Acad Psychiatry DOI 10.1007/s40596-014-0278-5
EMPIRICAL REPORT
Social Media: Portrait of an Emerging Tool in Medical Education Durga Roy & Jacob Taylor & Christine C. Cheston & Tabor E. Flickinger & Margaret S. Chisolm
Received: 28 July 2014 / Accepted: 5 November 2014 # Academic Psychiatry 2015
Abstract Objective The authors compare the prevalence of challenges and opportunities in commentaries and descriptive accounts versus evaluative studies of social media use in medical education. Methods A previously published report of social media use in medical education provided an in-depth discussion of 14 evaluative studies, a small subset of the total number of 99 articles on this topic. This study used the full set of articles identified by that review, including the 58 commentaries and 27 descriptive accounts which had not been previously reported, to provide a glimpse into how emerging tools in medical education are initially perceived. Each commentary, descriptive account, and evaluative study was identified and compared on various characteristics, including discussion themes regarding the challenges and opportunities of social media use in medical education. Results Themes related to the challenges of social media use in medical education were more prevalent in commentaries and descriptive accounts than in evaluative studies. The potential of social media to affect medical professionalism adversely was the most commonly discussed challenge in the commentaries (53 %) and descriptive accounts (63 %) in comparison to technical issues related to implementation in the evaluative studies (50 %). Conclusions Results suggest that the early body of literature on social media use in medical education—like that of previous Electronic supplementary material The online version of this article (doi:10.1007/s40596-014-0278-5) contains supplementary material, which is available to authorized users. D. Roy : J. Taylor : M. S. Chisolm (*) Johns Hopkins University School of Medicine, Baltimore, MD, USA e-mail: [email protected] C. C. Cheston Harvard Medical School and Boston University School of Medicine, Boston, MA, USA T. E. Flickinger University of Virginia School of Medicine, Charlottesville, VA, USA
innovative education tools—comprises primarily commentaries and descriptive accounts that focus more on the challenges of social media than on potential opportunities. These results place social media tools in historical context and lay the groundwork for expanding on this novel approach to medical education. Keywords Curriculum development . Teaching methods History indicates that the early use of any innovative medical education tool initially generates a variety of expert and notso-expert opinions, each speculating whether the new tool will offer any advantage to learners over those that already exist. If a tool is found to be superior, skepticism gradually gives way to acceptance, adoption, and incorporation into mainstream use. Over the past few decades, several new medical education tools have emerged, each at first generating its share of negative opinions. Those able to demonstrate effectiveness are adopted as others are left behind. Thus, an evidence base evaluating the educational impact of a new teaching tool is essential to address questions to determine whether or not a new tool merits adoption. Educators must evaluate both the negative and positive impacts of implemented curriculum before advocating the use of any new tool in medical education. For example, problembased learning (PBL) initially had authors arguing variously for and against its effectiveness. In its early stages, much of the PBL literature consisted of opinions based primarily on anecdotal evidence, if any evidence at all [1, 2]. However, as more data-driven evaluations of PBL emerged, an evidence-base accumulated for its use in medical education [3, 4]. Simulation education provides another, more recent, example of an emerging medical education tool. As with PBL, the simulation literature initially contained mainly opinion-based articles [5, 6]. As the strength of simulation’s evidence base grew, however, the number of articles supporting its benefits gradually began to outnumber those concerned about its risks [7]. As expected, these new tools were initially met with skepticism, but, as the evidence base grew, this skepticism
Acad Psychiatry
gradually gave way to acceptance. (The transition from skepticism to acceptance parallels curriculum development stages, which move from general/targeted needs-assessment through evaluation [8]. One might anticipate this same pattern applying to contemporary medical education innovations, such as social media. And, indeed, concerns have been raised widely in the medical education literature around challenges posed to medical professionalism with increasing social media use by medical trainees and professionals. Most of these concerns are based primarily on opinion/anecdotes [9, 10], although some are based on evidence, albeit weak [11–13]. Regardless of the concerns’ origins, worries about threats to professionalism are worthy of attention. However, understanding the basis of these concerns and—if evidence-based—the strength of the evidence is necessary to perform an accurate risk/benefit analysis regarding the use of social media in medical education. A systematic review of social media use in medical education was conducted, the primary outcome of which has been previously reported [14]. That report focused on only one category of articles: those that evaluated implemented curricula (evaluative studies). It did not identify or describe in detail the other non-evaluative articles (commentaries and descriptive accounts) found by systematic review of the literature of social media use in medical education. The report did establish, however, that social media use in medical education is in its early stages, because the number of the identified evaluative studies was small (n=14) in comparison to the number of commentaries (n=58) and descriptive accounts [n=27]. If social media tools are similar to past emerging medical education tools, that is, initially airing concerns regarding risks of use, the authors hypothesized that the commentaries and descriptive accounts (non-evaluative) identified by systematic review would contain more themes related to the challenges of social media use in medical education in comparison to the evaluative studies. This study aims to test that hypothesis by using the data set collected by systematic review to compare the prevalence of specific themes of challenges and opportunities in commentaries and descriptive accounts with those in evaluative studies.
Methods The present study is a secondary data analysis of a systematic review of social media use in medical education, of which the evaluative studies were the focus of the primary report [14]. The review searched MEDLINE, CINAHL, ERIC, EMBASE, PsycINFO, Proquest, Cochrane Library, Web of Science, and Scopus (from the start of each database through September 12, 2011). Keywords related to social media and medical education were used. Of the 99 articles on this topic identified by systematic review, 58 (58.5 %) were categorized as commentaries, 27 (27 %) as descriptive accounts, and 14
(14 %) as evaluative studies. A detailed description of the review, including a flow chart and data from the 14 evaluative studies, has been previously reported [14]. Data extracted from each article included type of publication journal, participants, perceived value of social media, and social media tool discussed. Commentaries were defined as reports of opinions or recommendations regarding social media use by physicians or physicians-in-training. Descriptive accounts were defined as reports gathered by the investigators regarding development and/or use of social media in medical education, including frequency, type, or content of use, but lacking evaluation. Evaluative studies were defined as reports on measured outcomes of a medical education curriculum using social media. Articles in these categories were further assessed as to discussion themes, including those related to challenges and opportunities of social media use in medical education. For all articles meeting criteria for final review, three authors (CC, TF, MC) independently identified each challenge and opportunity regarding social media use in medical education discussed in the articles. Subsequently, one author (CC) categorized these independently identified challenges and opportunities into over-arching themes. The three authors then met as a group to identify subthemes, in order to define distinct categories for further analysis and comparison. The specific challenge subthemes were risks to professionalism (“professionalism”), threats to privacy (“privacy”), questionable information quality (“info quality”), threats to intellectual property (“ownership”), absence of research proving efficacy (“needs research”), and technical problems (“technical issues”). The specific opportunities subthemes were increased social connection among learners and teachers (“social”), greater accessibility of educational activity (“accessible”), increased opportunities for professional development (“prof development”), increased popularity of educational activity (“popular”), greater opportunities for reflection (“reflection”), and more dynamic and interactive learning environment (“dynamic”). The primary outcome measure was comparison of all challenges and opportunities reported in each commentary or descriptive account (non-evaluative article) versus each evaluative study. Commentaries and descriptive accounts were categorized as non-evaluative articles because they did not report on outcomes of implemented curricula.
Results The online supplementary table contains citations for all commentaries and descriptive accounts on the topic of social media use in medical education identified by systematic review. These citations have not previously been reported, unlike those of the evaluative studies [14]. Table 1 lists the general characteristics of all articles, by article category. Non-evaluative articles were commonly published in general medicine journals, whereas
Acad Psychiatry Table 1
General characteristics of each article category
Journal type General medicine Informationist Medical education Specialty Technology Participants Undergraduate medical students Graduate medical trainees Practicing physicians All levels of medical education Value of social media Positive Negative Mixed Social media tool Blogs Facebook General LinkedIn Media sharing sites Myspace Second Life Twitter Videoconference
Table 2 Comparison of challenges and opportunities sub-themes by article category
% % Commentariesa Descriptive (n=58) accountsb (n=27)
% Evaluativec (n=14)
27 2 17 47 7
26 11 44 7 11
7 14 50 29 0
28
67
86
24
41
7
31
19
7
55
7
7
60 9 31
37 7 56
93 0 7
66 59 16 7 14
41 70 15 0 11
71 14 0 0 7
10 3 28 3
7 0 14 7
0 0 14 29
a
Commentaries defined as reports of opinions or recommendations regarding social media use by physicians or physicians-in-training
b
Descriptive accounts defined as reports gathered by the investigators regarding development and/or use of social media in medical education, including frequency, type, or content of use, but lacking evaluation c
Evaluative studies defined as reports on measured outcomes of a medical education curriculum using social media
evaluative studies were most commonly published in medical education journals. More non-evaluative articles were opposed to social media use (9 % of commentaries, 7 % of descriptive accounts) than evaluative studies (0 %). Table 2 presents the specific challenges and opportunities subthemes found in the commentaries, descriptive accounts, and evaluative studies. (Henceforth, for brevity, these subthemes will be referred to as “challenges and opportunities” rather than “challenges and opportunities subthemes.”) The potential of social media to affect medical professionalism
% Commentariesa (n=58)
% Descriptive accountsb (n=27)
% Evaluativec (n=14)
53
63
7
36 29
30 30
21 14
19 14
11 18
0 7
10
22
50
86
15
14
79 44 34
52 26 22
93 50 21
24 24 22 17
56 22 15 15
29 29 36 14
Challenges Professionalism Privacy Information quality Ownership Needs research Technical issues Other Opportunities Social Accessible Professional development Popular Reflection Dynamic Other a
Commentaries defined as reports of opinions or recommendations regarding social media use by physicians or physicians-in-training
b Descriptive accounts defined as reports gathered by the investigators regarding development and/or use of social media in medical education, including frequency, type, or content of use, but lacking evaluation c
Evaluative studies defined as reports on measured outcomes of a medical education curriculum using social media
adversely was the most prevalent challenge discussed in the commentaries (53 %) and descriptive accounts (63 %). In the evaluative studies, the only commonly identified challenge was technical issues, discussed in half of the studies, in comparison to 29 % and 22 % of commentaries and descriptive accounts, respectively. The potential of social media to increase social interactions among teachers and learners was the most commonly identified opportunity, regardless of article category. The potential of social media to increase the popularity of medical education initiatives was an opportunity found in the majority of descriptive accounts (56 %) in comparison to 24 % and 29 % of commentaries and evaluative studies, respectively.
Discussion This study confirmed the authors’ hypothesis that commentaries and descriptive accounts (non-evaluative articles)
Acad Psychiatry
contained more discussion of challenges using social media in medical education than did evaluative studies. The challenge most frequently discussed in the commentaries and descriptive accounts was the adverse impact of social media use on medical professionalism, whereas the evaluative studies focused more on technical implementation challenges. These results suggest several interpretations, including the following: (1) challenges to professionalism were not a problem when curricula were actually implemented and/or (2) technical implementation challenges eclipsed those related to medical professionalism. A recently published review of implemented curricula using social networking sites supports that social media use in medical education poses few challenges to professionalism [15]. Regardless of category, most articles suggest that social media use in medical education has the potential to enhance opportunities for social connections and increased accessibility among learners. In addition, regardless of category, most identified popularity, accessibility, dynamic use, reflection, and professional development as opportunities to be harnessed by social media use in medical education. Evaluative studies were most commonly published in medical education journals and offered no opposition to use in this setting, which further may potentiate widespread acceptance of the opportunities of social media use in medical education. A recent review showed that integrating medicine’s core cultural values of privacy, confidentiality, one-on-one interactions, and formal conduct with social media’s cultural values of sharing and openness, connection, transparency, and informality present challenges, as well as opportunities, for medical professionalism [16]. The present study identified a broader range of opportunities including popularity, accessibility, dynamic use, reflection, and professional development. In addition, this study suggests that the technical problems associated with social media eclipse the challenges to medical professionalism when curricula are implemented and evaluated. Although this study captures a moment of historical transition and interest, it has several limitations. Given the exponential growth of this field, numerous relevant articles have been published since the end-date of the systematic review, including an additional review [15]. That report concluded that, although social-networking sites have been used in medical education without problems of professionalism and have received positive feedback from learners, there is no clear evidence that social-networking sites are equally or more effective than other social media tools used in medical education. Additionally, a recent paper provides an excellent summary of the ethical, professional, and social implications of social media use in clinical care, also relevant to medical education [17]. The present report, in part because of this limitation, supports that social media—like other emerging
medical education tools—was met initially with skepticism, but as newer, more evidence-based studies of have been reported in the literature, this skepticism is giving way to greater acceptance. Other limitations include the lack of clear definitions regarding form and content of social media technology in the articles, resulting in possible inappropriate exclusion from review. In addition, publication bias favoring articles demonstrating benefits versus equivalence or negative results may be present, as well as gender and cultural biases. Also, general medical and medical education journals may have been more likely to publish results supporting social media use, and gender and cultural backgrounds may have been factors in respondent experiences. Despite these limitations, this study establishes a body of evidence from which to consider the challenges and opportunities of social media as an emerging medical education tool. Results offer useful information to those aspiring to develop innovative curricula in undergraduate, graduate, and continuing medical education. Findings suggest there may be more opportunities than challenges associated with social media use and that significant challenges are associated with implementation of the technology. These data lay the groundwork for expanding on novel approaches to medical education and strongly suggest the need for continued development, implementation, and evaluation of curricula, as well as increased publication in general medical education journals and further systematic identification of articles published on this topic. Future research into this emerging field would benefit from evaluation of curricula in terms of learner outcomes (knowledge, attitudes, skills, and behaviors) and systematic assessment of all risks, including any related to medical professionalism, encountered in implementation. Ultimately, further and higher-quality research regarding the impact on patients of social media use in medical education will be needed to establish best practices in harnessing this emerging technology to enhance medical education.
Implications for Educators • Emerging tools in medical education have traditionally been met with skepticism when introduced, yet implementation of such tools in medical curricula over time allows for more evaluation and—if the evidence supports—greater acceptance. • The early literature on social media use in medical education—as that of most new educational methods—was more opinion-based, but as more studies describing implementation of social media-based curricula have been introduced, this emerging tool has gained more evidence supporting its use. • Commentaries and descriptive accounts (non-evaluative articles) are based more on opinions, anecdotal evidence, and/or needs assessment data and highlight more challenges to social media use in medical education compared with evaluative studies. • Further studies evaluating implemented medical education curricula that use social media can strengthen the evidence base and—if warranted—bring this emerging tool to more mainstream acceptance.
Acad Psychiatry Disclosure On behalf of all authors, the corresponding author states that there is no conflict of interest. 8.
References 1. Brynhildsen J, Dahle LO, Behrbohm Fallsberg M, Rundquist I, Hammar M. Attitudes among students and teachers on vertical integration between clinical medicine and basic science within a problem-based undergraduate medical curriculum. Med Teach. 2002;24(3):286–8. 2. Khoo HE, Chhem RK, Gwee MC, Balasubramaniam P. Introduction of problem-based learning in a traditional medical curriculum in Singapore—students' and tutors' perspectives. Ann Acad Med Singapore. 2001;30(4):371–4. 3. Yaqinuddin A. Problem-based learning as an instructional method. J Coll Physicians Surg Pak. 2013;23(1):83–5. 4. Hartling L, Spooner C, Tjosvold L, Oswald A. Problem-based learning in pre-clinical medical education: 22 years of outcome research. Med Teach. 2010;32(1):28–35. 5. Dawson S. Perspectives on performance assessment in medical simulation. Surgeon. 2011;9 Suppl 1:S21–2. 6. Hagen SS, Ferguson KJ, Sharp WJ, Adam LA. Residents' attitudes about the introduction of a surgical skills simulation laboratory. Simul Healthc. 2010;5(1):28–32. 7. Griswold S, Ponnuru S, Nishisaki A, Szyld D, Davenport M, Deutsch ES, et al. The emerging role of simulation education to achieve
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patient safety: translating deliberate practice and debriefing to save lives. Pediatr Clin North Am. 2012;59(6):1329–40. Kern D, Thomas P, Howard D, Bass E, editors. Curriculum development for medical education: a six-step approach. Baltimore, MD: Johns Hopkins University press; 1998. Greysen SR, Chretien KC, Kind T, Young A, Gross CP. Physician violations of online professionalism and disciplinary actions: a national survey of state medical boards. JAMA. 2012;307(11):1141–2. Chretien KC, Greysen SR, Chretien JP, Kind T. Online posting of unprofessional content by medical students. JAMA. 2009;302(12): 1309–15. Kind T, Patel PD, Lie D, Chretien KC. Twelve tips for using social media as a medical educator. Med Teach. 2014;36(4):284–90. Farnan J, Paro JA, Higa J, Edelson J, Arora VM. The YouTube generation: implications for medical professionalism. Perspect Biol Med. 2008;51(4):517–24. Greysen SR, Kind T, Chretien KC. Online professionalism and the mirror of social media. J Gen Intern Med. 2010;25(11):1227–9. Cheston CC, Flickinger TE, Chisolm MS. Social media use in medical education: a systematic review. Acad Med. 2013;88(6): 893–901. Cartledge P, Miller M, Phillips B. The use of social-networking sites in medical education. Med Teach. 2013;35(10):847–57. Gholami-Kordkheili F, Wild V, Strech D. The impact of social media on medical professionalism: a systematic qualitative review of challenges and opportunities. J Med Internet Res. 2013;15(8):e184. Chretien KC, Kind T. Social media and clinical care: ethical, professional, and social implications. Circulation. 2013;127(13):1413–21.
EMPIRICAL REPORT
Social Media: Portrait of an Emerging Tool in Medical Education Durga Roy & Jacob Taylor & Christine C. Cheston & Tabor E. Flickinger & Margaret S. Chisolm
Received: 28 July 2014 / Accepted: 5 November 2014 # Academic Psychiatry 2015
Abstract Objective The authors compare the prevalence of challenges and opportunities in commentaries and descriptive accounts versus evaluative studies of social media use in medical education. Methods A previously published report of social media use in medical education provided an in-depth discussion of 14 evaluative studies, a small subset of the total number of 99 articles on this topic. This study used the full set of articles identified by that review, including the 58 commentaries and 27 descriptive accounts which had not been previously reported, to provide a glimpse into how emerging tools in medical education are initially perceived. Each commentary, descriptive account, and evaluative study was identified and compared on various characteristics, including discussion themes regarding the challenges and opportunities of social media use in medical education. Results Themes related to the challenges of social media use in medical education were more prevalent in commentaries and descriptive accounts than in evaluative studies. The potential of social media to affect medical professionalism adversely was the most commonly discussed challenge in the commentaries (53 %) and descriptive accounts (63 %) in comparison to technical issues related to implementation in the evaluative studies (50 %). Conclusions Results suggest that the early body of literature on social media use in medical education—like that of previous Electronic supplementary material The online version of this article (doi:10.1007/s40596-014-0278-5) contains supplementary material, which is available to authorized users. D. Roy : J. Taylor : M. S. Chisolm (*) Johns Hopkins University School of Medicine, Baltimore, MD, USA e-mail: [email protected] C. C. Cheston Harvard Medical School and Boston University School of Medicine, Boston, MA, USA T. E. Flickinger University of Virginia School of Medicine, Charlottesville, VA, USA
innovative education tools—comprises primarily commentaries and descriptive accounts that focus more on the challenges of social media than on potential opportunities. These results place social media tools in historical context and lay the groundwork for expanding on this novel approach to medical education. Keywords Curriculum development . Teaching methods History indicates that the early use of any innovative medical education tool initially generates a variety of expert and notso-expert opinions, each speculating whether the new tool will offer any advantage to learners over those that already exist. If a tool is found to be superior, skepticism gradually gives way to acceptance, adoption, and incorporation into mainstream use. Over the past few decades, several new medical education tools have emerged, each at first generating its share of negative opinions. Those able to demonstrate effectiveness are adopted as others are left behind. Thus, an evidence base evaluating the educational impact of a new teaching tool is essential to address questions to determine whether or not a new tool merits adoption. Educators must evaluate both the negative and positive impacts of implemented curriculum before advocating the use of any new tool in medical education. For example, problembased learning (PBL) initially had authors arguing variously for and against its effectiveness. In its early stages, much of the PBL literature consisted of opinions based primarily on anecdotal evidence, if any evidence at all [1, 2]. However, as more data-driven evaluations of PBL emerged, an evidence-base accumulated for its use in medical education [3, 4]. Simulation education provides another, more recent, example of an emerging medical education tool. As with PBL, the simulation literature initially contained mainly opinion-based articles [5, 6]. As the strength of simulation’s evidence base grew, however, the number of articles supporting its benefits gradually began to outnumber those concerned about its risks [7]. As expected, these new tools were initially met with skepticism, but, as the evidence base grew, this skepticism
Acad Psychiatry
gradually gave way to acceptance. (The transition from skepticism to acceptance parallels curriculum development stages, which move from general/targeted needs-assessment through evaluation [8]. One might anticipate this same pattern applying to contemporary medical education innovations, such as social media. And, indeed, concerns have been raised widely in the medical education literature around challenges posed to medical professionalism with increasing social media use by medical trainees and professionals. Most of these concerns are based primarily on opinion/anecdotes [9, 10], although some are based on evidence, albeit weak [11–13]. Regardless of the concerns’ origins, worries about threats to professionalism are worthy of attention. However, understanding the basis of these concerns and—if evidence-based—the strength of the evidence is necessary to perform an accurate risk/benefit analysis regarding the use of social media in medical education. A systematic review of social media use in medical education was conducted, the primary outcome of which has been previously reported [14]. That report focused on only one category of articles: those that evaluated implemented curricula (evaluative studies). It did not identify or describe in detail the other non-evaluative articles (commentaries and descriptive accounts) found by systematic review of the literature of social media use in medical education. The report did establish, however, that social media use in medical education is in its early stages, because the number of the identified evaluative studies was small (n=14) in comparison to the number of commentaries (n=58) and descriptive accounts [n=27]. If social media tools are similar to past emerging medical education tools, that is, initially airing concerns regarding risks of use, the authors hypothesized that the commentaries and descriptive accounts (non-evaluative) identified by systematic review would contain more themes related to the challenges of social media use in medical education in comparison to the evaluative studies. This study aims to test that hypothesis by using the data set collected by systematic review to compare the prevalence of specific themes of challenges and opportunities in commentaries and descriptive accounts with those in evaluative studies.
Methods The present study is a secondary data analysis of a systematic review of social media use in medical education, of which the evaluative studies were the focus of the primary report [14]. The review searched MEDLINE, CINAHL, ERIC, EMBASE, PsycINFO, Proquest, Cochrane Library, Web of Science, and Scopus (from the start of each database through September 12, 2011). Keywords related to social media and medical education were used. Of the 99 articles on this topic identified by systematic review, 58 (58.5 %) were categorized as commentaries, 27 (27 %) as descriptive accounts, and 14
(14 %) as evaluative studies. A detailed description of the review, including a flow chart and data from the 14 evaluative studies, has been previously reported [14]. Data extracted from each article included type of publication journal, participants, perceived value of social media, and social media tool discussed. Commentaries were defined as reports of opinions or recommendations regarding social media use by physicians or physicians-in-training. Descriptive accounts were defined as reports gathered by the investigators regarding development and/or use of social media in medical education, including frequency, type, or content of use, but lacking evaluation. Evaluative studies were defined as reports on measured outcomes of a medical education curriculum using social media. Articles in these categories were further assessed as to discussion themes, including those related to challenges and opportunities of social media use in medical education. For all articles meeting criteria for final review, three authors (CC, TF, MC) independently identified each challenge and opportunity regarding social media use in medical education discussed in the articles. Subsequently, one author (CC) categorized these independently identified challenges and opportunities into over-arching themes. The three authors then met as a group to identify subthemes, in order to define distinct categories for further analysis and comparison. The specific challenge subthemes were risks to professionalism (“professionalism”), threats to privacy (“privacy”), questionable information quality (“info quality”), threats to intellectual property (“ownership”), absence of research proving efficacy (“needs research”), and technical problems (“technical issues”). The specific opportunities subthemes were increased social connection among learners and teachers (“social”), greater accessibility of educational activity (“accessible”), increased opportunities for professional development (“prof development”), increased popularity of educational activity (“popular”), greater opportunities for reflection (“reflection”), and more dynamic and interactive learning environment (“dynamic”). The primary outcome measure was comparison of all challenges and opportunities reported in each commentary or descriptive account (non-evaluative article) versus each evaluative study. Commentaries and descriptive accounts were categorized as non-evaluative articles because they did not report on outcomes of implemented curricula.
Results The online supplementary table contains citations for all commentaries and descriptive accounts on the topic of social media use in medical education identified by systematic review. These citations have not previously been reported, unlike those of the evaluative studies [14]. Table 1 lists the general characteristics of all articles, by article category. Non-evaluative articles were commonly published in general medicine journals, whereas
Acad Psychiatry Table 1
General characteristics of each article category
Journal type General medicine Informationist Medical education Specialty Technology Participants Undergraduate medical students Graduate medical trainees Practicing physicians All levels of medical education Value of social media Positive Negative Mixed Social media tool Blogs Facebook General LinkedIn Media sharing sites Myspace Second Life Twitter Videoconference
Table 2 Comparison of challenges and opportunities sub-themes by article category
% % Commentariesa Descriptive (n=58) accountsb (n=27)
% Evaluativec (n=14)
27 2 17 47 7
26 11 44 7 11
7 14 50 29 0
28
67
86
24
41
7
31
19
7
55
7
7
60 9 31
37 7 56
93 0 7
66 59 16 7 14
41 70 15 0 11
71 14 0 0 7
10 3 28 3
7 0 14 7
0 0 14 29
a
Commentaries defined as reports of opinions or recommendations regarding social media use by physicians or physicians-in-training
b
Descriptive accounts defined as reports gathered by the investigators regarding development and/or use of social media in medical education, including frequency, type, or content of use, but lacking evaluation c
Evaluative studies defined as reports on measured outcomes of a medical education curriculum using social media
evaluative studies were most commonly published in medical education journals. More non-evaluative articles were opposed to social media use (9 % of commentaries, 7 % of descriptive accounts) than evaluative studies (0 %). Table 2 presents the specific challenges and opportunities subthemes found in the commentaries, descriptive accounts, and evaluative studies. (Henceforth, for brevity, these subthemes will be referred to as “challenges and opportunities” rather than “challenges and opportunities subthemes.”) The potential of social media to affect medical professionalism
% Commentariesa (n=58)
% Descriptive accountsb (n=27)
% Evaluativec (n=14)
53
63
7
36 29
30 30
21 14
19 14
11 18
0 7
10
22
50
86
15
14
79 44 34
52 26 22
93 50 21
24 24 22 17
56 22 15 15
29 29 36 14
Challenges Professionalism Privacy Information quality Ownership Needs research Technical issues Other Opportunities Social Accessible Professional development Popular Reflection Dynamic Other a
Commentaries defined as reports of opinions or recommendations regarding social media use by physicians or physicians-in-training
b Descriptive accounts defined as reports gathered by the investigators regarding development and/or use of social media in medical education, including frequency, type, or content of use, but lacking evaluation c
Evaluative studies defined as reports on measured outcomes of a medical education curriculum using social media
adversely was the most prevalent challenge discussed in the commentaries (53 %) and descriptive accounts (63 %). In the evaluative studies, the only commonly identified challenge was technical issues, discussed in half of the studies, in comparison to 29 % and 22 % of commentaries and descriptive accounts, respectively. The potential of social media to increase social interactions among teachers and learners was the most commonly identified opportunity, regardless of article category. The potential of social media to increase the popularity of medical education initiatives was an opportunity found in the majority of descriptive accounts (56 %) in comparison to 24 % and 29 % of commentaries and evaluative studies, respectively.
Discussion This study confirmed the authors’ hypothesis that commentaries and descriptive accounts (non-evaluative articles)
Acad Psychiatry
contained more discussion of challenges using social media in medical education than did evaluative studies. The challenge most frequently discussed in the commentaries and descriptive accounts was the adverse impact of social media use on medical professionalism, whereas the evaluative studies focused more on technical implementation challenges. These results suggest several interpretations, including the following: (1) challenges to professionalism were not a problem when curricula were actually implemented and/or (2) technical implementation challenges eclipsed those related to medical professionalism. A recently published review of implemented curricula using social networking sites supports that social media use in medical education poses few challenges to professionalism [15]. Regardless of category, most articles suggest that social media use in medical education has the potential to enhance opportunities for social connections and increased accessibility among learners. In addition, regardless of category, most identified popularity, accessibility, dynamic use, reflection, and professional development as opportunities to be harnessed by social media use in medical education. Evaluative studies were most commonly published in medical education journals and offered no opposition to use in this setting, which further may potentiate widespread acceptance of the opportunities of social media use in medical education. A recent review showed that integrating medicine’s core cultural values of privacy, confidentiality, one-on-one interactions, and formal conduct with social media’s cultural values of sharing and openness, connection, transparency, and informality present challenges, as well as opportunities, for medical professionalism [16]. The present study identified a broader range of opportunities including popularity, accessibility, dynamic use, reflection, and professional development. In addition, this study suggests that the technical problems associated with social media eclipse the challenges to medical professionalism when curricula are implemented and evaluated. Although this study captures a moment of historical transition and interest, it has several limitations. Given the exponential growth of this field, numerous relevant articles have been published since the end-date of the systematic review, including an additional review [15]. That report concluded that, although social-networking sites have been used in medical education without problems of professionalism and have received positive feedback from learners, there is no clear evidence that social-networking sites are equally or more effective than other social media tools used in medical education. Additionally, a recent paper provides an excellent summary of the ethical, professional, and social implications of social media use in clinical care, also relevant to medical education [17]. The present report, in part because of this limitation, supports that social media—like other emerging
medical education tools—was met initially with skepticism, but as newer, more evidence-based studies of have been reported in the literature, this skepticism is giving way to greater acceptance. Other limitations include the lack of clear definitions regarding form and content of social media technology in the articles, resulting in possible inappropriate exclusion from review. In addition, publication bias favoring articles demonstrating benefits versus equivalence or negative results may be present, as well as gender and cultural biases. Also, general medical and medical education journals may have been more likely to publish results supporting social media use, and gender and cultural backgrounds may have been factors in respondent experiences. Despite these limitations, this study establishes a body of evidence from which to consider the challenges and opportunities of social media as an emerging medical education tool. Results offer useful information to those aspiring to develop innovative curricula in undergraduate, graduate, and continuing medical education. Findings suggest there may be more opportunities than challenges associated with social media use and that significant challenges are associated with implementation of the technology. These data lay the groundwork for expanding on novel approaches to medical education and strongly suggest the need for continued development, implementation, and evaluation of curricula, as well as increased publication in general medical education journals and further systematic identification of articles published on this topic. Future research into this emerging field would benefit from evaluation of curricula in terms of learner outcomes (knowledge, attitudes, skills, and behaviors) and systematic assessment of all risks, including any related to medical professionalism, encountered in implementation. Ultimately, further and higher-quality research regarding the impact on patients of social media use in medical education will be needed to establish best practices in harnessing this emerging technology to enhance medical education.
Implications for Educators • Emerging tools in medical education have traditionally been met with skepticism when introduced, yet implementation of such tools in medical curricula over time allows for more evaluation and—if the evidence supports—greater acceptance. • The early literature on social media use in medical education—as that of most new educational methods—was more opinion-based, but as more studies describing implementation of social media-based curricula have been introduced, this emerging tool has gained more evidence supporting its use. • Commentaries and descriptive accounts (non-evaluative articles) are based more on opinions, anecdotal evidence, and/or needs assessment data and highlight more challenges to social media use in medical education compared with evaluative studies. • Further studies evaluating implemented medical education curricula that use social media can strengthen the evidence base and—if warranted—bring this emerging tool to more mainstream acceptance.
Acad Psychiatry Disclosure On behalf of all authors, the corresponding author states that there is no conflict of interest. 8.
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