We read with interest the recent article in the Journal of Graduate Medical Education about social media etiquette by Camacho et al.1 We appreciate that the authors highlighted this important topic and believe the issue is much more nuanced than initially presented, meriting deeper exploration.
We recently posted a survey on Twitter that asked the question, “Attendings: are you friends with residents you supervise on Facebook?” and encouraged respondents to read Camacho et al1 by including a link. After 24 hours there were 95 responses, with 59 (62%) stating that they are not friends with trainees on Facebook, while 36 (38%) indicated that they do friend trainees on Facebook. A spontaneous online discussion ensued. Responses ranged from full support of friending learners to complete opposition. While thematic analysis of a small Twitter sample would lack methodological rigor, several interesting themes emerged that add substantially to this conversation.
First, it became clear that this issue is more expansive and complex than the attending-resident dyad and that concerns extend to the other members of the health care team. Recognizing the important perspectives of a broader scope of health professionals, a fellow asked, “What about support staff and other people you may supervise? MAs, RNs, PAs, ARNPS, etc?” One attending was comfortable accepting friend requests from residents but argued that “students are off-limits.” It will be important for future research to elicit perspectives from the interprofessional and interdisciplinary members of the health care team who are engaged on Facebook.
The second theme is that the popularity of social media challenges cultural norms around work and professionalism, with respondents noting that Facebook friending “always blur[s] professional boundaries.” Recognizing the range of reasons for social media use, an attending physician argued, “I think it 100% depends on how you run your social media. If [your use of] Facebook [is] largely personal, probably don't; if professional, yes.” Others argued that as work and life have become more integrated, a culture of transparency has emerged. A fellow noted that learners may feel they have “nothing to hide. Life is integrated.” This may reflect generational differences that exist around work boundaries. As an attending pointed out, “This is the space where our [millennial] residents now live their life.” As the cusp of the millennial generation is around 1980, some attending physicians are part of this generation. Local culture around social media use is an important part of exploring the appropriateness of Facebook friend requests. What is acceptable at one institution may not apply to another, which raises questions about navigating resident–attending relationships, especially in smaller centers and cities where lines can naturally blur.
Third, comments centered on the interpersonal relationship issues raised by Facebook friending. There is an inherent hierarchy in the attending–resident relationship, which may complicate Facebook interactions. One commenter noted, “If a [resident] can't feel comfortable ‘friending' an attending, hierarchical relationship is encouraged which hurts team approach.” While these relational issues may have a negative impact on the workplace, it may also negatively impact the social environment. An attending was concerned that friending may make residents “think this is one more place they can't let their hair down.” Others raised concerns over privacy arising from the social hierarchy, and a commenter noted, “I don't friend request anyone who isn't [equal] or above me in hierarchy . . . [It] would seem like violation of privacy.” Several agreed with Camacho et al that not all friend requests are created equal.1 An attending urged us “to think about the etiquette of who initiates friend requests,” to which multiple attendings responded that they accept friend requests but do not initiate their own. These relational issues may be no different on Facebook than they are in in-person relationships. A commenter satirically added, “And God forbid attendings become friends and socialize with residents in . . . gulp . . . real life.” Residents may feel pressure to accept an attending's friend request for fear of repercussion, whereas a request initiated by a resident met with a refusal from an attending may be interpreted as disapproval. Selective acceptance or refusal of friend requests may unintentionally signal favoritism. A resident admitted, “As a current [resident] I felt I couldn't reject my [attending] friend requests though I really wanted to.”
The fourth theme is that attendings in favor of Facebook friending of residents emphasized the importance of role modeling and feedback on professionalism in the digital space, arguing that friending offers a chance to provide “feedback on bad choices and modeling of good social media behavior.” Another commenter stressed the attending physician's vital role in feedback, noting the opportunity “to subtly remind learners new to ‘professional' life what's appropriate for [social media]. Who else will teach this?” Some felt it foolish to ignore this important responsibility by unfriending a resident, going so far as to say, “Unfriend [equals an] ostrich head in sand.”
It is important to note that this is not an extensive survey. In fact, the results raise more questions than they answer. Respondents mostly were avid users of social media, which may bias the results. We plan to use these pilot data to inform a larger study of this topic. It does, however, provide us with several differing viewpoints on a heretofore unexplored subject. The current data suggest that decisions to become friends on Facebook (or other social media) are not as binary as has been suggested. Similar to in-person relationships, these virtual friendship decisions are often shrouded in complexity. The topic is timely as society evolves away from traditional notions that frown on friendships with colleagues outside of work.2 Concurrent with this change, we recommend evolving from the question of whether or not we should interact with one another on social media to how to interact mindfully in ways that integrate work and personal life in beneficial ways.
