item was not always equal to the total number of respondents to the survey). Comparison of groups was performed with Student t test or Mann–Whitney U test when appropriate for continuous variables, and the χ2 or Fisher exact test when appropriate for categorical variables. All values were considered statistically significant at p<0.05.

    Results

    Population

    The questionnaire was sent to 355 residents and 50 fellows (total 405) and was returned by 202 (50%): 160 residents (79% of responders and 45% of the total number of residents) and 42 fellows (21% of responders and 84% of the total number of fellows). The distribution of responders according to their speciality is represented in figure 1. Mean age was 29±3 (median 28) years, and there were 92 men (46%) and 110 women (54%).

    Figure 1
    Figure 1

    Distribution of residents and fellows according to specialty.

    Facebook activity and characteristics of online profiles

    One-hundred and forty-seven residents and fellows (73%) currently had a Facebook profile (of whom 117 (80%) had held the account for more than 1 year), six (3%) had held a profile previously and 49 (24%) had never had a profile. Facebook users were younger than non-Facebook users (28.4±2.4 vs 29.6±2.0 years, respectively; p=0.03) and were more often residents than fellow (79% of residents were registered vs 57% of fellows, p=0.02). Facebook users had a mean of 138±100 (median 118) friends, of whom 51±21% belonged to the medical field (median 50%). Thirty-four users (24%) connected to Facebook several times per day, 40 (28%) once per day, 30 (21%) several times per week, 27 (19%) several times per month and 10 (7%) once per month or less. Twenty-five users (18%) edited their profile at least several times per week, 29 (21%) several times per month and 87 (62%) less than once a month.

    Among responders, 138 (99%) provided their real name on their profile, 136 (97%) their birthday, 83 (59%) their current college/university, 76 (55%) their current employer/position and 128 (91%) a personal photo (whether as the main ‘Profile picture’ or in an online album) (table 1). Among the 141 users who answered whether they had changed the default privacy settings, 86 (61%) modified at least one of the following confidentiality parameters: access to their profile information (that is, who can see their profile and post comments on it) (n=73); access to their contact information (that is, who can contact them on Facebook and see contact information and email) (n=58); and control of who can reach their profile via a search on Facebook or other search engines (n=43). Twenty-four responders (17%) did not remember if they had changed the privacy settings of their profile. Facebook users registered for more than 1 year were more likely to have changed privacy settings than users registered for less than 1 year (63% vs 40% respectively, p=0.02).

    View this table:
    Table 1

    Description of information available on Facebook accounts

    Friend requests from patients

    Eight users (6%) had received a friend request from a patient and four accepted it. Among the 179 residents and fellows who imagined their reaction if they faced such situation, none would automatically accept the request, 152 (85%) would automatically decline the request and 26 (15%) would decide on an individual basis. Reasons that might contribute to accepting a friend request were feeling an affinity with the patient (n=62, 35%), fear of embarrassing the patient (n=11, 6%), fear of losing the patient's confidence (n=9, 5%) and fear of losing the patient (n=1, 1%). Reasons that might contribute to rejecting the patient's friend request were the need to keep a distance from the patient (n=175, 98%), wishing to protect one's personal information (n=174, 98%) or photos (n=176, 99%), considering such interaction as unethical (n=157, 88%) and suspecting that the patient was seeking a romantic relationship (n=164, 92%).

    Facebook and the doctor–patient relationship

    Most residents and fellows (93%) believed that doctors should not be forbidden from registering on Facebook, but that they should limit access to their profile to Facebook friends only (82%) (table 2). Eighty-eight participants (48%) believed that the doctor–patient relationship changes if a patient that discovers his/her doctor is member of Facebook, but 139 (76%) considered that the relationship would be altered only if the patient had access to the doctor's profile, independent of its content (table 2). Compared with non-Facebook users, Facebook users were less likely to believe that doctors should not register on Facebook (1% vs 20% respectively, p<0.001). They were more likely to consider that the doctor–patient relationship would change if the patient had access to the doctor's profile (73% vs 56% respectively, p=0.02) or to the doctor's personal information (52% vs 35% respectively, p=0.03).

    View this table:
    Table 2

    The opinions of residents and fellows regarding the use of Facebook by doctors

    Discussion

    Popularity of Facebook

    Three out of four residents and fellows had a Facebook profile and over half connected to the site every day. The popularity of Facebook has been reported in surveys of medical and pharmacy students6–9 (with ≥78% of students having an account), but to our knowledge only one study focused on residents.10 In this study by Thompson et al, 12.8% of residents had a profile on Facebook, as did 64.3% of medical students at the same institution. One explanation for such a low prevalence of Facebook use compared with our study may be that we conducted our study at a time when Facebook use was far more widespread in the general population. In any case both studies underline the fact that the percentage of users among medical trainees decreases with career progression. We also found that younger trainees have adopted Facebook at a higher rate than older individuals, highlighting the fact that they are now growing up in a digital era where online interactions are commonplace.

    Raacke et al9 analysed the use and reasons for having a Facebook account. To keep in touch with old friends (96%) and with current friends (91%) were the most commonly reported reasons for students to register on Facebook. Even if joining Facebook may in part be regarded as a trend, it is of note that social networks have become an important component of an individual's social environment, particularly among the younger generations. As with other online communication media, Facebook allows shy individuals to widen their circle of relationships.14 However, it is unlikely that non-users will feel isolated, since most residents and fellows using Facebook rarely update their profile and consequently are not expecting to engage actively in online social interactions.

    Sharing personal information on Facebook

    At least nine out of ten residents and fellows revealed their real name or birthday (even though the latter is required upon joining Facebook, but can be hidden after having created the profile) and uploaded a personal photo. More than a half revealed their current educational level or employment. In the study by Thomson et al,10 83.3% of students and residents listed at least one piece of information that would help to identify them. In other surveys Facebook users thought that online content should be available to family members and friends but should not be accessible to employers, faculty or patients.6 8 This distinction between public and private spheres is, however, endangered by the insufficient protection of personal information. Previous studies have shown that only 37.5% to 79% of students restrict access to their profile.6 9 10 In our study, 61% of users changed at least one of Facebook's default privacy settings. The consequences of the availability of unprotected information are usually underestimated8 11 and familiarity with the website (registration for >1 year in our study) is an important determinant of increased data protection. This mismatch between information disclosure and information control may be explained by the fact that these two elements reflect different aspects of one's personality. Christofides et al7 have found that disclosure was predicted by the need for popularity, while information control was predicted by levels of trust and self-esteem.

    Facebook and the doctor–patient relationship

    Many observers feared that Internet would result in a dramatic change in the doctor–patient relationship, but most studies suggest that better informed patients do not necessarily challenge their doctor's authority.15–18 In a traditional visit doctors frequently disclose information about themselves,19 but they choose what information is disclosed. Uncontrolled Facebook activity can change the relationship between a doctor and his patient in several ways. Few residents or fellows have already received a friend request from a patient, but if they faced this situation most would reject the invitation. The need to keep a distance from the patient and to protect one's personal information and photos outweighs the fear of embarrassing the patient or losing his/her confidence. Some residents or fellows may consider accepting the patient's friend request if they feel an affinity with the patient, but this new interaction (whether it is romantic or not) results in an ethically problematic situation because it is unrelated to direct patient care.20 Moreover, public availability of information on the doctor's private life may threaten the mutual confidence between doctor and patient if the patient accesses information not intended for them. For example, how should a doctor react when he discovers that a patient is still smoking if this patient had assured the doctor that he has stopped? Should the doctor take advantage of this knowledge in order to provide additional patient information and counselling or should he not mention this fact in order to avoid being accused of spying on his patient? Conversely, what if a patient happens upon an embarrassing photo of his doctor drinking excessively at a party during off-duty hours? Should he doubt the physician's professionalism at the next office visit or should he simply dismiss this discovery, considering it unrelated to quality of care provided during work hours? We believe that both physicians and patients should not seek personal information concerning the other party by searching the web. If a physician became familiar with such information, it should be discussed at an office visit before eventually being added to a patient's record.

    Residents and fellows in our study consider that doctors are as entitled as any other professionals to have a Facebook account, but believe that access to their profile should be limited to Facebook friends only. For them the doctor–patient relationship would change only if the patient had access to the personal content of the doctor's profile. Compared with non-Facebook users, Facebook users seemed to be more aware of the potential implications of a doctor's Facebook activity on the doctor–patient relationship. However, the protection of information and privacy required to ensure adequate separation of public and private spheres is still suboptimal in residents and fellows' online profiles. In the light of this, we propose several recommendations on how physicians should approach their use of Facebook and other online media dedicated mainly to non-professional activities. We believe that physicians should not engage in online interactions with patients unless pertaining exclusively to direct patient care. For this reason, friend requests from patients should be declined, as Facebook profiles usually contain personal information that is not disclosed in a face-to-face interaction. Doctors must be aware that comments and pictures posted online may be misinterpreted outside their original context and may not accurately reflect their opinions and real-life behaviour. This information could also become accessible to people that it was not intended for. We advise doctors to use caution and restraint in displaying online material, keeping in mind that they cannot control the potential consequences of public knowledge of private information on their professional practice. Finally, we encourage doctors to read Facebook's privacy settings and understand how the settings may be customised, and to monitor the regular updates of Facebook's privacy policy to adjust their data protection accordingly.

    Interactions with patients via Facebook are unusual at the moment,12 13 but will certainly become more frequent in the near future. Social networking sites represent a novel portal for communication and discussion between patients and various healthcare providers.3 Facebook's growing popularity creates a new type of interaction between doctors and patients. Concerns about the accountability for information displayed on Facebook emphasise the need for reflection on this ethical issue, referred to as ‘e-professionalism’ by Jeff Cain.11

    Limitations

    Our study contained a self-report on the posting activities of residents and fellows that may not accurately reflect their actual online persona. As in all surveys, responses may be influenced by the social desirability bias, with participants possibly under-reporting their disclosure of information and interactions with patients. This issue was partly addressed by the anonymous completion of the questionnaire. Demographic characteristics and data on the prevalence of Facebook activity of non-responders were not available. Finally, research on patients' online behaviour and attitudes towards online interactions with their doctors would be valuable.

    Conclusion

    Residents and fellows frequently use Facebook and publish much personal information without always protecting their privacy. Facebook use by healthcare professionals may generate an ethical dilemma regarding their relationship with patients through the blurring of public and private spheres. Careful reflection is needed to define better the implications of electronic communication media on the traditional role of doctors and on the new aspects of medical professionalism.

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    View Abstract

    Footnotes

    • Competing interests None declared.

    • Ethics approval This study was conducted with the approval of the Institutional Review Board.

    • Provenance and peer review Not commissioned; externally peer reviewed.

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