Case

A urology residency program director (PD) is evaluating a record number of applicants in a competitive pool, mirroring the national trend. In addition to the large volume of files to review, some aspects of the resident selection process have recently become more challenging. Standardized examinations and medical school courses are increasingly graded as “pass/fail,” complicating separation of candidates by performance. Interviews in the COVID-19 era are now conducted in a virtual format and certain subjective aspects of the applicants are more difficult to assess. The current residents in the program also lament the loss of in-person interview dinners, and with them the opportunity to engage with applicants more personally.

Intending to learn more about the applicants’ interests and profiles, the PD searches social media and identifies public Facebook and Twitter accounts that appear to belong to applicants. While scrolling through the accounts, the PD discovers several posts that catch their attention. One shows an intraoperative photo with identifiable patient information in the background. Another expresses opposition to mask mandates and references controversial views about vaccines. Others describe patients and hospital staff using memes that the PD finds offensive.

The PD wonders what to do next. They consider comprehensively searching for the accounts of all the candidates to ensure fairness but wonder how the accounts ought to be judged, and whether the content should be included in the review process at all. The PD also worries whether there is an ethical obligation to notify candidates about this kind of review.

Discussion

This case highlights an ethical quandary faced by many PDs. If one aim of residency application review is to assess candidates’ professionalism and preparedness comprehensively, should personal social media content be part of the review? Should programs inform applicants about searching their social media accounts? Which findings matter? Should applicants be permitted to respond to these findings, perhaps through a supplemental application or personal statement to provide context or explanation for discoverable content? Further, are programs ethically permitted to include social media data formally or informally in their assessment of applicants? If so, how far back should they look? These questions give context to the ethical considerations that are increasingly relevant as newer generations of residency applicants will have longer-standing social media accounts compared to years past.

The average number of applications received by urology residency programs has markedly increased over the last 3 cycles (243 in 2020, 282 in 2021 and 347 in 2022).¹ This coincided with an increase in registered urology applicants (484 in 2020, 528 in 2021 and 601 in 2022). With the introduction of virtual interviews in 2021 AUA Match, the dynamics of interactions between applicants, interviewers and residents has changed. Our program, for example, hosts a virtual meet and greet with the applicants and residents in small group format to mimic the traditional interview dinner. Other opportunities for noninterview interactions may include virtual open houses prior to interview season, and virtual tours of the respective hospital and clinic. In the virtual setting, interactions may seem more structured compared to years past. This climate may motivate PDs to turn to additional virtual forms of information gathering, such as searching social media accounts.

Both programs and applicants have reported increased social media use to learn more about each other. A recent study of urology PDs found that the majority believe that social media played a more important role in the 2021 AUA Match compared to previous cycles; 15% of PDs reported that applicants’ social media activity helped their chances of matching to their program, while 12% of PDs reported that it hurt applicants’ chances.² However, only 5% of PDs reported social media as a formal part of the residency applicant assessment. Incomplete or absent data assessment may contribute to perceived importance; a separate survey of PDs after the implementation of virtual interviews reported that applicants’ social media activities were the least important factor during application review (mean rating 1.94 out of 5).³ On the applicant side, recently surveyed applicants have also reported increased use of social media, particularly Twitter, to obtain information about programs and make decisions about whether to apply.⁴

In an environment of increasing reliance on social media for potentially actionable information, professional social media guidelines may have an important and evolving role for both parties. The Society of Academic Urologists AUA Match Code of Conduct dictates that PDs and interviewing team members “will respect an applicant’s right to privacy and confidentiality,” discouraging interviewers from inquiring about applicants’ interest in other programs or certain aspects of applicants’ personal lives.⁵ However, it is unclear whether this applies to applicants’ online activities as well. Professional organizations including the AUA,^6–8 as well as medical institutions like ours,⁹ have published social media use guidelines, which underscore and uphold ethical codes for professional behavior. Despite the existence of guidelines like these (which in the case of the AUA, urology residency applicants typically agree to when they join as student members), 64% of urology trainees have not reviewed professional guidelines on appropriate social media use and 80% of trainees report not receiving any instruction from their institution or department regarding professional social media use.¹⁰ Urology residency applicants may have a similar lack of experience with and understanding of these guidelines. If programs elect to incorporate social media content during applicant review, these guidelines may collectively serve as a reasonable standard on which to base evaluation.

The increasing volume of residency applicants, coupled with the transition to virtual interviews and other limitations to objective data sources, have shifted practices and attitudes regarding candidate assessment. If social media data are to be used in reviewing candidates, we suggest that programs articulate the principles for conducting the review and assessing the available data. While some applicants may already assume that their social media content is discoverable and adjust the visibility of this content (eg changing privacy settings, using pseudonyms on their accounts), programs that choose to conduct formal reviews of applicants’ social media data should disclose this to applicants¹¹ and ensure legal compliance for using these data in hiring decisions.¹² In addition, entities like the AUA and Society of Academic Urologists could consider compiling best practices underpinning social media related expectations and permissions between applicants and programs in the future. We suggest forming these principles and best practices with the following considerations:

1. Inform applicants if their social media accounts may be included in the review process.
2. In cases of an explicit professional violation, such as HIPAA violation, communicate concerns to the candidate and/or their respective medical school.
3. Acknowledge and account for reviewers’ implicit biases during review of social media content (eg posts related to political affiliation or causes).