e-Learning & Technology
The role of social media in clinical excellence Samantha Batt-Rawden, King’s College London, UK Tabor Flickinger, Department of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, USA John Weiner, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia Christine Cheston, Harvard Medical School and Boston University School of Medicine, Boston, USA Margaret Chisolm, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, USA
Social media may help facilitate the achievement of clinical excellence
SUMMARY Background: The provision of excellent patient care is a goal shared by all doctors. The role of social media (SM) in helping medical students and doctors achieve clinical excellence is unknown. Purpose: This report aimed to identify examples of how SM may be used to help promote the achievement of clinical excellence in medical learners. Methods: Three of the authors previously conducted a systematic review of the published literature on SM use in undergraduate, graduate and continuing medical education. Two
authors re-examined the 14 evaluative studies to identify any examples of SM use that may facilitate the achievement of clinical excellence and to consider whether there were any aspects of clinical excellence for which no studies had been performed, and, if so, whether SM was relevant to these domains. Results: Each study touched on one or more of the following domains of clinical excellence: communication and interpersonal skills; professionalism and humanism; knowledge; diagnostic acumen; exhibiting a passion for patient care; a scholarly approach to clinical practice; and explicitly
modelling expertise to medical trainees. No study addressed the role of SM to promote the skillful negotiation of the health care system, and in collaboration with investigators to advance science and discovery; however, additional evidence suggested that SM may play an adjunctive role in promoting the achievement of these aspects of clinical excellence. Conclusion: This report supports the hypothesis that SM may help facilitate the achievement of clinical excellence; however, further research is needed into the role of SM in promoting the achievement of clinical excellence.
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INTRODUCTION
T
he provision of excellent patient care is a goal shared by all doctors. Based on systematic review and expert consensus, the Johns Hopkins Miller-Coulson Academy of Clinical Excellence defined clinical excellence as encompassing nine domains: (1) communication and interpersonal skills; (2) professionalism and humanism; (3) knowledge; (4) diagnostic acumen; (5) exhibiting a passion for patient care; (6) skillful negotiation of the health care system; (7) a scholarly approach to clinical practice; (8) modelling expertise to medical trainees; and (9) collaboration with investigators to advance science and discovery.1 These domains are congruent with international professionalism guidelines. Social media (SM) use in medical education is increasingly adopted by doctors and doctorsin-training worldwide. It can build on the success of e-learning in ways that are more learnergenerated, collaborative and engaging. Figure 1 shows a conceptual model demonstrating a possible role for virtual interactions (via SM tools), in addition to face-to-face interactions, in promoting clinical excellence. This model was developed using other proposed models for the role of SM in doctor–patient relationships,2 and sources framing the concept of clinical excellence.1
colleagues, trainees or other members of health care systems in order to share knowledge, hone clinical reasoning and advance scholarship. The authors aimed to test this hypothesis by identifying exemplars of SM use in promoting clinical excellence from a previously published systematic review of evaluative studies on the use of SM in medical education.3
The provision of excellent patient care is a goal shared by all doctors
METHODS Three of the authors (TF, CC, MC) previously conducted a systematic review on SM use in medical education. MEDLINE, CINAHL, ERIC, EMBASE, PsycINFO, Proquest, Cochrane Library, Web of Science and Scopus were searched from the start of each database to 12 September 2011 for English-language, peerreviewed papers on SM in medical education. The full methods are described elsewhere, including a flow chart reflecting the design of the review.3 Of 231 full-text articles, 14 studies met the inclusion criteria as evaluative studies describing interventions using SM tools with measurable educational outcomes, including: learner satisfaction; knowledge; attitudes; and skills for doctors and doctors-in-training. Two authors of the present report (SBR, MC) subsequently re-examined these studies to identify exemplars of SM use in promoting the achievement of clinical excellence. The authors considered whether there were any domains
of clinical excellence for which no evaluative studies had been performed, and if so whether SM was relevant to these domains. Where available, additional examples from the wider literature and the worldwide web have been presented to augment the review.
RESULTS The results are summarised in Table 1 and include the URL addresses of the exemplary SM tools identified. Communication and interpersonal skills Communication and interpersonal skills are at the heart of clinical excellence and SM; the latter – by definition – facilitates multi-user interaction around expressive user-generated content.3 One study evaluated a humanities course that successfully incorporated SM to promote reflection
Physicians
The authors hypothesised that the use of SM could promote clinical excellence in a number of ways. These tools could impact doctor–patient interactions directly: by providing fast, up-to-date access to experts and resources for solving clinical problems, or by providing access to patient education materials and online communities. Furthermore, they could be used to facilitate interaction with
In-person interaction
Virtual interaction Clinical Excellence
Patients
Colleagues
Systems Trainees
Figure 1. Our conceptual model shows clinical excellence in the context of relationships between doctors and patients, colleagues, trainees and systems, which can be enhanced both by face-to-face interactions and virtual interactions (e.g. via social media)
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Adoption of SM by both doctors and patients challenges privacy and traditional doctor–patient boundaries
and creativity among fourth-year medical students.4 In the wider literature there is evidence that blogging can enhance clinical practice,5 and that SM promotes professional networking.6 Indeed, there are now established social networking sites (SNSs) dedicated to medical students and doctors. In addition, there is growing interest in SM facilitating
efficient clinician–patient communication.7 Professionalism and humanism Online communication between doctors, students and patients represents a cause of concern for many clinical teachers. The worldwide adoption of SM by both doctors and patients challenges privacy and traditional
doctor–patient boundaries.8 Indeed, this concern is reflected in recently published guidelines on the professional use of SM in clinical practice from the American College of Physicians, the Federation of State Medical Boards and other professional organisations.9–11 However, there is also evidence that SM may foster the critical values of
Table 1. Summary of results of systematic review on social media use in medical education Domain of clinical excellence
Selected examples from Social media tools used systematic review of social media use for clinical excellence
Communication George et al.4 and interpersonal skills
Other examples of social media use for clinical excellence
Blogs to promote reflection, creativity and collaboration
Medical student- and doctordedicated social networking sites promoting professional networking (e.g. studentdoctor.net, sermo.com, doximity.com, osmosis.org) Open-access social media sites to enhance communication and advance medicine (e.g. medpedia.com)
Professionalism and humanism
Varga-Atkins et al.12 Rosenthal et al.13 Fischer et al.14
Wikis to promote professionalism Blogs to promote empathy
Knowledge
Triola et al.16 Carvas et al.17
Links to citations on Virtual microscopy and social networking to teach histology open-access sites to keep abreast of current literature Blogs, podcasts, video-conand developments (e.g. ferencing, wikis in clinical twitter.com/mededchat) research course
Diagnostic acumen Zolfo et al.18 Dinh et al.19
Doctor-dedicated websites Smartphone technology to to draw on expertise of consult with international specialists for diagnosis HIV specialists Customisable interactive web- (e.g. sermo.com, doximity. com, osmosis.org) sites to enhance Emergency Specialist-to-specialist Department training interaction (e.g. aaaai.org/ ask-the-expert.aspx)
Passion for patient Calderon et al.22 care Poonawalla et al.23
Blogs to increase student Social media sites to encourand trainee interest in age patients to participate nephrology and dermatology in their own health care (e.g. whatsmym3.com)
Scholarly approach Geyer and Irish24
Evidence-based practice in medical informatics
Medical wikis (askdrwiki.com) Blogs (e.g. academiclifeinem.blogspot.co.uk)
Modelling clinical excellence
Chretien et al.25 Fischer et al.14
Faculty role-modelling through blog posts and moderating blog-based discussion by students
Medical question banks with user-generated questions and answers to share clinical cases (e.g. gmep.org)
Interfacing with researchers
N/A
N/A
Social media for recruitment for clinical trials (23andMe.com)
Skillful negotiation of the health care system
N/A
N/A
Dedicated social media sites to help patients with specific diseases negotiate the health care system (patientslikeme.com)
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professionalism, humanism and empathy. For example, one study reviewed used a Wiki page to encourage first-year medical students to share web links, clarify discussion points and achieve professional confidence.12 Two others used blogs effectively to promote empathy and achieve reflection among medical students.13,14 SM sites also connect doctors and patients, thus supporting the view of medicine as a public trust. Knowledge A substantial body of literature endorses e-learning as an efficacious medical education strategy,15 and some evidence suggests that SM may also help pre-clinical and clinical teachers effectively and efficiently impart knowledge. For example, one study of SM found that virtual microscopy improved first-year medical students’ knowledge of histology, and reduced the time spent in laboratory sessions for both faculty staff and students.16 Another study found a positive correlation between the number of web posts and final grades in a clinical research training course that employed a variety of SM tools.17 In addition, SNSs allow clinical teachers to improve their own knowledge by sharing up-to-date literature. Diagnostic acumen Tapping into shared knowledge may support doctors in honing their diagnostic acumen. SM presents an opportunity to engage in evidence-based discussions with expert doctors, allowing clinical teachers to become familiar with contrasting approaches to diagnosis. One study reported on how doctors in Peruvian HIV/AIDS clinics used smartphone technology to share clinical cases and consult with HIV specialists in other countries18; another reported on the use of collaborative customisable SM tools to support training of emergency department
staff.19 There have also been reports in the wider literature of doctors turning to doctor-dedicated SNSs in order to draw on the expertise of their members in making a diagnosis.6,20 Such sites may assist a doctor in developing diagnostic acumen, and can also bring educators into contact with a wider pool of knowledge. Exhibiting a passion for patient care Enthusiasm and passion for patient care is infectious.21 A clinical teacher who harnesses SM is well placed to cut across hierarchies of medical students, doctors and patients. Two studies demonstrated the use of blogs to promote interest in nephrology and dermatology among medical trainees.22,23 Passionate doctors may also encourage patients to engage in their own health care decisionmaking via SNSs designed to assist patients in achieving their health goals. Scholarly approach to clinical practice By using SM to learn from expert clinicians and keep abreast of current literature, a clinically excellent doctor can embody a scholarly approach to clinical practice and apply this evidence in teaching students, and in making patient care decisions. One study demonstrated a high exam pass rate for trainees in a longitudinal medical informatics course that used various SM tools, including a blog.24 Clinical teachers also contribute to online banks of knowledge via SM sites. By disseminating their own clinical knowledge, doctors can drive improvements in patient care systems and new avenues of research. Explicitly modelling expertise to medical trainees Social media can be used to explicitly model clinical excellence to trainees. This can be via a faculty-moderated blog, as
demonstrated by one study designed to promote professionalism in clinical medical students via personal reflection, modelled, in part, by faculty staff.25 Another also used a blog to promote reflective practice, again modelled by clinical teachers.14 The widely accessible nature of SM can extend the reach of master teachers and clinicians, modelling excellence for trainees beyond their own institutions. SM has been effective in imparting knowledge,18,24 improving grades and exam scores,16,17,26 and in improving learner satisfaction.19,22,23 Other examples of SM modelling clinical expertise are those SNSs where members contribute questions and solutions based on real clinical cases, promoting continued professional development.
Social media can be used to explicitly model clinical excellence to trainees
Interface with researchers to advance discovery Clinical teachers may also use SM to interface with researchers to advance discovery, thus advancing medicine. Although no educational intervention study specifically addressed this domain of clinical excellence, SM can foster professional collaboration, and thus facilitate the sharing of observations and hypotheses among researchers. One paper in the wider literature reported on how certain SNSs enable doctors to participate in protocol design review, ethical discussions, statistical analyses, trial commentary, and aid in the recruitment of patients to clinical trials.27 Skillful negotiation of the health care system No reviewed study specifically addressed this domain, despite an abundance of Facebook groups, Twitter pages, blogs and other SM designed to help patients with a wide range of illnesses negotiate an often overwhelming health care system. A clinician who is knowledgeable about these resources can direct patients to the best sources of
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SM may also play an a adjunctive role in attaining aspects of clinical excellence
information, and may choose to become advocates for certain patient groups, by lending their online profile and virtual voice to campaigns.
CONCLUSION Only studies with measurable educational outcomes published before September 2011 were included in the original systematic review.3 Because of the rapid growth of SM and interest in the subject, other articles relevant to this paper have subsequently been published and several of these have been incorporated into the discussion. The formally reviewed studies touched on the following domains of clinical excellence: communication and interpersonal skills; professionalism and humanism; knowledge; diagnostic acumen; exhibiting a passion for patient care; a scholarly approach to clinical practice; explicitly modelling expertise to medical trainees. No study addressed SM use to promote skillful negotiation of the health care system or collaboration with investigators to advance science and discovery; however, additional evidence suggests that SM may also play an adjunctive role in attaining these aspects of clinical excellence. Many concerns have been raised about the use of SM, including the risk of breaches in professionalism and threats to privacy. But the literature also suggests several benefits of its use, such as a greater sharing of medical knowledge and enhanced reflective practice.3 Although acknowledging that the use of SM is not essential to the achievement of clinical excellence, this report suggests that SM is an additional tool that clinical teachers may use to help their learners attain this goal. More research in this area is warranted, especially research that: (1) focuses on the domains of promoting skillful negotiation of
the health care system and collaborating with investigators; (2) targets practicing doctors’ continuing medical education; and (3) measures knowledge- and skill-based outcomes. REFERENCES 1. Wright SM, Kravet S, Christmas C, Burkhart K, Durso SC. Creating an academy of clinical excellence at Johns Hopkins Bayview Medical Center: a 3-year experience. Acad Med 2010;85:1833–1839. 2. Chretien KC, Kind T. Social media and clinical care: ethical, professional, and social implications. Circulation 2013;127:1413–1421. 3. Cheston CC, Flickinger TE, Chisolm MS. Social media use in medical education: a systematic review. Acad Med 2013;88:893–901. 4. George DR, Dellasega C. Use of social media in graduate-level medical humanities education: two pilot studies from Penn State College of Medicine. Med Teach 2011;33:e429–e434. 5. Lowney AC, O’Brien T. The landscape of blogging in palliative care. Palliat Med 2012;26:858–859. 6. Giordano C, Giordano C. Health professions students’ use of social media. J Allied Health 2011;40:78–81. 7. Hawn C. Take two aspirin and tweet me in the morning: how Twitter, Facebook, and other social media are reshaping health care. Health Aff (Millwood) 2009;28:361–368. 8. Chretien KC, Greysen SR, Chretien JP, Kind T. Online posting of unprofessional content by medical students. JAMA 2009;302:1309–1315. 9. Farnan JM, Snyder Sulmasy L, Worster BK, Chaudhry HJ, Rhyne JA, Arora VM. American College of Physicians Ethics, Professionalism and Human Rights Committee; American College of Physicians Council of Associates; Federation of State Medical Boards Special Committee on Ethics and Professionalism. Online medical professionalism: patient and public relationships: policy statement from the american college of physicians and the Federation of state medical boards. Ann Intern Med 2013;158:620–627. 10. Dizon DS, Graham D, Thompson MA, Johnson LJ, Johnston C, Fisch MJ, Miller R. Practical guidance: the use of social media in oncology practice. J Oncol Pract 2012;8:e114–e124.
11. Lowney AC, O’Brien T. The landscape of blogging in palliative care. Palliat Med 2012;26:858–859. 12. Varga-Atkins T, Dangerfield P, Brigden D. Developing professionalism through the use of wikis: A study with first-year undergraduate medical students. Med Teach 2010;32:824–829. 13. Rosenthal S, Howard B, Schlussel YR, Herrigel D, Smolarz BG, Gable B, Vasquez J, Grigo H, Kaufman M. Humanism at heart: Preserving empathy in thirdyear medical students. Acad Med 2011;86:350–358. 14. Fischer MA, Haley H-L, Saarinen CL, Chretien KC. Comparison of blogged and written reflections in two medicine clerkships. Med Educ 2011;45:166–175. 15. Wutoh R, Boren SA, Balas EA. eLearning: a review of Internetbased continuing medical education. J Contin Educ Health Prof 2004;24:20–30. 16. Triola MM, Holloway WJ. Enhanced virtual microscopy for collaborative education. BMC Med Educ 2011;11:4. 17. Carvas M, Imamura M, Hsing W, Dewey-Platt L, Fregni F. An innovative method of global clinical research training using collaborative learning with Web 2.0 tools. Med Teach 2010;32:270. 18. Zolfo M, Iglesias D, Kiyan C, Echevarria J, Fucay L, Llacsahuanga E, de Waard I, Suàrez V, Llaque WC, Lynen L. Mobile learning for HIV/ AIDS healthcare worker training in resource-limited settings. AIDS Res Ther 2010;7:35. 19. Dinh M, Tan T, Bein K, Hayman J, Wong YK, Dinh D. Emergency department knowledge management in the age of Web 2.0: evaluation of a new concept. Emerg Med Australas 2011;23:46–53. 20. von Muhlen M, Ohno-Machado L. Reviewing social media use by clinicians. J Am Med Inform Assoc 2012;19:777–781. 21. Christmas C, Kravet SJ, Durso SC, Wright SM. Clinical excellence in academia: perspectives from masterful academic clinicians. Mayo Clin Proc 2008;83:989–994. 22. Calderon KR, Vij RS, Mattana J, Jhaveri KD. Innovative teaching tools in nephrology. Kidney Int 2011;79:797–799. 23. Poonawalla T, Wagner RF Jr. Assessment of a blog as a medium for dermatology education. Dermatol Online J 2006;12:5.
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24. Geyer EM, Irish DE. Isolated to integrated: an evolving medical informatics curriculum. Med Ref Serv Q 2008;27:451–461. 25. Chretien KF, Goldman EF, Faselis C. The reflective writing class blog:
Using technology to promote reflection and professional development. J Gen Intern Med 2008;23:2066–2070. 26. Raupach T, Muenscher C, Anders S, Steinbach R, Pukrop T, Hege I,
Tullius M. Web-based collaborative training of clinical reasoning: a randomized trial. Med Teach 2009;31:e431–e437. 27. Allison M. Can web 2.0 reboot clinical trials? Nat Biotechnol 2009;27:895–902.
Corresponding author’s contact details: Tabor Flickinger, Johns Hopkins University School of Medicine, 2024 E. Monument Street, Suite 2-600, Baltimore, MD 21287, USA. E-mail: [email protected]
Social Media is an additional tool that clinical teachers may use to help their learners attain [clinical excellence]
Funding: Dr. Batt-Rawden was awarded the JASME medical elective bursary 2012, the Gilchrist Educational Grant for Academically Outstanding Individuals and an Elective Grant from the Doubleday Fund which supported the research elective at Johns Hopkins University where this research was conducted. Conflict of interest: Dr Chisolm is a member of the Miller-Coulson Academy of Clinical Excellence. Ethical approval: This study was not performed with human subjects and was exempt from review by our Institutional Review Board. doi: 10.1111/tct.12129
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The role of social media in clinical excellence Samantha Batt-Rawden, King’s College London, UK Tabor Flickinger, Department of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, USA John Weiner, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia Christine Cheston, Harvard Medical School and Boston University School of Medicine, Boston, USA Margaret Chisolm, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, USA
Social media may help facilitate the achievement of clinical excellence
SUMMARY Background: The provision of excellent patient care is a goal shared by all doctors. The role of social media (SM) in helping medical students and doctors achieve clinical excellence is unknown. Purpose: This report aimed to identify examples of how SM may be used to help promote the achievement of clinical excellence in medical learners. Methods: Three of the authors previously conducted a systematic review of the published literature on SM use in undergraduate, graduate and continuing medical education. Two
authors re-examined the 14 evaluative studies to identify any examples of SM use that may facilitate the achievement of clinical excellence and to consider whether there were any aspects of clinical excellence for which no studies had been performed, and, if so, whether SM was relevant to these domains. Results: Each study touched on one or more of the following domains of clinical excellence: communication and interpersonal skills; professionalism and humanism; knowledge; diagnostic acumen; exhibiting a passion for patient care; a scholarly approach to clinical practice; and explicitly
modelling expertise to medical trainees. No study addressed the role of SM to promote the skillful negotiation of the health care system, and in collaboration with investigators to advance science and discovery; however, additional evidence suggested that SM may play an adjunctive role in promoting the achievement of these aspects of clinical excellence. Conclusion: This report supports the hypothesis that SM may help facilitate the achievement of clinical excellence; however, further research is needed into the role of SM in promoting the achievement of clinical excellence.
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INTRODUCTION
T
he provision of excellent patient care is a goal shared by all doctors. Based on systematic review and expert consensus, the Johns Hopkins Miller-Coulson Academy of Clinical Excellence defined clinical excellence as encompassing nine domains: (1) communication and interpersonal skills; (2) professionalism and humanism; (3) knowledge; (4) diagnostic acumen; (5) exhibiting a passion for patient care; (6) skillful negotiation of the health care system; (7) a scholarly approach to clinical practice; (8) modelling expertise to medical trainees; and (9) collaboration with investigators to advance science and discovery.1 These domains are congruent with international professionalism guidelines. Social media (SM) use in medical education is increasingly adopted by doctors and doctorsin-training worldwide. It can build on the success of e-learning in ways that are more learnergenerated, collaborative and engaging. Figure 1 shows a conceptual model demonstrating a possible role for virtual interactions (via SM tools), in addition to face-to-face interactions, in promoting clinical excellence. This model was developed using other proposed models for the role of SM in doctor–patient relationships,2 and sources framing the concept of clinical excellence.1
colleagues, trainees or other members of health care systems in order to share knowledge, hone clinical reasoning and advance scholarship. The authors aimed to test this hypothesis by identifying exemplars of SM use in promoting clinical excellence from a previously published systematic review of evaluative studies on the use of SM in medical education.3
The provision of excellent patient care is a goal shared by all doctors
METHODS Three of the authors (TF, CC, MC) previously conducted a systematic review on SM use in medical education. MEDLINE, CINAHL, ERIC, EMBASE, PsycINFO, Proquest, Cochrane Library, Web of Science and Scopus were searched from the start of each database to 12 September 2011 for English-language, peerreviewed papers on SM in medical education. The full methods are described elsewhere, including a flow chart reflecting the design of the review.3 Of 231 full-text articles, 14 studies met the inclusion criteria as evaluative studies describing interventions using SM tools with measurable educational outcomes, including: learner satisfaction; knowledge; attitudes; and skills for doctors and doctors-in-training. Two authors of the present report (SBR, MC) subsequently re-examined these studies to identify exemplars of SM use in promoting the achievement of clinical excellence. The authors considered whether there were any domains
of clinical excellence for which no evaluative studies had been performed, and if so whether SM was relevant to these domains. Where available, additional examples from the wider literature and the worldwide web have been presented to augment the review.
RESULTS The results are summarised in Table 1 and include the URL addresses of the exemplary SM tools identified. Communication and interpersonal skills Communication and interpersonal skills are at the heart of clinical excellence and SM; the latter – by definition – facilitates multi-user interaction around expressive user-generated content.3 One study evaluated a humanities course that successfully incorporated SM to promote reflection
Physicians
The authors hypothesised that the use of SM could promote clinical excellence in a number of ways. These tools could impact doctor–patient interactions directly: by providing fast, up-to-date access to experts and resources for solving clinical problems, or by providing access to patient education materials and online communities. Furthermore, they could be used to facilitate interaction with
In-person interaction
Virtual interaction Clinical Excellence
Patients
Colleagues
Systems Trainees
Figure 1. Our conceptual model shows clinical excellence in the context of relationships between doctors and patients, colleagues, trainees and systems, which can be enhanced both by face-to-face interactions and virtual interactions (e.g. via social media)
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Adoption of SM by both doctors and patients challenges privacy and traditional doctor–patient boundaries
and creativity among fourth-year medical students.4 In the wider literature there is evidence that blogging can enhance clinical practice,5 and that SM promotes professional networking.6 Indeed, there are now established social networking sites (SNSs) dedicated to medical students and doctors. In addition, there is growing interest in SM facilitating
efficient clinician–patient communication.7 Professionalism and humanism Online communication between doctors, students and patients represents a cause of concern for many clinical teachers. The worldwide adoption of SM by both doctors and patients challenges privacy and traditional
doctor–patient boundaries.8 Indeed, this concern is reflected in recently published guidelines on the professional use of SM in clinical practice from the American College of Physicians, the Federation of State Medical Boards and other professional organisations.9–11 However, there is also evidence that SM may foster the critical values of
Table 1. Summary of results of systematic review on social media use in medical education Domain of clinical excellence
Selected examples from Social media tools used systematic review of social media use for clinical excellence
Communication George et al.4 and interpersonal skills
Other examples of social media use for clinical excellence
Blogs to promote reflection, creativity and collaboration
Medical student- and doctordedicated social networking sites promoting professional networking (e.g. studentdoctor.net, sermo.com, doximity.com, osmosis.org) Open-access social media sites to enhance communication and advance medicine (e.g. medpedia.com)
Professionalism and humanism
Varga-Atkins et al.12 Rosenthal et al.13 Fischer et al.14
Wikis to promote professionalism Blogs to promote empathy
Knowledge
Triola et al.16 Carvas et al.17
Links to citations on Virtual microscopy and social networking to teach histology open-access sites to keep abreast of current literature Blogs, podcasts, video-conand developments (e.g. ferencing, wikis in clinical twitter.com/mededchat) research course
Diagnostic acumen Zolfo et al.18 Dinh et al.19
Doctor-dedicated websites Smartphone technology to to draw on expertise of consult with international specialists for diagnosis HIV specialists Customisable interactive web- (e.g. sermo.com, doximity. com, osmosis.org) sites to enhance Emergency Specialist-to-specialist Department training interaction (e.g. aaaai.org/ ask-the-expert.aspx)
Passion for patient Calderon et al.22 care Poonawalla et al.23
Blogs to increase student Social media sites to encourand trainee interest in age patients to participate nephrology and dermatology in their own health care (e.g. whatsmym3.com)
Scholarly approach Geyer and Irish24
Evidence-based practice in medical informatics
Medical wikis (askdrwiki.com) Blogs (e.g. academiclifeinem.blogspot.co.uk)
Modelling clinical excellence
Chretien et al.25 Fischer et al.14
Faculty role-modelling through blog posts and moderating blog-based discussion by students
Medical question banks with user-generated questions and answers to share clinical cases (e.g. gmep.org)
Interfacing with researchers
N/A
N/A
Social media for recruitment for clinical trials (23andMe.com)
Skillful negotiation of the health care system
N/A
N/A
Dedicated social media sites to help patients with specific diseases negotiate the health care system (patientslikeme.com)
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professionalism, humanism and empathy. For example, one study reviewed used a Wiki page to encourage first-year medical students to share web links, clarify discussion points and achieve professional confidence.12 Two others used blogs effectively to promote empathy and achieve reflection among medical students.13,14 SM sites also connect doctors and patients, thus supporting the view of medicine as a public trust. Knowledge A substantial body of literature endorses e-learning as an efficacious medical education strategy,15 and some evidence suggests that SM may also help pre-clinical and clinical teachers effectively and efficiently impart knowledge. For example, one study of SM found that virtual microscopy improved first-year medical students’ knowledge of histology, and reduced the time spent in laboratory sessions for both faculty staff and students.16 Another study found a positive correlation between the number of web posts and final grades in a clinical research training course that employed a variety of SM tools.17 In addition, SNSs allow clinical teachers to improve their own knowledge by sharing up-to-date literature. Diagnostic acumen Tapping into shared knowledge may support doctors in honing their diagnostic acumen. SM presents an opportunity to engage in evidence-based discussions with expert doctors, allowing clinical teachers to become familiar with contrasting approaches to diagnosis. One study reported on how doctors in Peruvian HIV/AIDS clinics used smartphone technology to share clinical cases and consult with HIV specialists in other countries18; another reported on the use of collaborative customisable SM tools to support training of emergency department
staff.19 There have also been reports in the wider literature of doctors turning to doctor-dedicated SNSs in order to draw on the expertise of their members in making a diagnosis.6,20 Such sites may assist a doctor in developing diagnostic acumen, and can also bring educators into contact with a wider pool of knowledge. Exhibiting a passion for patient care Enthusiasm and passion for patient care is infectious.21 A clinical teacher who harnesses SM is well placed to cut across hierarchies of medical students, doctors and patients. Two studies demonstrated the use of blogs to promote interest in nephrology and dermatology among medical trainees.22,23 Passionate doctors may also encourage patients to engage in their own health care decisionmaking via SNSs designed to assist patients in achieving their health goals. Scholarly approach to clinical practice By using SM to learn from expert clinicians and keep abreast of current literature, a clinically excellent doctor can embody a scholarly approach to clinical practice and apply this evidence in teaching students, and in making patient care decisions. One study demonstrated a high exam pass rate for trainees in a longitudinal medical informatics course that used various SM tools, including a blog.24 Clinical teachers also contribute to online banks of knowledge via SM sites. By disseminating their own clinical knowledge, doctors can drive improvements in patient care systems and new avenues of research. Explicitly modelling expertise to medical trainees Social media can be used to explicitly model clinical excellence to trainees. This can be via a faculty-moderated blog, as
demonstrated by one study designed to promote professionalism in clinical medical students via personal reflection, modelled, in part, by faculty staff.25 Another also used a blog to promote reflective practice, again modelled by clinical teachers.14 The widely accessible nature of SM can extend the reach of master teachers and clinicians, modelling excellence for trainees beyond their own institutions. SM has been effective in imparting knowledge,18,24 improving grades and exam scores,16,17,26 and in improving learner satisfaction.19,22,23 Other examples of SM modelling clinical expertise are those SNSs where members contribute questions and solutions based on real clinical cases, promoting continued professional development.
Social media can be used to explicitly model clinical excellence to trainees
Interface with researchers to advance discovery Clinical teachers may also use SM to interface with researchers to advance discovery, thus advancing medicine. Although no educational intervention study specifically addressed this domain of clinical excellence, SM can foster professional collaboration, and thus facilitate the sharing of observations and hypotheses among researchers. One paper in the wider literature reported on how certain SNSs enable doctors to participate in protocol design review, ethical discussions, statistical analyses, trial commentary, and aid in the recruitment of patients to clinical trials.27 Skillful negotiation of the health care system No reviewed study specifically addressed this domain, despite an abundance of Facebook groups, Twitter pages, blogs and other SM designed to help patients with a wide range of illnesses negotiate an often overwhelming health care system. A clinician who is knowledgeable about these resources can direct patients to the best sources of
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SM may also play an a adjunctive role in attaining aspects of clinical excellence
information, and may choose to become advocates for certain patient groups, by lending their online profile and virtual voice to campaigns.
CONCLUSION Only studies with measurable educational outcomes published before September 2011 were included in the original systematic review.3 Because of the rapid growth of SM and interest in the subject, other articles relevant to this paper have subsequently been published and several of these have been incorporated into the discussion. The formally reviewed studies touched on the following domains of clinical excellence: communication and interpersonal skills; professionalism and humanism; knowledge; diagnostic acumen; exhibiting a passion for patient care; a scholarly approach to clinical practice; explicitly modelling expertise to medical trainees. No study addressed SM use to promote skillful negotiation of the health care system or collaboration with investigators to advance science and discovery; however, additional evidence suggests that SM may also play an adjunctive role in attaining these aspects of clinical excellence. Many concerns have been raised about the use of SM, including the risk of breaches in professionalism and threats to privacy. But the literature also suggests several benefits of its use, such as a greater sharing of medical knowledge and enhanced reflective practice.3 Although acknowledging that the use of SM is not essential to the achievement of clinical excellence, this report suggests that SM is an additional tool that clinical teachers may use to help their learners attain this goal. More research in this area is warranted, especially research that: (1) focuses on the domains of promoting skillful negotiation of
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Corresponding author’s contact details: Tabor Flickinger, Johns Hopkins University School of Medicine, 2024 E. Monument Street, Suite 2-600, Baltimore, MD 21287, USA. E-mail: [email protected]
Social Media is an additional tool that clinical teachers may use to help their learners attain [clinical excellence]
Funding: Dr. Batt-Rawden was awarded the JASME medical elective bursary 2012, the Gilchrist Educational Grant for Academically Outstanding Individuals and an Elective Grant from the Doubleday Fund which supported the research elective at Johns Hopkins University where this research was conducted. Conflict of interest: Dr Chisolm is a member of the Miller-Coulson Academy of Clinical Excellence. Ethical approval: This study was not performed with human subjects and was exempt from review by our Institutional Review Board. doi: 10.1111/tct.12129
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