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We sit down with anesthesiologist Jonathan Cohen to explore the impact of social media on the medical learning environment. Recent posts by senior physicians have sparked debate on the public shaming of trainees and the consequences for psychological safety in medicine. Jonathan shares insights on how online behavior can affect the dynamics between mentors and trainees, the importance of creating a culture that views mistakes as learning opportunities, and the ethical considerations surrounding social media use in health care.
Jonathan Cohen is an anesthesiologist.
He discusses the KevinMD article, “Physicians’ social media criticism of trainees sparks controversy.”
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Jonathan Cohen. He’s an anesthesiologist. Today’s KevinMD article is titled, Physicians’ Social Media Criticism of Trainees Sparks Controversy. Jonathan, welcome to the show.
Jonathan Cohen: Thank you so much for having me, Kevin.
Kevin Pho: So, Jonathan, you’re an anesthesiologist. Just briefly, before we get into your article, share your story and journey.
Jonathan Cohen: I’m an anesthesiologist, also trained in critical care medicine, although I practice solely anesthesiology now at Moffitt Cancer Center in Tampa, Florida. I have a master’s degree in patient safety, and that’s really where the focus of most of my interest and work lies—in patient safety.
Kevin Pho: As you know, I’ve been in the social media space for a while now. So, I’ve seen the evolution of that intersection between medical training and social media, and it has changed so much because there are so many tools that come out almost on a yearly basis. What led you to write this article in the first place? And then talk about the article itself.
Jonathan Cohen: Well, I think it was seeing two posts in a relatively short amount of time that were criticizing trainees. That’s something that doesn’t sit well with me. A lot of that comes from understanding how this impacts patient safety. Certainly, these aren’t the only two posts that are out there criticizing trainees, but when I was in graduate school, we were introduced to the concept of psychological safety through the work of Amy Edmondson and her book at the time, Teaming.
Her next book, The Fearless Organization, talks about the role psychological safety plays in keeping people safe. Psychological safety is, at least in part, the ability to make mistakes and admit not knowing something without the fear of embarrassment or being ignored or blamed. When you criticize people openly, it kind of shuts down that psychological safety.
Kevin Pho: Can you tell us what these posts said, without, of course, going into too much detail?
Jonathan Cohen: Yeah. One of them was critical of a trainee who didn’t know something during an operation—in a procedure in the operating room. Another one was about a trainee who was wearing a shoe cover as a bouffant cap in a procedure suite. Another one that comes to mind criticized residents for ordering a test in a patient with sepsis when the source of infection was obviously from somewhere else.
The thing is, especially in the case of the shoe cover, I’ve grabbed a shoe cover before as a bouffant. I never put it on, but I came pretty close. These are all stressful times for trainees, and it’s acceptable to see these mistakes. I think it’s best—and it’s been said before—that we praise people in public and criticize them in private. Social media allows us to criticize people to a large audience very quickly.
I mentioned in the article some mistakes I’ve made myself. Fortunately, these were before social media, so people would chuckle or laugh in a group, and we’d all get embarrassed and get over it. But now, with the ability for someone to pull out their phone and post, it can spread very quickly. All of these posts have been taken down, incidentally, but before they were removed, they collectively had over a million views.
Kevin Pho: Which platforms were these posts available on?
Jonathan Cohen: The ones that I saw were on Twitter (now X).
Kevin Pho: And Twitter, of course, is a public forum. Do you ever see these posts on physician-only groups, like on Facebook, or in closed groups? Or are they primarily in forums accessible to the public?
Jonathan Cohen: I’ve seen them pretty much everywhere over the years. It’s important to say that, in no case, were the people who were involved explicitly identified. But it doesn’t necessarily make it anonymous because if you’re involved in that situation and you pull up Twitter and see something that describes you, you’re going to know it’s you. The people who were with you at the time are going to know it was you. People who work at the same institution and know the person who posted can reasonably infer who you are.
Kevin Pho: So, it’s not really anonymous at all. And to be clear, were these posts by attending physicians, other hospital staff, or other trainees? Who made these posts in general?
Jonathan Cohen: One of them was by an attending physician, one was by a resident, and one was by a nurse.
Kevin Pho: Okay. So everyone. And as far as you could tell, you said they were taken down. What was the immediate response to these posts in general?
Jonathan Cohen: It was mixed. What led to them being taken down was that there was a fair amount of pushback against making posts like that, which is encouraging. But there were certainly people who supported it and who defended it. Some believe that shaming is a way of encouraging people to perform better. We know that it does, to a very limited degree, but it’s very short-lived. If you embarrass someone, they may perform better in the acute phase, but we also know—and there’s a growing body of evidence behind this—that there’s a lot that we don’t see that happens.
When you embarrass someone, maybe they’re not going to want to work with you in the future. Maybe they’re going to avoid doing something new or pointing out things that they see as being wrong because they’re afraid. They don’t want to be the subject of the next post.
Kevin Pho: As far as you know, is there any education among the hospital staff and attending physicians regarding appropriate social media behavior?
Jonathan Cohen: There is, at least at our institution. We have a social media policy. I know that it varies by institution. There’s a lot of talk about what’s appropriate to post and what’s not. Sometimes, telling stories—as long as they don’t include a photo or anything explicitly identifiable—may be acceptable to a certain degree.
A lot of these posts need to be captured and seen by someone from the organization who will say, “This is not appropriate; it needs to be taken down.” I think there’s a growing emphasis on what’s appropriate to post and what’s not, but some posts still slip through.
Kevin Pho: Now, to your knowledge, what was the impetus behind posting it? Was it purely just for entertainment value? Do you think there was a legitimate educational motive to these posts? Or were they just doing it to get views? What do you think was the motivation for shaming the residents in the first place?
Jonathan Cohen: I think some of it was for entertainment. Some of it was probably to express frustration with the actions of others—not knowing something or not handling a situation the correct way. But, again, I think the best way to handle that is to do it in private, not in a public forum. In a public forum, you’re limited by the space you’re provided. You can’t tell the whole story. It’s important to realize that these posts are one person’s perception, not the perspective of both parties involved.
It’s easy to criticize someone for not knowing something. I’ve been in an operating room before as a student, as I’m sure you have too. When the lights are on you and you’ve been in there for hours, you can forget things that you otherwise would know. It doesn’t mean that you don’t know it.
Kevin Pho: Let’s talk about this from the medical trainee standpoint. You alluded to this earlier—the effect of shaming on the learning process. As far as you know, have you had any discussions with medical trainees about how this affects their psyche when they see posts about their fellow trainees being shamed online?
Jonathan Cohen: I haven’t had any direct conversations with them, but there is more discussion now in medical curriculum about the importance of creating psychological safety in health care. There’s been an explosion of articles on how to create that environment and the importance it has on trainees in terms of getting them to participate and come forward.
It’s not a conversation related to these specific posts, but, yeah, we are mindful of what we do and the effects that it could have on somebody else. Now, to be clear, it’s easy to talk about this; it’s hard to be perfect in it. I know for a fact that I’ve engaged in these types of behaviors before that may have shut people down and may have shamed them. In fact, I probably did shame people. It’s not something I’m proud of, but it’s not something I paid attention to at the time. I’d like to think I’ve gotten a lot better over time, now that I realize the importance of treating them well and engaging in behaviors that don’t shame people.
Kevin Pho: Does social media play a role when it comes to highlighting mistakes that we could learn from? We have morbidity and mortality rounds, which highlight medical errors in a closed setting, but do you think social media can play a role in amplifying the publication of potential mistakes more as a learning tool rather than a shaming tool?
Jonathan Cohen: Absolutely. The key is how it’s handled and how it’s addressed. Are we focusing on the event, or are we focusing on the people who made the mistake? We know that people make mistakes all the time, and focusing on the people and the errors they make doesn’t make it less likely to occur. We’ve known that for decades in industries outside of health care as well. So, I think it depends on the intent.
If we focus on the case itself and what can be learned—without focusing on the people—I think that’s helpful. Instead of posting other people’s errors, why don’t we post our own? If we share our own errors, we’re admitting that we’re fallible ourselves, and we get other people to come forward and admit their errors as well. It takes the shame away from it. It shows that this is part of learning and growing. It’s a continuous process throughout our entire lives.
Kevin Pho: In these particular cases, were there any repercussions against the people who posted these messages on X?
Jonathan Cohen: Other than the social response and people telling them it was really inappropriate, I’m not aware of any repercussions.
Kevin Pho: Whenever physicians, nurses, or medical staff post stories from the operating room or clinic, there is always the risk of a HIPAA violation by inadvertently revealing patient information, right?
Jonathan Cohen: Correct. The same is true with case reports. I come from a time when we would just post a case report without receiving permission. We’d make sure there were no identifying characteristics, but if we’re reporting a rare case that occurred, patients can certainly recognize themselves in it.
I think that has changed dramatically over time. Now, we’re getting permission to publish case reports even when we’ve completely de-identified them. We need to pay attention to that with social media as well. You don’t want a patient hearing their story online.
Kevin Pho: Let’s talk about the evolution of social media in general. Many new platforms have come out since I first got involved with social media. Now we have medical trainees and physicians who are influencers and post content online. Where do you see the role of social media in medical education going forward?
Jonathan Cohen: I’m personally a late adopter. I joined X just a couple of years ago, and I started kicking myself immediately for not joining sooner. There’s so much I have learned from it. I found articles I never would have been exposed to. I’ve met people from institutions across the United States and the world, and I’ve done work with them as a result of social media.
So, I think there’s still a lot to be gained from it, and there will continue to be in the future. As journal subscriptions fade and people stop reading hard copies of journals, publishing things on social media and getting them out there for a larger audience helps to expand knowledge in a variety of areas of medicine.
Kevin Pho: What are some tips you have for other late adopters, like other attending physicians who may not see any benefit to social media and only see the negatives, like your story about attendings shaming residents?
Jonathan Cohen: I think it’s just like anything else—watching TV or the news. You have to filter what you’re looking for and realize that there are some discouraging things, but there’s still plenty of good out there. It’s about finding the right platform for the right message—whether it’s Instagram, LinkedIn, Twitter, or Facebook—and then finding the community you want to be involved with and joining them.
Kevin Pho: These episodes of resident shaming—are they isolated? Or have you seen an increased frequency of these types of posts?
Jonathan Cohen: I don’t think I’ve seen an increased frequency. It’s been steady. What prompted me to write this article was seeing these two posts within a short amount of time. There wasn’t any malice, I think, in the original posters. They weren’t doing it to be mean. I think they just didn’t realize the effect of these posts—not only on the people involved but also on others who see them.
If you and I argue outside of social media, it doesn’t just affect you and me; it affects the people around us who see that interaction. On social media, if I criticize or shame someone, there could be tens or hundreds of thousands of views. What effect does that have on those people? Are they going to be less likely to come to me because they don’t want to be in my next post? Are people at other institutions going to say, “Wow, an attending criticized a resident. I hope my attending won’t criticize me like that”? It causes people to pull back. There’s this huge ripple effect we need to be mindful of.
Kevin Pho: You publicized this story on KevinMD. Any responses from attendings or medical trainees after you shared it?
Jonathan Cohen: A couple of people have come up to me and talked about their perception of some of these posts and the effect it has on them. A couple of years ago, I started adding slides on my own errors to my presentations on medical errors. That really gets people talking because, once you open up about your own ability to make mistakes, it takes the shame away. Other people start admitting their mistakes, and it creates a dialogue around it.
Kevin Pho: We’re talking to Jonathan Cohen. He’s an anesthesiologist. Today’s KevinMD article is titled, Physicians’ Social Media Criticism of Trainees Sparks Controversy. Jonathan, we’ll end with some of your take-home messages that you want to leave with the KevinMD audience.
Jonathan Cohen: I think social media is a great tool. You just need to use it responsibly and pay attention to the fact that your actions with one person can affect many more. Social media just has the ability to amplify that beyond probably your intended audience or what you originally intended.
Kevin Pho: Jonathan, thank you so much for sharing your story, perspective, and insight. Thanks again for coming on the show.
Jonathan Cohen: Thank you so much for having me, Kevin.
