e-Professionalism: Challenges in the Age of Information
Article Outline
ACGME, Accreditation Council for Graduate Medical Education
Recent advances in technology have revolutionized the medical environment and expanded the reach of communication both within and outside the medical community. Clayton Christensen, a noted professor at Harvard Business School, has discussed the concept of “disruptive technologies” and their role in creating organizational change.1 “Health care may be the most entrenched, change-averse industry in the United States,” according to Christensen. The age of information clearly has affected the culture of medicine in ways that we are just beginning to understand. Never before have there been so many ways to communicate. In the past, we were limited to face-to-face conversations, postal mail, telegrams, and telephone calls. Physicians communicated about their credentials through listings in the telephone book and in local medical society publications, or by hanging a shingle outside the office.
With the development and diffusion of new technologies, our means of communicating about ourselves, as well as with colleagues, patients, families, and learners grew enormously. At the same time, the types of new technologies expanded; e-mail, video conferences, webinars, text messaging, text pagers, websites, blogs, and social networking sites all entered our culture within the past 20 years. The use of these technologies is pervasive and increasing.
Professionalism, as one of the core competencies established by the Accreditation Council of Graduate Medical Education (ACGME), has been the subject of much discussion in the last several years. The American Board of Internal Medicine developed a charter for medical professionalism in the new millennium that articulated fundamental principles and a set of professional responsibilities.2 The American Board of Pediatrics, in conjunction with the Association of Pediatric Program Directors, developed a guidebook for teaching and assessing professionalism in pediatric residency that set forth specific examples of exemplary behavior, lapses in professionalism, and behaviors that warrant immediate attention.3 Although much has been written and discussed about this subject recently, it is notable that the subject of professionalism in electronic communication, e-Professionalism, has not been addressed.
Examples of lapses in professionalism in the electronic realm are just beginning to be appreciated. Personal cellular phones may be used for professional communication, which challenges the boundaries of patient confidentiality and may lead to blurred hierarchical roles between faculty and learners in education and clinical care. Physicians posting on online social networking sites must be reminded that their professionalism may be judged by such content. For example, photographs, social group affiliations, and personal information that are not generally shared in the doctor-patient relationship may be inadvertently revealed to patients via postings on social networking sites. In 2008, Thompson et al4 at the University of Florida studied Facebook pages of medical students and residents and found that 46.3% of medical students and 12.8% of residents had accounts. A majority of the accounts were not private and, in some cases, there was inappropriate or unprofessional content posted. At a recent meeting of pediatric program directors, Matz et al5 facilitated a workshop on e-Professionalism and began to illuminate this developing issue. At this workshop, the 3 that characterize electronic professionalism were coined: electronic communication is Public, Permanent, and Powerful.
Lang et al6 recently surveyed pediatric residency program directors regarding their knowledge of their own residency program's ethics and professionalism curriculum. Thirty-five percent of the programs did not have a professionalism curriculum despite ACGME requirements since 2007 for the formal teaching and evaluation of professionalism.7 Program directors cited curricular crowding and lack of faculty expertise as the two largest barriers to implementing an effective professional curriculum. The content of existing professionalism curricula is unknown, but there is little evidence that professionalism issues related to technology use are being addressed formally. There is also little known about how technology actually is being used in patient care and health care team communication. Challenges for medical educators in the e-Professionalism realm include lack of systems to identify, track, and remediate professionalism lapses; generational differences defining appropriate behavior; and difficulty anticipating new technological advances. As academic leaders, we must establish values, standards, behaviors, policies, and best practices.
As we embrace the importance of professionalism, we face challenges in organized medicine about how these new technologies will affect our professional standards and values. The American Medical Association has published guidelines on the appropriate use of physician-patient electronic communication, including appropriate content, administrative, and medico-legal issues.8 Tunick and Mednick9 warned of the ethical dilemmas that may arise from physicians reading patient blogs, a practice that is becoming increasingly common. Patients with chronic disease and life-threatening illnesses often create blogs to provide narrative of their illness experience. If treating physicians read these blogs, they must be aware of potential ethical dilemmas and should consider obtaining permission in advance. Physician disclosure of the intent to read patient blogs may be an opportunity to educate patients about the inherent risks and liabilities of posting such information online.
It is incumbent on us as medical professionals to address this rapidly evolving area that intersects with our personal and professional lives and those of our patients and their families (Table). At the very least, we must establish guidelines for professional conduct and ethical practices to guide appropriate use. As educators and leaders in academic pediatrics, we must inform our students, residents, and faculty about e-Professionalism and begin a national dialogue to preserve the integrity of our profession, establish appropriate boundaries, and protect the privacy of our patients, families, and ourselves. We need to turn these “disruptive technologies” into enhancing features of our complex medical environment.
Table. How do we address e-Professionalism?
| • Raise awareness |
| • Develop policies |
| • Create and evaluate case-based curricula |
| • Identify and track behaviors |
| • Develop remediation strategies |
| • Establish best practices |
| • Stay current with cutting-edge technologies |
We thank Sarah S. Long, MD for review of this manuscript.
References
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- . Medical professionalism in the new millennium: a physician charter. Ann Internal Med. 2002;136:243–246
- American Board of Pediatrics. Teaching and Assessing Professionalism: A Program Director's Guide. Available at: www.abp.org/ABPWebsite/publicat/professionalism.pdf. Accessed November 20, 2009.
- . The intersection of online social networking and medical professionalism. J Gen Intern Med. 2008;23:954–957
- Matz P, Spector ND, Smals L, et al. Electronic Professionalism: Appropriate Behavior in the New Age of Communication. Annual Meeting, Association of Pediatric Program Directors, April 30, 2009. Baltimore, MD.
- . Ethics and professionalism in the pediatric curriculum: a survey of pediatric program directors. Pediatrics. 2009;124:1143–1151
- Accreditation Council on Graduate Medical Education. Common Program Requirements. Available at: http://www.acgme.org/acWebsite/dutyHours/dh_dutyhoursCommonPR07012007.pdf. Accessed November 19, 2009.
- American Medical Association. Guidelines for Physician-Patient Electronic Communications. Available at: http://www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/young-physicians-section/advocacy-resources/guidelines-physician-patient-electronic-communications.shtml. Accessed November 19, 2009.
- . Commentary: electronic communication in the pediatric setting: dilemmas associated with patient blogs. J Pediatr Psychol. 2009;34:585–587
PII: S0022-3476(09)01307-9
doi:10.1016/j.jpeds.2009.12.047
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