#MedBikini and Why “Professionalism” is a Problematic Term
How Professionalism is Weaponized to Control Aspiring Physicians and Protect Those in Positions of Power
A recently published (and soon to be retracted) paper ignited condemnation and widespread backlash for the sexist way it characterized unprofessional social media activity. The issue: Young female surgeons who had posted pictures of themselves in swimwear were characterized as potentially unprofessional, while their male colleagues were not. The internet response was fierce, and health professionals flooded social media with photos of themselves in bikinis with the hashtag #Medbikini.
How could seasoned researchers make such a glaring mistake? The most salient answer: (un)conscious bias. Indeed, data was scrubbed from social media accounts by a male vascular fellow, a male medical student and a male research coordinator for a project that was led by a male vascular surgeon in a traditionally male profession in order to submit a manuscript to a male editorial board. The inherent sexism is undeniable, but it is not the only issue. Indeed, the article is emblematic of how problematic the notion of “professionalism” has become. If “unprofessional behavior” can include anything from hanging out with your friends in a bikini to violating patient privacy and safety, what value does the term actually have?
A Look at the Research
The article titled, Prevalence of Unprofessional Social Media Content Among Young Vascular Surgeons, was published in the August 2020 issue of the Journal of Vascular Surgery. The authors used the vascular surgery directory to compile a list of graduating vascular surgery trainees. Fake social media accounts were created and used to search personal social media accounts. The social media content, which was obtained without the consent or knowledge the the “participants,” was then categorized as being “clearly unprofessional” or “potentially unprofessional” as follows:
- Clearly unprofessional content: Health Insurance Portability and Accountability Act (HIPAA) violations, intoxicated appearance, unlawful behavior, possession of drugs or drug paraphernalia, and uncensored profanity or offensive comments about colleagues/work/patients.
- Potentially unprofessional content: holding/consuming alcohol, inappropriate attire, censored profanity, controversial political or religious comments, and controversial social topics.
Of course, the preceding categories only further beg the question: What exactly did the authors find? Unfortunately, at least with respect to ‘clearly unprofessional content,’ no additional information was provided. This is problematic because the category includes critical items that are important to patient care, and there is an important difference between having an “intoxicated appearance” in a social media post and violating the HIPAA protections of your patients. However, had they not included “potentially unprofessional” content, criticisms pertaining to the heterogeneity of what was considered unprofessional content probably would have stayed in the realm of academic debate. The problem is that the “potentially unprofessional” category alone didn’t provide enough data for publication. Indeed, there were no instances of HIPAA violations, only 6 instances of “intoxicated appearance,” and 12 instances of “offensive comments.”
The inclusion of “potentially unprofessional” content in the study is the root of the controversy. “Provocative halloween costumes” and “provocative posing in bikinis/swimwear” were considered potentially unprofessional, which means that a handful of male students and fellows were scouring their colleagues’ personal social media accounts for pictures of them in bikinis — all in the name of science? — The creepiness of the whole endeavor is undeniable. However, in addition to blatant sexism, there is a broader absurdity in the notion that something like holding/consuming alcohol or expressing controversial beliefs could be lumped into the broader category of behaviors which include violations of patient privacy, slander of colleagues, and illegal drug use.
The Sword and the Shield
The #Medbikini article is emblematic of why “professionalism” is a complicated designator. However, given that the article was limited to social media postings, it only scratches the surface of the issue. In practice, “professionalism” violations can be defined so broadly as to be deemed meaningless. At my own institution, for example, professionalism violations comprise any instance where students fail to “conduct themselves in a professional manner.” In other words, professionalism is literally defined as professionalism. A professionalism violation could qualify as anything from someone not liking your tone, to writing an email that doesn’t start with a formal ‘good morning/afternoon/evening.’
In truth, trivial matters rarely lead to formal professionalism violations. However, this doesn’t make them any less pointed. In fact, most of the time, the threat of a violation alone is enough to dissuade someone from standing up for themselves. For example, in my first year of medical school there was an incident in which students were incorrectly charged for damages at a school retreat. Without verifying that the charges were valid, administrative staff paid for the damages. They then told students that they were on the hook for several hundred dollars that had to be paid back immediately. Most students weighed the costs of objecting, deciding that a few hundred bucks wasn’t worth potentially jeopardizing their relationship with the administration. Those who tried to explain their situation and object to the charges were told that, in addressing the faculty on the matter, they were at risk of a professionalism violation. Ultimately, all the students involved ended up paying the school back for the fraudulent changes.
Because professionalism violations include things like intellectual/academic dishonesty and misconduct in patient care settings, being labeled as unprofessional can deliver a fatal blow to one’s career. In most cases, the risks of standing up for yourself are far outweighed by the potential cost of your actions being labeled or interpreted as unprofessional. In effect, professionalism can be used as a flexible ‘sword’ to exercise control or justify bias. For example, it wouldn’t be hard to imagine a residency director justifying their decision to pick a less qualified male applicant over a more qualified female applicant based on “potentially unprofessional” social media pictures they saw on their profile.
The “professionalism” qualifier neatly packages problematic behaviors into a single category, but doesn’t really tell us anything about what actually occurred. This means that, in addition to its potential for weaponization, the broad nature of “professionalism” can also be used to shield egregious offenders in positions of power. For example, the statement, “Dr. Jones has a history of abusive, sexist behavior” carries very different weight than the statement, “Dr. Jones has a history of potential professionalism issues”. The act itself, not the “professionalism” descriptor, is what is important. Unfortunately, the details pertaining to a professionalism violation are not always readily available.
What Should be Done?
Given the way medicine broadly characterizes unprofessional behavior, it is tempting to think that all that is needed is a more concise definition. However, I’d propose that we do away with the term “professionalism” entirely. In the medical field; however, to suggest we shouldn’t categorize something is almost considered heresy. After all, doctors categorize everything, from drugs and diseases to personality types and ethical principles. However, before you throw up your arms in objection, it is worth asking what value the term offers over simply describing the so-called “unprofessional” behavior.
In order to understand why we should reject “professionalism” as the formal category, we need to understand why it exists in the first place. Unlike the laws of a nation, which are intended to be as clearly-defined and objective as possible, the rules of a professional organization are designed to allow for more wiggle-room. In other words, professionalism is defined to be a fluid concept intentionally. In the context of rapid political/social change and technological innovation, it is easy to see why administrators want a tool that will allow them flexibility in responding to inappropriate behavior. As such, it is not entirely different from formal law in that it attempts to establish a framework that is able to respond to a constantly changing world. However, unlike formal law, there aren’t the same mechanisms in place to correct imbalances of power. Judgments pertaining to professionalism infractions tend to be levied by committees or individuals that sit in positions of power against those with little recourse.
Even if imbalance of power wasn’t an issue, it isn’t clear what value the term “professionalism” offers. From the mundane to the extreme, what more do we learn when we add that the activity was considered “unprofessional”? Consider the following examples:
- Student X was reprimanded for unprofessional intellectual/academic dishonesty
- Resident Y was reprimanded for unprofessional pictures on FaceBook depicting drinking
- Faculty Z was reprimanded for unprofessional sexist comments made to his colleagues
In each of the above examples, describing the action as “unprofessional” tells us nothing new. It is the detailing of what those behaviors entailed that makes the difference. In contrast, consider what would be lost if all we knew was that the above individuals had been reprimanded for unprofessional behavior?
Final Thoughts
Not all research into professionalism is as bad as the #medbikini article. There are cases where studies have successfully explored associations related to “professionalism.” For example, a 2005 paper titled Disciplinary Action by Medical Boards and Prior Behavior in Medical School, did a reasonably good job linking early “unprofessional behavior” to later disciplinary action taken against practicing physicians. However, studies like this one are successful because they evaluate behaviors in their broader context and are less concerned about trying to fit specific actions into a one size fits all definition of unprofessionalism.
The argument I am making is not that we should deny that unprofessionalism exists. Rather, the crux of the issue is that administrators should not (and don’t need to) be able to label individuals as “unprofessional”. Labeling actions as “unprofessional” serves to obscure the nature of that behavior. The system may not have been intentionally designed to discourage dissent or evade culpability, but the opaque nature and inherent flexibility of the term ‘professionalism’ makes it a tool that can be too easily misused.
