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JAOA/AACOM Medical Education  |   February 2019
Incorporating a Standardized Online Professionalism Curriculum in Osteopathic Medical School
Author Notes
  • Financial Disclosures: None reported.  
  • Support: None reported.  
  •  *Address correspondence to Bernadette Riley, DO, Associate Professor, Department of Family Medicine, Director, Ehlers-Danlos Syndrome/Hypermobility Treatment Center, New York Institute of Technology College of Osteopathic Medicine, Northern Blvd, PO Box 8000, Old Westbury, NY 11568-8000. Email: briley@nyit.edu
     
Article Information
JAOA/AACOM Medical Education   |   February 2019
Incorporating a Standardized Online Professionalism Curriculum in Osteopathic Medical School
The Journal of the American Osteopathic Association, February 2019, Vol. 119, 112-115. doi:https://doi.org/10.7556/jaoa.2019.017
The Journal of the American Osteopathic Association, February 2019, Vol. 119, 112-115. doi:https://doi.org/10.7556/jaoa.2019.017
Abstract

Online social media platforms increase patients’ access to physicians, thus potentially blurring the boundaries between physicians’ professional and private lives. Although many medical organizations have established guidelines on how physicians should proceed on social media and social networking sites (SNSs), there has not been a mandated standardized curriculum on the use of social media, SNSs, and online professionalism for physicians or medical students. With the increase in physician involvement on social media and SNSs, professionalism issues can emerge. Online professionalism complaints have been increasing. Therefore, osteopathic medical students need to be taught the dangers and benefits of engaging with online media. This article seeks to address the need for mandating a standardized online professionalism curriculum for osteopathic medical students and show how a simulation-based medical education curriculum can help accomplish this goal.

Professionalism encompasses many aspects of medical competency domains, including medical ethics, social accountability, and responsibility1 and should be adhered to online as well. Both the National Board of Osteopathic Medical Examiners and the National Board of Medical Examiners include professionalism competency in their licensing examinations.1,2 The idea that professionalism can be taught and tested has changed the admissions process for both osteopathic and allopathic medical schools.3 In 2015, the Medical College Admissions Test changed its format to include testing on “social and behavioral factors” to determine whether a potential medical student had a “foundation of physician professionalism.”3 Social and behavioral factors in the online setting, however, need to be taught and tested as well. Medical schools should consider offering simulation-based medical education (SBME) in the area of online professionalism. 
The purpose of the present article is to draw attention to online professional situations, predictors of unprofessionalism, and methods of teaching and testing professionalism in the online setting. 
Unprofessional Behavior Online
With the rise in professionalism complaints,4 osteopathic medical schools should consider implementing an online professionalism curriculum. Social networking sites are popular among medical students; 90% of medical students use social media.5 The interrelationship between the use of social media and SNSs and medical professionalism is therefore an important topic that medical schools should address.6 More than half of US medical school deans reported complaints of inappropriate online postings by their medical students.7 Research has shown that a medical student at risk for an in-person or online professionalism complaint in the future can exhibit red flags early in his or her medical career.8,9 Osteopathic medical schools can implement an online professionalism curriculum to identify and remediate students at risk. Such a program could include the dangers and benefits of social media and SNSs and the appropriate behavior a student should display on these websites. 
Papadakis et al8 showed that “disciplinary actions by medical boards was strongly associated with prior unprofessional behavior in medical school.” Papadakis et al9 also identified predictive variables for unprofessional behavior in medical students, including male sex, undergraduate grade point average, scores on the Medical College Admission Test, grades in medical school, and scores on the National Board of Medical Examiners Part 1.9 Medical students who scored low on the clinical skills examination also tended to have higher future rates of complaints against them to medical boards.10 As Calabrese12 noted, “Empathy [is] widely accepted as an essential element of professionalism.” However, several studies, such as one from McTighe et al,11 have shown that medical students’ empathy decreases from the third to the fourth year. Tools may exist to increase empathy. For example, Hendriksz13 found that first- and second-year osteopathic medical students exposed to “patient perspective sessions” increased student empathy scores. 
A study of the severity of behaviors in physicians who were disciplined in Ohio showed no difference between men and women or between type of physician (ie, osteopathic or allopathic).14 In a survey of US medical boards, Greysen et al15 assessed levels of consensus about whether unprofessional online behaviors would trigger investigations. The findings revealed agreement that some of the survey's hypothetical vignettes were in violation of professionalism and thus would prompt board investigations, further showing support for medical education in online professionalism. 
What if a medical student does not realize that he or she is involved in a possible online professionalism scenario? A study that followed physicians’ privacy settings on Facebook found that most physicians were unaware of their own privacy settings.16 A study of US urology residency graduates found that most of their Facebook settings were not private, and more than half posted unprofessional content.17 This behavior was seen equally among osteopathic and allopathic urologists, both male and female. 
The Federation of State Medical Boards released their Model Guidelines for the Appropriate Use of Social Media and Social Networking in Medical Practice18 because of the increase in online professionalism complaints against physicians. These guidelines urge physicians to “adhere to the same principles of professionalism online as they would offline.”18 Specific specialty colleges have also followed suit. The American Board of Pediatrics discussed the importance of patient privacy, confidentiality, and appropriate relationships while also encouraging education on online professionalism.19 
Osteopathic medical students need to be taught about online professionalism before they enter their residency programs. Kesselheim et al20 surveyed pediatric residency program directors and found that more than half experienced instances in which residents posted inappropriate material on SNSs. The results of this study show the importance of medical students being educated regarding online professionalism.20 
Online Professionalism Training and Testing Using SBME
Standardized online professionalism education could be achieved through SBME to identify learners who are at risk for unprofessional behavior or those who lack empathy. Many boards already use SBME for their maintenance of licensure.21 Different types of SBME include using standardized patients for oral board examinations or simulated scenarios using high-fidelity simulators. In a standardized SBME session, the students would participate in a videotaped scenario containing an online professionalism issue. After the simulated session, the learner and faculty member review the videotape and assess how the student handled the situation. Considering personal reflection with guidance has been shown to be an important tool in teaching professionalism, the debrief portion of the SBME session provides an avenue for self-reflection.22 Students can reflect on their reaction to specific professionalism scenarios and become familiar with the appropriate way to deal with them. Mueller23 suggested that physicians create a professionalism portfolio showing proof of training. Research done using simulation to assess for professionalism and communication competence has yielded positive results.24 A study of emergency medicine residents who used simulation to represent ethical dilemmas showed that second- and third-year residents performed better overall than first-year residents, suggesting that professional behaviors are learned over the course of residency training.25 Incorporating an SBME curriculum has been suggested26 and could incorporate online professionalism as well. Professionalism should no longer be a “hidden curriculum, leaving a lot to chance.”27 
Embracing Social Media and SNSs Through an Online Professionalism Curriculum
Medicine is in a unique position to embrace social media and SNSs appropriately while teaching and understanding the risk of unprofessional online behavior by medical students. The American Academy of Family Physicians released “Social Media for Family Physicians,” which cautions physicians on the danger of social media but also talks about the platform it provides for physician learning and networking.28 Currently, the American Board of Osteopathic Family Physicians requires that board-certified physicians participate in Osteopathic Continuing Certification and complete a professionalism module.29 Kesselheim et al30 state that “As educators teach trainees principles of online professionalism, appropriate use of SNSs needs to be included in the training process.” As Kind et al state, “it is the clinical educator's responsibility to help them [medical students] apply principles of professionalism that exist offline to the online arena.”31 
George Washington University School of Medicine added an online professionalism course to their first-year curriculum. They found that the vast majority of students reported that their awareness of their online behavior increased, and most changed their online behavior.32 This course included topics on privacy settings, postings, and potential legal issues with postings.32 Considering most medical students are probably more familiar with social media and SNSs than their educators, educating medical school faculty on the benefits and harms of social media is also needed. 
Conclusion
An online professionalism curriculum may help students avoid professionalism complaints or future medical board investigations. This initiative could also include the positive aspects of social media in medicine. Incorporating SBME into the online professionalism curriculum provides a mechanism for reflection on behavior, which has been found to be a key to learning. It is time to mandate a standardized curriculum on the use of social media, SNSs, and online professionalism for osteopathic medical students. 
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