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practice applicationsBUSINESS OF DIETETICS

Toward E-Professionalism: Thinking through the

Implications of Navigating the Digital World

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n August 2009, the University ofLouisville School of Nursing wasordered to reinstate a student it

ad dismissed for posting to herySpace page a questionable account

f an unidentified patient givingirth. The school held that the stu-ent, Nina Yoder, had violated itsode of professional conduct by usingrude language and providing poten-ially identifying details such as theate the patient gave birth. Yoderued the school on First Amendmentrounds and won. US District Judgeharles R. Simpson III ruled that be-

ause Yoder had not posted in a pro-essional medical context or as a rep-esentative of the school, her case fellutside those grounds. Furthermore,e noted that “professionalism” wasot defined in the school’s code, andhat Associate Dean of Nursing Er-alynn Kiehl couldn’t define it when

sked at a deposition (1).The issue of “e-professionalism” for

ealth care providers is an increas-ngly hot topic. As we spend more ofur work and personal lives online,veryone has the same questions:hat kind of content and interactiv-

ty should one strive for on a blog?hat information is best to tweet?ill my colleagues be glad to join my

inkedIn or Facebook network, or an-oyed by the request? Is my personalobile phone acceptable to use for

ny patient-related communication?s text messaging an acceptable wayo communicate professionally? Howhould I handle Facebook “friend” re-uests from students or patients?here are the ethical and legal lines?oes a collapsing of hierarchies and

raditional boundaries erode profes-ionalism? “We’re still trying to figure

This article was written by SaraAase, an award-winningfreelance writer in Minneapolis,MN.

hdoi: 10.1016/j.jada.2010.08.020

442 Journal of the AMERICAN DIETETIC ASSOCIATI

ut what real life looks like on theselectronic systems,” says Jason M.itchell, MD, assistant director of

he Center for Health IT at the Amer-can Academy of Family Physicians.lmost overnight, it seems, we areow faced with an onslaught of vir-ual communication choices that onhe surface seem as simple as signingp, but upon reflection, require a goodit of thinking through about whatace we want to present, to what in-ended user, to what ends.

Professional associations find them-elves struggling to adapt traditionalefinitions of professionalism to thisew world. “Medical societies haven’tome out with regulations and a lot ofedical schools don’t have social me-

ia policies yet,” says Amy Cunning-am, program administrator and an-lyst for the American Board ofnternal Medicine (ABIM) Founda-ion, which focuses on issues of med-cal professionalism. (The American

edical Association recently passed aesolution in June 2010 to study phy-icians’ use of social networking, asxemplified on sites such as Facebooknd Twitter, and a report will be is-ued within the year.) A report in theournal of the American Medical As-ociation last year found in a surveyf medical schools that of those re-ponding, only 38% had policies thatover student-posted online contentnd that deans reporting “incidents”ere significantly more likely to re-ort having such a policy (2). Theritzker School of Medicine at theniversity of Chicago joined that listhen, in 2007, it allowed first-year

tudents to post on YouTube a musicideo spoof from a year-end talenthow. “It was put up on a Friday, andy Sunday the Dean had gotten aomplaint and it was taken down,”ays Jeanne Farnan, MD, MHPE, as-istant professor at the University ofhicago Medical Center. But the classho had made the video petitioned to

ave it reposted, which it since has d

ON © 2010

een (3). “That’s when we realizedhis is clearly an area that needs pol-cy.”

EFINING E-PROFESSIONALISMrom its inception, dietetics foundersdopted rigorous educational stan-ards, and dietetics continues to pro-ote the principle of continuous learn-

ng as one of its core professionalenets (4)—something for which morenterconnectedness can prove invalu-ble. For example, Vineet Arora, MD,APP, assistant professor in the De-

artment of Medicine at Pritzker andeff Cain, EdD, MS, director of edu-ation technology at the University ofentucky’s College of Pharmacy usewitter to stay abreast of information

n their field with more people thanould be possible by e-mail or tele-hone. New applications for thePhone and iPad make it possible foriabetic patients to track their bloodugars and share that log with regis-ered dietitians (RDs) or physicians.acebook and LinkedIn make it easyo organize around a cause or interestnd promote and share related infor-ation. The American Dietetic Asso-

iation’s (ADA’s) current president-lect, Sylvia Escott-Stump, for example,ut up an election campaign page onacebook. And the ADA has a pres-nce on Facebook and TwitterADAFNCE) to provide the publicith the most up-to-date evidence-ased information.But technology can complicateany of the other tenets RDs must

ollow, such as following federal,tate, local, and organizational lawsnd regulations, avoiding personal bi-ses and conflicts of interest, and re-pecting others’ views (5). Nothing inhe current codes directly addressesoday’s main points of contention re-ated to the digital world: Whether toeep one’s personal life at a distance,nd to what degree; and how to con-

uct oneself over virtual tools that, by

by the American Dietetic Association

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BUSINESS OF DIETETICS

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heir very interactivity, make it mucharder to control the flow of informa-ion. “It’s a great big conversationhat you really have no control over,”ays Michael Stephens, assistant pro-essor in the Graduate School of Li-rary and Information Science at Do-inican University in River Forest,

L. “So there is the potential for allorts of things to be out there—good,ad, and in the middle.” Not so longgo, students, patients, and maybeven colleagues wouldn’t necessarilynow that you love knitting, paper-ack mysteries, and visits to Iceland.ot to mention your religious or po-

itical views. But now that previouslyrivate information can sit rightlongside listings of your professionalffiliations and interests, collapsinghat had been a traditional, profes-

ional boundary. “Take all thosehings you’re charged with as a pro-essional—honesty, altruism, integ-ity, and putting the patient first—andhen what do you do with your Face-ook page?” says Joey Mattingly, phar-acy manager at Kroger in Louisville,Y.The loss of those clear boundaries

reates confusion. “The ubiquity of so-ial media is making it difficult to sep-rate audiences and contexts thateople could previously easily keeppart,” says Zeynep Tufekci, whotudies the social impacts of technol-gy as an assistant professor at theniversity of Maryland in Baltimoreounty. “Nobody behaves the sameay with their colleagues, their pa-

ients, their friends, or their moms,nd when they’re now all convergingnd collapsing, that creates quite ailemma.” Of course, it’s not justfriending” that’s the issue. There arelso many unresolved legal issuesbout interacting online. Also affect-ng issues of identity, including thats a professional, is the fact that elec-ronic information is potentially per-anent and searchable, making it

ossible that some detail you considerutdated or peripheral is having moref an effect on your image than youould like, simply because it’s easy tond.Because of the way online social

etworking sites can blur the per-onal with the professional, “e-profes-ionalism” has to address this fact,nd that this blurring can runounter to some professional and eth-

cal tenets. In “E-professionalism: A p

444 October 2010 Volume 110 Number 10

ew Paradigm for a Digital Age,”ain and Frank Romanelli, PharmD,PH, BCPSb, write:If trends toward online social com-unications continue as expected, weust all adapt to a new paradigm inhich physical location no longer de-

ermines whether we are in public orn private . . . (thus) Attentiveness tonline personas and the possible in-lusion of attitudes and behaviorsrom private settings are two new pri-

ary considerations that may neces-itate an expansion of the profes-ionalism paradigm . . . We define-professionalism as the attitudesnd behaviors (some of which may oc-ur in private settings) reflecting tra-itional professionalism paradigmshat are manifested through digitaledia (6).What does this new landscapeean for health professionals and for

he concept of professionalism? Al-hough there are no clear answers,everal practical and ethical issuesre emerging to drive the conversa-ion. They revolve around balancinghe growing usefulness and ubiquityf these tools with still-evolving stan-ards of practice, legality, etiquette,nd perception.

NE-TO-MANY COMMUNICATIONS: PROSany health professionals have em-

raced interactive Web sites, Face-ook, Twitter, and blogs as conve-ient tools for this purpose. The Mayolinic, for example, started the Nutri-

ion-wise blog 3 years ago as an out-rowth of its Web site. “We’re able toonnect to so many more individualsn an immediate, engaging, and funay,” says Jennifer K. Nelson, MS,D, LD, director of clinical dieteticsnd an associate professor of nutri-ion at Mayo Clinic College of Medi-ine. “At the same time, we make surehat the message matches the me-ium. We say that the information isot meant as an individual prescrip-ion.”

Disclaimers can be an effective wayo remind patients that even thoughvirtual” contact can feel quite per-onal, practice boundaries are still inlace. Nelson says that for manyears—predating electronic media—er staff would receive inquiries fromeople with complicated medical is-ues asking questions that were quite

ersonal. So they developed a proto- s

ol: Each response thanks the personor writing, empathizes with their sit-ation, provides links or directs the

ndividual to appropriate resources,nd emphasizes that they need to beeen in person. “If it sounds reallymmediate and they’ve included ahone number, we will call them,”elson says. “Its important to knowour boundaries and be able to com-assionately say, ‘I’m sorry, I don’tave access to your medical historynd in order to get the best care, youhould be seen in person.’ ” A greatay for RDs to use Facebook, Arora

ays, is to set up a “fan” page whereo friending is required, so one-wayommunication remains in place.This is a very savvy way to use Fa-ebook,” she says. “You can provideealth information over the Internet,otentially attract new clients or pa-ients, and you are conveying atrictly professional image.” Becausehey are not “friend”-oriented, Linke-In and Twitter also provide logicalays for RDs to create a virtual pres-

nce and promote and share profes-ional information.

ATIENTS: TO FRIEND OR NOT TORIEND?n 2002, according to a Harris Inter-ctive Survey, almost all Internet us-rs would like to communicate withheir doctors online, more than halfould choose doctors based on their

nline availability, and more thanne third would even be willing to payor this service (7). There is also evi-ence of increased patient satisfac-ion and compliance online when thatxperience is interactive. For exam-le, in her studies, Deborah Tate,hD, assistant professor at the Uni-ersity of North Carolina at Chapelill, has found that patients lostore weight in online programs that

ffered e-mail support than thaterely directed patients to resources

8).In the absence of widespread adop-

ion of patient health portals, pa-ients and physicians alike are natu-ally gravitating toward Twitter andacebook. According to the Pew Inter-et and American Life Project, 47% ofmerican adults 18 and older (as of008, so the percentage is likelyigher now) and 65% of teens (ages 12o 17 years) use a social networking

ite. Facebook is the most popular,

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BUSINESS OF DIETETICS

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446 October 2010 Volume 110 Number 10

laiming 73% of users who have annline profile, and therefore is almostinglehandedly driving debates overssues of ethics and professionalism9).

Many health care providers are ea-er to foster more personal connec-ions to their patients. “I’m very bign connecting with other people,”attingly says. “I would probably

onnect via Facebook to a regular cus-omer. I want to have that personalelationship with people I care for.” Inguest post on KevinMD.com, Juliet. Mavromatis, MD, who practices in-

ernal medicine in Atlanta, GA,rites:

I encounter patients daily in the su-permarket, at soccer games, swimmeets, and school events . . . Withmy foray into social networking, be-ginning with participation in Face-book in 2008, I have “friended” mypatients in cyberspace. They in-quire about my family and areaware of my hobbies and interests.Perhaps against my better judg-ment, we have talked politics andhealth reform . . . My view is thatallowing some blending of doctor-patient-friend roles is likely to en-hance the individualized advicethat I am able to give my patientsabout their health problems (10).

Tufekci, the social media scholar,rgues otherwise. “It’s important toaintain a professional distance so

eople feel comfortable confiding inou and knowing that their informa-ion stays within that context,” sheays. “And frankly I don’t want tonow more about my doctor. I don’tant to know if they’re feeling good orad, because I don’t want that extraurden of managing that relationships if it were a friendship. How they’reeeling is not my problem, and ithould be a professional boundary.”Social networking also is raisingore legal questions than have so far

een answered. According to an op-edy Washington, DC–based physicianatherine Chretien, MD, who alsouthored the Journal of the Americanedical Association survey on the Fa-

ebook-medicine intersection:

Violations of the Health InsurancePortability and Accountability Act[HIPAA], the law that protectsagainst unauthorized disclosure ofidentifying health information, canresult in fines up to $250,000 and/or

imprisonment, besides being anethical breach. The mere existence

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BUSINESS OF DIETETICS

of a patient-physician relationship(e.g. having others suspect a Face-book friend is a patient) could be aviolation of HIPAA (11).

Licensure is another question, saysianne Polly, RD, LDN, JD, chair of

he ADA Ethics Committee. Wouldounseling someone who lives in an-ther state by e-mail or through aocial network, even informally, po-entially violate that law? Given thattandards and protocols for deliveringedical care electronically are still

eing developed, that would be an is-ue of concern. Could a patient sueou if he or she discloses a medicalondition on your Web page? Couldou be held liable for false informa-ion posted on your page by someonelse—be it a patient, colleague, orome other person? If a patient will-ngly consents to electronic forms ofommunication, will that protect pro-iders? Will courts eventually decidehether such information is consid-red public or private, and how it maye used? “I’m waiting for that kind ofase to make it to the Supremeourt,” says Mattingly. “All of theseocial media tools and issues are stilln their infancy, and no one knowsow they will play out.”In a blog post, Bryan Vartabedian,D, FAAP, a pediatric gastroenterol-

gist in Houston, TX, suggests thathysicians have an offline discussionith patients who want to connect

hrough social networks regardingonfidentiality and privacy issues andhe need to document communicationn their medical record. He also sug-ests that health care providers de-elop a personal social media policy touide them, so they are consistent12). “You have to be savvy about thepplication you’re using, about all ofts capabilities,” Arora says. “And youave to set personal boundaries andround rules and make them clear.”or example, you might stipulate thatou cannot provide any medical coun-el through Facebook. Or you couldse Facebook’s list function to groupriends by level of access. “I keep aimited profile list, so if I don’t knowhe person very well, all they reallyee is my profile information, where Iork and where I went to school,”ain says. “If I’m posting somethingore personal to me and I don’t nec-

ssarily want people I work with to

ee, I can easily post it and make my a

ork group list an exception so theyon’t see it.”

TUDENTS: TO FRIEND OR NOT TORIEND?ike patients, students may want toonnect to you as teachers or mentors.n early study shows that such con-ections are powerful. In “I’ll See Youn ‘Facebook’: The Effects of Comput-r-Mediated Teacher Self-Disclosuren Student Motivation, Affective Learn-ng, and Classroom Climate,” the

ore personal information professorsncluded on their Facebook page, the

ore a group of 133 undergraduatetudents thought they would learn inhat professor’s upcoming class (13).

Interestingly, the amount of infor-ation teachers included on Face-

ook did not affect students’ percep-ions of professionalism. Rather,tudents homed in specifically on howirectly the professor’s Facebook pro-le correlated with the actual class-oom experience:While our findings reveal a positive

ssociation between teacher self-dis-losure and important student out-omes, teachers should be consistentith their self-disclosure on Facebooknd their teaching style in the class-oom. In other words, teachers whoxhibit a relaxed personality on Face-ook with informal photographs andntertaining messages, but show them-elves to be strict in the classroom, mayreate violated student expectationshat may result in negative effects ontudents. In their open-ended re-ponses, students encouraged teacherso use Facebook so that they could havehe opportunity to become acquaintedefore meeting in the classroom. How-ver, students recommended thateachers “be themselves” on Facebooko they can “get a better feel for theirersonality.”In addition, students gave com-ents that most of us, consciously or

nconsciously, try to practice today,uch as: “Don’t put (sic) anythingbout politics,” and “Be cautious ofhat people say on your wall. Know

hat your students can see it and beareful what perceptions you are giv-ng” (13).

It’s one thing to encourage moreommunication for a class over Face-ook, which could be done on a groupage set up for that purpose. It’s yet

nother to accept a friend request g

October 2010 ● Journal

rom a student to your personal pro-le page. “Some are all for it, andome say that line should never berossed,” Cain says. “That’s the re-earch question.” The troubling as-ect for both sides is over the issues oferception and power. Students don’tant teachers monitoring their per-

onal lives and passing judgment.ikewise, most professors also don’tant to take that role. “I don’t want to

ee that they were partying some-here, and then they blow my exam.”Mattingly says surveys among phar-acy students and faculty showed a

ery clear generational divide over per-eptions of privacy online. Studentsaised on the Internet tended to be-ieve that their views, pictures, andther information on social network-ng sites was inherently “private,”nd shouldn’t be counted againstheir professional mien. Mattingly,ho graduated with a pharmacy de-ree in June 2009, says he firstiewed Facebook this way. “When Ias first in pharmacy school early on,

t was my own personal page and Ielt like I was just speaking to myriends.” But then Mattingly ran forpeaker of the House for the Ameri-an Pharmacists Association, andomeone told him she thought he hadoo many pictures with beer kegs inhe background, and that they poten-ially threatened his image as a seri-us candidate. “When are the timesou take pictures with your friends?”attingly says. “I’m 26 years old and

t’s not illegal for me to have a drink.ut do those pictures portray a differ-nt message than I want?” Althoughattingly won the election, that ex-

erience, as well as the evolution ofacebook itself, has changed how hehinks about the site. “You are creat-ng your own brand through social

edia,” he says. “I think of it nowore as something that’s trade-arked, and to be protected.”Older generations have held the

iew that once posted, information iso longer private whatever its naturend, therefore, fair game. As we’veeen from news reports of rescindedob offers due to unprofessional Face-ook, Twitter, or MySpace content, soar, like it or not, the “fair game” prin-iple holds sway. Enter the gray eth-cal issues of monitoring, perception,nd power. “I have had several peopleell me about candidates who did not

et residency positions or jobs be-

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BUSINESS OF DIETETICS

ause of something on their social me-ia profiles,” Cain says. “But the in-titution in question is never going toell the candidate that that was theeason.” Likewise, in a forthcomingaper, Cain says of the faculty he in-erviewed, only 10% to 15% said theyefinitely would not use social mediarofiles to help them make a hiringecision. “About 25% of them saidhey would use social media, and theest are waiting to see what happenss we wade through these issues.”Yet Cain and others argue that this

rend is somewhat troubling, as it’sery tricky to interpret personal in-ormation you see online. “There’s aultitude of data that show that peo-

le will say and do things on socialedia they wouldn’t necessarily do in

erson,” Farnan says. Not to mentionhe difficulty of interpreting contextr intent. Is someone simply postur-ng for friends? Telling an “in” joke?rying on an identity? Being outra-eous just to gain attention or pro-oke comment? Being able to see aide of their students they previouslyadn’t raises troubling questions foraculty. If you see something you wishou hadn’t on a student or patient’sersonal site, do you tell him or her?oes it influence a decision aboutrading, hiring, recommendation, orreatment?

UTURE POLICY IMPLICATIONS: MOREEDIA, BETTER USEhen Farnan and Arora surveyed

tudents on their use of digital media,hey found that a little knowledge isangerous. Those most likely to crossrofessional lines were the casual us-rs. “People who used social medianly once a week or so were veryuch unaware of the potential reper-

ussions of their behavior,” Farnanays. “They also didn’t necessarilygree that that they should representhemselves professionally.” So-calledsuper users,” on the other hand, saidhey were keenly aware of potentialepercussions as well as professionalesponsibilities.

The way forward, they say, ishrough education. Cain teaches reg-lar seminars on e-professionalism to

ncoming students at the College ofharmacy at the University of Ken-ucky, as do Farnan and Arora at theniversity of Chicago. “I’m doing ses-

ions for administrators reviewing

he new tools and how to use them,ecause in order to develop a policyou need to get up to speed first.” Allhree professors are in demand asuest lecturers for other departmentsnd organizations facing the same is-ues.What will professional social media

nteractions look like in the future? Inheir paper, Cain and Romanellirite:

Perhaps, when the students of thisgeneration join the work-force andbecome leaders in the field, theywill change the culture so that on-line personas become immune fromprofessionalism judgments. Con-versely, however, the public andprivate personas may continue tomerge, forming identities that aredifficult to separate into public andprivate components (6).

Whatever happens, no one doubtshat there’s no going back to pre-dig-tal ways. “One hundred percent ofncoming medical students use socialetworking sites,” Arora says. Shenderstands resistance, especially byenerations not raised on them. “Ini-ially, the reaction can be, ‘Thesehould be banned immediately!’ Buthen you’re just creating a digital un-erground. We need to create guide-ines so people know how to not get inrouble, but still able to use them tonnovate—to start thinking abouthem in the context of furthering clin-cal care and practice.”

eferences1. Wolfson A. U of L told to reinstate student:

Judge: ‘Crass’ blog. Courier-Journal. August4, 2009:B.1. http://www.courier-journal.com/.Accessed June 23, 2010.

2. Chretien K, Greysen S, Chretien J, Kind T.Online posting of unprofessional content bymedical students. JAMA. 2009;302:1309-1315.

3. MedSchoolRock. Scrubin’. YouTube Website. http://www.youtube.com/watch?v�8y8G4s1yxi0. Accessed June 23, 2010.

4. McNeil S, Shearer J, Johnson R, Kent S,Klein C, McClusky K, McCollum G, Nevin-Folino N, Price J, Schofield M, Thompson E,Vogelzang J, Otto M, Hager M, McCauley S.American Dietetic Association revised 2008Standards of Practice for Registered Dieti-tians in Nutrition Care; Standards of Profes-sional Performance for Registered Dieti-tians; Standards of Practice for DieteticTechnicians, Registered, in Nutrition Care;and Standards of Professional Performancefor Dietetic Technicians, Registered. J AmDiet Assoc. 2008;108:1538-1542.e9.

5. Edge M, Fornari A, Bittle C, Derelian D,Kicklighter J, Pringle L, Holler H, Reidy C,

Busey J. American Dietetic Association/Commission on Dietetic Registration Code of

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Ethics for the profession of dietetics andprocess for consideration of ethics Issues.J Am Diet Assoc. 2009;109:1461-1467.

6. Cain J, Romanelli F. E-professionalism: Anew paradigm for a digital age. Curr PharmTeach Learn. 2009;1:66-79.

7. Patients want online communication withtheir doctors. Harris Interactive HealthcareNews. 2002;2(8). Medscape Medical NewsWeb site. http://www.medscape.com/viewarticle/431849. Accessed June 21, 2010.

8. Tate D, Jackvony E, Wing R. Effects of in-ternet behavioral counseling on weight lossin adults at risk for type 2 diabetes: A ran-domized trial. JAMA. 2003;289:1833-1836.

9. Lenhart A, Purcell K, Smith A, Zickuhr K.Social media & mobile internet use amongteens and young adults. Pew Research Cen-ter Web site. http://pewresearch.org/pubs/1484/social-media-mobile-internet-use-teens-millennials-fewer-blog. Accessed June 24,2010.

0. Mavromatis J. Twitter and Facebook canaffect the doctor-patient relationship.KevinMD Web site. http://www.kevinmd.com/blog/2010/06/twitter-facebook-affect-doctorpatient-relationship.html. AccessedJune 24, 2010.

1. Chretien K. A doctor’s request: Please don’t‘friend’ me. USA Today Web site. http://www.usatoday.com/news/opinion/forum/2010-06-10-column10_ST1_N.htm. AccessedJune 24, 2010.

2. Vartabedian B. When patients contact you viasocial media—9 pointers. 33 Charts Web site.http://www.33charts.com/2009/10/9-things-to-consider-when-patients-contact-you-via-social-media.html. Accessed June 22, 2010.

3. Mazer J, Murphy R, Simonds C. I’ll see you on‘Facebook’: The effects of computer-mediatedteacher self-disclosure on student motivation,affective learning, and classroom climate.Commun Educ. 2007;56:1-17. http://dx.doi.org/10.1080/03634520601009710. AccessedJune 21, 2010.

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