SNSs have become ubiquitous in modern society. A large part of everyday information gathering, expression, communication, and social interaction has been transferred to this medium [49]. This phenomenon is also evident in our studied sample, as just over three quarters (75.4%, n = 753) of all surveyed and eligible respondents are SNS users. This is consistent with the findings of a recent scoping review, where investigated research reported from 50% to 80% of responders being SNS users [15]. Facebook is the predominant SNS (91.6%) while Instagram (63.1%) and LinkedIn (52.1%) are 2nd and 3rd respectively. Apart from the fact that these are the most important SNSs, the results mirror the distribution of SNS usage in the general population (GP) [50]. The median age of our studied population is 35 years, which places them directly at the nascent stage of SNSs and perhaps somewhat limits the knowledge and appeal for new and emerging SNSs like Snapchat (6%) and TikTok (4.6%). Twitter (10.4%) has never been a popular SNS in Europe or Croatia and YouTube is surprisingly low (32.9%), even though 71% of the Croatian GP uses YouTube [50]. This could perhaps be a “semantic” discrepancy because YouTube usage does not require an account, so not having a profile does not necessarily equate to a lack of use. However, there are interesting statistically significant differences between the two studied groups with DMDs being statistically significantly more likely to have an account on Facebook (χ21 = 9.271, p < 0.01), Instagram (χ21 = 19.350, p < 0.01), Snapchat (χ21 = 4.967, p = 0.026) and TikTok (χ21 = 8.862, p < 0.01). MDs are statistically significantly more present on LinkedIn (χ21 = 6.637, p = 0.01) and YouTube (χ21 = 6.584, p = 0.01). The differences can be partially explained by the fact that the DMDs in our studied population were predominantly (69.1%) and statistically significantly more (χ21 = 164.481, p < 0.001) employed in private practice. It is possible that DMDs are using Facebook, Instagram and TikTok as marketing tools for self-promotion or advertisement of personal dental practices, as these are the main popular marketing platforms for advertising. Since the market in Croatia is saturated with DMDs and there is also a large dental tourism business, SNS platforms provide great tools and opportunities for advancing patient recruitment, patient communications and education [51]. One of the reasons for such differences in LinkedIn usage among the MD and DMD population in Croatia is that LinkedIn has been used recently as a platform for job recruitment of MDs, with a significant number of MDs emigrating from Croatia after being contacted by head-hunter agencies via LinkedIn or other SNS sites [52, 53]. YouTube is used as a teaching tool during undergraduate and postgraduate education for MDs, which could explain the difference in usage of that platform.
Regardless of individuals being active or passive in the online environment, all information, activities and actions on the internet are traceable once posted, so individuals have to act accordingly [31]. Even though many people are active on SNSs, only a smaller number are in careers that uphold certain professional standards, where the general public assumes they will behave professionally. In contrast to individuals from the general public, who can be passive in the virtual environment and are simply required to abide by general SNS rules for content, this small group of professions, which includes HCPs, according to the findings of a recent study should play an active role in online media [32]. By being required to follow, unwritten, stricter protocols, HCPs carry a greater burden of duties. This could make their self-perception of their e-professionalism much more rigorous. Results from our research reflect this in two ways. First, only 7.4% of the total HCPs in the sample state that they are “more active than passive” or “exclusively active”. This low activity on SNSs can be explained by a reluctance to post content that will be scrutinized more than content from sectors of the population that are not held to such a standard of professionalism. It is easier to play it safe by being inactive than to suffer the consequences of potential mistakes. Being inactive should not be confused with a lesser usage rate. Both groups are heavy users with 81.1% using SNS sites at least once a day, with DMDs being statistically significantly more online with access 5 to 10 or more times per day (U = 54,641.5, p = 0.003). Mobile devices are the preferred medium for accessing SNSs, with DMDs again being statistically significantly more inclined towards these devices than MDs (χ21 = 11.258, p = 0.001).
To explain the second reflection on our research we must start by addressing the perception of professional behaviour. The perception of e-professional behaviour of our study group is very similar to that in previous research, both from our group involving the student population [13], as well as other authors’ research on practising HCPs [12]. Clear legal and HIPAA violations are perceived as highly unprofessional and there are no differences between groups in those items. However, the items “Photos of patients/client” and “Posts describing an interaction with a patient/client that does not reveal any identifying information” significantly differ with DMDs being more open to these items. Dental medicine is a field of medicine with a strong visual aesthetic, and educational content is most often conveyed through visual representations of treatment options. A recent study by Douglas et al. demonstrates that Instagram, being a very visually driven SNS, can be successfully used in dental education [54]. As DMDs are educated and consequently possibly desensitised to such content, they perhaps lose a high sensitivity of professionalism perception to such content. Finally, the item “Endorsements of a pharmaceutical or health product without a conflict-of-interest disclosure” also statistically significantly differs between MDs and DMDs. Pharmaceutical companies are not engaging aggressively with DMDs for drug/material/therapy application, as they do with MDs. This could explain DMDs not sensitized to such transgressions. As this instrument only examines individual items, overall perception could not be measured and we decided to use a coding scheme to categorize the items and develop the ePACI index.
As previous coding schemes had been developed for a different era of professionalism and especially in the wake of the “medbikini affair” [39, 55], a re-examination of professional standards became necessary and a SMePROF coding scheme that included a SMePROF rubric for the assessment of unprofessional content on Facebook was developed by Vukušić Rukavina et al. [40]. Categorizing of content has been arranged in three distinct groups: professional, potentially unprofessional, and unprofessional, taking into consideration new and updated perceptions of the professional online behaviour of HCPs. As the SMePROF coding scheme [40] can now be percieved as the centre value for e-professionalism, tendencies of professionalism can be explored: either towards a more lenient, relaxed perception—liberal, or a more cautious and rigid perception—conservative. PCA confirmed our initial coding of the modified White et al.’s e-professional behaviour perception items [12]. Four PCA components can be categorized into two fields: professional (somewhat unprofessional behaviour, professional behaviour) and unprofessional (serious unprofessional behaviour, illegal and condescending behaviour).
Behaviours in items forming the component somewhat unprofessional behaviour could be unwanted because they shed a bad light on the perception of HCPs on SNS [14]. The component professional behaviour experienced the most revisions from its perception in previous literature and introduced context as an important factor in judging a post on SNS. Showing alcohol consumption is unprofessional only in certain and very specific contexts (such as in the medical/dental office, or while wearing physician’s attire) [40]. Also, the opportunity to express opinions on SNSs is something that all users have and should not be perceived as damaging to professionalism. Excluding MDs and DMDs diminishes their basic right of free speech and robs the overall discussion of another (HCP’s) opinion [56].
Behaviour and posts in the serious unprofessional behaviour remained in the realm of activity which should evoke a formal response from governing bodies [15, 29].
Finally, the component of illegal and condescending behaviour is formed by two items describing illegal activities, and interestingly a third item—expressing superiority based on professional status. Several studies, including our current results, have reported the first two items as being the highest ranked in the perception of unprofessional behaviour [12, 13, 57]. The fact that the item expressing superiority based on professional status aligned with the last component (illegal and condescending behaviour) instead of with, for example, the first (somewhat unprofessional behaviour) shows that DMs and DMDs are very conscious of this kind of behaviour, its ethical and social consequences and the potential for poor reputation that it can represent.
While reviewing literature, although there are available scales and indexes in some form or another for the student population [44, 58], we did not encounter a way to easily measure and scale perceptions of e-professionalism among graduate MDs and DMDs.
The ePACI index provides a simple tool that allows us to assess and compare professionalism perceptions of and between different groups of HCPs. The deviation towards liberal may expose HCPs more to the dangers of SNSs and those HCPs need to be educated about the dangers of SNSs, or there could be negative impacts to their professional reputation. Those respondents who fall into the conservative category may be more sensitive to the dangers of SNSs. It could also be understood as some form of self-protection mechanism that shields users from the dangers, but may also limit their ability to exploit all the benefits SNSs provide. This is important for all HCPs because these deviations can have serious, although contrasting, effects on e-professionalism.
In this study the ePACI index values deviated for both MDs and DMDs towards the positive—conservative (mean = 0.36, SD = 0.433), with no statistically significant differences between the two groups. This overall coherence of perception, and a deviation to a more careful consideration of professional behaviour on SNSs can be explained by the higher expectation of HCPs themselves regarding their online presence, and their awareness of the general public’s assumption that they will behave professionally. This hypothesis integrates well with our results of HCPs’ unwillingness to act actively on SNSs, but rather be more passive, thus shielding themselves from peer and public scrutiny. Interestingly, even employment type did not a have a significant influence on the ePACI values of both groups, perhaps emphasizing more the underlying high standards of professionalism perception even in the face of business-driven motives. The age of the respondents, however, did have a statistically significant influence on ePACI values. Our results show that the increasing age of HCPs correlated with a deviation slightly towards the positive values of the ePACI index. Also, there are statistically significant differences between respective age groups, with the digital natives (< 35 yrs. old) being the most liberal of the four examined age groups. Possible explanations for this are that younger HCPs are more versed in how to navigate SNSs and are more accustomed to SNSs being a part of their identity [2]. This can lead them to be more error-prone and more likely to post unprofessional content [12, 14, 59]. This was also seen in the definitive results of the mixed methods study conducted by Vukušić Rukavina et al., which found more unprofessional content on the Facebook profiles of students (5.8%) than faculty (0%) [40]. Age can also play a role in the terms “older and wiser”, meaning more cautious about posting unprofessional behaviour online, was proven in studies comparing students’ and faculties’ online behaviour [15]. Medical students were proven more likely than faculty to display content they would not want patients to see (57% vs. 27%), report seeing inappropriate content on colleagues’ SNS profiles (64% vs. 42%), and ignore harmful postings by colleagues (25% vs. 7%)” [47]. Another predictor of liberal perceptions is the access frequency: the higher the daily consumption of SNSs, the more liberal the perception. This is again in line with the idea of comfort and knowledge of SNS usage and higher digital literacy skills. The final piece of evidence adding to this idea is the number and type of SNS profiles correlation to ePACI. Not having one of the seven major SNS profiles we included in our questions, or having only a Facebook profile (today's “old person’s SNS”) was a statistically significant predictor of having a more conservative perception of e-professionalism. The more SNS profiles one had (between 2 and 7 profiles), and the more “modern” they were (Instagram, LinkedIn), the more values deviated towards liberal. We perceive any deviation (either towards liberal or conservative) from the centre value as an error in perception. However, this mechanism of perceiving all such behaviour as unprofessional brings with it the danger of missing the opportunities that SNSs bring to medical care, professional reputation, business, and so on [15]. This emphasizes the need for education—not only for nascent HCPs during graduate studies but for all levels of HCPs, particularly those in the latter stages of their careers. Walton et al. have stressed that there is a need for instructions for use of these developing media and communication training for HCPs before they begin using SNSs for their professional work [60]. Mosalenajad et al. indicate that education can improve professionalism on SNSs and set appropriate boundaries between HCPs and the public, but also how it can help HCPs embrace and execute the active role society expects from them as professionals [32]. Recognizing one's need for further education is a step in the right direction, and 74.1% of our respondents stated that they would benefit from additional guidelines on e-professionalism. Exposure to problems of e-professionalism by opening debate and dialogue with HCPs at all levels to raise attention and awareness, especially on conflicting or blurred issues, could perhaps alert an even larger percentage of HCPs to the need for guidelines on e-professionalism [15, 32, 59]. The best example of a successful debate is the #medbikini movement, which sparked awareness, opened a debate, and led to the re-examining and directing of e-professionalism towards a new, better understanding of professionalism on SNSs [40].