Saturday, December 1, 2012

Why don't we see patients in our pajamas?

Professional identity and social media are being hotly debated ever since the rise of Facebook.  The topic raises questions about how physicians should  behave on social media.

The fact is that social media is bringing to the forefront something that has been around for ever.  Lets look at some of the background literature on this.

Goffman in 1967 wrote in the "Interaction Ritual - Essays on Face-to-Face Behaviour;
"Every person lives in a world of social encounters, involving him either in face-to-face or mediated contact with other participants.  In each of these, he tends to act out .... a pattern of verbal and nonverbal acts by which he expresses his view of the situation and through this his evaluation of the participants, especially himself. Regardless of intent, he will find that he has done so in effect.  The other participants will assume that he has more or less willfully taken a stand, so that if he is to deal with their response to him, he must take into consideration the impression they have possibly formed of him."
"When an individual appears in the presence of others, there will usually be some reason for him to mobilize his activity so that it will convey an impression to others which it is in his interests to convey"
Schlenker wrote about Impression Management and self-presentation:
 "Impression management is the goal-directed activity of controlling or regulating information in order to influence the impressions formed by an audience.  When people are trying to control impressions of themselves, as opposed to other people or entities, the activity is called self-presentation."
Schlenker goes on to discuss that self-presentation does not have to be Machiavellian or purely there for self-advancement or self-prormotion.
"Self-presentation is a fundamental feature or characteristic of interpersonal experience.  It is inconceivable to discuss human social behavior without employing the concept.... we package information to help audiences draw the right conclusion.  This packaging is a pervasive feature of interpersonal behavior."
One must be aware of how people are perceiving and responding to our self-presentation so that we can deliver the package to meet the appropriate goal - something that does not have to be deceptive or immoral.  It may take as much social skill to create an accurate self-presentation as a misleading one.

This fact has been highlighted by the popular press with books like, "How to win friends and influence people" and "Getting to yes".  Social media has truly brought this home into every minute of our awake state.

Sherry Turkle in her NY Times op-ed talks wistfully about the loss of conversation for mere connection.
"Texting and e-mail and posting let us present the self we want to be.  This means we can edit.  And if we wish to, we can delete.  Or retouch: the voice, the flesh, the face, the body.  Not too much, not too little - just right.
She laments how we are getting comfortable with the intrusion of technology into "real" life
"We expect more from technology and less from one another...We use technology to define ourselves by sharing our thoughts and feelings as we're having them.  
Nathan Jurgenson has coined the term "Digital Dualism" for this separation between online and offline and calls it a fallacy.
"Instead, I want to argue that the digital and physical are increasingly meshed, and want to call this opposite perspective that implodes atoms and bits rather than holding them conceptually separate augmented reality."
And in the Atlantic he writes,
"Emile Zola stated back in 1901, 'You cannot claim to have really seen something until you have photographed it.'  Today, we joke, 'It did not happen unless it is posted on Facebook.  Photography caused a global sensation around the new possibility: to document ourselves and our world in new ways, in greater detail and in lasting permanence."  
Just as photographers who may not be able to look at a scene without imagining how it would look through a camera's viewfinder, today's digital native may perceive "reality" by how it could be posted on Facebook.  Our parents took photographs on vacation trips and did looooong presentations at dinner parties with Kodachrome slides!  We now take photos with our smartphones and post these instantly on social networking sites.

But every time we do this, we are doing impression management and more specifically self-presentation.  We are constantly creating, modifying and managing our identity in the social networking space.  We are consciously or subconsciously aware of our environment and our perceived audience and have have an impression of how they perceive us and how each share in the social space affects that perception.

This again is just an extension of our life as usual.  Physicians wear a white coat and/or a tie or other appropriate clothing when they see patients.  Why don't they wear their pajamas?  There is a perception of what patients think a physician should be wearing.  This has been drilled into us often subliminally as we go through medical schools and residency training.  It may be difficult to break out of that mold.
But we dress differently when we go to watch a football game or to the grocery store.  Thus physicians clearly have a sense of self-presentation for different environments and perceived audiences.

So why do we have all these cases of unprofessional conduct in social media?

Firstly the problem in case of new entrants to the profession might be due to them not recognizing that the rules of engagement are now different.  Some of the folks who saw them as a college kid now might expect to see them as a future doctor.  But more importantly they now may have a new audience that perceives them only as a future doctor.  This is a problem if they have not locked down their social media profile and thus may be visible to the public.

Secondly, any person can make a slip and in a momentary lapse forget to don his social media white coat when interacting on a public forum.

I would suppose that when there is a wide gap between the baseline persona and the self-presentation situation, a person would find that environment more stressful and if not careful, is more likely to commit a bigger lapse of professionalism.

This leads to a question of why can a person not be "himself" (if there is such a thing), instead of having to don all these different personas?  I guess one should study mindfulness or Engaged Buddhism where Thich (Thay) Nhat Hahn preaches how to be truly happy,

"To be beautiful means to be yourself. You don’t need to be accepted by others. You need to accept yourself. When you are born a lotus flower, be a beautiful lotus flower, don’t try to be a magnolia flower. If you crave acceptance and recognition and try to change yourself to fit what other people want you to be, you will suffer all your life. True happiness and true power lie in understanding yourself, accepting yourself, having confidence in yourself."


  1. Neil, this is brilliant as usual. I am going to share this with my community, with full attribution of course!

  2. @Ken thanks! Feel free to distribute.