THE EDUCATIONAL IMPACT OF SOCIAL MEDIA IN RADIOLOGY
Use of Social Media in Radiology Education Saad Ranginwala, MD a, Alexander J. Towbin, MD a Abstract Social media has become the dominant method of mass digital communication over the past decade. Public ﬁgures and corporations have learned how to use this new approach to deliver their messages directly to their followers. Recently, medical educators have begun to use social media as a means to deliver educational content directly to learners. The purpose of this article is to describe the beneﬁts of using social media for medical education. Because each social media platform has different platform-speciﬁc constraints, several different popular social media networks are discussed. For each network, the authors discuss the basics of the platform and its beneﬁts and disadvantages for users and provide examples of how they have used each platform to target a unique audience. Key Words: Social media, education, marketing, radiology, Instagram J Am Coll Radiol 2017;-:---. Copyright 2017 American College of Radiology
INTRODUCTION Recently, new modes of electronic education have emerged, including online microlessons provided at sites such as Khan Academy (https://www. khanacademy.org) and online courses such as those provided at Coursera (https://www.coursera.org). Education has also become more interactive through the use of tools such as NearPod (https://nearpod.com) and RSNA Diagnosis Live (https://live.rsna.org). The emergence of social media as a dominant platform for information delivery opens another frontier in education by allowing learners to identify and engage with topics of their choosing at a time of their choosing. Social media is a unique educational tool in that it is inherently dependent on interaction with others. Its use for education in medicine has exploded in recent years [1-17]. In this report, we describe the history and beneﬁts of using social media for education and describe how we have used different platforms to target a unique set of users.
Department of Radiology, Cincinnati Children’s Hospital Medical Center. Corresponding author and reprints: Alexander J. Towbin, MD, Department of Radiology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, ML 5031, Cincinnati, OH 45229; e-mail: alexander. [email protected]
Dr Towbin has received grant funding from Guerbet, Siemens, and the Cystic Fibrosis Foundation; has received royalties from Elsevier; and is a consultant to IBM Watson Health and Applied Radiology. Dr Ranginwala has no conﬂicts of interest related to the material discussed in this article.
ª 2017 American College of Radiology 1546-1440/17/$36.00 n https://doi.org/10.1016/j.jacr.2017.09.010
HISTORY One of the earliest adopters of social media use for medical education was emergency medicine. Free openaccess medical education (FOAM or FOAMed) was a term coined by Michael Cadogan to describe a movement to gather educational resources from altruistic practitioners using increasingly accessible online resources [18,19]. This movement ﬁrst took hold in the form of emergency medicine and critical care podcasts and on Cadogan’s blog, Life in the Fast Lane (https:// lifeinthefastlane.com). Twitter was becoming popular around the same time and began to be used within the FOAM community, with users identifying content using the #FOAMed hashtag. As #FOAMed grew, other specialties developed communities to share FOAM content. The radiology community adopted #FOAMRad as the hashtag for content in our specialty. Although Twitter remains the most popular network for medical professionals, other social media platforms, such as Instagram, Facebook, and dedicated blogs have been created to share educational content. In addition, platforms dedicated to medical education, such as Figure 1, have been created. Each platform has unique value and limitations deriving from the speciﬁc constraints imposed by the platform’s developers. In this report, we describe several of the more popular social media platforms used in medical education. Through this report, we hope to highlight the value of each platform and its ability to reach a large number of learners in a unique way.
Fig 1. An example of a tweet from a JACR (#JACR) tweet chat. Typically, a response is preceded by a letter and number, the letter indicating either a question or an answer and the number indicating which question is being addressed. In this case, T3 refers to the answer to question 3, and A3 refers to an answer to the same question.
TWITTER Twitter is centered on text-based interactions between users called tweets. As of April 2017, Twitter had 328 million active monthly users, with more than 1 billion unique visits to websites embedded within tweets [20,21]. Tweets are messages composed of no more than 140 characters, providing brief but direct communication to all followers of a user. Other users 2
can stumble upon tweets when they search for speciﬁc hashtags. With its large user base and text-centered format, Twitter has become the predominant social media platform for medical education. Discussions on Twitter can include comments about a medical conference using the conference hashtag, responses to individual tweets on a speciﬁc topic, and even organized “tweet chats” on Journal of the American College of Radiology Volume - n Number - n Month 2017
predetermined topics (Fig. 1). JACR runs the most popular radiology-focused tweet chat each month using the hashtag #JACR. Topics for the tweet chat range from the value of social media to artiﬁcial intelligence. Although interpersonal interactions can serve great educational purpose, Twitter also has several favorable characteristics for more traditional education. Apart from text-based capabilities, users are also able to embed media such as links, pictures, and videos within tweets. Many early accounts dedicated to education took a primarily
text-based approach (Fig. 2). However, the use of media has become more prevalent, and many users now add images or videos to supplement text-based teaching points. Our department has used Twitter (@CincyKidsRad) to engage the radiology community. We frequently tweet during meetings, interacting with other attendees and promoting presentations delivered by departmental faculty members, fellows, and staff members. In addition, we use Twitter to promote departmental research, sharing a link to the abstract for each publication. Finally, Twitter
Fig 2. An example of text-based educational posts on Twitter. Each Monday morning, the @CincyKidsRad account shares teaching points related to interesting cases from the previous weekend under the hashtag #WeekendReview. Journal of the American College of Radiology Ranginwala, Towbin n Social Media in Radiology Education
is used to consolidate all our other social media channels. Our Instagram case of the day and blog posts shared on Facebook are automatically posted on Twitter.
INSTAGRAM Instagram is an image-based social media platform with more than 700 million active monthly users and more than 400 million active daily users [22,23]. The design is centered on a visual mobile experience. Users can take a picture, edit it, add a caption with searchable hashtags, and then share the resulting image. Each user’s feed is populated with images shared by the people or organizations the user follows. As on Twitter, other users can ﬁnd public posts when they search for speciﬁc hashtags. Followers or other users can like an image or comment on the image. The posting user can interact with the fans of the image in the comments of the post. The image-based focus of Instagram makes it well suited for radiology education. Instagram’s generous 2,200-character limit on captions and comments allows in-depth explanations and discussion beyond the initial caption. Newer features such as the ability to post videos and multiple images further enrich the potential capabilities for educational use (Fig. 3). There are several popular radiology feeds on Instagram, each with more than 3,000 followers and some with more than 20,000 followers (@radiopaedia, @thexraydoctor, @mri_technologist, @russian.radiology, @pediatricradiology, @radiologyacr). These feeds use different techniques to teach, including sharing video content, annotating images, and providing quizzes. However, even with these differences, most posts share images with focused teaching points in their captions. We have found Instagram to be an incredibly powerful tool to teach pediatric radiology to other medical professionals. Each business day we use our account (@CincyKidsRad) to share a single case under the following themes: #MSKMonday, #TummyTuesday, #NeuroWednesday, #ThoraxThursday, and #FridayQuizDay. The cases shared on Monday through Thursday typically consist of a single image with a single focused teaching point. For the Friday quiz, our format changes. On that day, we ﬁrst share an image and ask a question related to the image. Later in the day, we share a second image revealing the answer and providing a teaching point related to the question asked earlier in the day. FIGURE 1 Figure 1 is an image-based social media network catering to medical professionals. As on Instagram, users create 4
posts consisting of images and captions. Followers can see the images on their feeds and interact with posts by liking the images or leaving comments. As with other social media platforms, hashtags can be used for searches and to group posts of a similar topic. Although Figure 1 is similar to Instagram, there are some important differences. First, when creating a post, users classify each image on the basis of the anatomy and specialty highlighted by the image, giving users the ability to focus on speciﬁc interests. Second, because of its medical focus, Figure 1 boasts a highly engaged yet smaller user base. Similar posts made on both Figure 1 and Instagram often evoke a greater amount and higher quality of discussion on Figure 1 . Third, Figure 1 has a web-based posting platform that simpliﬁes the process of uploading content. Like Instagram, Figure 1 also allows posting of multiple images. However, in addition to separate images, series of images such as an entire series from a CT scan can also be uploaded. Last, Figure 1 takes speciﬁc measures to ensure patient privacy. The app provides built-in consent forms, if necessary, for a given case and automatically detects and censors faces and other types of protected health information (Fig. 4). Our Figure 1 feed (@CincyKidsRad) shares the same content as Instagram. However, because Figure 1 more speciﬁcally targets the medical community, we often get more questions and comments related to our cases on this channel. Even though users frequently ask questions about the cases we share, we rarely answer questions on Figure 1. We have taken this stance for two reasons. First, many of the questions are related to speciﬁc patients. Our stance is that we provide as little information as possible about patients, instead focusing on teaching the disease or disease process to protect the patient’s privacy. Second, we have found that the cases produce more interest and discussion if the community is allowed to generate and moderate its own discussion. Other users will answer the questions and teach one another. Interestingly, we have found that this allows the discussion to move in directions that we have not considered. For example, we recently shared a case showing splenomegaly on an abdominal radiograph. The point of this case was to show the ﬁnding and to provide a general differential diagnosis. Because we did not provide a speciﬁc diagnosis in this case, other users have shared their thoughts on the speciﬁc diagnosis on the basis of the common causes of splenomegaly in their part of the world. The discussion has thus ranged from entities such as infectious mononucleosis to chronic malaria or kala Journal of the American College of Radiology Volume - n Number - n Month 2017
Fig 3. Example of an educational post on Instagram. Each post has multiple components: (1) posting user, (2) an image, (3) the number of likes, and (4) a focused caption.
Journal of the American College of Radiology Ranginwala, Towbin n Social Media in Radiology Education
Fig 4. Example of an educational post on Figure 1. Many similar characteristics to Instagram are present, but medicine-speciﬁc features can also be entered, such as subspecialty and body region. Note the use of the #TummyTuesday hashtag for indexing and identiﬁcation.
azar leishmaniasis. Because of this discussion, this basic-level radiology case has nearly 440,000 views and 158 comments. If we had answered one of the early questions with the underlying cause of splenomegaly in this patient, we believe that there would have been little to no discussion. 6
FACEBOOK Facebook has the largest user base of any social media platform, with 2 billion active monthly users . Facebook is centered predominantly on text-based interactions, with the ability to embed photos, links, and videos. It also has a dedicated platform for businesses that Journal of the American College of Radiology Volume - n Number - n Month 2017
incorporates advanced analytics and makes it easy to create paid advertisements (Fig. 5). Even though Facebook has the largest user base of any social media platform, it is uncommonly used for medical education. However, it is frequently used to educate patients and providers. Many departments and medical practices use Facebook to share content with patients and families. Typically, this content is directed toward patient advocacy and patient engagement. On the provider side, many academic societies maintain Facebook pages as a way to keep in touch with members and promote societal events. We use Facebook as a means to engage patients, families, and employees. When we ﬁrst launched our Facebook page (www.facebook.com/CincyKidsRad), we shared photographs of employees and special events, announcements that affected our patients such as changing business hours or the opening of a new facility, and articles appearing in the lay press. Over the past 3 years, our use of Facebook has changed. Currently, we use Facebook primarily to share our blog content. Facebook is ideal for this, as it allows us to embed a link in a post and share a short overview of the post. Because our posts target families, they are shared by users who follow our page.
BLOGS A web log, or “blog,” is a personalized social media platform with parameters set primarily by the provider of
content. Unlike other platforms, a blog offers complete control of style, branding, content, and method of content delivery with virtually no constraints. Blogs generally consist of a feed of blog posts, composed of a mix of text, images, and videos (Fig. 6). There are many popular blogs in the medical sphere. These blogs share several common traits, including a focused theme, dedicated writers with engaging voices, and frequently updated content. In general, medical blogs target one of two different audiences: patients, or providers. Popular patient-directed blogs are typically hosted by medical centers (such as the Mayo Clinic: http://sharing. mayoclinic.org/) or the lay press (such as the New York Times: https://www.nytimes.com/section/well). Other patient-directed blogs are hosted by patients themselves and are typically focused on speciﬁc diseases or illnesses. Popular provider-directed blogs can be hosted by providers themselves (http://www.kevinmd.com/blog/), medical societies (https://acrbulletin.org/departments/blog), medical journals (http://blogs.nejm.org/now/), and popular medical websites (http://www.auntminnie.com). Our department uses a blog (http://blog. cincinnatichildrens.org/category/radiology/) to educate patients and families. Our posts have several themes, such as what makes us different, research, how we do it, meet the team, and patient stories. The goal of our blog is to provide an enduring resource for parents when they need our services.
Fig 5. Example of a Facebook page for a radiology department. Contact information and posts for followers can be disseminated on Facebook.
Journal of the American College of Radiology Ranginwala, Towbin n Social Media in Radiology Education
Fig 6. Example of a blog page for a radiology department. Each blog can be customized with its own layout and content. This post contains several common components: (1) the post title, (2) a lead photograph, (3) a text-based story with embedded links, and (4) related video content.
Some of our most popular posts address topics such as “What’s the Difference Between Sedation and General Anesthesia?” (http://blog.cincinnatichildrens.org/radiology/ difference-between-sedation-and-general-anesthesia/) or “Why Can’t My Child Eat Anything Before an Ultrasound” (http://blog.cincinnatichildrens.org/radiology/why-cantmy-child-eat-anything-before-an-ultrasound/). As a children’s hospital, we also make an effort to engage the children we treat. To this end, we have also created posts that include games (Thanksgiving Fun: http://blog.cincinnatichildrens. org/radiology/thanksgiving-fun/) or use radiology in an 8
interesting way (Halloween Candy X-posed!: http://blog. cincinnatichildrens.org/radiology/halloween-candy-x-posed/).
DISCUSSION It can be difﬁcult to measure the impact of social media on education. Because learners are online and often unknown, there is no way to measure their growth in knowledge or their retention of content. Instead, the impact of social media education is measured in the number of users who have seen or Journal of the American College of Radiology Volume - n Number - n Month 2017
interacted with the content. These measures are encapsulated with two terms: impressions and engagement. Impressions are deﬁned as unique views of a given piece of content on social media. Because a single individual can provide multiple impressions, impressions are not equivalent to the size of an audience. However, impressions are a standard metric used to measure level of reach on social media. Engagement occurs when a user takes action on a piece of content such as opening it for an expanded view, liking the content, commenting on the content, or clicking a link within the content. Because engagement requires more from the user, it is thought to be a greater indicator of the success of a post. Social media can provide several beneﬁts over traditional forms of education. With its large user base numbering in the hundreds of millions, there is potential for educators to reach massive audiences [25-32]. If educators can tap into this audience, they are able to teach to an audience several orders of magnitude larger than the largest educational conferences. For example, between July 2016 and May 2017 the @CincyKidsRad account on Figure 1 had more than 6 million impressions. Ease of access is another beneﬁt of social media [33-35]. With the prevalence of smart devices and social media apps, educational resources are easily retrievable and enable point-of-care learning [36-38]. Because social media use is prevalent on a personal level, educational content can be consumed during microbreaks within an individual’s daily routine. In addition, because all social media apps are designed for mobile use, information is available at the point of need using hashtags. Social media–based education has a few disadvantages. With the large number of participants in social media, it is often difﬁcult to determine the quality or accuracy of a teaching point. Users must rely on the comments of others to correct an error. Despite this, as the use of social media for education has grown, the individuals maintaining social media resources have built a reputation as educators and have demonstrated their value to the community. Platform-speciﬁc constraints impose another potential disadvantage of social media–based education, as these constraints can inﬂuence the method and delivery of content. For example, character limits imposed on Twitter can often limit explanations or inconveniently spread text-based content over multiple tweets. In contrast, a platform such as Instagram Journal of the American College of Radiology Ranginwala, Towbin n Social Media in Radiology Education
provides generous character limits on captions, which may be better suited for in-depth explanations. Thus, it is important to understand each platform’s strengths and weaknesses to best use each technology to its full potential. The inherent tendency of social media to educate in small pieces also has an impact on the type of education it can deliver [39-45]. Although there is a large volume of content on social media, most educators do not adhere to a curriculum. If used as a sole source of content, learners may have gaps in knowledge or insufﬁcient depth of knowledge on a given topic. Thus, although educational content on social media can be highly beneﬁcial, it is likely best used in a supplementary form to established curriculums for learning [46-49]. Perhaps the most important factor to consider with social media–based medical education is patient privacy [50,51]. Although patient vignettes allow learners to better understand a disease process, care must be made to protect the identity of patients and not reveal protected health information. Because of this concern, we take multiple precautions to ensure that we do not post protected health information . First, we use a screen capture application (SnagIt; TechSmith, Okemos, Michigan) to obtain each image. This allows us to exclude all burned-in or overlaid patient information. If needed, we can digitally edit images to ensure that no patient-identifying information is included. Second, when sharing a case, we include as little identifying information as possible. For example, we use general terms such as neonate, child, and adolescent to describe the patient’s age, and if we share a history, it is provided in general terms (such as “trauma”) rather than more speciﬁc terms (such as “fall from a ﬁfth-story window”). Third, we avoid extremely rare or newsworthy cases. Finally, we focus our teaching on the disease process rather than the speciﬁc patient. To this end, we do not share speciﬁc follow-up, treatment, or patient outcomes. We have found that the use of social media has had a positive impact on our department’s reputation and employee engagement. Although it is hard to provide direct correlation, we believe that our use of social media has led to increased recognition in the radiology community and the medical education community at large. We have also found that employees enjoy being featured on our blog and share content about themselves and their friends on their personal social media channels. 9
CONCLUSIONS Social media provides a new opportunity for educators to reach learners. With a variety of diverse platforms and a massive user base, social media has the potential to reach and teach greater numbers of individuals than other modes of education. It is important for both educators and learners to be cognizant of the speciﬁc advantages and drawbacks of each social media platform to optimize education.
TAKE-HOME POINTS -
Social media is an emerging technology for delivering medical education with speciﬁc promise for radiology. Radiology’s image-centric nature makes it an ideal specialty for certain social media platforms. Each social media platform has inherent advantages and disadvantages that should be taken into consideration in design and delivery of educational content. Radiology practices should consider these platform-based constraints when developing content. Social media provides a unique opportunity to reach larger audiences than traditional educational avenues. However, as an educator, it is harder to gauge the learner’s progress on most social media platforms. Measures should be taken to ensure protection of patient privacy when using social media for educational purposes. This is particularly true in radiology, in which patient-speciﬁc information can be included in an image.
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