While open accessibility increases our efficiency in reaching large audiences and might even change the very fabric of our society, as health care providers we may wonder if our audience includes more people than intended. We also need to be sensitive to how our posted information may be interpreted in a way other than how it was intended.7
Most Internet users will remember the popular viral video “David After Dentist,” featuring eight-year-old David DeVore’s now-famous post-sedation tirade on his ride home from a visit to the dentist.8
This video is referred to as “viral” because of the widespread Internet sharing it experienced,9
spreading in a manner similar to a virus. After being uploaded to Facebook and YouTube, it attracted more than 80 million viewers. David’s delusional screams of confusion even had exposure during the 2010 American Dental Education Association (ADEA) Annual Session & Exhibition plenary session.10
The publicity this video has garnered is in part due to its open public accessibility, as most user-generated content is, and its distribution at no cost with the ability to travel simultaneously from user to multiple users in the social media or Web 2.0 world. As was noted in this case, it is not uncommon to see this Web 2.0 world overlap with what we know as the “traditional media” world—newspapers and television programming—thus increasing exposure to an entirely new level of viewers.
So where is the harm in posting what David’s father, David DeVore Sr., thought was just an amusing account of his son as he recovered from sedation? As we investigate further, we find that David Sr. was interviewed by, among others, The Wall Street Journal
and the Today
During these interviews he faced the need to consistently defend his decision to post this video on the Web, which exposed him to great public scrutiny among parents. The controversy in this case relates to the exploitative nature that the posting implied to some. David DeVore Sr. is on record as saying that it was his intention to film his son in order to alleviate his fears about doctors’ appointments.11
He went on to say, “I was trying to teach him that the anticipation is probably much worse than the actual event,” though he also admitted, “This might not have been the right case to give an example.” After later posting it on Facebook and dealing with increased demands from friends and family to view it, he decided to post it on YouTube, stating that he felt it would be easier to share with other friends and relatives.13
During the Today
show interview, David’s mother, Tessie, told Matt Lauer that when David Sr. decided to post the video on YouTube late one Friday night, they did not notice there was a way to make the posted link “private.”13
This unintended release contributed to the viral birth of the video, for it was instead posted to the world to view and interpret as they wished for a period of time that will likely live beyond David’s and our own life spans.
How Do Social Media Dilemmas Relate to Dental Education?
Questions to consider
Now, imagine if this video had been filmed by one of your dental students after his nephew was treated under general anesthesia. Imagine further that the video was not titled “David After Dentist,” but instead “David After Treatment at the University of [enter your institution’s name]”? Would you feel comfortable allowing your students to decide, as the DeVores did, what may be right or wrong content to post? Suppose another student or a friend of the student took this video and remixed it using the now well-recognized audio from the video and called it “David After Dentist All Grown Up,” showing a drunken confused adult engaging in sexually explicit behavior (as was done to the “David After Dentist” video)?14
(Despite the DeVores’ intentions, we imagine that remixes like this one were not part of their original plan.) Which risk management and public relations personnel at your institution would you involve to manage such a media exposure? What would happen to the student? Would it matter to you if the student claimed that posting this video at a public level was unintentional as David Sr. did? What changes, if any, would you suggest that the faculty member who teaches professionalism consider as a result of this indiscretion?
Every digital media-based action we take, even a visit to a website without any real “action,” leaves a “digital footprint” that cannot be erased any longer. Thanks to services like the Internet Archive Wayback Machine,15
even an erased webpage or the long-ago removed spelling error on our admissions homepage is stored forever. Or, as Wired
’s Clive Thompson puts it, users are under the aegis of the “perfect recall of silicon memory.”16
This trail of “where we have been” and “what we post” can lend information to “who we may be perceived to be.”17
This very “perception” is emphasized in the health care environment, where ethics and professionalism are under constant public and peer scrutiny as professional expectations and laws such as the Health Insurance Portability and Accountability Act (HIPAA) prevail. As the use of Web 2.0 applications rises among the general population, with 86 percent of eighteen to twenty-nine-year-olds using social networking sites,18
health care professionals are slowly following this trend.
A recent survey reported that 94 percent of physicians stated they use smartphones to manage personal and business workflows and to access medical data.19
According to the survey, “growth in smartphone use is driven by physicians’ desire to in part improve communication and collaboration and improve patient care and safety.” The number of physicians who said they used this technology in 2010 had increased by 60 percent from 2006. Many federal agencies have already started using Web 2.0/social media tools to disseminate information, e.g., communications during the H1N1 outbreak, the Centers for Disease Control and Prevention (CDC) social media guidance,20
and the Agency for Healthcare Research and Quality (AHRQ) social media tools.21
However, so far there are insufficient data demonstrating the effectiveness of these technologies in improving knowledge of current clinical guidelines. Individual Web 2.0 technologies have been used successfully in medical education and practice,22-33
but have not been evaluated in dentistry.
The dental education community has yet to begin a discourse in the literature regarding the implications assumed by dental education as these worlds intersect. These preparations should include discussing the need to develop professionalism and ethics guidelines specifically related to how our students, faculty, and staff are expected to use these new communication tools. While our current professionalism guidelines have seen numerous iterations over several decades and have helped health care providers make well-informed decisions about what is right and what is wrong, current evidence suggests that although their fundamental principles still apply, they may not be specific enough to adequately guide us in this new world infused with technology and instant accessibility.17,34,35
Opportunities for Using Social Media
Over several years, the medical community has closely followed and evaluated the role of social media on their profession. They have found that the increased use and growing technologies of social media can change communication patterns on health care topics across the country.36
Several claims in support of social media use in health care communication have been noted, including the following: increased social support by patients through Internet-based social networks; individual patient-focused information sharing through the increase of patient-controlled, user-generated content; and increased reach of communication efforts related to health promotion topics such as dietary interventions and smoking cessation.36
Studies on Web 2.0 interactive e-communities have found that study participants are open to receiving new factual information, solutions to problems, learning, and insight.37
These benefits are derived from interpersonal and group interactions within the communities.38
Related specifically to dentistry, a recent oral cancer public service announcement used social media coupled with the public’s fascination with celebrities to attempt to positively influence oral health. Actor Jack Klugman stars in this educational YouTube video describing the benefit of regular oral cancer screenings as he shares his personal history with the disease.39
In another example, on the talk show The View
(a television program, although the information was subsequently posted to YouTube), Whoopi Goldberg shared her personal story of periodontal disease in addition to strongly endorsing the point that oral health is linked to overall systemic health.40
As a result, clinics across the country experienced an increase in dental patients showing concern for their periodontal health. These two examples demonstrate the impact celebrities can have on our interpretation of health care-related topics. Social media forums that have the ability to reach millions of individuals with just one click of the mouse beyond the television viewing audience can easily exploit the opinions of admired individuals for the greater good of the dental health mission.
Challenges in Using Social Media
Medical research has analyzed the challenges we are facing as health care providers regarding the use of social media and its interaction with ethical principles. Recent areas of interest include but are not limited to the following: the use of social networking sites; evaluation of the content posted, including unprofessional content and HIPAA compliance; medical students’ use and knowledge of privacy settings available on social media sites; the consequences and overall effect of unprofessional postings on the public’s trust in the profession; and the call for regulations and guidelines related to online activity.34,35,41
Since no evidence related to the online activity of dental students exists, we reference recent research in the medical profession, which reveals that medical students, residents, and other health care providers violated professional standards when posting information on social networking sites.42-44
Examples include postings of identifiable photos of patients; sexual-related content; negativity related to a medical school, its faculty, courses, and/or fellow classmates; and content that includes alcohol or other illicit substance use.41
It is evident that the negative perceptions these postings may create apply not only to the individual, but also to the institution/hospital and/or professional as suggested in the thought experiment above about the variation on “David After Dentist.” Although it is not our intent to suggest that the unprofessional behaviors of the dental community (or any health care community, for that matter) are so prevalent as to cause alarm, it should be noted that the misguided actions of a few individuals can negatively affect the trust of the public in the entire profession or the institution.
Due to the distribution capacity of social media, a single individual can cause an amount of damage to an institution that only a few decades ago required access to a mainstream news media outlet. It must be accepted that one no longer needs to “know someone at the newspaper” to gain access to the public; all he or she needs to do is log-in to the Internet. As noted, Whoopi Goldberg’s and Jack Klugman’s YouTube video postings exerted a positive impact on how patients perceive periodontal disease and oral cancer and how their dentist may play an important professional role in treating these conditions. On the other hand, Matt Lauer’s comments made during his interview with the DeVore family may have had the opposite effect. Lauer implied that the dentist from the “David After Dentist” video may have been negligent in allowing the boy to leave the office “too early” in a seemingly dangerous state of mind. Celebrity comments such as these may quickly divert the listener, and the media at large, away from scrutinizing the parents in this case to second-guessing the dentist and his or her professionalism and expertise. One can imagine how these comments have the potential to create negative publicity about the dental profession as a whole.
Appropriateness and Accessibility
There appear to be two issues at play related to the dangers of social media in any health care community. One is related to the content of what is posted, while the other is related to who has access to that content. Defining professional or unprofessional content can be complicated.35,41
A study that interviewed focus groups of medical students, many of whom have grown up as digital natives using Web 2.0 technologies, revealed inconsistencies in interpretations across the board. Although students uniformly agreed that the posting of patients’ pictures or any other identifiable information is a violation of privacy, many could not agree on whether it was appropriate to post pictures depicting intoxication and sexually suggestive material. While some felt it was inappropriate to post disparaging comments about a classmate, faculty member, or school, others felt it was not an issue; still others felt it was only an issue if it was “to the point that it impacts your own personal relationship with your clients or your group.” These students described their risk in posting unprofessional material as a “personal risk” as opposed to acknowledging how these postings may have the potential to elicit a negative reflection on the profession as a whole. Some medical students felt having a Facebook page is “not by choice,” stating that without an active account, they “would have no communication whatsoever” in the social forum. In the busy and stressful academic environment, some students feel that this forum is their only social outlet. Although this report suggests that some students were not opposed to school guidelines related to online activity, others argued that these regulations should recognize that “personal time was off-limits.”41
Questions to consider
How does one decide what content is considered personal vs. professional when it comes to online activities? How do we protect ourselves and our students from the ambiguity of determining what is or is not permissible? What are the rights and obligations a dental education institution has concerning its students’ social media activities? How might this overlap with our students’ First Amendment rights? Should the topic of student social media use be off limits to school administrators? How will we measure when it is safe to expect that our students are prepared to act professionally? In 2010, the Associated American Dental Schools Application Service (AADSAS) instituted a mandatory background check for all applicants. Does this suggest that a mandatory “past-Internet activity check” or examination of one’s “digital footprint” should be considered a next step, or might dental schools consider presenting a “social media dilemma” during their interview process to help uncover the applicant’s position on ethics in the Web 2.0 world? We recognize that breaking the law is different from posting risky behavior on the Internet; however, we might ask ourselves how we would feel as dental educators and members of the dental profession accepting a person among our ranks who has posted a string of videos of himself or herself publicly displaying unprofessional activity?
The issue of accessibility warrants a more indepth discussion as the very nature of social media lends itself to free access, although social networking sites such as Facebook provide ample opportunity to limit accessibility of personal profiles and posted comments. The topic has been investigated in medical education regarding the use of privacy settings among medical students who hold Facebook accounts. In 2008, Thompson et al. reported that only a third of the Facebook accounts listed by medical students were made private, with the rest allowing anyone to access their profiles.44
These findings match anecdotal evidence reported by two predoctoral course instructors at our school regarding their observations from an online session about social media for first-year dental students.45
These instructors observed that a majority of the students seemed to believe that information posted on social networking sites such as Facebook affects people’s opinion of professional health care providers. The majority of these students also seemed to believe that dental students should be held to a higher standard than others regarding their Facebook image and should be held accountable for unprofessional behavior discovered through social network postings. Most of these dental students said they have a Facebook account and felt they would rather it not be connected to a faculty member of their school nor would they want to accept them as a “friend.”
While schools should certainly respect the privacy of their students, the fact that faculty members are actively excluded from a large part of their students’ semi-public online lives might suggest that the information posted may not be congruent with our professional expectations. Although it seems prudent that the purposeful use of privacy settings to avoid exposing specific content to an unintended audience may appear as a safe approach since it implies access limited only to “friends,” a false sense of security may occur when a “friend” may expose information that otherwise is meant to be kept in a closed community.
Questions to consider
Do dental students know how to proactively and appropriately set their privacy settings as they use social media? Are they aware of the potential exposure of information they post, in that it may be inadvertently, or purposely, remixed with a dishonorable agenda? Are they aware of the potential privacy status changes of existing information that can occur, e.g., when Facebook decided to change the privacy settings of all its users in 2009 as a result of “rolling out new controls”?46
The Dental Community
Despite the obvious parallels in professional standards in the medical and dental communities, the scholarly activity and resulting collegial discourse observed among medical professionals remain unmatched in the dental education literature. At the time this article was written, sixty out of seventy-one North American dental schools were using a Facebook page or Wikipedia entry in addition to a web presence to reach out to their perceived consumers, as an initial step in recognizing the advantages of using social media. The extent of this presence will become more important as we become participants in this new world to avoid becoming obsolete in our efforts to attract applicants belonging to the Net Generation. Driven by marketing needs or pressured by our parent institutions, we may choose to use these Web 2.0 tools to communicate with patients or applicants and publish our research successes. Some dental schools have already adopted this route as demonstrated by the YouTube video from the University of Texas Health Science Center at Houston Dental Branch47
in which the dean published a V-flash or the Facebook page of the University of Michigan48
that serves as another media mode of communication.
Questions to consider
How do we handle the fact that after we have carefully crafted our text and images for our school’s Wikipedia entry, anyone can edit it and post potentially disagreeable “new data” visible to the entire world? Since Wikipedia editors promote a neutral point of view,49
how do we feel about the fact that we may not be able to remove what they feel are reasonable postings? Will we post “contact us” information on our web pages? If we do, who will we ask to answer these inquiries given that answers might be reposted on publicly accessible sites created by a community of applicants who compare notes about their dental school applications?50
Will this person’s training include sensitivity to patients, regulations related to HIPAA, and student/staff/faculty privacy issues?