Facebook, the most widely used application of online social media, reached its 10-year anniversary with over a billion current users.1 This astronomical number of users reflects the widespread appeal of digitally sharing our personal lives, and prospective employers and admissions officers are now capitalizing on the popularity of social media. Profiles on social networking sites (SNS) such as Facebook, where users share thoughts and experiences, photos, videos, and other media, and endorse other users' content, are visible to the public in varying degrees and can therefore offer searchers a glimpse of applicants' online behavior. It is estimated that 19% to 31% of collegiate admissions officers currently vet applicants through online searches,2,3 while nearly half of employers may do so.4 Data are more sparse regarding medical schools and residency programs but suggest that searches with SNS are already a considerable tool for evaluating candidates. A survey of program directors in surgical specialties found that 17% screened applicants by using SNS, and 33% of this group gave lower rankings to applicants based on SNS content.5 In contrast, a study of more general Google searches with program directors in emergency medicine demonstrated little consequence to applicants' standings.6 

As a fourth-year medical student applying to residency programs and a member of my medical school's Committee on Admissions, I have pondered the ramifications of both my own presence on the Internet and potentially probing the online profiles of the premedical students I interview. The ethical implications of exploring applicants' profiles on SNS are equally relevant to graduate medical programs. Is it fair to look up applicants online without a clear approach and policy? What potential hazards underlie this practice and how can professionals ensure that they use information gleaned from online searches in an appropriate manner?

The Problem With “Public”

A majority of medical students now use Facebook, and a compelling case can be made for evaluating their online behavior when they apply to residency programs.7,8 Uncovering worrisome online misconduct (eg, defamatory and obscene remarks, boasting of substance use, violations of patients' privacy) may seem useful and justified given the public interest of advancing medical trainees without patterns of unprofessional behavior. This goal is reinforced by the findings that almost every state medical board in the United States has handled at least 1 case of online unprofessionalism,9 and unprofessional behavior during undergraduate medical training strongly predicts future offenses as a physician.10 Furthermore, sleuthing applicants' online activity and use of social media may not appear problematic, since those who fail to conceal their accounts from public view lay bare their misadventures. A majority of medical school admissions officers and program directors may believe that searches of applicants on SNS do not constitute violations of applicants' privacy.11 

Nonetheless, the question remains of whether exploring what are known to be personal accounts is in some way exploitative, especially given Facebook's propensity for deceptively large audiences and cryptic privacy settings.12,13 In other words, if details of an applicant's personal life and behavior happen to be publicly available on Facebook, does this justify actively pursuing them? Facebook and other SNS pose an additional dilemma by sometimes making momentary indiscretions of years past indelible and easily retrievable. Should older, online transgressions impact a student's evaluation when he or she may have matured significantly in the years since?

Be Careful What You Search For

Social networking sites may seem like a promising tool for gathering telling data on applicants, but these sites are remarkably unreliable. Acquaintances with offbeat humor and spamming schemes may link inappropriate content to an applicant's accounts on social media. While the Electronic Residency Application Service entails a uniform method of collecting and presenting information, searches on SNS are highly variable in what they convey. Visible content on Facebook, in particular, can at times be difficult to decipher.

An underacknowledged reality is that even the most protected accounts on social media are never completely private, and seemingly innocent information could exert undue influence on the perception of a candidate. Depending on what types of photos students post or what content they endorse on a fully secured Facebook account, many aspects of their personal lives that might constitute sensitive information can still be directly ascertained or inferred, such as involvement in same-sex or interracial relationships, religious affiliation, political leanings, and parenthood. Much of this information would be illegal to obtain during in-person interviews under federal and state laws. Less sensitive personal information could also potentially lead to an unfair appraisal. Applicants may purposefully—and prudently—exclude certain activities (eg, participation in fraternities and sororities, beauty pageants and modeling, or risky sports) from their application materials that they consider irrelevant to their professional qualifications. Nevertheless, these past pursuits may be unearthed during online searches and elicit strong reactions from searchers, based on their personal beliefs, which could negatively impact an applicant's standing.

The potential for unwitting misrepresentation on the part of students can make SNS tenuous sources of information. Misinterpreting content on the part of program directors and implicit bias can further undermine a fair assessment. Applicants to residency programs have a right to self-expression when it comes to Internet-based identities, though they should certainly maintain discretion, secure their accounts from public view, and recognize that their online behavior may have important implications for clinical care should their patients search for them on SNS—a topic of professionalism excellently suited for discussion during the training years.14 When program directors investigate residency applicants' Facebook accounts, however, they face a separate ethical quandary of blurring personal and professional contexts when judging applicants' merits and inviting their own prejudices to play a likely greater role. Furthermore, they may stumble on content that falls on a cloudy spectrum of acceptability, as evidenced by 1 study of program directors in which interrater reliability on assessing applicants' unprofessional Facebook content ranged from poor to fair.15 

Recommendations

The practice of looking up applicants on SNS is so fraught with pitfalls that it might best be avoided altogether. Nonetheless, if SNS searches are performed, they should be based on more principled and equitable terms. The program practice of possibly searching SNS should be explicitly publicized on programs' websites in the interest of transparency and honesty; moreover, acknowledging online searches appears to spur students to maximize their privacy settings and be more cognizant of what they post.16 Searches should be performed by someone other than the program director either randomly or on all applicants at certain phases of the selection process, and queries should generate reports only on a standardized set of unequivocal offenses in order to prevent potential bias. When more dubious findings surface, programs might consider allowing applicants to explain the content during an interview.

These are useful steps with which to start, though crafting clear policies will inevitably become thornier as applicants more often present with their personal lives firmly rooted in social media. Applicants would be wise to consider the potential impact of their online behavior on their professional development as physicians-in-training and on the profession as a whole. At the same time, medical educators should be mindful of how they use SNS to evaluate applicants' qualifications. When faced with Facebook, all parties might find that less is truly more.

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Author notes

Deva M. Wells, BS, is a Fourth-Year Medical Student, University of Washington School of Medicine.