Ethics. Research. Community.

#MedBikini and Social Media Peer Review

By Louise P. King

Recently, #MedTwitter was awash with pictures of medical professionals in bikinis as a unique and effective protest to a flawed, and now retracted, journal article.

Those posting objected to the methods used and implicit bias contained in a recently published article in the Journal of Vascular Surgery. The authors replicated the methods and conclusions of a prior 2014 study, which did not garner the same attention at the time.

In both studies, various authors from different branches of surgery created fake accounts on social media and then used Accreditation Council for Graduate Medical Education (ACGME) lists of residents to scrutinize their public profiles for evidence of “unprofessional” conduct. Each of these studies was presented at a national meeting.

But having men create fake accounts to then secretly monitor residents’ social media profiles for what they personally find objectionable is not scientifically rigorous, and itself represents unprofessional behavior.

Notably, in the retracted study, the authors did not receive permission to use the resident lists.

Another major problem was how both studies defined potentially unprofessional conduct.

The original 2014 study, which has not been retracted, states that the authors used “used the ACGME’s components of professionalism and the American Medical Association’s report on professionalism in the use of social media as frameworks for the creation of 3 categories, as a validated instrument for this process does not exist.”

Yet, neither cited source (AMA or ACGME) references the types of behavior described in the study’s “potentially unprofessional” category.

The three categories, per the 2014 study, are:

Professional: No evidence of unprofessional content

Potentially unprofessional: Alcohol or tobacco in hand, questionable attire (including costumes and revealing swimwear), polarizing political or religious statements, and weapons

Clearly unprofessional: HIPAA violation, inappropriate language, picture or reference to binge drinking, drug use, racist or sexist content, and sexually suggestive material

In the 2020 paper, “revealing swimwear” was defined with specific reference to bikinis, hence the #medbikini trend. With this hashtag, many posted pictures of themselves in bikinis with drinks saying they are simply normal people on off hours.

In one amazing post, a doctor posted a picture of herself in a bikini saving a man after a boating accident. It’s a disturbing image given how severely injured the man is and the amount of blood – but there are no eyes on the bikini – only on the stern gaze of the physician directing care.

Padmasini Kandadai, a urogynecologist and clerkship director at Boston Medical Center (the institution that is also home to the authors of retracted study) did a beautiful job summarizing her view of the issues in this tweet:

1. I have a couple of thoughts about this. The classification of “culturally appropriateness” in terms of attire, holding alcohol, and #MedBikini shows a single world-view can skew results and demonstrates the importance of diversity. https://t.co/9xH3roqQpw

— Padma Kandadai MD MPH (@PadmaPande) July 24, 2020

She noted that “classification of ‘cultural appropriateness’ in terms of attire, holding alcohol … shows a single world-view can skew results and demonstrates the importance of diversity.”

Perhaps more importantly, Kandadai disagrees with the “classification of physicians commenting on political and social issues as unprofessional.” She continues, “It is exactly because physicians have remained silent for so long on topics such as abortion and gun control, that we are in this political battle.” She goes on to give excellent examples of how health professionals’ silence on science hurts society.

Our students, residents, and colleagues have a right to share their lives on social media. The behaviors cited – drinking alcohol, wearing swimsuits, having political opinions – are not in and of themselves unprofessional. For most, these are part of our normal lives.

If we hold otherwise, then professionalism becomes a method of controlling behavior in a way that far exceeds its purpose. This then bleeds over into micro-aggressions, as we’ve seen in articles that Black students have written about being told to change their hair from weaves or afros to something “more professional,” and in stories told by our BIPOC and LGBTQ colleagues. “Professionalism” becomes a weapon meant to change and silence the “other.”

Citing expression of political opinions as unprofessional seems especially tone deaf at this time in history.

The retracted 2020 publication defined “controversial social comments” as “largely limited to comments centered around specific stances on abortion and gun control,” without further explanation.

The cited examples—abortion and gun control—are both political issues on which national medical organizations (ACOG and AAP) have taken firm stands. Many commenting on Twitter felt it would be unprofessional NOT to comment on these issues. In these times of #MeToo and #BlackLivesMatter, among other movements, it is our duty to have opinions, to state them, and to back them up with critical arguments and evidence.

The Journal responded fairly quickly to the #MedTwitter Peer Review by retracting the article. Some of the authors have since apologized and claimed that they retracted the article.

The goal these authors and those working on prior papers had was, actually, a good one—to call attention to the fact that health professionals’ social media presence is public and that some might draw negative conclusions from it. But this could be accomplished simply by stating that fact, which is already well-known to our students and residents. Creating arbitrary and judgmental categories without adhering to proper social science research methods resulted in an overly biased account of unprofessionalism.

That being said, drawing lines here can be difficult. We should turn to our colleagues in the social sciences, and involve diverse stakeholders, to use proven methods in studying how best to make use of social media as a tool of personal and political expression while still maintaining professionalism. Their expertise would be incredibly helpful in creating meaningful studies in this area.

As we prepare for our incoming first year medical students, we plan to discuss these issues with them and trust them to make well-informed decisions on their use of social media. I will encourage them to be their true selves, to share as they feel comfortable doing so, and to express their deeply held political beliefs. I will strongly discourage the “clearly unprofessional” behavior flagged by most institutions, but note that there is plenty of room simply to be human.

 

Louise P. King is Director of Reproductive Bioethics at the Harvard Medical School Center for Bioethics and Assistant Professor of Obstetrics, Gynecology and Reproductive Biology at Harvard Medical School.

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