MEdIC series: The Case of the Facebook Faceplant

MEdIC series: The Case of the Facebook Faceplant


Medical Education has taken social media by storm. Twitter, Facebook, the Blogosphere…  Medical Educators have used these often misused and misinterpreted forms of social interaction to share resources and educate. However, social media is quickly merging our private and public personae. As educators, we must be savvy and up-to-date regarding our learners’ social media usage, since the worlds can often collide.

This week we present the case of Greg, a junior faculty member and attending emergency physician, who is experiencing a social media-mediated quandary.

The Concept

Inspired by the Harvard Business Review Cases and led by Dr. Teresa Chan (@TChanMD) and Dr. Brent Thoma (@BoringEM), the Medical Education In Cases (MEdIC) series puts difficult medical education cases under a microscope. On the fourth Friday of the month we will pose a challenging hypothetical dilemma, moderate a discussion on potential approaches, and recruit medical education experts to provide “Gold Standard” responses. Cases and responses will be made available for download in pdf format – feel free to use them!

If you’re a medical educator with a pedagogical problem, we want to get you a MEdIC. Send us your most difficult dilemmas (guidelines) and help the rest of us bring our teaching game to the next level.

The Case

Greg, a brand new EM attending, woke up from his nap after a long night shift and immediately was flooded with memories. It had been one of those nights where the patients never stopped coming. To make matters worse, he had been on with one of the junior EM residents, Tammi, who the program director had flagged to Greg as a ‘resident at risk.’

He had hoped to use the shift to build up her confidence, but near the end she got in a disagreement with one of the senior nurses. The nurse had held some questionable orders for Greg’s approval, and Tammi did not take it well when she found out. Greg had tried to debrief the event with her before she went home, but they did not get very far as she seemed to be on the verge of tears. He figured he would give her a call today to talk about it after she had slept and all of the dust had settled.

Greg walked to the fridge, thinking of all the ways he could re-frame the problem to Tammi.  He could role play the situation in reverse; he could have her reflect upon the words he had overheard… Hmmm.

But first… some Facebook time.

Typing in his password, he quickly scanned his wall to find some funny new memes, a few quasi-political rants from his college roommate, some cute pictures of his sister’s cats in costume… And then his face dropped.


Facebook ALiEM


Greg was shocked. He knew that Tammi had been upset, but he hadn’t thought that she would react like that. The last thing he wanted to do was come down hard on her, but he had to say something. Before he spoke with her he decided to phone a friend for some advice.

Questions for Discussion

  1. As Greg’s friend, what advice might you give him?
  2. What are your own/local/hospital/state-wide/provincial/national policies for social media engagement?
  3. How would you approach this scenario if you were Tammi’s friend?
  4. What advice do you have for educators who encounter social media transgressions?
  5. Can you share your difficulties with confusion over the blurry border between virtual and real identities?

We look forward to hearing your thoughts over the week (Sept. 27 – Oct 4, 2013).

*UPDATED OCTOBER 4, 2013:  All the comments have been analyzed and incorporated into the curated community commentary that was released today (Oct. 4, 2013).   Please feel free to still add your words of wisdom to our comments, but the PDF compilation has been rendered as of this date.*

Next Week

Just like last time, we used the community responses to curate a commentary and published it with two expert responses. This month’s two medical education experts were well-versed on the topic of social media and professionalism:

Their response was published on October 4, 2013 along with the curated community response:

The case, the expert responses and the curated commentary can be found at this link (Click here)

Thanks to Dr. Brent Thoma (@BoringEM) for developing this second case. We will continue sharing writing/editing/recruiting duties for this series from here on out!

All characters in this case are fictitious. Any resemblance to real persons, living or dead, is purely coincidental.

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Teresa Chan, MD
ALiEM Associate Editor
Emergency Physician, Hamilton
Assistant Professor, McMaster University
Ontario, Canada + Teresa Chan
  • rp

    If this was posted on my Facebook wall and I had the power to delete this message, I would do so immediately. This discussion shouldn’t be in a public arena. Then I would promptly tell Tammi I deleted her message giving the reason why and offer to discuss in person. First save Tammi from making a mistake she cannot revoke then help her find ways to better address that troublesome interaction.

    • Michelle

      Great points, Rahul. With all of Facebook’s changing privacy settings, I just assume all Facebook posts are at risk for going public. Thanks for commenting.

      • Brent Thoma

        That does bring up the question of privacy settings on Facebook. While the post discussed in this scenario would be professional no matter what the settings, Facebook is also used to communicate with our friends and family. If a resident posts photos/comments about a night of… reckless indiscretion… that is only available to their friends and family, is that also unprofessional? Is there a role for privacy settings in allowing physicians to post personal things?

        • Michelle

          All it takes is for one person to “share” your post and it’s out. So I just assume everything go “viral” in a very public way.

        • rp

          Facebook’s privacy settings change often. I have deleted pictures and videos only to find them reappear. Their privacy statement (at one point) claimed they owned anything I posted on their site. Everything is backed up on many servers so you can’t really ever delete it. The same can be said for the Internet. I deleted my account as well but apparently it has resurfaced.

          • Brent Thoma

            Great points. I think they illustrate risks that are not appreciated by everyone.

  • Michelle

    Great but very challenging case. There are some short-term and long-term issues that need to be addresses.

    SHORT TERM: I would recommend that Greg immediately reach out to Tammi by phone or at least text message to remove the FB post, from the perspective of being her advocate rather than her supervisor. You basically are watching out for her ultimate reputation and don’t want her to get in trouble with the specific nurses, the entire nursing staff, administrators, or even governing bodies. Everyone is allowed to have a bad day — just keep it private. The bottom line message should be that social media forums should all be treated as potentially publicly accessible material– no matter what the platform’s privacy statement says. I love Mayo’s short-and-sweet social media policy: “Don’t Lie, Don’t Pry. Don’t Cheat, Can’t Delete. Don’t Steal, Don’t Reveal.” For me, my mantra is:
    1. Use common sense.
    2. Don’t share while angry.
    3. When in doubt, leave it out.

    LONG TERM: Tammi can’t have been the first resident EVER to feel frustrated by disagreements between physicians and nurses. Communication, misguided expectations, and wounded egos are often the culprit. Questioning things in the medical profession SHOULD be welcome for the sake of patient care and error reduction, much like how the airline industry is promoting. It’s a big culture change in medicine, but it’s got to be done.

    As a suggestion to educators/administrators, I would try NOT to crucify Tammi out as a “bad example” but address more the underlying, big-picture issues. Everyone’s human – move on. We’re ALL still learning how to navigate our personal and professional persona using social media.

    • Brent Thoma

      Awesome reply! I love Mayo’s social media policy – it is perfectly to the point. Also, great idea about the occasional closed door meetings. If there is nowhere to vent safely, I imagine there would be more potential for public outbursts like the one described.

  • TChanMD

    Thanks for your comments so far folks! Very excited to hear your opinions! Definitely this is a complicated case with various issues! Thanks for sharing your thoughts on how Greg should handle things!

  • njoshi8

    The real question is: why did this resident go to vent her issues on facebook? Facebook is a great tool, but also an amazing arena where people can go to vent. I wrote a piece for July’s issue in EP Monthly about this same exact concept:

    There is a feedback loop in Facebook, that almost sucks us all in and almost encourages unprofessional comments.

    • Michelle

      Congrats! Wow, how did I miss that? Nice summary of Facebook’s allure as an easily accessible 24/7 place to vent.

    • Brent Thoma

      Yes – nice work on that! We will have to reference you in the community response! 🙂

  • Rob Woods

    I think this case reminds of us how important it is for trainees to be aware of guidelines and policies that govern our institutions. Orientation is often perceived as boring, but is absolutely necessary, and why it is an accreditation requirement for residency programs. At our College of Medicine, we are just finalizing our social media policy.

    Residents need to know that they are ‘in control of their audience’. By going to social media, their audience can be the entire world in a matter of days or weeks. I like Michelle’s comments about avoiding social media when you are angry. Much like the angry email you send in the moment. If you are denting your keyboard keys as you send your reply, it’s probably a sign you should pause and reflect. I’m sure we’ve all had an email we wish we didn’t send, and that is just to one person!

    If Tammi had been made aware of her school’s social media policy, the scenario changes a bit. Her actions would be in clear violation of the policy. Contacting her immediately to debrief and support is key, however there would need to be some form of remediation for her unacceptable actions.

    • TChanMD

      Hi Dr. Woods: Thanks for your comments. I love your quote re: denting the keyboards! 😀 I do think Debriefing and Supporting are key themes… but figuring out how to determine limits and boundaries are important as well.

      In a scenario like this, would you want a third party mediator? Or a Program admin taking notes? I could see how Tammi may also want a resident rep, etc..

      How are these handled at U of S?

      • Brent Thoma

        Teresa, U of S students just don’t do bad things! 😉
        To answer your question, I believe our SM policy is under development and Dr. Woods is a member of the committee. I look forward to seeing it!

  • Michelle Gibson

    Answering as a program director:

    I think that this represents not exactly a social media issue as an insight/judgment/’what do you do when you’re upset’ issue. It is magnified by social media, but ranting about a nurse the night before in any kind of public setting (key word there is ‘public’) is an issue. In general, it’s normal/OK/actually a good thing to feel upset when a co-worker does something we perceive as wrong (if it doesn’t bother you at all, then I’m worried about you). However, the difference between what one feels and what one does is the key distinction in being a professional (well, maybe in being human, actually).

    So, you feel what you feel, but you need to manage your actions. This is important in all settings, but becomes increasingly important when your actions can be broadcast electronically to thousands in a matter of seconds.

    Thus, Greg can advise Tammi about how to develop “better” (there should be another adjective) for managing her frustrations, while highlighting the perils of social media.

    However, as a PD, I might want to know about this, even unofficially speaking, because what Greg might not know is that Tammi has done this sort of thing 10 times before (since he’s new…) and this might not be a one-time issue.

    You can tell from the above that I subscribe to the “there is no professional/personal divide” philosophy in social media when one is a physician. I find this helps keep things clean. I do have ways to vent, and that’s OK, but it’s with people who don’t feed the negative cycle (I liked that below) and who can support me and let me know if I’m over-reacting or not – which usually means I’m getting stressed out and I need a break.

    So, if I was hearing about this as PD, I’d probably have a chat with Tammi, but if it was a first offence in general re: professional behaviour, I wouldn’t bring the hammer down on her, but I would note it. However, seeing as she is ‘at risk’, my PD spidey sense is going off that this might not be a first-time event. 🙂

    Anyhow- my 2 cents, for what they’re worth.

    • TChanMD

      Hi Dr. Gibson,
      Thanks for your input! Multiple pearls in this post about the big picture. Track records important – and Greg has some ‘duty to report’ as you state, so that the PD can put together the big picture. But does bias also occur more often because of this??

      • Michelle Gibson

        Where there are concerns about patient safety, then bias issues might need to take a back seat. I think my job as a PD is to be fair about these things. Depends on how bad the issue was – but the people we miss are those that always fly just under the radar until something glaring happens, and then there is a lot of 20/20 hind-sight. They need help, but don’t get it if no one sees the pattern. People are absolutely allowed bad days (heck, I have enough of them!) but if they’re having too many bad days, then they need help/support and I need to worry about that.

        Still curious about the “at risk” thing – that’s a bias right off the bat, and presumably wasn’t forwarded to the brand-new attending without reason. This probably tipped me into thinking Greg should talk to the PD. As a PD, I wouldn’t forward-feed that info without good reason – and one bad day doesn’t constitute a “resident at risk”.

        PDs are (or I think anyway) the keepers of the big picture. Info should flow to us, but maybe not out without compelling evidence, if that makes sense.

  • Sandy Dong

    Thanking stars that Tammy did not name the nurse. General rule is don’t post on social media you wouldn’t says in person in public. Tammy should be encouraged to delete the post and meet up to talk about more positive ways to vent. At least sleep on it before hitting “send”.

    • TChanMD

      Thanks for sharing your thoughts, Dr. Dong! It’s so true…. Sleep before send! 😀

  • Eve Purdy

    Thank you for the great post. As a third year medical student, active on social media this is one of my biggest fears. I know that fears about professionalism are what keep many of my peers from engaging more actively with this remarkable online community.

    Though I am careful about what I post, and agree with the above comments on how to stay professional on SoMe, what if I get it wrong? What if I misjudge and what if I mess up? I am grateful to see the very rational responses of program directors posted above. Are these responses just those of social media savvy PDs or could the same rational, learner-centred responses be expected by most “in charge”?

    At our medical school, third year students work with small groups of first year students through cases related to professionalism. The hope is that from day one medical students begin to understand just what a privilege and responsibility it is to be a part of the profession. This year I was lucky enough to facilitate a group. Much of the discussion centred around social media and we discussed cases very similar to this one. Every first year medical student in that room would have pegged this as unprofessional, so why then do these posts (or ones slightly less blatantly unprofessional) continue to pop up? I think it’s because it is very easy to identify unprofessional behaviour when you are reading another person’s posts but we are notoriously bad at self-evaluating. I offered a few practical tips to help with this self-evaluation to first years worried about professionalism on social media.

    1) Gut check: if it feels wrong it probably is. Don’t push the send button.
    2) Ask yourself “why?” and “why here?”: Challenging yourself to answer these questions before posting on social media should help make sure that the right message gets out to the right audience.
    3) Listen to feedback and give feedback: If you are lucky enough to get the type of feedback discussed in the previous comments you HAVE to be humble enough to listen to it. Along the same lines if a peer posts something that isn’t quite right you have a responsibility to let them know (in a professional way of course).

    • Brent Thoma

      Great response Eve.

      I especially like the “Why?” and “Why here?” questions. It’s always important to think about what we’re trying to accomplish and if the use of SM is the best way to do that. In some cases it might be. In this case, there are certainly better ways to vent.

      I find feedback key in the blog-o-sphere. Getting another perspectives, especially on anything that has the potential to be unprofessional, provides an additional layer of safety.

  • S. Ludlow RN

    The lure of Facebook as a private platform can be misleading. Before posting anything, running the comment through your ‘internal filter’ is very important. As a medical professional (MD, RN, RT etc) it is vital to maintain a level of professionalism in all forms of social media. This time the rant was about a fellow health care provider. Next time it could be about a patient which would violate provincial privacy laws.

    Employers of all kinds use IT professionals to monitor social media use by both current and future employees. Once it’s on the net, it’s there forever. Be sure that your posts or tweets do not bring into question your ability to follow privacy policies or to deal with interpersonal conflicts.

    Perhaps the nurse could have clarified the orders with the resident, since she is the MD that wrote them. In the interest of patient safety, if the resident was not receptive to that discussion, going to the attending was the appropriate course of action. A key element is for Tammi not to take the nurses action as a personal attack. Nurses question orders all the time. Whether it’s to clarify or because we don’t agree, it’s always in the best interest of the patient. Being prepared for these discussions is an important part of working together as a team in the ER.

    Greg needs to have a discussion with Tammi very soon. If it is not dealt with it, these things tend to balloon out of control.

    • Lindsay Melvin

      Could not agree more. As an Internal Medicine resident, some of my best and worst experiences have taken place in the ER – the environment is busy and often hectic, but usually, everyone is just trying to do what is best for the patient. It is imperative everyone stays on the same page. Exactly as pointed out above – these discussions are important to have with eachother, and provide some of the richest learning experiences.

      It is important to remember that even though social media feels private (“My profile is locked!”) it is actually incredibly public. Anything that goes on social media should be something one would be willing to share in person, face-to-face.

      I don’t believe people often consider their employees policies (for right or wrong) when posting on Facebook, Twitter, etc. However, there are standards as adults and human beings that, for whatever reason, is sometimes forgotten when Facebook becomes someone’s private diary. It isn’t.

      I would contact Tammi ASAP and have to remove the post, explain why it was inappropriate, and ask her to apologize to the nurse in question. I would also probably have a chat with her about the use of social media and thinking twice before posting anything emotionally charged.

      As my mentor once told me: If you feel emotionally involved in a situation giving feedback, hold off until you can be neutral. Strong emotions can lead to crossing the line in professional settings (anger & frustration especially). The same applies to social media in the professional realm I believe.

      • TChanMD

        Thanks Sherri & Lindsay! Two beloved friends from my IRL world. Love having you share your thoughts!!

        I think both of you hit the nail on the head… #SoMe is an extension of your identity is all. I designed this case, however, with the complexities of real life situations. Sometimes those of us who grew up with #SoMe at our finger tips remember the boundaries… but it is also easy to forget as well – esp when emotions run high. And you’re tired. And disinhibited.

  • amywalsh

    The fact that this was posted the Facebook is actually less concerning to me than other professionalism issues here. If she had posted something reflecting on her emotions alone (e.g. “Frustrating night at work last night, had a disagreement with a nurse, stressful”) I don’t think there would be much of an issue at all. Certainly the broad and rapidly increasing audience is concerning, but I guess I naively assume that people who have grown up around Facebook know that their statuses can become very public very quickly and understand the potential consequences of this. (When/if that’s not the case, certainly further guidance is needed)

    Previous commenters made the great point that looking at the underlying reason that this grievance found itself on Facebook is very important. Especially with residents that are known to be at risk, a very reasonable explanation may be overlooked because of reputation, or it may call attention to a structure that does not allow residents to voice their concerns in a more constructive fashion.

    Much more concerning is the attitude that physician orders cannot or should not be questioned. In my view, physicians are experts in creating treatment plans while nurses are experts in executing treatment plans (rather than the historical, hierarchical notion of physician as the “boss” of a healthcare team). Certainly, you want the person executing a plan to have a clear understanding of what they are doing and why, and if you can’t explain your rationale for doing something you probably shouldn’t be doing it in the first place. A resident that cannot accept that healthcare is not a hierarchy will struggle long term and likely their patients will suffer as well.

    • TChanMD

      Thanks for your insightful post Amy. I totally agree that this case has many layers. The surface is the Social Media…. but again, as I have been saying a lot lately, the “Medium is the Message”. Things that we used to just say over coffee or rant in the change room… people sometimes are posting online. But often it’s the undercurrent of the whole situation that needs to be examined.

  • TChanMD