This article published in the Journal of Vascular Surgery received a lot of attention this week when it made the claim that ‘unprofessional content’ on social media pages may lead patients to choose another physician. The article was picked apart, Twitter erupted, and the discussion on #MedBikini and professionalism was born.
The three investigators (a 33 year-old fellow, a 28 year-old research coordinator, and a 37 year-old medical student, all male) made so-called “neutral” accounts to find “potentially unprofessional” or “clearly unprofessional” content on the social media pages of 235 graduating vascular surgeon trainees with publicly identifiable social media accounts.
What the authors considered to be potentially unprofessional content included activities like drinking alcohol, discussing controversial political, social or religious issues, wearing provocative Halloween costumes, and provocative posing in bikinis or swimwear. Clearly unprofessional content included possession of drugs, intoxicated appearance, HIPAA violations, and (gasp) uncensored profanity.
As someone who sometimes just looks drunk in photos on account of being incredibly fun, talks about issues like racial injustice because it is a health issue, and enjoys wearing beach-appropriate attire while I am at the beach, these criteria didn’t strike me as unprofessional.
#MedBikini was started by Twitter user @londyloo to address the fact that doctors can wear bikinis, have piercings, swear, and still be able to comport themselves professionally.
It gained a lot of traction yesterday, and as a MedTwitter-adjacent human who has worried about the career impact of having visible opinions or boobs, I had to partake. My tweet got far more traction than I had anticipated, with many joining in to comment on the underlying misogyny of the paper or to advocate for the right of healthcare workers to have a life beyond their workplace.
Beyond the sexism and bizarre need for purity even outside of professional spaces, this article is just plain old bad science.
In addition to analyzing why this article is problematic, I’ve come up with a number of critiques from doing what I do best—analyzing the science of the article.
Defining “professionalism” by image alone is troublesome. Even more so when the criteria for what constitutes professionalism is created and evaluated by exclusively male screeners.
The definition of professionalism has adapted in the COVID-19 era, but the concept of what constitutes professional composure has usually been defined by white men. “Professionalism” has been used to create policies that can force women into a pair of heels, or to sexualize and shame children at school.
In a time period where 10% of workers admit to not wearing pants on Zoom calls, I would think that the occasional vacation picture shouldn’t really pose a problem. But this is why much of the rhetoric surrounding “professional image” is dangerous.
Women in particular, especially women of color, have been deemed ‘unprofessional’ for a variety of reasons. From Black women being told that their natural hair is unprofessional or that they should remove it for “image” purposes, to Latina women being pressured into removing their hoop earrings while the same jewelry is regarded as “trendy” on white women.
LGBTQ+ people constantly deal with image policing in the workplace, from being told they dress too butch/too gay to being told that they need to alter their speech/voice or dress in a gendered manner. As the authors’ definition of unprofessionalism also extends to ‘political opinions’, those whose identities have been made a political issue could be considered unprofessional simply for their existence.
As I am white and able-bodied, it is easier for me to conform to the “professional” codes that are put into place. Even then, I am left wondering if a shirt that gapes in the front will unexpectedly reveal my chest and earn me a less-than-favorable professional reputation.
It is worth noting that the authors didn’t report statistically significant differences in overall unprofessional content by sex. However, it’s hard to imagine that there isn’t bias in a study where three male researchers admit to making fake accounts to stalk trainees social media, citing ‘provocative posing’ and ‘provocative Halloween costumes’ as a marker of unprofessionalism.
Any other “unprofessional” content is poorly defined.
The paper makes little attempt to define what a controversial political or social issue is beyond the mention of abortion and gun control. Even if one removes the fact that both of these issues are highly pertinent to the medical profession, the definition of what is considered to be controversial is highly variable, and could not be determined by a panel of three relatively homogenous individuals.
The article draws conclusions from a tenuous relationship.
The paper purports to understand the problem with perceived ‘unprofessionalism’ and the impact this has for patients and their doctor choice. While they cite that their goal was to look at the prevalence of publicly available social media content and the impact on patient choice, there is little evidence to support that this relationship even exists.
The paper cites that 44% of adults search for their doctor online. Maybe I’m the only one, but in searching for my doctor, I usually look for “Dr. XYZ phone number” and not “Dr. XYZ pics consuming a strawberry daiquiri on vacation”. As there are many reasons one may Google their doctor, the meaning of this number is ambiguous.
They go on to cite that 41% of adults report that information found on social media would impact their choice of a physician or medical facility. Again, this is highly dependent on what information was found on social media, something that was not clarified in the paper. If the information found on social media was a Facebook comment of “Hey this doctor seems to have a weird streak of patients with outstanding lawsuits and bizarre deaths“, or “this hospital facility charged me way more than I should’ve been charged“, those could be potentially more believable predictors of patient choice. But with no evidence as to what type of content impacts patient choice, the article fails to even establish the relationship it is attempting to study.
Even if the study were looking for the impact of perceived professionalism on patient’s choice in the instance that patient trust or laws were clearly violated, there is no evidence to suggest that social media would elucidate any of this information. Not one single HIPAA violation was found on all of the social media accounts studied. After the article mentions this finding, it takes an irrelevant turn, stating “Although HIPAA violations were not encountered, holding or consuming alcohol continues to be prevalent”. Sorry, but where are these two things related?
The methods are… dubious.
The methods of the article leave quite a bit of information to be desired, stating that 96% of the Facebook accounts were visible to the public. As an observation from my own Facebook friends, I do not know a SOUL that has their Facebook set so it is entirely visible to the public.
Sure, people set varying degrees of privacy, from only a profile picture and name, to select posts and photos. While maybe vascular surgery trainees are just a rare exception in the world of human beings on the Internet, I find it hard to believe that it would be possible to gather significant data from Facebook accounts without first being a friend of the account holder.
The article is based on the findings of three investigators. All male.
Having only three investigators on a study that doesn’t depend on subjective judgments is fair. Having only three investigators on a study where criteria to determine “unprofessional” content is highly subjective, makes for an incredibly biased review. Even when the investigators convened to discuss their findings, the article states that there were “no discrepancies among the reviewers that required a consensus vote among the authors”. Not one? Yikes.
I assumed the authors of this paper, as self-appointed judges of character and professionalism, would have had prior experience in the domain and would not make the same professionalism blunders on their social media. Not one of the listed authors has previously published any literature on professionalism or discrimination. On their social media, I found posts about support for gay marriage, shirtless beach pics, and shares/likes of Rush Limbaugh. I fully defend their right to have all of this content, but it goes against the content of their paper. One can come up with many explanations as to why they feel they are in a position to suggest to trainees what content would impact their professionalism, while equivalent content exists on their own social media.
Many people have potentially incriminating content on social media. Younger generations are all acutely aware of how everything we say, do, or experience will be documented in some form or another. Students have had college acceptances rescinded for racist posts, people have lost their jobs for posting company secrets or showcasing illegal drug use. The social media content addressed in this article is not that type of content.
Posting a photo in a bikini or holding a beer does not diminish anyone’s capacity to complete their professional duties. Awareness and discussion of “political” issues that directly relate to the health of one’s patients and public health is an important part of understanding how systemic factors impact health. The definition of “professionalism” presented in this paper is unnecessarily hostile to women, LGBTQ+ individuals, and people of color. It is an unfounded, biased piece of research that should have not been funded nor published, and it is immensely frustrating to think that researchers were paid to stalk trainees on social media with the myriad of other health issues that could be studied.
I am a woman, with a body. I exist as a human being outside of my professional capacities, as does everyone else under #MedBikini. Judging others for their physicality rather than their capacity reveals far more about the one placing judgment than it does about the one wearing a swimsuit on social media.
P.S. I wrote this article while sitting on a bikini on my porch.