As the digital revolution has unfolded, and smartphones and social networks have begun to permeate and expand the boundaries of medical practice, lapses in online professionalism and decorum have surfaced. In 2010, more than half of the US medical school deans reported breaches of professionalism related to online conduct [1], and 92% of responding American state medical boards (44 out of 48) reported having received at least one report of online professionalism violations, ranging from inappropriate online communication with patients to the use of Internet for inappropriate practice, including misrepresentation of credentials online [2].

In response to these professionalism breaches and the resulting sanctions, medical organizations published several reports and developed professional guidelines, standards, and consensus statements regarding responsible physician use of social media and the Internet [4] (Table 1). However, in an effort to promote and preserve open communication, access to care, and innovation, government agencies have been reluctant to over-regulate online content, placing the onus on physicians to “self-regulate” and comply with “voluntary codes of conduct” [5]. Indeed, this expectation for self-monitoring and peer-based reporting of online unprofessional behavior is embedded in some professionalism guidelines (American Medical Association (AMA) American College of Physicians, and Federation of State Medical Boards (FSMB); Table 1).

Table 1 Sample resources for educators
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Psychiatric trainees and experienced, well-established psychiatrists lie at the precipice of a generational crossroads in the mobile era. Psychiatric trainees are predominantly “digital natives,” adept at utilizing and manipulating new technologies, while many seasoned psychiatrists are considered “digital immigrants,” forced to adapt to the digital revolution midway through their career [6]. In this generational divide, the learner may be more technologically savvy, while the teacher’s experience and expertise deem them more competent to recognize professionalism breaches. Inexperience in either realm could inadvertently have a negative impact on patient care and compromise physicians’ personal and professional reputations. Licensing authorities in many jurisdictions can discipline physicians for unprofessional behavior, taking actions that range from a letter of reprimand to revocation of their medical license [7].

Despite the sensitive nature of their profession, psychiatrists cannot realistically be expected to abstain from social media use or refrain from cultivating an online presence. Indeed, there are benefits to learning these skills; for instance, Twitter and other social media platforms can help facilitate professional development and advocacy, provide information about trends in the field, and enhance knowledge about current treatment practices [8]. Thus, psychiatric training should dually highlight the potential privacy pitfalls of social media and educate trainees on how to appropriately interact with digital platforms.

There is a compelling need for effective e-professionalism training, yet few curricula are currently available to educators. In 2010, the American Association of Directors of Psychiatric Residency Training (AADPRT) Taskforce on Professionalism and the Internet developed a curriculum to advise psychiatric residents about professionalism and social media use. The authors created vignettes organized around nine professionalism issues—liability, confidentiality, and privacy; psychotherapy and boundaries; safety issues; mandated reporting; libel; conflicts of interest; academic honesty; netiquette; and professionalism remediation—for group discussion and/or individual study [3, 4]. In another study, Flicklinger et al. designed a curriculum to enhance medical students’ knowledge of professionalism and social media use. After completing a social media needs assessment, students participated in a workshop to learn social media professionalism skills. A complementary, longitudinal, social media-based curriculum to promote professionalism was subsequently created [9]. The authors found that personal-professional boundaries in the setting of social media use were an area of concern for students and that the workshop format and curricula were well received by the students.

In addition to some guidelines for online professional decorum (Table 1), there is a dearth of formal curricula that address violations that can arise in psychiatric training and practice. A 2015 anonymous survey of American adult psychiatry program directors and program administrators found that only 16% of the responders utilized any formal curriculum on e-professionalism; those that did most often used the published, case-based curriculum from AADPRT (Laothavorn J, Wrzosek MI, Finkenbine R, Jojic M, Zalpuri I. The professionalism e-frontier: how are we teaching psychiatry residents to navigate pitfalls and privileges of online presence? Poster presented at the American Association of Directors of Psychiatric Residency Training Annual Meeting, March 4-7, 2015, Orlando, FL and the Association for Academic Psychiatry Annual Meeting, September 16-19, 2015, San Antonio, TX). The rationale for the underutilization of these guidelines/curricula was beyond the scope of this survey and not assessed. However, since the AADPRT curriculum was the most commonly used among programs that were using a formal curriculum, the authors wanted to capitalize on that finding and create supplemental material for the AADPRT curriculum, in the hopes that it would enhance its efficacy and expand its use. The authors created a series of three video vignettes as an innovative and interactive teaching tool to augment the AADPRT curriculum, help trainees gain a better understanding of e-professionalism breaches, as well as provide tools for chief residents, supervisors, and/or program directors on how to address them when they inevitably arise in training.

Use of Videos as an Interactive Teaching Tool

Educational lessons augmented with digital videos help pique learners’ interest, engage their attention, and generate curiosity for the presented material [10, 11]. By transcending the limitations of spoken and written didactics, videos allow educators to create and share educational content that is accessible to all learners, regardless of reading comprehension, mentalization, or auditory processing abilities [12]. They are valuable teaching tools [13] that generate learners’ interest [14], effectively capture audience attention [14, 15], provide more information in a limited amount of time, and stimulate discussion during didactics. Use of technology additionally increases peer-to-peer interactions [16], which enhances learning through collaborative problem-solving and engaged discussion and promotes interactive learning beyond simply reading or watching content in isolation.

In order to capitalize on the promise of visual, interactive teaching tools, the authors designed a series of video vignettes to showcase and address online ambiguities that may arise during psychiatric training and practice. The videos are meant not only to serve as examples of professional pitfalls but also to guide trainees and educators on the use of appropriate language in approaching and addressing colleagues about these delicate topics. Ultimately, the videos aim to spur reflection and discussion in hopes of providing trainees and educators with a framework for approaching these issues as well as practical and sustainable tools in teaching and practice.

The Video Vignettes

Three video vignettes were developed to serve as an innovative and engaging approach to teach trainees and faculty on how to recognize and address nuanced online professionalism issues. In an attempt to broaden our dissemination platform, these videos are available for viewing online as individual media files on YouTube (Table 2). Although intended to serve as an interactive complement to the existing AADPRT Professionalism and the Internet curriculum, the video vignettes can also be used as standalone teaching modules. Each video features a unique scenario regarding an e-professionalism breach followed by a proposed solution to the dilemma. The variety of potential discussion points makes this format adaptable to numerous facets of curricular implementation. Ultimately, the authors hope that these videos will become viable tools for educators to empower trainees to confidently and successfully navigate the social media and e-professionalism frontier.

Table 2 E-professionalism video vignettes with suggested discussion questions and teaching points
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The videos commence with a conversation between a Chief Resident (either adult or child and adolescent psychiatrist [CAP]) and a junior resident. Table 2 lists the e-professionalism concerns highlighted in each video and offers suggested questions and teaching points that can be used by faculty to guide trainee discussions.

“The Dating Fellow”

The Dating Fellow vignette highlights a potential boundary crossing between a resident and patient’s family member. In this scenario, Arya (CAP Chief Fellow) has technical difficulties with her computer and is assigned Peter’s (junior CAP resident) office while he is out sick with a migraine. When she turns on his computer, Arya sees Peter’s dating profile open and notes a message from a patient’s mother asking him on a date. The patient’s mother notes that Peter plans to terminate her daughter’s treatment next week. Arya is concerned and calls Peter. Peter is notably upset by the call and accuses Arya of invading his privacy. He states he has done nothing wrong, as he canceled the next appointment with his young patient and has not responded to her mother. Peter acknowledges that this situation has contributed to his headache but adds that he has not discussed the situation with his supervisor, who reportedly “discourages social media use.” Arya empathically educates Peter about social media use and its potential impact on patient care. She encourages him to seek supervision on the matter from his direct supervisor or another mentor and to discuss the matter with his patient’s mother in an informed and professional manner.

“The Blogging Resident”

The Blogging Resident vignette covers physician blogging, particularly relevant as this platform now also includes microblogging, or character-limited micro communications (e.g., Twitter). Sue, an adult psychiatry resident, is called to meet with her chief resident after Sue’s co-residents read her blog post detailing a patient encounter in the emergency room. Even though Sue did not name the patient, she included enough descriptors in her post, including diagnosis, profession, and social history that the patient was easily identifiable. Sue’s blog also identifies her as a psychiatry resident in Central Massachusetts, adding to the lack of anonymity, as there is only one program in the region. In her defense, Sue states that the post is private and only accessible to those with the link. The chief resident helps Sue understand how and why her blog post is unprofessional and a violation of patient privacy. The chief resident suggests several remediation strategies, specifically that Sue discusses the situation with her program director, both to inform him/her and to spur a broader, anonymous discussion with all of the trainees about the appropriate use of social media and how to ensure trainees abide by Health Insurance Portability and Accountability Act (HIPAA) when posting content online.

“The Vacation Flaunting Intern”

The Vacation Flaunting Intern vignette addresses the use of Facebook and how that may impact personal and professional boundaries. The scenario begins when the chief resident meets with Sam, a junior resident, after Sam has posted photos of himself at the beach on the same day that he called out sick from work. Sam is initially upset with the chief resident for “creeping his Facebook,” which he perceives to be a violation of his privacy. The chief resident helps Sam recognize how content posted on social media platforms is easily discoverable and part of the public domain, and thus cannot be considered “private.” He further discusses how being deceptive and taking a sick day for the purpose of vacation can be seen as unprofessional and unfair to his covering co-residents.

These videos have been presented as interactive workshops to professional peers at national conferences [2015 Association of Academic Psychiatry annual meeting, 2016 AADPRT annual meeting, 2016 American Academy of Child and Adolescent Psychiatry annual meeting, 2017 American Psychiatric Association annual meeting]. Overall, the workshops have been well received and spurred significant discussion and sharing of similar personal anecdotes. Participants have found the content to be educationally useful, noting that the content learned would advance their knowledge of the topic and change their practice. Each session incorporated some didactic teaching on e-professionalism, viewing of video vignettes, and finally small and large group discussion. The discussion always included components of harnessing classic principles of practice (professional decorum, respect for boundaries, appropriate communication) and adapting them to current technological trends. The objectives were to increase awareness of how social media use can impact patient care and demonstrate how practicing physicians, especially psychiatrists, can honor classic concepts without having to spurn electronic communication and social media in their personal and professional lives. The authors have also used these videos in didactics and received informal positive feedback about how the interactive and engaging nature of the vignettes made the discussions lively and helpful.

Potential Teaching Methods

These videos are one example of how learners can evoke real-life examples to enhance their medical school and/or residency training skill sets. Learners may then generate their own vignettes to discuss. These videos can help learners appreciate how social media use can impact professionalism, understand the implications of social media-driven professionalism breaches on practice, and, by way of directive dialogue, demonstrate at least one way to address these issues outside the classroom. They can supplement or enhance existing curricula on social media and professionalism in a variety of ways. For instance, although the videos showcase one example of how to discuss a social media breach, the instructors may choose to only show the scenario and ask trainees to role-play possible discussions before presenting the suggested approach. Since these videos demonstrate potential language one can use to address these issues, they can assist the learners to go from “observer of an abstract scenario” to one where they are empowered to approach these scenarios in independent practice. As with any teaching tool, the authors recommend instructors to view the videos in their entirety before presenting them to the residents or faculty. Authors share some questions that can enhance engagement and be used during discussion to stimulate discourse on numerous topics, making the lecture more interactive (Table 2). These can be customized to specific situations.

Future Directions

As the next step, the authors plan to implement these video vignettes in 3–5 training programs as a more formal “pilot” program, from which the authors would hope to develop a formalized video vignette-based curriculum to facilitate teaching e-professionalism in training. The pilot will involve pre- and post-curricula surveys to assess the ease of implementation and efficacy of this model to enhance trainees’ knowledge of e-professionalism.

Conclusion

Psychiatric residents are increasingly digital natives, and digital technology is now inextricably linked with interpersonal communication. While the decision to engage with social media is personal, the impact of that choice on professional boundaries is important and warrants concerted education and training. Indeed, Zalpuri et al. created an Accreditation Council for Graduate Medical Education framework for social media/networking competencies for psychiatric assessment and treatment, given that novice and more advanced learners, alike, require competency-based education on this topic [17]. Regardless of their personal preferences and comfort with online communication methods and social media platforms, educators have an obligation to inform and arm their trainees with the critical thinking skills necessary to conscientiously navigate the digital realm. In residency, trainees have a unique opportunity to engage supervisors with their digital world and seek individual guidance on how to translate professional to e-professional, to snail mail to e-mail, and private opinion to public “likes.” Supervisors, in turn, have a unique chance to learn from their trainees and seek to understand the draw of tweets and hash tags. In addition, a video vignette series, while not exhaustive, provides a concrete example of how to address an abstract concept, and, in combination with the AADPRT written materials, offers the opportunity for multimodal learning. The authors hope that the use of video vignettes promotes ongoing discussion and creation of toolkits as programs around the country grapple with how to best supplement their existing curricula to keep up with the dynamic technological landscape.

It is no longer a question of “should” physicians engage in social media and use digital technology; that ship has long sailed. The goal is now to effectively equip the next generation of psychiatrists with the tools necessary to apply classic principles of professionalism to a brave new technological world.