Social media and dentistry: some reflections on e-professionalism

In 2014 it was estimated that approximately three billion people used the internet.¹ According to the Office for National Statistics² 36 million (73%) British adults have access to the internet every day, and a further 53% access the internet via mobile devices. The widespread availability of information online, and our easy ability to access and share this information through various mobile devices means that social media is changing how we communicate with each other. Social media is defined as the 'software that enables individuals and communities to gather, communicate, share and in some cases collaborate or play'.³ These include Social Networking Sites (SNS) such as Facebook, and micro blogging platforms such as Twitter, Snapchat and Instagram.⁴

The role that social media plays in the training and continued development of healthcare professionals is worth assessing. Recent UK health policy documents have announced the social and health benefits of a social media savvy healthcare workforce in which social media can act as a vehicle for personal and professional development and lifelong learning.^5,6 Many dental schools use social media to promote their courses and communicate with their students.⁷ Dental educators also use YouTube and blogs to enhance the classroom learning experience and increase reflective thinking and learning.^8,9,10 Social media has also been used to promote new dental techniques (through uploaded videos on YouTube and vimeo), advertise private dental practices, as well as the sharing of dental research through twitter and the RSS news feeds of leading journals and conferences.

Nevertheless, regulatory bodies in the UK, such as the General Medical Council (GMC) and GDC, are holding a more hard-line approach regarding the effects of social media by focusing on its impact on the conduct of healthcare professionals.^11,12,13 This situation contrasts with the American experience, where individual medical schools rather than national professional bodies have drafted and locally enforced social media guidelines for their students. American research indicates that medical and pharmacy students are confused about the ethical, legal and professional implications of their online behaviour and activities.^3,14 There is also US evidence that student healthcare professionals struggle to understand a) what e-professionalism is and b) the difference between being professional and unprofessional in their online activities.¹⁴ Based on this body of literature it would appear that e-professionalism, or 'behaviour related to professional standards and ethics when using electronic communications',¹⁵ could pose a formidable challenge for dentists and dental students alike.

On 30 September 2013, the GDC published its Guidance on using social media.¹⁶ This document highlighted the various ways in which social media, digital communications and online activities can adversely impact on professional practice. While the prescriptive approach taken by the GDC guidelines assures that they are performing their legal responsibility towards their members and the public at large, the task of educating or informing dental health professionals about how to use social media responsibly is less clear.

In this paper, we will present some of the challenges that social media presents to dental professionalism. Much of this literature frames social media usage and the internet as risky behaviour, exposing dental health professionals to various counts of unprofessionalism. Admittedly, dental health professionals need to be made aware of the risks associated with online communications and behaviour. However, research suggests that a didactic teaching approach on 'the do's and don'ts' of social media is not particularly effective.¹⁷ The challenge of teaching social media awareness as a professional skill will be taken up at the end of the paper. We contend that social media awareness resonates as a professional skill for the practice of dentistry in the twenty-first century and that more research needs to be undertaken on how social media practice is changing perceptions of dental professionalism (Table 1).

The advancement of digital technology over the past ten years has resulted in the emergence of a new 'communications culture'.¹⁸ Digital communication is no longer exclusively concerned with sharing information – it also enables social interactions between people who may or may not be known to each other.¹⁹ The relative ease with which users can create, share, upload, tag and comment on information posted on social media platforms also means that social media allows users to be more expressive and participatory online.²⁰ This mix of the expressive nature of social media in combination with its inherent ability to forge connections between people underpins the popularity and attractiveness of social media to the current generation. While authors like Marc Prensky contend that people born after 1980 are 'digital natives' and are better equipped to live with 'the instantaneity of hypertext, downloaded music, phones in their pockets, a library on their laptops, beamed messages and instant messaging',²¹ the fact of the matter is that all working professionals, regardless of their age, have a more dynamic and immersive relationship with digital technology than previously¹⁸ and one which can overlap with their working life.

This 'always-on/always-on-us'¹⁸ relationship with technology and social media has particular implications for healthcare professionals and our construction of professionalism. While some insist that professionalism is hard to define,²² at its most general 'professionalism refers to the conduct and/or behaviour of the individual in upholding the social contract between society and the profession'.²³ This social contract refers to the position of trust and authority which is conferred on the profession by society and which the professional, as a representative of their profession, must uphold through their norms, values and behaviour. The research literature reveals four ways in which digital technology and social media are undermining the social contract of the healthcare professions.

Firstly, social media blurs the personal-professional divide: many dental practices have their own practice websites and Facebook pages through which they post practice opening hours, updates on health topics and often, testimonials from satisfied patients.²⁴ While such online activities can be interpreted as a form of community service, the increased availability of professional people online also has the effect of reducing the social distance that traditionally separated healthcare professionals from the public. Such a blurring of the boundary between public and private spheres and its potential impact on professionalism needs to be recognised.²⁵ Most SNS sites such as Instagram and Facebook have privacy settings which, when activated, can help limit the number of people who can access the content you post on these platforms. However, the terms of reference for these privacy policies are regularly updated so social media users need to remain vigilant in terms of ensuring they have the full protection they require when using social media.

Secondly, social media content can colour personal and professional reputations: the advent of SNS means that an array of personal information is now available online. Personal Facebook pages can reveal a detailed account of someone's personal life. For healthcare professionals, this 'online persona'²⁶ can adversely impact on patient trust. Garner and O'Sullivan²⁷ found that 52% of undergraduate medical students admitted to having embarrassing photos of themselves on Facebook. In a 2013 survey of 377 pharmacy students in the UK, 45% stated that they have posted items online that they would not like a future employers to see.²⁸ Although, to our knowledge, there is no similar survey of dental students it is easy to see that prospective and current patients might question a dentist's professional competency if they were to find online photographs of their dentist drunk or involved with some high jinks. Because 'the distribution capacity of social media'⁷ is so fast and global, any unprofessional behaviour captured online will have an untold, and possible permanent impact on an individual's professional reputation and career. This 'digital footprint'²⁹ detracts from one's reputation and reflects badly on the profession as a whole, calling into doubt the trust that exists in the profession of dentistry.^7,30 While it may be unfair to judge an individual's professional competency based on historic online content, the fact remains that all online content is potentially retrievable and permanent. Healthcare professionals need to become more circumspect about the content they create and post online in order to ensure that they do not skew patients' perception of dentistry and the level of care they expect to be provided with.

Another way in which social media can have an undermining effect is via the dangers of self-expression in social media: by using and posting information on SNS sites, clinicians risk disclosing inappropriate information about themselves, thereby violating their own privacy.²⁴_. They may also violate patient confidentiality if they choose to discuss their work online. Lagu et al.³¹ analysed 271 medical blogs and found enough information in 56.8% of them for the author to be identified, and an additional 16.6% had information from which patients or their doctor were identifiable. Chretien et al.³² analysed 5,156 tweets from 216 self-identified physicians over one month and found 4.7% to be unprofessional in content; 38 individual tweets potentially violated patient confidentiality. Dental health professionals must also be cautious in terms of the photographs they post online themselves as well as those they are willing to pose for that may be posted by others. An awareness of e-professionalism will direct dentists to always ask where a photograph will be displayed and refuse permission for the images to be posted if necessary.

Finally, it is important to consider patient confidentiality in a multi-media world: computer mediated communications are not only text-based (that is, emails, Facebook posting and twitter feeds), but also increasingly visual in nature as photographs and videos are regularly uploaded (for example, Instagram). Although the same standards of patient consent and confidentiality apply to the use of patient photographs in the clinical setting and online, evidence suggests that healthcare professionals are less circumspect about what constitutes professional online visual communication. Thompson et al.³³ analysed 1023 Facebook profiles from medical students and residents and found 12 instances of potential patient privacy violations. All of these consisted of photographs that students uploaded from a medical outreach trip to a developing country. In 2009 a Swedish nurse was suspended from her position after she posted a photo of her holding a piece of flesh during an operation onto a SNS.³⁴ It is also important to note that photographing one's place of work or study also exposes employers and institutions to the risk of negative public responses. In this instance, the repercussions of unprofessional online conduct can be serious, requiring the employer or institution to put a 'risk management'⁷ strategy in place.

It is clear that there is a degree of urgency about raising awareness of the risks and benefits of social media for professional practice. Though regulatory bodies like the GDC issue social media guidelines to clarify what breaches of e-professionalism entail, little is known of dental students' and, more generally, dental care professionals' and qualified dentists' perceptions of e-professionalism. Attention should also be paid to the public's perception of e-professionalism and what they consider to be appropriate or inappropriate online behaviour. In their study, Jain et al.³⁵ found that the public's perception of simulated Facebook pages that contained various examples of inappropriate content was much more critical than that of medical students.

Media studies research points to the importance of striking the right balance in the message or tone of social media teaching. Considering how mundane and omnipresent social media is in our lives it would be unrealistic to insist that professionals stop using social media altogether. Nevertheless, social media users and the public need to be made aware of the online risks they may be exposing themselves to. We need to empower social media users about their choices and options when online so as to protect their own reputation, the profession itself and the interests of the public at large.³⁶ This means that any dental practitioner, at any stage of their career, should know to pause and reflect before they tweet or post a comment or photo in any context; they must know and be enabled to always ask where a comment or photograph will be displayed and be willing to refuse permission for inappropriate content to be posted if necessary.

That said, little research has been conducted on how best to teach or increase awareness of e-professionalism both within the classroom context and as part of lifelong learning/continuing professional development.³⁷ The traditional method of teaching professionalism relies on role modelling.³⁵ However, this approach may not be suitable in this instance. One email survey of 221 educators across five different dental schools in the US found that the majority of university faculty used social media for personal and not educational purposes⁸ and so might not necessarily act as positive role models of professional online communications. In media studies, research suggests that online awareness is best taught by combining offline with online elements.^38,39 Furthermore, since social media is expressive and participatory in nature, it has been remarked that an active experiential learning approach might be best.²⁰ One such approach is the living lab model.³⁸ Real-life scenarios are presented as practical learning opportunities for students, such as getting students to create examples of appropriate and inappropriate Facebook pages or devising social media tips sheet. As a result, learners do not assume the position of passive subjects but are active co-creators of the learning experience.³⁸ By acknowledging the existing social media skills, knowledge of our students and their ability to guide the learning experience,³⁸ one assumes that students will be more receptive to messages about the risks and benefits of online behaviour. However, until more empirical research has been carried out in the classroom learning environment, we will continue to be at a disadvantage on how best to teach e-professionalism.

Since the drafting of social media guidelines in 2013 we can expect that complaints about how practitioners and students use social media will feature increasingly in the fitness to practice cases investigated by the GDC. However, the lack of discipline specific research on these issues makes it difficult to plan a way forward for the teaching and learning of social media awareness. It is in the best interests of patients and the profession as a whole that more research is undertaken on the types of online behaviour that dental students, and practitioners alike, engage in so as to identify areas where online behaviour compromises professional standards. From this research base we will be better able to design specific training activities and approaches for the raising of awareness about professional social media practice.