• View in gallery

    Fictional examples of inappropriate social media use in a global health elective setting.

  • View in gallery

    Social media and photography contract for global health electives.

  • 1.

    Icahn School of Medicine at Mount Sinai, 2018. Mount Sinai Health System Social Media Guideline. Available at: http://icahn.mssm.edu/about-us/services-and-resources/faculty-resources/handbooks-and-policies/faculty-handbook/institutional-policies/social-media-guidelines. Accessed February 8, 2018.

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    Pew Research Center, 2018. Social Media Fact Sheet. Available at: http://www.pewinternet.org/fact-sheet/social-media/. Accessed February 7, 2018.

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    Kesselheim JC, Schwartz A, Belmonte F, Boland KA, Poynter S, Batra M; Association of Pediatric Program Directors Longitudinal Educational Assessment Research Network (APPD LEARN) Study Group on Social Media and Professionalism, 2016. A national survey of pediatric residents’ professionalism and social networking: implications for curriculum development. Acad Pediatr 16: 110114.

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    Lagu T, Greysen SR, 2011. Physician, monitor thyself: professionalism and accountability in the use of social media. J Clin Ethics 22: 187190.

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    Institute of Medicine (US Committee on the US Commitment to Global Health), 2009. The U.S. Commitment to Global Health: Recommendations for the Public and Private Sectors. Washington, DC: National Academies Press.

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    Association of American Medical Colleges, 2015. Medical School Graduation Questionnaire, 2015. Available at: https://www.aamc.org/download/440552/data/2015gqallschoolssummaryreport.pdf. Accessed March 1, 2018.

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    Kerry VB, Walensky RP, Tsai AC, Bergmark RW, Rouse C, Bangsberg DR, 2013. US medical specialty global health training and the global burden of disease. J Glob Health 3: 020406.

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    Butteris SM et al. 2015. Global health education in US pediatric residency programs. Pediatrics 136: 458465.

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    Coombs PG, Feldman BH, Lauer AK, Paul Chan RV, Sun G, 2015. Global health training in ophthalmology residency programs. J Surg Educ 72: e52e59.

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    Lyons JL, Coleman ME, Engstrom JW, Mateen FJ, 2014. International electives in neurology training: a survey of US and Canadian program directors. Neurology 82: 119125.

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  • 12.

    Ho T, Bentz M, Brzezienski M, Gosman A, Ingraham J, Wong MS, Verheyden C, 2015. The present status of global mission trips in plastic surgery residency programs. J Craniofac Surg 26: 10881090.

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  • 13.

    Butteris SM, Gladding SP, Eppich W, Hagen SA, Pitt MB; SUGAR Investigators, 2014. Simulation use for global away rotations (SUGAR): preparing residents for emotional challenges abroad—a multicenter study. Acad Pediatr 14: 533541.

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    Dell EM, Varpio L, Petrosoniak A, Gajaria A, McMcarthy AE, 2014. The ethics and safety of medical student global health electives. Int J Med Educ 5: 6372.

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    Gharib M, 2017. Volunteering Abroad? Read this Before You Post that Selfie. Available at: https://www.npr.org/sections/goatsandsoda/2017/11/26/565694874/volunteering-abroad-read-this-before-you-post-that-selfie. Accessed January 12, 2018.

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    Wells KM, 2011. Social media in medical school education. Surgery 150: 24.

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    Kind T, Genrich G, Sodhi A, Chretien KC, 2010. Social media policies at US medical schools. Med Educ Online 15: 5324.

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    Black EW, Thompson LA, Duff WP, Dawson K, Saliba H, Black NMP, 2011. Revisiting social network utilization by physicians-in-training. J Grad Med Educ 2: 289293.

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    Chretien KC, Greysen SR, Chretien JP, Kind T, 2009. Online posting of unprofessional content by medical students. JAMA 302: 13091315.

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    Chretien KC, Goldman EF, Beckman L, Kind T, 2010. It’s your own risk: medical students’ perspectives on online professionalism. Acad Med 85 (10 Suppl): S68S71.

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    Moubarak G, Guiot A, Benhamou Y, Benhamou A, Hariri S, 2011. Facebook activity of residents and fellows and its impact on the doctor-patient relationship. J Med Ethics 37: 101104.

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  • 22.

    Hsieh HF, Shannon SE, 2005. Three approaches to qualitative content analysis. Qual Health Res 15: 12771288.

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    Pedersen P, 1994. The Five Stages of Culture Shock: Critical Incidents Around the World. Westport, CT: Greenwood Press.

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    Butteris S, Conway J, 2009. Toward Best Practices in the Global Health Institute: Culture Shock and Communication—Avoiding Misadventures in Cross Cultural Relations. Available at: https://ghi.wisc.edu/wp-content/uploads/sites/168/2012/03/owards-Best-Practices-in-the-Global-Health-Institute.pdf. Accessed August 16, 2018.

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    Lukolyo H, Keating EM, Butteris SM, 2018. Short-term experiences in global health in the digital world: blogs, social media and more. Arya AN, Evert J, eds. Global Health Experiential Education: From Theory to Practice. New York, NY: Routledge.

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    St Clair NE et al. 2017. Global health: preparation for working in resource-limited settings. Pediatrics 140: e20163783.

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    Baylor College of Medicine, 2017. Baylor College of Medicine Social Media Policies. Available at: https://media.bcm.edu/documents/2015/94/bcm-code-of-conduct-final-june-2015.pdf. Accessed August 16, 2018.

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    Icahn School of Medicine at Mount Sinai, 2016. Mount Sinai Health System Social Media Guideline. Available at: http://icahn.mssm/edu/about-us/services-and-resources/faculty-resources/handbooks-and-policies/faculty-handbook/institutional-policies/social-media-guidelines. Accessed November 3, 2017.

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    Regions Hospital, 2010. Regions Hospital Social Media Use and Behavior. Available at: www.regionshospital.com/ucm/groups/public/@hp/@public/documents/documents/dev_057502.pdf. Accessed November 3, 2017.

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    Unite for Sight, 2016. Ethics and Photography in Developing Countries. Available at: www.uniteforsite.org/global-health-university/photography-ethics. Accessed March 13, 2018.

  • 31.

    UW Health, 2016. University of Wisconsin Global Health Elective Professionalism Agreement. Available at: www2.aap.org/sections/ish/Documents/toolkit/International%20Electives/Professionalism%20Agreement/2-%20U%20Wisc%20Professionalism%20Agreement%20and%20Cultural%20Competence.pdf. Accessed November 3, 2017.

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  • 33.

    St Clair N et al. AAP and CUGH, 2013. Global Child Health Educational Modules Project “Preparation for Global Health Electives” Preparation Packet. Content was Adapted from Codes of Conduct from the Following Institutions: Medical College of Wisconsin, UW-Madison, University of Minnesota, & UW-Milwaukee. Available at: https://www.cugh.org/training-module-topic-area/global-child-health-gchemp. Accessed September 10, 2018.

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Socially Awkward Abroad: A Call for Social Media Policies in Residencies that Offer Global Health Electives

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  • 1 Department of Pediatric Emergency Medicine, University of Utah, Salt Lake City, Utah;
  • | 2 Department of Pediatrics, Baylor College of Medicine, Houston, Texas;
  • | 3 Department of Pediatric Emergency Medicine, Baylor College of Medicine, Houston, Texas;
  • | 4 Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota;
  • | 5 Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin

Both social media use and the popularity of global health electives (GHEs) have increased in recent years. Social media use during GHE is commonplace and has benefits, yet sharers may not consider the ramifications of these posts, including privacy violations. Social media policies—which have become more common in residency programs—may aid in providing clear expectations to trainees abroad. The authors aimed to determine the prevalence of social media policies among pediatric residency programs that offer GHE. The authors used a cross-sectional survey design in which educators at pediatric residency programs that offer GHE were surveyed using REDCap®. For all quantitative data, proportions of responses were calculated and analyzed using Microsoft Excel 2013®. The authors analyzed qualitative data using a conventional content analysis approach. The survey was sent to 74 educators; 39 (53%) responses were received. Most (62%; n = 24) of the pediatric residency programs that offer GHE reported that their institution had a social media policy. About one-third (34%; n = 13) of respondents stated that their programs had social media guidelines that pertained specifically to GHE and fewer indicated that social media guidelines were included in their programs’ GHE predeparture curricula (32%; n = 12). This study found that most of the residency programs surveyed had social media guidelines, but few had guidelines applicable or specific to GHE. Informed by this study and a literature review, the authors propose template language for a social media guideline with considerations for social media use in the context of GHE.

Introduction

The twenty-first century has become the era of social media, with a generation who will be unable to imagine a time when they could not instantaneously share experiences with their networks. Formally defined as internet-based tools designed for the exchange of content allowing individuals to communicate electronically,1,2 social media is ever-evolving and far-reaching. The use of social media by the public has increased dramatically, from 7% in 2005 to 69% in 2018, with the highest rates of social media use in 2018 among young adults aged 18–29 years (88%).3

Health-care professionals and trainees are not immune to the growth in social media use. Social media offers many benefits to health-care professionals, such as enhancing professional networking, opportunities for advocacy, and sharing educational resources. Furthermore, social media has the ability to connect colleagues and international partners, and many partner sites rely on social media applications for communication over long distances. Social media posts that avoid disparaging programs or identifying patients, and highlight not just challenges but also strengths, can be an important way to engage with friends and colleagues during an international rotation. Despite these benefits, there are unique risks to social media use among health-care providers.4 These risks extend to both patients and health-care systems when confidentiality is breached, distributed information is inaccurate, professional image is damaged by unprofessional behavior, or personal–professional boundaries are violated.2,5

Social media use has increased in parallel with medical trainee interest in global health electives (GHE). In the United States (U.S.), participation in GHE among medical students increased from 8% in 1986 to 31% in 2015.6,7 Meanwhile, a 2013 query of residency program websites across all specialties found that 20% offered global health programs,8 with at least half of residency programs in pediatrics,9 ophthalmology,10 neurology,11 and plastic surgery12 offering GHE.

Medical trainees completing GHE are known to experience a range of emotions such as homesickness, social isolation, and culture shock.13,14 Many trainees struggle with processing these emotions alone and may reach out via social media to a digital community. Although this allows trainees an opportunity to gain support from family and friends, it can also be a setup for challenges, which may forever be documented via an errant post (Figure 1). There have been calls in popular media to limit inappropriate social media use during GHE—including putting an end to the so-called “poverty porn,” where images of impoverished people or settings are posted, regardless of intention, to generate emotional reactions in the viewers.15 These types of posts made by trainees not only jeopardize the home institution but also risk harming institutional partnerships.

Figure 1.
Figure 1.

Fictional examples of inappropriate social media use in a global health elective setting.

Citation: The American Journal of Tropical Medicine and Hygiene 99, 5; 10.4269/ajtmh.18-0501

Many U.S. residency programs have created guidelines for appropriate social media use.16,17 However, to our knowledge, literature describing the extent to which residency programs have adopted social media guidelines for residents participating in GHE is lacking. Thus, an increasing number of technologically advanced trainees may be completing GHE with no specific guidelines regarding social media use while abroad, which could put them, their institutions, and their patients at risk.

In this article, we report the extent to which pediatric residency programs that offer GHE have social media guidelines in place and, when they exist, whether there are aspects that specifically address social media use while on GHE. We also report how frequently social media guidelines are a part of GHE predeparture curricula in these programs. In addition, we provide a list of considerations for social media use for trainees in global health settings that could be addressed in predeparture preparation. Finally, we provide a social media guideline with considerations for social media use in the context of GHEs informed by this study and a literature review.

Materials and Methods

We used a cross-sectional survey design. Our team, including individuals with survey design expertise, developed the survey through an iterative process after a literature review.1621 All authors approved the survey (Supplemental Appendix), which included multiple-choice and free-response questions.

The research population was derived from a database maintained by the University of Wisconsin, created in 2013, by global health educators within the Association of Pediatric Program Directors for the purpose of identifying residency programs with GHE offerings. We uploaded the survey onto REDCap software (version 6.10.11; Vanderbilt University, Nashville, TN, at https://www.project-redcap.org/) and distributed it via email to global health educators, program directors, residency coordinators, and/or chief residents at all known U.S.-based pediatric residency programs that offer GHE. The survey was open for 31 days in 2017; reminder emails were sent before survey closure. The Baylor College of Medicine Institutional Review Board approved the study. Individualized links were valid for a one-time response from each respondent. We removed incomplete surveys from analysis.

We managed data in secured Microsoft Excel 2013 (Microsoft Corp., Redmond, WA) spreadsheets, in which we pooled responses and performed descriptive statistical analyses.

We analyzed all qualitative data using a conventional content analysis approach to identify themes.22 One author reviewed the provided social media guidelines in their entirety to identify content specifically related to GHE. The author also looked for content that described how learners should appropriately use social media that may have applicability to global health settings, and identified illustrative quotes.

We used the results of these analyses to collaboratively propose a standard social media guideline with considerations for social media use in the context of GHE.

Results

The survey was sent to 74 respondents. Useable responses were received from 39 (53%) individual programs across the country. Respondent demographics are found in Table 1.

Table 1

Demographics of survey respondents

Respondent Demographics (n = 39)ResponseFrequencyPercentage
Role in programProgram director718
Associate program director821
Global health educator2256
Residency coordinator13
Chief resident13
Other (global health coordinator, global health residency director, and faculty advisor)38
Region where program locatedNortheast923
Midwest1333
South1128
West615
# Residents in program1–20513
21–3038
31–40615
41–50410
> 502154

General social media guidelines.

Twenty-four (62%) programs reported that their institution had social media guidelines, whereas 13 (33%) were unsure if their program had them (Table 2). Two programs reported their institutions did not have social media polices. Nearly all programs with known guidelines (92%; n = 22) provided them for review.

Table 2

Social media survey questions and responses (not pertaining to global health electives)

Question (n = 39)ResponseFrequencyPercentage
Existence of social media guidelineYes2462
No25
I do not know1333
Residents made aware of guidelinesAddressed during intern orientation1539
Online1641
Emailed to residents38
Given to residents at another time other than orientation615
I do not know1436
Other38

Of the general social media guidelines provided, none included any language or policies pertaining specifically to global work. Some documents did include language that policies apply to employees “at and away from work” and that social media posts outside of the institution may reflect on the institution. Several suggested the use of disclaimer language to indicate that one is not speaking on behalf of the organization, although one guideline cautioned that one “must consider whether personal thoughts they publish may be misunderstood as expressing (institution) positions.” By contrast, one institution’s policy stated that it does not apply to social media use “on personal time.”

Common themes that emerged in social media documents include the needs to be aware of permanence of social media posts, display “respectful and professional behavior,” and limit contact with patients or parents/guardians of patients on social media. One guideline mentioned such contact “may inappropriately blur the personal and professional relationship, result in an invasion of privacy, or create potential liability for staff or the (institution).” Patient privacy was also highlighted in most guidelines, which discouraged staff from discussing the institution’s patients on social media. However, no document addressed patients not affiliated with the institution, such as those that may be seen during a GHE.

Global health-specific social media guidelines.

Despite 13 of the survey respondents stating that they have guidelines on use of social media pertaining to GHE (Table 3), only two programs provided formal, written social media guidelines pertaining to residents completing GHE. For one institution, this content was in a separate document pertaining to risks associated with GHE rather than incorporated as part of the institution’s social media guidelines. Another respondent stated that residents are required to sign an agreement before travel that includes the following statements: “I will use discretion in taking photographs. I will seek permission (with full transparency of purpose) from individuals being photographed and my host institution before taking any photographs. I will respect the privacy of my host community and individuals, and will not post patient or facility photos or details in online venues (blogs, photo websites, etc.).” Two additional respondents replied via free text that guidelines pertaining to GHE are reviewed by informal discussion, rather than using a written document.

Table 3

Survey questions and responses pertaining to GHE preparation and guidelines

QuestionResponseFrequencyPercentage
# Resident participants in GHE per year (n = 38)0–51847
6–101129
11–1538
16–20411
21–2500
26–3025
Who coordinates GHE predeparture preparation (n = 39)Residency program director25
Associate program director718
Global health educator2872
Chief residents13
We do not have a faculty assigned to global health education13
Program guidelines or policies pertaining to GHE (n = 38)Donations guidelines616
Social media use guidelines1334
Risk reduction guidelines2053
Occupational exposure guidelines1847
Photography guidelines1334
Professionalism guidelines2361
Other (approval guidelines and evidence-based community health guidelines)411
I do not know513
How residents are made aware of guidelines specific to GHE (n = 39)Addressed during orientation for GHE2154
Online615
Emailed to residents718
Given to residents at another time other than orientation25
I do not know1231
We do not have guidelines13
Social media guidelines, a formal part of predeparture preparation curriculum for GHE (n = 37)Yes1232
No2362
I don’t know25
Residents disciplined for inappropriate use in a GHE setting (n = 39)Yes25
No2974
I don’t know821

GHE = global health elective.

Blogs associated with GHEs and run by residency programs were rare, with only two respondents (5%) reporting they existed within their programs. One of these blogs was password protected, whereas the other was accessible by the general public. A global health educator monitored the content of posts on the password-protected blog, but not the publicly accessible blog.

Five respondents described challenges encountered regarding residents’ social media use during GHE. One respondent described an incident in which a resident befriended on Facebook the parent of a patient encountered on a GHE; this became an issue when the mother messaged the resident frequently when the child was ill. Another respondent commented that although the pediatric department has clear expectations for social media use while on GHE, not all departments within the institution follow these guidelines, and sometimes even faculty will violate the policies. A few respondents remarked that their programs encourage residents to adhere to the same standards regarding social media use abroad as they would in the United States. Another respondent expressed that some sharing of photographs is important for educating those at the home institution, provided photos are taken in a culturally appropriate manner.

Discussion

To our knowledge, this is the first published study that quantifies the use of social media guidelines for GHE within pediatric residency programs. Although most of the programs surveyed had social media guidelines (62%, n = 24), these policies often did not adequately relate to social media use during GHE where several nuances might pose additional risk to stakeholders. Furthermore, few programs surveyed had GHE-specific social media guidelines and are not routinely included in programs’ predeparture curricula. Our study suggests that although social media problems are rare, they do exist and were reported anecdotally.

Some respondents (33%, n = 13) were not aware whether their residency or institution had a social media policy, which suggests that programs need to increase awareness of such guidelines. In instances where an affiliated hospital has a social media policy, but the residency program or affiliated academic institution that uses residents do not, residency program directors and GHE staff must be cognizant that hospital social media policies may not apply to the nonhospital patients for which residents on GHE provide care.

Although many of the guidelines reviewed mentioned that an employee’s personal posts on social media may reflect on the institution, these documents centered around the risks to the institution itself and did not address risks to other parties. On a GHE, learner posts could reflect poorly not only on the sending institution but also on the host institution. These posts could negatively impact partnerships between sending and host organizations, damaging long-standing relationships.

Only about one-third (34%, n = 13) of respondents stated their programs had social media guidelines that pertained to GHE, and only two provided written documents for review. It is possible that respondents may not have had a physical copy accessible when completing the survey or, as two respondents stated, guidelines pertaining to GHE may have been discussed informally with residents and were not based on a written document. Regardless, these guidelines are important, as learners may use social media as a way to help with culture shock related to GHE, and their posted portrayals of their situation can at times appear judgmental, unprofessional, or may violate patient and institutional privacy rights.23,24 Thus, it is imperative that social media policies pertaining to GHE not only exist but also are made clear to learners before their elective.

Blogs associated with GHEs and run by residency programs were rare in our survey. Because blogging involves real-time transparency of thoughts, even a well-intentioned post that lacks cultural understanding by a learner can come across as insensitive and undermine relationships with hosts.25 If blogs are not monitored by global health faculty, it is possible that posted content could cause problems. Furthermore, U.S.-based faculty who monitor blogs may lack the same perspective as someone from the host site. Password protection and host faculty monitoring of GHE blogs should be considered.

Social media guidelines were reported to be a formal part of preparation curriculum for GHE in only about one-third of respondents. There is an increasing body of literature surrounding the importance of predeparture preparation for GHE.26 Because of the unique challenges of social media use in GHE, social media guidelines should be included in such predeparture curricula.

Given the potential value of social media with respect to connectivity over long distances in global health partnerships, it should not be removed from learners’ experiences completely. Rather, learners must have education, mentorship, and guidance to promote thoughtful social media use. There are few formal existing guidelines in the literature for responsible social media use for learners completing GHE. The following table of considerations for social media use while abroad is adapted from Lukolyo et al.25 and several domestically focused guidelines on use of social media (Table 4).2732 These considerations could be addressed in predeparture preparation before GHE.

Table 4

Considerations for social media use while on GHE*

Institutional Policies
 Contract for social media and photography useConsider having learners sign a social media or photography contract before the GHE that makes clear expectations about appropriate use.
 Speaking for yourselfEnsure learners know that they are speaking for themselves while abroad and not on behalf of their institution. Oftentimes adding a disclaimer such as “the views expressed on this page belong to me and do not reflect those of my employer” is appropriate.
 Include social media in predeparture curriculaInclude social media guidelines in pre-departure curricula and require reading related to responsible social media use and photography. This encourages learners to think about appropriate use of and consequences of social media use while abroad.
Individual policies
 Good judgment and checking accuracyRemind learners that they alone are responsible for the content they post on social media. Stress to them the importance of respect and how others might perceive their post. Ask them to check the accuracy of everything they post, and understand that posts can damage relationships with host sites, undermine reputations, and discourage teamwork.
 Appreciating permanencyLearners must understand that after being posted, content is difficult to remove completely. Even when deleted, often data are stored where the learner may not have anticipated. Future employers can often see this information and may use it to evaluate the learner.
 Asking for helpMany institutions have social media policies, departments of communication, or global health departments who are available to provide guidance to learners regarding social media use. Consider contacting them.
Confidentiality policies
 Protecting patient privacyDisclosing information about patients, including photographs, without permission is unadvisable and may go against local as well as home institution policies. Learners must know the seriousness of this offense.
 Protecting learner privacyLearner privacy is also a concern when learners are not aware of the privacy of sites where they are posting content. Even when one may think they are posting to a few trusted people, oftentimes the general public is still able to see this information.
Philosophical policies
 “Would I post this back home?”With all posts, learners should ask themselves if they would feel comfortable posting the same information or photographs of people from their home institution. If the answer is no, the learner has no such business doing so in the host community.
 Using other tools for processing emotionsOther avenues are available for emotional processing during GHE, such as a personal journal or personal communication including a phone call.

GHE = global health elective.

Adapted from Lukolyo et al.25

Based on a literature review and results of this study, our group proposes the following social media and photography contract as a standard for preparation for social media use in GHE (Figure 2). It was adapted from St Clair et al., Lukolyo et al., Unite for Sight.org Bhattacharya, and also incorporates elements from the guidelines for ethical reporting on children from the United Nations Children’s Fund.25,30,3335

Figure 2.
Figure 2.

Social media and photography contract for global health electives.

Citation: The American Journal of Tropical Medicine and Hygiene 99, 5; 10.4269/ajtmh.18-0501

Limitations

The database used to recruit respondents may not have been comprehensive and those who responded may have been compelled because of existing policies, thus leading to selection bias. Respondents were asked to recall institutional policies, making recall bias possible. In addition, program directors may not have been as familiar with the global health-specific social media guidelines, and global health educators not as familiar with the general program guidelines. It is possible that some respondents did not have knowledge of policies within their institutions, and thus may not have given accurate responses. In addition, because we were only provided two existing formal, written social media guidelines pertaining to residents completing GHE despite 13 programs reporting having them, we were unable to assess the overall quality or impact of most of the guidelines. Although we believe that the development of guidelines could be an important step for programs, without evaluating the content of these guidelines as a whole, we are not able to comment on potential unintended negative consequences related to guideline development and use. Finally, although we surveyed only pediatric residency programs, trends may be similar across specialties and the proposed contract remains relevant for learners completing GHE in many specialties.

Conclusions

As both social media use and GHE become increasingly common, attention to trainees’ social media use is paramount. As shown in this study, guidelines for social media use for learners completing GHE are often overlooked, exposing residency programs and international partnerships to vulnerabilities. Furthermore, social media guidelines specific to GHE should be included in predeparture curricula. We provide a template social media guideline with considerations for social media use in the context of GHE. As more social media guidelines pertaining to GHE are created, future research should focus on assessing the quality and impact of these guidelines.

Supplementary Material

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Author Notes

Address correspondence to Elizabeth M. Keating, Department of Pediatric Emergency Medicine, University of Utah, Williams Bldg., 295 Chipeta Way, Salt Lake City, UT 84158. E-mail: elizabeth.keating@hsc.utah.edu

Authors’ addresses: Elizabeth M. Keating, Department of Pediatric Emergency Medicine, University of Utah, Salt Lake City, UT, E-mail: elizabeth.keating@hsc.utah.edu. Heather Lukolyo, Department of Pediatrics, Baylor College of Medicine, Houston, TX, E-mail: heather.lukolyo@bcm.edu. Heather L. Crouse, Department of Pediatric Emergency Medicine, Baylor College of Medicine, Houston, TX, E-mail: hlcrouse@texaschildrens.org. Michael B. Pitt, Department of Pediatrics, University of Minnesota, Minneapolis, MN, E-mail: mbpitt@umn.edu. Nicole St Clair and Sabrina Butteris, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, E-mails: nstclair@wisc.edu and sbutteris@pediatrics.wisc.edu.

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