Protecting institutions from medical students

Social media policies at medical schools lag behind adoption. 

It may be helpful to sort policy goals for students into three categories:

1- How to protect patients.

2- How to protect institutions.

3- How to protect students themselves.

This post addresses protecting institutions. I offer some typical institution-relevant guidelines, and then give my two cents. Your thoughts are greatly appreciated.

Good guidelines for protecting institutions that I've come across:

Be factually correct- don't overstate your knowledge. 

Be transparent- disclose your connection to and your role with the institution your institution.

Control your institution email address- only use you .edu address for official business.

Control your privacy settings.

Weak guidelines:

Adhere to the institution pledge/code- pledges and codes offer few specifics.

Obtain permission- what warrants permission? Every single tweet? Blog posts that mention the institution? 

My Two Cents:

One of the first things newly minted medical students do is sew their school’s seal on their white coat, offering a continual reminder that they represent their medical institution whenever they wear this coat. However, they do not have any badge to remind them of this when they are online.

Medical school has particular demands and stresses beyond those of many other educational settings. In my experience, stress and unhappiness were commonly transferred to professors, courses, and the institution as a whole, often with discomfiting vehemence. It was not uncommon to see these expressions find their way to facebook.

More than simply protecting themselves, medical schools owe it to their students to prepare them to represent the institutions to which they will belong in the future. As future doctors, medical students will find themselves building and maintaining professional relationships for decades, each with different cultures and expectations of openness, sharing, and representation. The earlier these skills are developed, the better off students will be.

Many of the obligations and features of operating in the social media space derive from issues of professionalism. Social media training is an opportunity to teach professionalism, not only in content but also in practice. In my experience, features of professionalism have been taught didactically, and participation has consisted only of personal reflection. Social media training, specifically regarding representing an institution, offers a means to actively engage students with these crucial issues.

How do we protect institutions from students’ damaging comments, made deliberately or spur-of-the-moment? Again, the middle way between abstinence and indifference lies in student training about creating content that appropriately represents those to whom institutional membership impinges upon. A first step is to characterize for students the nature and extent of their obligations to the institution. The specific stakeholders who depend on the institution’s “good name” should be detailed, along with their depth of connection. A potential method is to start with the individual student and work outward. When you speak about your school, you are indirectly speaking for yourself, your classmates, all students, and all alumni who have dedicated years of study and will have/do have certification/validation of their life’s calling in the form of diplomas. You speak for the faculty and staff who have staked their livelihood on service to the institution. You speak for the administration who have staked their professional reputations. You speak for the clinicians you aspire to be. You speak for the patients who have chosen to be treated here. You speak for the community members who respect your institution as an integral community fixture.

What Can You Say in an Elevator? Protecting patients from medical students

I have argued previously that, prior to encouraging medical students to engage with social media, we should establish guidelines to protect patients, institutions, and students themselves from naive transgressions.

My post received some welcomed criticism for being overly conservative. Here, I outline my specific concerns about the subtleties of the risks medical students pose to patients. 

            As the number one priority of medicine, patients should be the number one privacy concern for medical schools. Patients are the most vulnerable stakeholders in the social media health space. Not only is their information the most potent, but their engagement with the medical profession explicitly entails protection of this information by a professional organization that is trained and federally mandated to do so. While the laws and consequences are detailed in the HIPPA documentation, medical students are rarely offered more insight than the commandment “Do not share patient information.” 

Here's why I think we need much more than such simplistic admonitions.

            Medical students are expected to share patient information all the time, and it is considered appropriate to discuss patients so long as they can’t be identified, but how can one be sure? Is it appropriate to discuss the particulars of a patient in a full elevator, so long as their name and demographics are left out? Can anything about the patient at all be discussed in an elevator? If the patient has heart disease, surely it’s okay to discuss the pathophysiology of the disease itself. But what if they have a rare condition? Isn’t it possible that discussion of a rare cardiac abnormality while stepping into an elevator may occur in the presence of family members leaving that elevator? Isn’t it likely that they may have just been Googling their loved-one’s symptoms and have that rare abnormality on their minds? The point is to illustrate the subtleties that are glossed over by the admonition “don’t share patient information.” If such subtleties exist on elevators, surely there is even more grey territory in social media situations. For example, it is not uncommon for students to post status updates about interesting cases. If something like “I saw Ebstein’s abnormality today!” were posted as a status update, it is conceivable that a distant friend viewing that update may connect this with a family member. Worse still are the consequences of a student blogging about such an experience.

            While we trust physicians to exercise appropriate judgment in these areas, we cannot expect medical students to have the knowledge and experience to make these judgments. Before the advent of social media, students simply did not have to worry about broadcasting patient information because the traditional media, print and television reporters, did not approach medical students for stories. If a medical student did find themselves in such a position, they were likely sophisticated enough to earn such interest and therefore mature enough to control their comments. In the connected age, however, medical students’ comments may instead find wide distribution specifically because they have injudiciously, and unknowingly, said things they shouldn’t.

            How do we adequately protect patients from such inadvertent transgressions? One option is to demand student abstinence from including medical content of any kind in the social media space. While tempting, this position is both unenforceable (social media and medicine are central to students’ lives) and excessively restrictive (prohibiting medical content on social media deprives students the opportunity to learn the many beneficial potentials of social media use in the healthcare space). The alternative, unfettered use, is equally untenable. The best path toward patient protection would be student training in appropriate use.

What would this training look like?

Are there examples out there?

Social media risks for medical students

Social media use by medical students is a dangerous proposition for five reasons:

1) The information that medical students steward is particularly sensitive, has massive consequences for the vulnerable populations from which it's drawn, and the privacy of which is protected by federal law.

2) Sharing this information with one’s colleagues and superiors, in write-ups, presentations, and casual discussion, is expected as part of a med student's medical education. Doing so appropriately within the traditional contexts is hard enough without trying to determine what's tweetable.

3) Medical students have a lot to lose, both in terms of resources invested and future career ramifications, if they are found in violation of patient privacy, if they insult their school, or if they say something boneheaded. Crucially, students are often naive to their own personal stakes.

4) As digital natives (having matured entirely in the connected, internet age), today’s medical students have deeply ingrained information sharing habits that may be incommensurate with their new responsibilities.  

5) There is a growing body of MD’s, healthcare workers, and commentators who encourage medical students to engage with social media as a central feature of medical education and future practice without adequately preparing these students to be responsible (and often without consensus even amongst themselves). 

Three concerns come to mind: 

1) How do we protect patients?

2) How do we protect institutions?

3) How do we protect students themselves?

Until we can robustly offer these three protections, I do not think it is right to encourage medical students to join the social media space.

Am I being overly cautionary? 

Am I missing any areas of protection?

Your thoughts are SO, so welcome!

The Listening Tour: Teaching, learning, and social media at academic hospitals

Hillary Clinton came through my little Upstate NY town in 1999 to kick off a “listening tour” on her senate campaign in which she handily defeated challenger Rick Lazio. She demonstrated the power of starting by listening.

Academic hospitals can channel the same power to broaden their reach, and teach.

The first step in launching a social media strategy, according to Hive Strategies, is to listen:

Listen to how patients are talking in the waiting rooms. Listen to the questions new moms in your birthing center are asking nurses. Go to the FAQ web pages created by your Centers to read what they feel are the issues of key concern to patients. Go sit next to the person who answers the hospital’s main phone line. What questions is he or she answering for patients? Listen to the voicemail introductions of each of your centers to give you insight into what the managers think their patients need to know? Listen to the conversations in Emergency Rooms. Listen to what your patients are saying on patient surveys, and listen to how the media talks about your hospital.

What if medical students were used to do this listening as an elective? They would gain exposure to the real needs of various stakeholders in healthcare. Reporting on their discoveries, they could research supporting evidence and share it using a social media tool like Yammer. All the students working on such a project could upload their findings and discuss them in a common, secure web document that could serve as an informative portfolio for the social media strategy.

Such a listening tour would offer students valuable insight into the realities of healthcare barriers and quality issues, as well as some exposure to the applications of social media both to share information and tackle these barriers to deliver better care. The hospital would get free “boots on the ground” for the fact-finding step as they reach to claim the mantle of "healthcare innovator." The college of medicine gets their students talking about issues and passing them along to the whole class, as well as incorporating social media into the curriculum. And, some day, patients get better care.