The Accreditation Council for Graduate Medical Education (ACGME), which oversees accreditation of the majority of US‐based postgraduate training programmes, has identified professionalism as one of six overarching ‘core competencies’ that trainees are expected to attain. The professionalism standards for trainees in urology include ‘respect for patient privacy and autonomy’ and ‘accountability to patients, society and the profession’ 7 .

The popularity of social media and online communication and the public accessibility of user‐generated content have raised concerns about medical professionalism on the Internet. In 2011, the Council on Ethical and Judicial Affairs of the American Medical Association (AMA) concluded that standards of privacy and confidentiality should apply in all environments, including online 6 . The AMA also recommended that physicians consider separating their personal and professional identities on social media.

The AUA has encouraged social media engagement and has published Social Media Best Practices 3 . These Best Practices support courteous, professional behaviour online by urologists and specifically indicate that members’ online activities ‘should be consistent with the AUA's professional Code of Ethics’. AUA members are reminded in the statements that the content urologists generate and share on social media may influence perceptions of the specialty. Non‐US societies have also disseminated similar guidelines on urologists’ use of social media, including the European Association of Urology (EAU) 4 and the journal BJUI 5 .

Social media encompasses a diverse group of Internet platforms that facilitate the creation and dissemination of original and shared content. The personal and professional use of social media among urologists continues to rise. A 2013 survey of American Urological Association (AUA) members estimated that 74% of respondents had a social media account 1 . Of these, Facebook was the most popular among attending urologists (89%) and urology trainees (98%). Most urologists characterized their social media use as being for personal reasons, rather than professional or business purposes 2 .

Using a list of all trainees who graduated from US urology residency programmes in 2015 obtained from the AUA, we queried Facebook to identify public profiles based on name, location and other public data that could be accessible to patients, such as photographs of the trainee and the name and location of the residency programme. Queries were performed in July 2015 to reflect completion of residency training in the academic year ending June 2015. All queries were conducted using a ‘neutral’ Facebook account created for the present study which was not associated with, connected to, or ‘Facebook friends’ with any other Facebook profile. This account was intended to mimic potential queries from patients, employers, or members of the public, and to capture content that would be publicly accessible. Profiles were reviewed for ‘unprofessional’ or ‘potentially objectionable’ content using a prospectively designed rubric based on online professionalism guidelines by the AUA, AMA and ACGME (Table 1 ). The authorship of all unprofessional content (self vs other) was determined. We also noted self‐identification as a urologist, such as a job title or description, and references to urological organizations in each profile. Comparisons of the presence of unprofessional content between demographic groups were performed using the chi‐squared test. Assessments were conducted by two independent reviewers; significant differences were resolved by consensus among all authors.

Facebook is the most‐accessed social media platform among urologists 1 . We selected Facebook as a representative platform because of its popularity and because it has been accessible to anyone aged ≥13 years since 2006, including potential patients and employers. Furthermore, current trainees are likely to have been familiar with Facebook prior to medical school.

In the overall sample, the presence of unprofessional or potentially objectionable content did not differ significantly for men vs women (63/160, 39% vs 17/41, 42%), Doctor of Medicine vs Doctor of Osteopathic Medicine degree‐holders (76/192, 40% vs 4/9, 44%), graduates of allopathic vs osteopathic and military residency programmes (74/189, 39% vs 6/12, 50%), or users who did vs did not self‐identify as a urologist (40/85, 47% vs 40/116, 35%; all P > 0.05).

To assess whether social media content could potentially reflect on urology as a specialty, each profile was reviewed for self‐identification as a urologist. Examples of self‐identification included ‘urologist’ or ‘urological surgeon’ as a job title, comments about working as a urologist, or posts about performing urological procedures. In our sample, 85 of the 201 profiles that had been positively identified as belonging to the trainee (42%) self‐identified as a urologist. Among these, 40 (47%) contained unprofessional or potentially objectionable content.

The authorship of each instance of unprofessional or potentially objectionable content was determined based on who created or posted the content. For example, a photograph depicting the urologist as intoxicated but posted to the urologist's profile by someone else was considered non‐self‐authorship; a profane comment by the urologist in reply to this photograph was categorized separately as self‐authorship. In our sample, the unprofessional or potentially objectionable content was authored by the urologist in 53 of the 65 (82%) content categories.

Potentially objectionable content included censored profanity, images of possession or consumption of alcohol, in which it was clear that alcohol was being consumed (e.g. a branded beer can), and appearing in sexually suggestive poses or attire. Images or posts about political, religious or controversial topics were also common, and included comments advocating or denouncing specific politicians, faith‐based organizations, or social issues such as same‐sex marriage or the legalization of marijuana.

The categories and frequency of unprofessional or potentially objectionable content are summarized in Table 2 . Common categories of unprofessional content included uncensored profanity, images of the urologist in an intoxicated state, references to specific episodes of intoxication, and images of being unprofessional at work or professional functions, such as conferences. We also identified multiple instances of protected health information, as defined by the US Health Insurance Portability and Accountability Act of 1996, containing explicit patient data, such as radiographic images where the patient name was visible, or sufficient clinical detail to identify a specific patient, such as a post about a particular complication that occurred during a surgery on a stated date.

Discussion

The rise of social media use among urologists and trainees has engendered concerns about privacy, professionalism, and the patient–clinician relationship. Although most urologists consider their social media accounts, and Facebook in particular, to be strictly for personal use 2, the increased visibility and accessibility of social media content by the public, including patients, colleagues and employers, make these concerns increasingly relevant to practising urologists. This is especially true for those who are newly entering practice and whose professional identities may be most subject to scrutiny. In a cohort of recent urology residency graduates, we found that nearly three out of four urologists had publicly accessible and identifiable Facebook profiles, and a substantial proportion of these contained self‐authored content that was or could be in violation of professionalism standards of national specialty organizations.

Although professionalism is an ACGME core competency, the findings suggest that contemporary residents are posting public content consistent with behaviour that some US medical schools and state licensing authorities would consider subject to disciplinary action. A 2009 survey of US medical schools reported that 60% of schools had found incidents of their students posting unprofessional content online, including profanity, discriminatory language, and depiction of intoxication, resulting in warnings or dismissals in the majority of cases 8. More recently, 92% of US state medical boards reported having investigated online professionalism violations by physicians, including violations of patient confidentiality, derogatory patient remarks, and depictions of intoxication 9. Most of these incidents were discovered and reported by patients and their families. In cases involving online professionalism, 56% of the boards had issued serious disciplinary actions, such as license suspension or revocation. Because residents with multiple instances of unprofessional behaviour may be at higher risk of future violations and repercussions in practice 10, the findings in the present study raise particular concern about the 13% of graduates whose public Facebook profiles contained explicitly unprofessional content.

Among the graduates who identified as urologists on Facebook, about half had posted unprofessional or potentially objectionable content, which may negatively impact public perceptions about urologists or the specialty. Social media guidelines by urological organizations differ with regard to how urologists’ social media accounts may affect the profession. The AUA advises that the organization is ‘best represented by its members’ and social media content ‘may reflect on the AUA’ 3. The EAU suggests including a disclaimer that content reflects only the author's views and does not represent an institution or professional body 4, while the BJUI guidelines recommend doing the same if the author's institutions are identifiable 5. In theory, individuals may strive to post content only on their own behalf and maintain professional separation from their institutions and societies, but in practice, urologists’ online identities are probably more fluid and difficult to disentangle from their affiliations, even with disclaimers. Future studies of patients’ and employers’ perceptions of unprofessional online content would help to clarify the potential impact of this content on individual physicians and the specialty overall.

Urology trainees are not unique among surgical specialties in posting unprofessional content on social media. A 2014 analysis of the Facebook accounts of US Midwestern general surgery residents found that 32% had identifiable profiles 11, a far smaller proportion than the 72% of urologists in the present study. It is unclear whether this difference could be related to specialty‐specific training in online professionalism, regional differences in attitudes toward social media use compared to our national cohort, more careful use of privacy settings among residents at earlier stages of training compared with graduates, or other reasons. In both groups, however, a similar proportion (12% of surgery residents) had posted clearly unprofessional material, suggesting that among surgical trainees who maintain public Facebook profiles, a small but consistent group may require particular attention and counselling regarding their social media habits.

A belief among some physicians is that unprofessional online content is a problem of ‘them’ and not ‘us.’ A survey of medical students and faculty about their social media experiences found that both groups reported seeing peer‐posted unprofessional content significantly more frequently than posting such content themselves 12. For instance, while <20% of respondents had self‐posted profanity, depictions of intoxication, or sexually suggestive material, >40% of the same respondents reported such content being posted by peers. For significant violations, such as confidential patient information, peer‐posting was reported much more frequently than self‐posting. In the present study, however, we noted self‐authorship in the large majority of concerning content. While incidents such as privacy violations may be underreported in survey studies, the present findings suggest that trainees may not fully understand the ramifications of their own content, particularly material that was posted prior to the current stages of their careers.

Definitions of appropriateness for social media content remain imprecise. The guidelines used in the present study are clear about protecting patient privacy and upholding ethical standards, but there is little consensus about topics that should be categorically off‐limits. One reason is that these definitions may be subjective. Trainees are more likely to post content that they consider benign but that faculty and members of the public would consider unprofessional 13. Since as many as one in five physicians has received a ‘Facebook friend’ request from a patient 14, public content is likely to be queried, accessed, and seen by interested parties, including patients. The discrepancy in definitions of unprofessional online content and behaviour may also have consequences in hiring and employment decisions. In a recent survey of surgery residency programme directors, 11% reported that unprofessional content on residency candidates’ social media profiles had adversely affected or ended their candidacies 15.

Taken together, the findings in the present study highlight a need for increased awareness of trainees’ online identities and strengthening standards of professionalism to include urologists’ expanding use of social media. Trainees’ fluency in seeking and sharing digital information, which can be clinically and educationally advantageous 16, raises the question of whether the ‘dual citizenship’ strategy of separating one's personal and professional identities online, as advocated in the guidelines of the AMA 6 and suggested by the EAU 4, is desirable, or even possible 17. Encouraging trainees to understand and self‐monitor their interactions, both online and offline, may be a more sustainable approach to contemporary professionalism 18. Many trainees and faculty, however, may not routinely monitor their public ‘digital footprint’ online 12 and have never read or are not aware of any guidelines on social media use 19. Although the vast majority do report using privacy settings to control the audience of their social media content 1, 12, 40% of the public Facebook accounts in the present study contained material that could have been made more private or removed altogether. Social media‐specific education aligned with published guidelines by urological societies 3-5 and targeted to urologists of all generations remains urgently needed.

Several limitations should be noted. First, because the findings are a cross‐sectional representation of urologists’ Facebook content, we cannot make conclusions about trends in how or what content trainees have posted over time. The point when these data were collected, however, represents a significant milestone at the completion of training and establishment of a professional identity. Second, we did not assess other social media platforms, such as Twitter, which is used by more urologists for mixed personal and business purposes 2, and LinkedIn, which is aimed at professional branding and networking. While Facebook remains the most popular and widely used social media site, both among urologists and the general public, other platforms merit future study as they gain more widespread use and are shown to have tangible benefits for professional networking, research, and clinical practice 20. Third, the sample consisted of one cohort of recent US residency graduates and may not be generalizable to trainees in non‐US systems or to urologists or physicians who have completed training. Individuals aged <30 years, however, as an age group have consistently been the most active social media users since 2006 21, and we would expect our cohort of recent trainees to be part of the demographic with the most experience using Facebook since its public introduction. The high prevalence of unprofessional content found on trainees’ Facebook profiles raises concern about what less experienced users may not know is publicly accessible to their patients and colleagues. Finally, we recognize that definitions of ‘professional’ or ‘objectionable’ may be subjective, which also reflects variation in public expectations of physician behaviour. To minimize these effects, we set our content definitions based on published professionalism guidelines and applied them strictly, with consistent inter‐reviewer agreement. In cases where reviewers were uncertain about whether a specific item met the definition for a content category (e.g. an image depicting intoxication), the item was not included in the analysis of that category.

In conclusion, the majority of recent US urology residency graduates had publicly accessible Facebook profiles, and a substantial proportion contained self‐authored, unprofessional content. Of those identifying as urologists on social media, about half violated published guidelines for online professionalism. As urologists’ social media use continues to expand, greater awareness of trainees’ online identities is needed, with implications for education and professionalism competencies.