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Professionalism in Surgery: How One Scientific Article Sparked a Social Media Revolution

It only takes a quick google search of the word ‘professionalism’ and you’ll be bombarded with a plethora of definitions and as to what professionalism is and how it can be achieved. Professionalism is one of the core principles underpinning the General Medical Council’s (GMC’s) ‘Good Medical Practice’, so it is fundamental for healthcare professionals to embody. A definition by Epstein and Hundert states that ‘Professional competence is the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served.’ (1) I believe this provides a comprehensive picture of the domains in which high standards must be maintained. However, as this definition was written in 2002, it fails to identify the technological revolution that has occurred over the last 18 years, especially the substantial rise in the popularity of social media platforms. Although the GMC and other regulatory bodies worldwide have released guidance for healthcare professionals on navigating social media, these platforms are ever evolving, which has led to more studies being conducted into professionalism on social media platforms.

This sets the scene for an article which has recently stirred outrage in the surgical community and sparked a worldwide debate regarding who determines what is professional or unprofessional and highlighted the lack of gender and ethnic diversity on journal editorial boards. The purpose of this blog is to raise awareness of the paper and the social media movements that stemmed from it, as well as to discuss the paper’s flaws and the reasons for its eventual retraction from the journal.

The particular article was published in the well-respected Journal of Vascular Surgery (JVS), titled ‘Prevalence of unprofessional social media content among young vascular surgeons’ (2) and authored by trainee vascular surgeons in the United States. I was alerted to the existence of this paper by the social media backlash it received, including the #medbikini on Instagram, so I decided to read it for myself. After only a few sentences, I started to notice areas that gave me cause for concern.

The first red flag for me was in the authors’ objective. This was stated as ‘to evaluate the extent of unprofessional social media content online among vascular surgery fellows and residents’ (2), as lots of patients now research their doctors online before a consultation. However, what is professional and unprofessional is highly subjective, and therefore I wanted to know more about the authors’ criteria. The criteria that was in the abstract sounded reasonable, until I delved deeper into the methods section of the paper. The authors identified posts on Facebook, Instagram and Twitter and collated these into two categories; unprofessional and potentially unprofessional content. Pictures of surgeons in ‘provocative Halloween costumes’ and in ‘provocative posing in bikinis/swimwear’, as well as ‘holding alcohol’, were all deemed as potentially unprofessional (2). I was immediately struck by the lack of clarification of the word ‘provocative’ and alarmed by the fact that it was deemed ‘inappropriate’ to have pictures of oneself online wearing swimwear, particularly for women to wear bikinis. As many surgeons have put forward on the medbikini hashtag, just because a man or a woman is wearing swimwear, doesn’t mean they are any less competent than if they were wearing their work attire. As Dr Candice Myhre, an emergency medicine doctor, eloquently commented, ‘All healthcare professionals can wear a bikini, a dress, or we can wear scrubs. This does not change how good we are at being a healthcare provider. We can wear whatever we want in our free time, and still save your life’. (3)

Furthermore, holding alcohol is a vague criterion as, for example, this could mean a picture of a medical professional holding a glass of champagne at a work-related event could be deemed unprofessional. Other categories of behaviour deemed unprofessional were any comments on social media from vascular surgeons regarding gun control, abortion and politics. Again, this raises many concerns, as clinicians, like any other individual, should be free to express their views and be a force for change. Ultimately, as Toniya Singh, chair of the American College of Cardiology’s Women in Cardiology Council, summed up, ‘why should physicians censor themselves from just doing things that normal people get to do?’(4)

It wasn’t just the nebulous criteria that led to the retraction of this paper. To be able to obtain data for the study from social media platforms, the three male researchers created fake (worded in the article as ‘neutral’ (2)) accounts to effectively spy on young vascular surgeons to glean information. This raises significant ethical concerns, as the consent of these study participants was not sought, due to the Boston University School of Medicine institutional review board approving the study meaning that informed consent was waived. From reading the results of the study, obtained and analysed by an all-male research group, in particular the inappropriate posing in bikini/swimwear section, it seemed as though misogyny and sexism was apparent.

In addition to its questionable methodology and analysis, filled with conscious and unconscious biases, this paper was eventually retracted when it was found that the authors did not obtain permission from the Association of Program Directors in Vascular Surgery (APDVS) to use the APDVS directory of program directors and trainees to conduct research (5).

Lastly, the publication of this paper, which had clearly flawed methods of data collection and analysis, has sparked concerns over the lack of female and minority representation on journal editorial boards (6). There is no doubt in my mind that in the future, this will be highlighted for further investigation and hopefully steps taken to correct this disparity. On the paper’s retraction, the Journal of Vascular Surgery issued a formal apology, of which can be found on Twitter: https://twitter.com/JVascSurg/status/1286831352520888320/photo/1.

I believe the take home messages from this are as follows. Professionalism is important and must be upheld by every healthcare provider. Therefore, in these times of expanding social media platforms, there should be more dialogue surrounding existing guidance for doctors and medical students using these platforms. However, the systematic biases of the authors acting throughout the paper, vague inclusion criteria and the lack of diversity amongst the authors meant that the original objective was not achieved and instead had the effect of angering the surgical community, particularly over its sexist stance against female vascular surgeons. However, the positives that have come out of the publication of this paper are that there will now continue to be more discussion about equal representation on editorial boards, as well as how to develop more stringent acceptance criteria. It has also ignited a huge sense of empowerment amongst clinicians, with members of the medical community all supporting each other. This serves as a reminder that social media also has the power to unite us, not just divide us.

Thank you for reading. I would be interested to know other peoples’ thoughts on the retracted article- so please feel free to leave your comments below. If you would like some resources to learn more about this debate, I would consider following @drcandysurfvival and #medbikini on Instagram, as well as the Twitter accounts of vascular surgeons, such as Miss Shipra Arya. The retracted article can be viewed from reference link number two.

Reference Links:

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1769526/#B1

2. https://www.jvascsurg.org/article/S0741-5214(19)32587-X/pdf

3. https://www.instagram.com/p/CDGMzfvF4s-/?igshid=1418yh0tzatla&fbclid=IwAR0M5kd5MaQEg_EBvcsHh0qt-Hkkpczyw5l7Yr-RRWjHZAXNCOBL8F1ZVLg

4. https://www.tctmd.com/news/medbikini-vs-jvs-paper-spurs-debate-over-sexism-social-media-medicine

5. https://www.jvascsurg.org/article/S0741-5214(19)32587-X/abstract

6. https://vascularnews.com/svs-president-jvs-editors-respond-to-controversial-paper-furor/

Author: Ruby Hill, SurgSoc Head of Vascular Surgery

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