Medical advertising in social networks: awareness and medical school education

ABSTRACT Objective: this study analyzed medicine students’ knowledge regarding medical advertising on social media. Method: this is a cross-sectional study carried out between January and May 2022 with 179 medical students from public and private institutions from Curitiba - PR, using a structured questionnaire with nine problem situations on medical advertising. It was established as “sufficient” knowledge ≥70% of the problem-situations based on current professional codes and resolutions. Results: five questions had the highest percentage of correct answers resulting from the acquisition of knowledge from different sources. Most students did not learn about medical marketing in their undergraduate course (84.9%), having already shared patients’ pictures on social media (89.9%), and fell the lack of discussions about medical advertising (96.6%). Conclusion: there is a need to direct undergraduate education towards the ethical use of advertising in order to better prepare them for professional practice.


INTRODUCTION
A ppropriate advertising and marketing strategies can educate the population, provide updated and accurate information to the patient, and give visibility to the physician, as more people look for referrals on the internet.Digital medical marketing is an emerging issue, which can be understood as "a set of actions and strategies that aim at adding value to medical practice through the identification of opportunities and markets and the desires and needs of patients" 1 .
The Federal Council of Medicine (CFM), through the Code of Medical Ethics (CEM) 2 and Resolutions 1974/2011, 2126, and 2133/2015, regulates medical advertising for all advertising vehicles 3 .Through the Regional Councils of Medicine, it promotes updated and continuing education 4,5 in various subjects for students and professionals, aiming at good medical practice and at building a solid career.
The General Data Protection Law (LGPD -Brazilian version of GDPR) 5,6 considers health related data (diseases, disabilities, medical reports, medical records, biometric data, test results, among others) to be sensitive 6 , and use of this data can only be done with the authorization of its bearer and in compliance with legal provisions.On their turn, physicians and medical students are subject to professional confidentiality 2,7 10 .
With the popularization of social networks and the advent of the pandemic, there was an increase in distance learning and work, and digital communication intensified in all areas.Added to these is the growing number of vacancies in Medical Schools and the consequent increase in the supply of professionals to the market 9,11 publicizing medical matters and services.The ability to communicate ethically, privately or in public, through verbal and non-verbal language, is one of the bases of professional practice provided for in the National Curriculum Guidelines (DCN) for medical courses 12 .However, most of the time, medical advertising is relegated to the hidden curriculum and is poorly understood by students.
The Medical Student Code of Ethics (CEEM) 7 guides attitudes, practices, and moral and ethical principles inside and outside the classroom and establishes the rights and duties of undergraduates towards their peers, teachers, and patients.This study thus aims at analyzing the knowledge of medical students about medical advertising on social networks.as well as sources of information about medical publicity.

Chart 1 . Problem-situations on medical advertising in view of the resolutions and professional codes in force in Brazil.
The percentage of students who did not learn about medical advertising in the undergraduate course was 84.9%, and who did not consider this training important for their professional practice, 65.4%.Most had already shared images of patients on social networks (89.9%), felt a lack of more discussions about medical advertising (96.6%), and sought to acquire this knowledge from different sources (Table 2).
We inserted problem cases (Chart 1) describing everyday situations related to professional marketing for the student to answer "true" or "false" regarding the current ethical principles that govern medicine (Resolution 1974/2011; Resolution 2015), with the degree of knowledge classified as "insufficient" (<70% of correct answers) and "sufficient" (≥70% of correct answers).
We tabulated the data in Microsoft Excel ® spreadsheets.We performed descriptive and inferential statistics using tests based on the Chi-Square distribution and Fisher's exact test, considering p<0.05 as significant.
All analyzes were performed using the SPSS 17.0 program.

RESULTS
The sample comprised 179 students, with a predominance (Table 1) of women (64.8%), young individuals (66.5%), white (89.9%), single (94.4%), coming from a private institution (52.5%), and who had already attended the Bioethics course or equivalent (96.1%).The Medical Publicity Manual was known by 54.2% of the students and the CEEM, by 50% (Table 2).As for the dissemination of images of patients through social networks, we found no statistical difference regarding the knowledge arising from the Medical Publicity Manual (p=0.702),CEEM (p=0.498),gender (p=0470), private or public institution (p=0.311),learning through the internet (p=0120), or having attended a Bioethics course (p=0.414).
Regarding questions about medical advertising, the lowest percentages of correct answers occurred in the situations listed in case 1 (41.3=3%), 3, 4 (both with 37.4%), and 7 (33.5%)(Figure 1).Knowledge about medical advertising was unsatisfactory among those who reported knowing the Medical Advertising Manual (p<0.0001), who learned it during graduation (p=0.006),through the internet (p=0.012), and who had come from a private institution (p<0.0001)(Figure 2).

DISCUSSION
The profile of students showed a predominance of female and young individuals, consistent with the literature 8,13 , and points out that, despite the curricular guidelines encouraging the teaching of communication skills 12 , there is an educational gap regarding advertising and professional marketing during medical graduation 9  The practices and attitudes of undergraduates 7 , inside and outside the virtual environment, must be aligned with the rules of moral conduct, current legislation, and the expected behavior of a future doctor 3,[13][14][15][16][17][18] .
When delimiting where the general knowledge of the medical student about medical advertising comes from, in this sample we observed that the formal curriculum, the professors, and the interaction with other doctors had indications of lower participation and that the students claimed to miss the teaching advertising in their training.On the contrary, they stated that they do not consider this training important for professional practice.
However, with the technological dynamics, cyberculture in health, changes in the doctor-patient relationship, and the expansion of telemedicine, this skill complements the construction of the contemporary professional profile 9,15 .
In this sample, remote teaching and social distancing due to the SARS-CoV-2 pandemic may have influenced the relationship with professors and interaction with doctors, as well as the perception of advertising.
Other possible explanations would be that, although digital natives, students have not critically reflected on how mass communication vehicles can impact the population's health choices 16,17 .
The distribution of content on the internet can influence the public perception of the profession and one's own personal image, and according to a survey carried out with medical students, the use of social networks can have positive and negative implications 13 .
The dissemination of images of patients on social networks by undergraduates, detected in the present study, is worrying and probably reflects a lack of knowledge of the legislation, codes, and norms and their consequences 1,8,18 .On the other hand, it may have been motivated by impulsiveness and the frequent placement in virtual social spaces and lay media of concrete cases, to increase audience and gain followers.Thus, students should be educated about medical confidentiality 2 and legislation5, to ensure the reliability and integrity of their actions, as well as to reinforce safety behavior and privacy policies to prevent, monitor, and mitigate risks 6 .
In the present study, the postings of patients' images did not show statistical differences in relation to gender, educational institution, attendance of Bioethics, learning through the internet, and knowing the CEEM or the Medical Publicity Manual, and may result from socio-behavioral characteristics of each student.This finding should be further investigated and serves as an alert to clarify medical ethics for students, due to the risk of breach of confidentiality and sanctions in the moral, legal, and administrative scope 1,17 .
Students showed a higher percentage of ignorance of current regulations on medical advertising in problem cases 1, 3, 4, and 7 (Chart 1, Figure 1), medical ethics in social media (websites, blogs, Facebook, Twitter, Instagram, YouTube, WhatsApp, and the like) being addressed by the CFM Resolution No. 2,126/2015 14 .The idea is not to censor or restrict the professional's activity, but to establish parameters for an ethical and healthy practice, avoiding abuse and unnecessary exposure, respecting the human being and the educational purpose of medical advertising (Article 111 of the CEM) 2 .
The trend of the 21 st century is the provision of medical services in a hybrid way, in person and through Telemedicine (Resolution CFM 2314 / 2022, article 3), whose regulations also determine that "the data and images of the patients contained in the medical records must be preserved, complying with the legal and CFM rules pertaining to the safekeeping, handling, integrity, veracity, confidentiality, privacy, irrefutability, and guarantee of professional secrecy of information" 15 .
The limitations of the present study are its design, possible self-selection, and response biases, as the questionnaire was distributed to medical students' social media and self-completed.Although subject to criticism, its findings reveal the importance of teaching medical advertising and provoke the reflection that the training of digital bioethics and telepropaedeutics is urgent for the future exercise of the medical profession 2,7 .
The Medical Student Medical Ethics Code and the rules of professional advertising can be included in the Bioethics Discipline or equivalent, due to its advertising.They were asked if they knew the Medical Publicity Manual (MPM -Resolution CFM 1974/2011), the Code of Ethics for Medical Students (CEEM), and if they had already attended the Bioethics course or equivalent,

Figure 1 .
Figure 1.Percentage of students' correct answers regarding questions about medical advertising.

Figura 2 .
Figura 2. Student's knowledge about medical advertising considering variables related to training/professionalization.

Table 1 -
Characteristics of the sample of medical students (n=179).