Surgical Education
Online and social media presence of Australian and New Zealand urologists Nicholas Davies, Declan G. Murphy†, Simon van Rij†, Henry H. Woo§ and Nathan Lawrentschuk†‡¶ Royal Hobart Hospital, Hobart, Tas , †Division of Cancer Surgery, Peter MacCallum Cancer Centre , ‡Department of Surgery, University of Melbourne, Melbourne, Vic. , §Sydney Adventist Hospital Clinical School, University of Sydney, Sydney, NSW , and ¶Olivia Newton-John Cancer Research Institute, Austin Hospital, Melbourne, Vic., Australia
Objective To assess the online and social media presence of all practising Australian and New Zealand urologists.
Subjects and Methods In July 2014, all active members of the Urological Society of Australia and New Zealand (USANZ) were identified. A comprehensive search of Google and each social media platform (Facebook, Twitter, LinkedIn and YouTube) was undertaken for each urologist to identify any private websites or social media profiles.
Results Of the 435 urologists currently practising in Australia and New Zealand, 305 (70.1%) have an easily identifiable social media account. LinkedIn (51.3%) is the most commonly used form of social media followed by Twitter (33.3%) and private Facebook (30.1%) accounts. About half (49.8%) have a private business website. The average number of social media
Introduction The early 2000s saw a rapid transition to the Web 2.0 era, transforming the way in which the internet is used. Almost overnight, individual internet users changed from passive viewers to contributors. Information could be disseminated easily and rapidly to an audience anywhere in the world. It was out of this environment that social media was born and continues to expand at an explosive pace. Social media comprises a diverse range of user-generated content including social networking (Facebook, LinkedIn), microblogging (Twitter), and video-sharing and photo-sharing sites (YouTube, Instagram). In 2014, Facebook celebrated its 10-year anniversary and now boasts over one billion active users [1]. Social media has pervaded almost every aspect of society and the medical
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accounts per urologist is 1.42 and 16 urologists (3.7%) have an account with all searched social media platforms. Over half of those with a Twitter account (55.9%) follow a dedicated urology journal club and have a median (range) number of ‘followers’ of 12 (1–2 862). Social media users had a median (range) of 2 (0–8 717) ‘tweets’ on Twitter, 2 (1–45) LinkedIn posts and 1 (1–14) YouTube video.
Conclusion This study represents a unique dataset not relying on selection or recall bias but using data freely available to patients and colleagues to gauge social media presence of urologists. Most Australian and New Zealand urologists have a readily identifiable online and social media presence, with widespread and consistent use across both countries.
Keywords social media, urology, Twitter, medico-legal, internet
profession is not immune. Medical conferences, particularly within the field of urology, have been rapid in their uptake [2]. The potential benefits and harms of medical engagement with social media are well documented [3] leading many health regulatory bodies, professional societies and academic journals to release their own guidelines on the responsible use of social media [4–6]. The medical profession must embrace the rapidly changing online environment or risk being left behind. Many urological journals have welcomed and adopted social media and now have a strong online presence through sites such as Facebook and Twitter [7]. The engagement with social media by urologists has been shown to be less universal [8]. The goal of the present study was to examine the online and social media presence of all currently practising Australian and New Zealand (ANZ) urologists.
© 2015 The Authors BJU International © 2015 BJU International | doi:10.1111/bju.13159 Published by John Wiley & Sons Ltd. www.bjui.org
Online and social media presence of ANZ urologists
Subjects and Methods Study Population All active members of the USANZ database were included. Fellows currently working overseas or undertaking further study were excluded as this study focuses on urologists in fulltime practice in ANZ. Additional practising urologists were identified from the Royal Australasian College of Surgeons database and current institutional appointments. The primary country (and state or territory if practising in Australia) was recorded for each urologist. Where an individual urologist was identified we then ‘cascaded’, searching for other members at their institution, hospital or practice who were not in either database to ensure completeness. Website Analysis A comprehensive ‘Google’ search for each urologist was performed using the practising member’s name and the term ‘urologist’. This identified any private practice websites and institutional sites to which the urologist was affiliated. Each website was assessed as to whether it contained links to any form of social media. Social Media Analysis Facebook, LinkedIn, Twitter and YouTube were individually searched for each urologist by full name. Once a urologist was identified, their profile was inspected for links to other ANZ urologists (where such information was publicly available). This included ‘friends’ lists for Facebook and ‘followers’ lists for Twitter and LinkedIn. Followers of the USANZ Twitter profile were also examined to find further urologist profiles. A social media profile was only attributed to the urologist if it was felt likely to represent that urologist. To this end, to be included the account had to identify as a urologist or surgeon, have a profile photograph that matched a verified photograph or be a friend/follower of two or more other known urologist profiles. Profiles that did not meet these criteria, even if suspected to represent the urologist, were excluded. LinkedIn, Twitter and YouTube profiles and postings are generally open to all members of those social media platforms. Facebook has more complex privacy settings and urologists were classified as having an ‘open public profile’ that was open to everyone on Facebook, or a ‘closed public profile’ that only allowed ‘friends’ or those vetted and accepted to view the full profile and postings. Further engagement analysis was undertaken with Twitter to seek the number of ‘tweets’, ‘followers’ and the number of accounts each urologist was ‘following’. Each account was assessed as
to whether or not it followed a dedicated Twitter urology journal club (@iurojc). The number of LinkedIn posts and individual videos on YouTube were also collated. Finally, gender and ‘academic’ vs ‘non-academic’ urologists were recorded for categories as best could be ascertained (academic = university title holder such as senior lecturer, professor and associate professor). Statistical Analysis Data were analysed using SPSS version 20 (IBM, New York, NY, USA) and a P < 0.05 was considered to indicate statistical significance. Population statistics for all Australian states were obtained from the Australian Bureau of Statistics and for New Zealand from the Statistics New Zealand websites [9,10]. Pearson’s correlation coefficient was used to compare social media use with urologist population density by state and country. This was to ascertain if higher density affected the use of social media, as it was hypothesised that competition may drive a greater online presence, or conversely social media may provide easier access to information for remote urologists and their patients.
Results There were 435 urologists identified to be currently practising in ANZ as of July 2014. All Australian States and Territories were represented based on each urologist’s primary state of practice. About half of Australian (49.7%) and New Zealand (50%) urologists are associated with a private business website with varying degrees of complexity (Fig. 1). At least one social media account was identified for 305 urologists, comprising 70.11% of all those practising. LinkedIn was the most widely used form of social media with 51.3% of urologists having an identifiable account (Table 1). Twitter (33.3%) and personal Facebook accounts (33.1%) were used by a similar number of urologists. Slightly more urologists (37.9%) had a Facebook presence when including either personal or business profiles. Of the 190 urologists with a Facebook account, 52 (27%) had ‘open access’ privacy settings allowing engagement between the urologist, their colleagues and their patients. A total of 58 ANZ urologists have a YouTube presence by appearing in online videos by name or hosting their own channel. The average number of different social media profiles was 1.42 (Table 2) and 40.2% of urologists had more than one social media profile. In all, 16 urologists (3.7%) were found to have an account with all four forms of searched social media (Twitter, private and business Facebook, LinkedIn and a presence on YouTube). In total, 83 urologists across both countries, comprising 19.1% of the cohort, had no online presence, that being either a social media account or website. © 2015 The Authors BJU International © 2015 BJU International
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Fig. 1 The percentage of urologists who have their own private business website.
100%
Website: No Website: Yes
Percentage of urologists
80% 60% 40% 20% 0%
NSW
VIC
QLD
WA
SA TAS ACT NT State/Territory/Country
Australia NZ
All
Table 1 The number and percentage of urologists using each form of social media by state/territory and country. State/Territory/Country
NSW VIC QLD WA SA TAS ACT NT Australia NZ All
Twitter site
Personal Facebook
Business Facebook
LinkedIn page
YouTube videos/ channel
N
%
N
%
N
%
N
%
N
%
51 37 20 14 12 0 1 0 135 10 145
42.1 35.6 27.4 40.0 40.0 0.0 16.7 0.0 35.7 17.9 33.3
35 31 19 18 13 3 2 0 121 23 144
28.9 29.8 26.0 51.4 43.3 33.3 33.3 0.0 32.0 41.1 33.1
20 3 10 3 4 0 0 0 40 6 46
16.5 2.9 13.7 8.6 13.3 0.0 0.0 0.0 10.6 10.7 10.6
58 58 31 20 18 4 2 1 192 31 223
47.9 55.8 42.5 57.1 60.0 44.4 33.3 100.0 50.7 55.4 51.3
21 14 7 3 3 0 2 0 50 8 58
17.4 13.5 9.6 8.6 10.0 0.0 33.3 0.0 13.2 14.3 13.3
Total urologists, n
121 104 73 35 30 9 6 1 379 56 435
Table 2 The number of urologists exhibiting each level of social media presence, on a 0–5 scale, scoring the number of different forms of social media (Twitter, personal and business Facebook, LinkedIn and YouTube). State/Territory/Country
NSW VIC QLD WA SA TAS ACT NT Australia NZ All
Level of social media presence: (Twitter, personal and business Facebook, LinkedIn, YouTube) 0
1
2
3
4
5
37 29 30 5 9 4 2 0 116 14 130
31 32 20 12 6 3 2 1 108 23 130
23 27 11 9 7 2 1 0 82 10 90
17 9 6 8 4 0 1 0 48 5 50
8 5 3 1 2 0 0 0 23 0 19
5 2 3 0 2 0 0 0 17 4 16
Australian urologists were statistically more likely to have a Twitter account than their New Zealand counterparts (P = 0.01). There was no statistical difference for website
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Mean social media level
Total urologists, n
1.53 1.38 1.19 1.66 1.67 0.78 1.17 1.00 1.57 1.39 1.42
121 104 73 35 30 9 6 1 379 56 435
ownership (P = 0.97), personal Facebook (P = 0.18), business Facebook (P = 0.976) or LinkedIn (P = 0.50) profiles, or YouTube presence (P = 0.83).
Online and social media presence of ANZ urologists
For the large part there was no statistically significant difference between utilisation of each form of social media between Australian states. Exceptions were that Western Australian urologists have a higher rate of personal Facebook utilisation of 51.4% (P = 0.04) and Victorian urologists have fewer identifiable business Facebook accounts with just 2.9% (P = 0.02). Across both countries there was one urologist for every 63 641 people (Table 3). Victoria had the highest number of urologists per population (one for every 55 683 people) and New Zealand the lowest (one for every 81 188 people). Population density was not found to have any statistically significant impact on the online and social media presence for urologists when comparing either Australian states or each country. Urologists with a Twitter account had a mean (median; range) of 77 (2; 0–8 717) ‘tweets’, were ‘following’ 21 (16; 1–524) accounts, and had 34 (12; 1–2 862) ‘followers’. Over half (81/145) were following a dedicated urology journal club on Twitter. LinkedIn postings were generally consistent across the cohort, with a mean (median; range) of 4 (2, 1–45) posts. The mean (median; range) number of YouTube videos posted was 2 (1; 1–14). Social media use based on the classification of ‘academic’ vs ‘non-academic’ urologists was similar across platforms (55% academic, 46% non-academic, P > 0.05). The percentage of female urologists (55%) with social media presence was greater than their male counterparts (48%), but not significantly (P > 0.05).
Discussion The ubiquity of the internet and social media has changed the way in which medicine is practiced. Gone are the days when patients would obtain all their health information through face-to-face contact with their doctor. In the internet-age, a second opinion is available from the other side of the world with just a few clicks, yet the quality of this health information may be questionable. Additionally, many patients now research their doctor online before an initial
consultation and doctor-rating websites are increasingly gaining market-share [11,12]. Around 72% of internet users now consult the internet for health information and 73% of online adults use social networking in some way [13,14]. The ‘diffusion of innovations’ curve described by Rogers [15] in 1962 has been used to explain the rate of uptake of a new technology, including social media. There is ongoing debate as to where urologists fit into this model – are they early adopters or laggards? [8]. The present study is the first to assess the online and social media presence of an entire specialty cohort of ANZ medical professionals. Our present data suggest that most ANZ urologists are already using social media, with 70% having a social media account. Other authors have reported varying degrees of social media engagement by urologists. Loeb et al. [16] found that 66% of attending urologist members of the AUA reported having a social media account. This is in contrast to Fuoco et al. [8] who reported a lower uptake of social media by Canadian Urologists. They found that only 26% of urologists use social media frequently with most avoiding it for professional use. Other similar studies have relied on self-reporting of social media use amongst health professionals. In contrast, the data obtained in the present study represents that which is readily available to the public, including patients and colleagues. It is a comprehensive cross-sectional analysis, albeit of limited scope, of all practising urologists without introducing nonresponse bias. Loeb et al. [16] reported a survey response rate of just 9.4% when assessing social media use amongst AUA members. If relying on selfreporting through surveys, there is potential introduction of bias if they are distributed or collected electronically, as those with more computer literacy may be over-represented in the sample. Our present study is the first to evaluate social media use by an entire medical cohort through independent search and data collection. This hopefully provides a more accurate and complete reflection of true social media uptake.
Table 3 The relative population density of urologists per state/territory and country. State/Territory/Country NSW VIC QLD WA SA TAS ACT NT* Australia New Zealand All *
Population, n
Number of urologists
Population/urologist, n
7 465 500 5 791 000 4 690 900 2 550 900 1 677 300 514 000 384 100 242 600 23 319 400 4 546 500 27 620 200
121 104 73 35 30 9 6 1 379 56 434
62 213 55 683 64 259 72 883 55 910 57 111 64 017 242 600 61 529 81 188 63 641
NT has a number of visiting urologists but only one identifiable permanent urologist, so population density data is inaccurate.
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So overall, are urologists’ leaders or followers? This is difficult to demonstrate from the present study alone as we would need comparative studies from alternative specialty groups in other regions; studies that have not yet been undertaken. Amongst colorectal surgeons in the UK LinkedIn membership of just over 37% was reported, which is under our regional urologists at 51% [17]. Additionally, as a craft group urology journals have willingly embraced social media in order to engage their readers [7]. Further, many medical conferences and scientific meetings now have a dedicated social media presence to not only inform delegates, but allow them to interact with proceedings, and urology has certainly led in this field [18]. Finally, an online urology journal club is available via Twitter that facilitates rapid communication and information dissemination on a global scale [19]. This was the second specialty journal club to be established in 2012 [20]. Thus, we may conclude that urology is in the first wave of medical specialties to embrace social media. The benefits of social media include allowing immediate access to worldwide experts, which may also make it a useful adjunct to formal multidisciplinary meetings and assist clinical decision-making [21]. Twitter, and social media on the whole, are able to react in real-time to health policy announcements. This is evidenced by the near doubling of tweets using the term ‘prostate cancer’ within 2 h of the United States Preventative Services Task Force releasing their guidelines against PSA screening [22]. However, there is an inherent potential for misuse. There are documented accounts, both in the medical literature and lay media, of medical professionals and students having their careers curtailed by unprofessional conduct on social media sites [23–25]. It can be very difficult to separate one’s personal and professional profiles online, something particularly relevant for medical professionals. These pitfalls have prompted many professional bodies and regulatory authorities to issue guidelines on the appropriate use of social media [4,5]. Common recommendations include: ensuring one’s online behaviour and profile fit the standards of their profession, maintaining boundaries with patients, protecting patient privacy and assuming anything posted will remain online indefinitely. Interestingly, only 36% of urologists are aware such guidelines exist and just 19% have read any such guidelines or relevant legislation [8]. There exists such a wide variety of platforms with which urologists can now engage the general public that regulation is difficult. Generally, social media use is subject to preexisting legal, ethical and professional obligations. Governing bodies have a duty to maintain the high professional standards of the medical profession, but the present study has highlighted the complexity of executing this duty. Already, a large number of urologists are using social media sites and identifying all of this content is onerous. Such bodies must
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develop directed measures to identify inconsistencies and enforce changes where necessary. This may be avoided by individual urologists having greater ownership and awareness of their public profile and adhering strictly to guidelines and regulations. It has been found that the quality of online health information is generally poor, and the use of tools such as the WHO Health On the Net Foundation code of conduct (HONcode) can help identify websites with good quality information [26,27]. No such system exists to date for social media, meaning patients cannot sort good information from bad. Australia has strict rules about the advertising of medical services; e.g. the use of testimonials by health professionals is prohibited. Social media may represent a way of legally promoting a urologist’s practice in order to garner more business. It was hypothesised that areas of greater competition between urologists might promote a larger online and social media presence. Our present data does not support this hypothesis, as there was no association between urologist population density and the utilisation of social media or business websites. A Pew Research report found that 42% of the online general population have more than one social media account, which is comparable to our present rate of 40.2% [14]. It should be noted that in ANZ, LinkedIn was the predominant identifiable social media platform used by urologists. This is in contrast to data from other countries where Facebook and YouTube were more likely to be used [28]. In fact, among the general public, Facebook is the predominant social media platform with 71% of internet users having an account [14]. The reason for a relatively higher rate of personal Facebook accounts in Western Australia is unclear. It is potentially due to the fact many were ‘friends’ with each other online, making identification of their accounts relatively easier than was the case in other states. There are some clear limitations of the present study. It is unlikely that every social media account was identified, particularly those with strong privacy settings. This may reflect why the use of personal Facebook presented in the present study was lower than that recorded in other countries or by the general public. Furthermore, the present study does not analyse the way in which social media is used, nor does it check if an identified account is active. However, our present data did show some degree of engagement, with a median of two tweets on Twitter, a median of two postings on LinkedIn and one YouTube video. There was significant variability between urologists, with some showing much higher engagement than others. There appeared to be trends towards greater engagement by female and academic urologists but at present these trends were not statistically significant. Certainly some urologists are dynamic contributors; some use social media in a passive way and some have an inactive account
Online and social media presence of ANZ urologists
with no true social media utilisation. The present study does not attempt to distinguish between these groups. Further data to explore the attitudes and use of social media amongst ANZ urologists would complement the present study. The present study represents a unique dataset, not relying on selection or recall bias but using data freely available to colleagues and the public to gauge social media presence of urologists. Most ANZ urologists have a readily identifiable online and social media presence. LinkedIn is the most commonly used social media platform with a significant number of urologists having a Twitter or Facebook account. The use of social media was widespread and consistent between all States and Territories of Australia. Social media offers a range of opportunities and only time will tell if ANZ urologists are willing to capitalise on them.
Conflicts of Interest None disclosed.
References 1 2
3
4 5 6
7 8 9
10
11 12 13
Facebook. Facebook Statistics 2014. Available at: http:// newsroom.fb.com/company-info/. Accessed August 2014 Wilkinson SE, Basto MY, Perovic G, Lawrentschuk N, Murphy DG. The social media revolution is changing the conference experience: analytics and trends from eight international meetings. BJU Int 2015; 115: 839–46 Panahi S, Watson J, Partridge H. Social media and physicians: exploring the benefits and challenges. Health Informatics J 2014; [Epub ahead of print]. DOI: 10.1177/1460458214540907 Murphy DG, Loeb S, Basto MY et al. Engaging responsibly with social media: the BJUI guidelines. BJU Int 2014; 114: 9–11 Mansfield SJ, Morrison SG, Stephens HO et al. Social media and the medical profession. Med J Aust 2011; 194: 642–4 Roupr^et M, Morgan TM, Bostrom PJ et al. European Association of Urology (@Uroweb) recommendations on the appropriate use of social media. Eur Urol 2014; 66: 628–32 Nason G, O’Kelly F, Kelly M et al. The emerging use of Twitter by urological journals. BJU Int 2015; 115: 486–90 Fuoco M, Leveridge MJ. Early adopters or laggards? Attitudes toward and use of social media among urologists. BJU Int 2015; 115: 491–7 Australian Bureau of Statistics. Australian Demographic Statistics 2014. Available at: http://www.abs.gov.au/ausstats/[email protected]/mf/3101.0. Accessed July 2014 Statistics New Zealand. Population Clock 2014. Available at: http:// www.stats.govt.nz/tools_and_services/population_clock.aspx. Accessed July 2014 Azu MC, Lilley EJ, Kolli AH. Social media, surgeons, and the Internet: an era or an error? Am Surg 2012; 78: 555–8 Ellimoottil C, Hart A, Greco K, Quek ML, Farooq A. Online reviews of 500 urologists. J Urol 2013; 189: 2269–73 Fox S, Duggan M. Health Online 2013: Pew Research; 2013. Available at: http://www.pewinternet.org/2013/01/15/health-online-2013/. Accessed August 2014
14 Duggan M, Smith A. Social Media Update 2013: Pew Research; 2013. Available at: http://www.pewinternet.org/2013/12/30/social-media-update2013/. Accessed August 2014 15 Rogers E. Diffusion of Innovations, 1st edn, New York: Free Press of Glencoe, 1962 16 Loeb S, Bayne CE, Frey C et al. Use of social media in urology: data from the American Urological Association (AUA). BJU Int 2014; 113: 993–8 17 McDonald J, Bisset C, Coleman M, Speake D, Brady R. Contemporary use of social media by consultant colorectal surgeons. Colorectal Dis 2015; 17: 165–71 18 Matta R, Doiron C, Leveridge MJ. The dramatic increase in social media in urology. J Urol 2014; 192: 494–8 19 Thangasamy IA, Leveridge M, Davies BJ, Finelli A, Stork B, Woo HH. International Urology Journal Club via Twitter: 12-month experience. Eur Urol 2014; 66: 112–7 20 Roberts M, Perera M, Lawrentschuk N, Romanic D, Papa N, Bolton D. Globalization of continuing professional development by journal clubs via microblogging: a systematic review. J Med Internet Res 2015; 17: e103 21 Rao K, Manya K, Azad A et al. Uro-oncology multidisciplinary meetings at an Australian tertiary referral centre – impact on clinical decisionmaking and implications for patient inclusion. BJU Int 2014; 114(Suppl. 1): 50–4 22 Prabhu V, Lee T, Loeb S et al. Twitter response to the United States Preventive Services Task Force recommendations against screening with prostate specific antigen. BJU Int 2014; 116: 65–71 23 Salter J. Nurses posts brain surgery pictures on Facebook. The Telegraph, 2008. Available at: http://www.telegraph.co.uk/news/uknews/2583411/ Nurses-posts-brain-surgery-pictures-on-Facebook.html. Accessed May 2015 24 Williams C. Doctors’ authorities probe suspension of mucky-mouthed medic: GMC investigates alleged abuse of power. The Register, 2008. Available at: http://www.theregister.co.uk/2008/11/12/dr_scot_gmc_probe/. Accessed May 2015 25 Collier R. Professionalism: social media mishaps. CMAJ 2012; 184: E627–8 26 Lawrentschuk N, Sasges D, Tasevski R, Abouassaly R, Scott AM, Davis ID. Oncology health information quality on the Internet: a multilingual evaluation. Ann Surg Oncol 2012; 19: 706–13 27 Chen EC, Manecksha RP, Abouassaly R, Bolton DM, Reich O, Lawrentschuk N. A multilingual evaluation of current health information on the Internet for the treatments of benign prostatic hyperplasia. Prostate Int 2014; 2: 2161–8 28 Yamout SZ, Glick ZA, Lind DS, Monson RA, Glick PL. Using social media to enhance surgeon and patient education and communication. Bull Am Coll Surg 2011; 96: 7–15
Correspondence: Nathan Lawrentschuk, Suite 5, 210 Burgundy Street, Heidelberg, Vic. 3084, Australia. e-mail: [email protected] Abbreviations: ACT, Australian Capital Territory; ANZ, Australian and New Zealand; NSW, New South Wales; NT, Northern Territory; NZ, New Zealand; QLD, Queensland; SA, South Australia; TAS, Tasmania; VIC, Victoria; WA, Western Australia.
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Online and social media presence of Australian and New Zealand urologists Nicholas Davies, Declan G. Murphy†, Simon van Rij†, Henry H. Woo§ and Nathan Lawrentschuk†‡¶ Royal Hobart Hospital, Hobart, Tas , †Division of Cancer Surgery, Peter MacCallum Cancer Centre , ‡Department of Surgery, University of Melbourne, Melbourne, Vic. , §Sydney Adventist Hospital Clinical School, University of Sydney, Sydney, NSW , and ¶Olivia Newton-John Cancer Research Institute, Austin Hospital, Melbourne, Vic., Australia
Objective To assess the online and social media presence of all practising Australian and New Zealand urologists.
Subjects and Methods In July 2014, all active members of the Urological Society of Australia and New Zealand (USANZ) were identified. A comprehensive search of Google and each social media platform (Facebook, Twitter, LinkedIn and YouTube) was undertaken for each urologist to identify any private websites or social media profiles.
Results Of the 435 urologists currently practising in Australia and New Zealand, 305 (70.1%) have an easily identifiable social media account. LinkedIn (51.3%) is the most commonly used form of social media followed by Twitter (33.3%) and private Facebook (30.1%) accounts. About half (49.8%) have a private business website. The average number of social media
Introduction The early 2000s saw a rapid transition to the Web 2.0 era, transforming the way in which the internet is used. Almost overnight, individual internet users changed from passive viewers to contributors. Information could be disseminated easily and rapidly to an audience anywhere in the world. It was out of this environment that social media was born and continues to expand at an explosive pace. Social media comprises a diverse range of user-generated content including social networking (Facebook, LinkedIn), microblogging (Twitter), and video-sharing and photo-sharing sites (YouTube, Instagram). In 2014, Facebook celebrated its 10-year anniversary and now boasts over one billion active users [1]. Social media has pervaded almost every aspect of society and the medical
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accounts per urologist is 1.42 and 16 urologists (3.7%) have an account with all searched social media platforms. Over half of those with a Twitter account (55.9%) follow a dedicated urology journal club and have a median (range) number of ‘followers’ of 12 (1–2 862). Social media users had a median (range) of 2 (0–8 717) ‘tweets’ on Twitter, 2 (1–45) LinkedIn posts and 1 (1–14) YouTube video.
Conclusion This study represents a unique dataset not relying on selection or recall bias but using data freely available to patients and colleagues to gauge social media presence of urologists. Most Australian and New Zealand urologists have a readily identifiable online and social media presence, with widespread and consistent use across both countries.
Keywords social media, urology, Twitter, medico-legal, internet
profession is not immune. Medical conferences, particularly within the field of urology, have been rapid in their uptake [2]. The potential benefits and harms of medical engagement with social media are well documented [3] leading many health regulatory bodies, professional societies and academic journals to release their own guidelines on the responsible use of social media [4–6]. The medical profession must embrace the rapidly changing online environment or risk being left behind. Many urological journals have welcomed and adopted social media and now have a strong online presence through sites such as Facebook and Twitter [7]. The engagement with social media by urologists has been shown to be less universal [8]. The goal of the present study was to examine the online and social media presence of all currently practising Australian and New Zealand (ANZ) urologists.
© 2015 The Authors BJU International © 2015 BJU International | doi:10.1111/bju.13159 Published by John Wiley & Sons Ltd. www.bjui.org
Online and social media presence of ANZ urologists
Subjects and Methods Study Population All active members of the USANZ database were included. Fellows currently working overseas or undertaking further study were excluded as this study focuses on urologists in fulltime practice in ANZ. Additional practising urologists were identified from the Royal Australasian College of Surgeons database and current institutional appointments. The primary country (and state or territory if practising in Australia) was recorded for each urologist. Where an individual urologist was identified we then ‘cascaded’, searching for other members at their institution, hospital or practice who were not in either database to ensure completeness. Website Analysis A comprehensive ‘Google’ search for each urologist was performed using the practising member’s name and the term ‘urologist’. This identified any private practice websites and institutional sites to which the urologist was affiliated. Each website was assessed as to whether it contained links to any form of social media. Social Media Analysis Facebook, LinkedIn, Twitter and YouTube were individually searched for each urologist by full name. Once a urologist was identified, their profile was inspected for links to other ANZ urologists (where such information was publicly available). This included ‘friends’ lists for Facebook and ‘followers’ lists for Twitter and LinkedIn. Followers of the USANZ Twitter profile were also examined to find further urologist profiles. A social media profile was only attributed to the urologist if it was felt likely to represent that urologist. To this end, to be included the account had to identify as a urologist or surgeon, have a profile photograph that matched a verified photograph or be a friend/follower of two or more other known urologist profiles. Profiles that did not meet these criteria, even if suspected to represent the urologist, were excluded. LinkedIn, Twitter and YouTube profiles and postings are generally open to all members of those social media platforms. Facebook has more complex privacy settings and urologists were classified as having an ‘open public profile’ that was open to everyone on Facebook, or a ‘closed public profile’ that only allowed ‘friends’ or those vetted and accepted to view the full profile and postings. Further engagement analysis was undertaken with Twitter to seek the number of ‘tweets’, ‘followers’ and the number of accounts each urologist was ‘following’. Each account was assessed as
to whether or not it followed a dedicated Twitter urology journal club (@iurojc). The number of LinkedIn posts and individual videos on YouTube were also collated. Finally, gender and ‘academic’ vs ‘non-academic’ urologists were recorded for categories as best could be ascertained (academic = university title holder such as senior lecturer, professor and associate professor). Statistical Analysis Data were analysed using SPSS version 20 (IBM, New York, NY, USA) and a P < 0.05 was considered to indicate statistical significance. Population statistics for all Australian states were obtained from the Australian Bureau of Statistics and for New Zealand from the Statistics New Zealand websites [9,10]. Pearson’s correlation coefficient was used to compare social media use with urologist population density by state and country. This was to ascertain if higher density affected the use of social media, as it was hypothesised that competition may drive a greater online presence, or conversely social media may provide easier access to information for remote urologists and their patients.
Results There were 435 urologists identified to be currently practising in ANZ as of July 2014. All Australian States and Territories were represented based on each urologist’s primary state of practice. About half of Australian (49.7%) and New Zealand (50%) urologists are associated with a private business website with varying degrees of complexity (Fig. 1). At least one social media account was identified for 305 urologists, comprising 70.11% of all those practising. LinkedIn was the most widely used form of social media with 51.3% of urologists having an identifiable account (Table 1). Twitter (33.3%) and personal Facebook accounts (33.1%) were used by a similar number of urologists. Slightly more urologists (37.9%) had a Facebook presence when including either personal or business profiles. Of the 190 urologists with a Facebook account, 52 (27%) had ‘open access’ privacy settings allowing engagement between the urologist, their colleagues and their patients. A total of 58 ANZ urologists have a YouTube presence by appearing in online videos by name or hosting their own channel. The average number of different social media profiles was 1.42 (Table 2) and 40.2% of urologists had more than one social media profile. In all, 16 urologists (3.7%) were found to have an account with all four forms of searched social media (Twitter, private and business Facebook, LinkedIn and a presence on YouTube). In total, 83 urologists across both countries, comprising 19.1% of the cohort, had no online presence, that being either a social media account or website. © 2015 The Authors BJU International © 2015 BJU International
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Fig. 1 The percentage of urologists who have their own private business website.
100%
Website: No Website: Yes
Percentage of urologists
80% 60% 40% 20% 0%
NSW
VIC
QLD
WA
SA TAS ACT NT State/Territory/Country
Australia NZ
All
Table 1 The number and percentage of urologists using each form of social media by state/territory and country. State/Territory/Country
NSW VIC QLD WA SA TAS ACT NT Australia NZ All
Twitter site
Personal Facebook
Business Facebook
LinkedIn page
YouTube videos/ channel
N
%
N
%
N
%
N
%
N
%
51 37 20 14 12 0 1 0 135 10 145
42.1 35.6 27.4 40.0 40.0 0.0 16.7 0.0 35.7 17.9 33.3
35 31 19 18 13 3 2 0 121 23 144
28.9 29.8 26.0 51.4 43.3 33.3 33.3 0.0 32.0 41.1 33.1
20 3 10 3 4 0 0 0 40 6 46
16.5 2.9 13.7 8.6 13.3 0.0 0.0 0.0 10.6 10.7 10.6
58 58 31 20 18 4 2 1 192 31 223
47.9 55.8 42.5 57.1 60.0 44.4 33.3 100.0 50.7 55.4 51.3
21 14 7 3 3 0 2 0 50 8 58
17.4 13.5 9.6 8.6 10.0 0.0 33.3 0.0 13.2 14.3 13.3
Total urologists, n
121 104 73 35 30 9 6 1 379 56 435
Table 2 The number of urologists exhibiting each level of social media presence, on a 0–5 scale, scoring the number of different forms of social media (Twitter, personal and business Facebook, LinkedIn and YouTube). State/Territory/Country
NSW VIC QLD WA SA TAS ACT NT Australia NZ All
Level of social media presence: (Twitter, personal and business Facebook, LinkedIn, YouTube) 0
1
2
3
4
5
37 29 30 5 9 4 2 0 116 14 130
31 32 20 12 6 3 2 1 108 23 130
23 27 11 9 7 2 1 0 82 10 90
17 9 6 8 4 0 1 0 48 5 50
8 5 3 1 2 0 0 0 23 0 19
5 2 3 0 2 0 0 0 17 4 16
Australian urologists were statistically more likely to have a Twitter account than their New Zealand counterparts (P = 0.01). There was no statistical difference for website
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Mean social media level
Total urologists, n
1.53 1.38 1.19 1.66 1.67 0.78 1.17 1.00 1.57 1.39 1.42
121 104 73 35 30 9 6 1 379 56 435
ownership (P = 0.97), personal Facebook (P = 0.18), business Facebook (P = 0.976) or LinkedIn (P = 0.50) profiles, or YouTube presence (P = 0.83).
Online and social media presence of ANZ urologists
For the large part there was no statistically significant difference between utilisation of each form of social media between Australian states. Exceptions were that Western Australian urologists have a higher rate of personal Facebook utilisation of 51.4% (P = 0.04) and Victorian urologists have fewer identifiable business Facebook accounts with just 2.9% (P = 0.02). Across both countries there was one urologist for every 63 641 people (Table 3). Victoria had the highest number of urologists per population (one for every 55 683 people) and New Zealand the lowest (one for every 81 188 people). Population density was not found to have any statistically significant impact on the online and social media presence for urologists when comparing either Australian states or each country. Urologists with a Twitter account had a mean (median; range) of 77 (2; 0–8 717) ‘tweets’, were ‘following’ 21 (16; 1–524) accounts, and had 34 (12; 1–2 862) ‘followers’. Over half (81/145) were following a dedicated urology journal club on Twitter. LinkedIn postings were generally consistent across the cohort, with a mean (median; range) of 4 (2, 1–45) posts. The mean (median; range) number of YouTube videos posted was 2 (1; 1–14). Social media use based on the classification of ‘academic’ vs ‘non-academic’ urologists was similar across platforms (55% academic, 46% non-academic, P > 0.05). The percentage of female urologists (55%) with social media presence was greater than their male counterparts (48%), but not significantly (P > 0.05).
Discussion The ubiquity of the internet and social media has changed the way in which medicine is practiced. Gone are the days when patients would obtain all their health information through face-to-face contact with their doctor. In the internet-age, a second opinion is available from the other side of the world with just a few clicks, yet the quality of this health information may be questionable. Additionally, many patients now research their doctor online before an initial
consultation and doctor-rating websites are increasingly gaining market-share [11,12]. Around 72% of internet users now consult the internet for health information and 73% of online adults use social networking in some way [13,14]. The ‘diffusion of innovations’ curve described by Rogers [15] in 1962 has been used to explain the rate of uptake of a new technology, including social media. There is ongoing debate as to where urologists fit into this model – are they early adopters or laggards? [8]. The present study is the first to assess the online and social media presence of an entire specialty cohort of ANZ medical professionals. Our present data suggest that most ANZ urologists are already using social media, with 70% having a social media account. Other authors have reported varying degrees of social media engagement by urologists. Loeb et al. [16] found that 66% of attending urologist members of the AUA reported having a social media account. This is in contrast to Fuoco et al. [8] who reported a lower uptake of social media by Canadian Urologists. They found that only 26% of urologists use social media frequently with most avoiding it for professional use. Other similar studies have relied on self-reporting of social media use amongst health professionals. In contrast, the data obtained in the present study represents that which is readily available to the public, including patients and colleagues. It is a comprehensive cross-sectional analysis, albeit of limited scope, of all practising urologists without introducing nonresponse bias. Loeb et al. [16] reported a survey response rate of just 9.4% when assessing social media use amongst AUA members. If relying on selfreporting through surveys, there is potential introduction of bias if they are distributed or collected electronically, as those with more computer literacy may be over-represented in the sample. Our present study is the first to evaluate social media use by an entire medical cohort through independent search and data collection. This hopefully provides a more accurate and complete reflection of true social media uptake.
Table 3 The relative population density of urologists per state/territory and country. State/Territory/Country NSW VIC QLD WA SA TAS ACT NT* Australia New Zealand All *
Population, n
Number of urologists
Population/urologist, n
7 465 500 5 791 000 4 690 900 2 550 900 1 677 300 514 000 384 100 242 600 23 319 400 4 546 500 27 620 200
121 104 73 35 30 9 6 1 379 56 434
62 213 55 683 64 259 72 883 55 910 57 111 64 017 242 600 61 529 81 188 63 641
NT has a number of visiting urologists but only one identifiable permanent urologist, so population density data is inaccurate.
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So overall, are urologists’ leaders or followers? This is difficult to demonstrate from the present study alone as we would need comparative studies from alternative specialty groups in other regions; studies that have not yet been undertaken. Amongst colorectal surgeons in the UK LinkedIn membership of just over 37% was reported, which is under our regional urologists at 51% [17]. Additionally, as a craft group urology journals have willingly embraced social media in order to engage their readers [7]. Further, many medical conferences and scientific meetings now have a dedicated social media presence to not only inform delegates, but allow them to interact with proceedings, and urology has certainly led in this field [18]. Finally, an online urology journal club is available via Twitter that facilitates rapid communication and information dissemination on a global scale [19]. This was the second specialty journal club to be established in 2012 [20]. Thus, we may conclude that urology is in the first wave of medical specialties to embrace social media. The benefits of social media include allowing immediate access to worldwide experts, which may also make it a useful adjunct to formal multidisciplinary meetings and assist clinical decision-making [21]. Twitter, and social media on the whole, are able to react in real-time to health policy announcements. This is evidenced by the near doubling of tweets using the term ‘prostate cancer’ within 2 h of the United States Preventative Services Task Force releasing their guidelines against PSA screening [22]. However, there is an inherent potential for misuse. There are documented accounts, both in the medical literature and lay media, of medical professionals and students having their careers curtailed by unprofessional conduct on social media sites [23–25]. It can be very difficult to separate one’s personal and professional profiles online, something particularly relevant for medical professionals. These pitfalls have prompted many professional bodies and regulatory authorities to issue guidelines on the appropriate use of social media [4,5]. Common recommendations include: ensuring one’s online behaviour and profile fit the standards of their profession, maintaining boundaries with patients, protecting patient privacy and assuming anything posted will remain online indefinitely. Interestingly, only 36% of urologists are aware such guidelines exist and just 19% have read any such guidelines or relevant legislation [8]. There exists such a wide variety of platforms with which urologists can now engage the general public that regulation is difficult. Generally, social media use is subject to preexisting legal, ethical and professional obligations. Governing bodies have a duty to maintain the high professional standards of the medical profession, but the present study has highlighted the complexity of executing this duty. Already, a large number of urologists are using social media sites and identifying all of this content is onerous. Such bodies must
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develop directed measures to identify inconsistencies and enforce changes where necessary. This may be avoided by individual urologists having greater ownership and awareness of their public profile and adhering strictly to guidelines and regulations. It has been found that the quality of online health information is generally poor, and the use of tools such as the WHO Health On the Net Foundation code of conduct (HONcode) can help identify websites with good quality information [26,27]. No such system exists to date for social media, meaning patients cannot sort good information from bad. Australia has strict rules about the advertising of medical services; e.g. the use of testimonials by health professionals is prohibited. Social media may represent a way of legally promoting a urologist’s practice in order to garner more business. It was hypothesised that areas of greater competition between urologists might promote a larger online and social media presence. Our present data does not support this hypothesis, as there was no association between urologist population density and the utilisation of social media or business websites. A Pew Research report found that 42% of the online general population have more than one social media account, which is comparable to our present rate of 40.2% [14]. It should be noted that in ANZ, LinkedIn was the predominant identifiable social media platform used by urologists. This is in contrast to data from other countries where Facebook and YouTube were more likely to be used [28]. In fact, among the general public, Facebook is the predominant social media platform with 71% of internet users having an account [14]. The reason for a relatively higher rate of personal Facebook accounts in Western Australia is unclear. It is potentially due to the fact many were ‘friends’ with each other online, making identification of their accounts relatively easier than was the case in other states. There are some clear limitations of the present study. It is unlikely that every social media account was identified, particularly those with strong privacy settings. This may reflect why the use of personal Facebook presented in the present study was lower than that recorded in other countries or by the general public. Furthermore, the present study does not analyse the way in which social media is used, nor does it check if an identified account is active. However, our present data did show some degree of engagement, with a median of two tweets on Twitter, a median of two postings on LinkedIn and one YouTube video. There was significant variability between urologists, with some showing much higher engagement than others. There appeared to be trends towards greater engagement by female and academic urologists but at present these trends were not statistically significant. Certainly some urologists are dynamic contributors; some use social media in a passive way and some have an inactive account
Online and social media presence of ANZ urologists
with no true social media utilisation. The present study does not attempt to distinguish between these groups. Further data to explore the attitudes and use of social media amongst ANZ urologists would complement the present study. The present study represents a unique dataset, not relying on selection or recall bias but using data freely available to colleagues and the public to gauge social media presence of urologists. Most ANZ urologists have a readily identifiable online and social media presence. LinkedIn is the most commonly used social media platform with a significant number of urologists having a Twitter or Facebook account. The use of social media was widespread and consistent between all States and Territories of Australia. Social media offers a range of opportunities and only time will tell if ANZ urologists are willing to capitalise on them.
Conflicts of Interest None disclosed.
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Correspondence: Nathan Lawrentschuk, Suite 5, 210 Burgundy Street, Heidelberg, Vic. 3084, Australia. e-mail: [email protected] Abbreviations: ACT, Australian Capital Territory; ANZ, Australian and New Zealand; NSW, New South Wales; NT, Northern Territory; NZ, New Zealand; QLD, Queensland; SA, South Australia; TAS, Tasmania; VIC, Victoria; WA, Western Australia.
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