Teaching through social media

Introduction

The use of social media (SM) in medical education and clinical practice is rapidly evolving. In the current educational landscape, we describe the incorporation of SM applications in medical education. Recognizing its increasing relevance albeit scarce robust evidence, we sought to consistently approach the concept of SM and how physicians as learners and medical educators can use these tools to benefit their clinical practice and their patients’ outcomes. We correlate education theories with the progression of the web phases and describe how this influences medical educators, curriculum design and learner skills. We discuss categories of tools with examples in current practice, expected benefits and effectiveness of SM in medical education, potential downsides, and requirements for effectively incorporating SM in medical education. Our concluding remarks underline the good practices in effectively utilizing SM in healthcare education. Although we consider the continuum of medical education, we place greater emphasis on continuing professional development (CPD) as this is the largest audience of learners and covers many years of professional practice.

Complex learning environments and the role of the internet

The healthcare workforce moves in complex systems and learning environments characterized by heavy and ever changing information load, fast-paced delivery, increasing duty hours with less time for formal classroom-based learning, and increasing scrutiny of cost/benefit of “classical” continuing education in venues as conferences and congresses, usually delivered by experts in content often with little or no background in educational strategies (1).

Internet-based technologies have wide reach and offer the potential to deliver cost-effective, personalized medical education. SM refers to internet-based tools that allow individuals and communities to gather and communicate (2). Also designated as “Web 2.0” or “social networking” these internet-based tools facilitate networking to search, share and store knowledge through online collaboration, interaction, and discussion, sometimes in real time. Overall in 2019 there are 3.5 billion active SM users, and 93% of these are mobile SM users, accessing SM using smart phones (3). Facebook is the most popular social network worldwide and in April 2019 had 2.32 billion monthly active users. Instagram allows users to share images, audio and video, and in April 2019 had 1 billion monthly active accounts (4). Although SM is considered a phenomenon of the millennial generation or Generation Y (born 1980–2000), more than 35% of “Facebookers” are older than 35 years old (5), and users older than 65 years are the fastest growing cohort (3).

SM in medical education

SM use has been rapidly adopted by medical professionals (6). Estimates are that 45–90% of medical students, residents and fellows use SM for several purposes, 67% of practicing physicians use Twitter and 48% of them use Facebook (7). The vast majority of academic physicians are predominantly “digital immigrants” who were born before the digital technology era. On the other hand, postgraduate trainees, the most junior members of the medical profession, and medical students, the soon-to-be members, are Millennial, Gen X and Gen Y “digital natives” who have grown up using SM integrated in their lives (8,9).

SM, including mobile learning, has also been adopted as a tool for CPD (10-12). Wang and associates surveyed a population of practicing physicians who had attended a continuing medical education (CME) course. Their positive attitudes on using SM in CME led the authors to conclude that CME course directors should guide SM strategies towards youthful, technology-savvy CME participants as they increasingly enter into their professional healthcare lives (7).

SM tools in medical education may be grouped by function (Table 1) and include social networking (Facebook, Google Plus, Twitter), professional networking (LinkedIn), media sharing (YouTube, Vimeo, Instagram), microblogs (Twitter), knowledge aggregation [wikis, free open access medical education (FOAM)], and gaming environments. Each of the SM tools has advantages and disadvantages (28). Some authors also consider learning management systems or virtual learning environments such as Blackboard and Moodle, and collaborative document writing such as Google Docs, to be categorized under the broad category of SM, but these are omitted from our review. Preferred sites can change rapidly (e.g., the demise of Myspace) and vary between age groups; for example, younger people are thought to favor Instagram and Snapchat, whilst older users prefer Facebook (2).

Education theory and development of the internet

An interesting correlation between the progression of the web in response to the users’ needs and educational theories can be drawn (29).

Education 1.0 and Web 1.0: a cognitivist and pedagogical approach to learning. One size fits all

Education 1.0 is based on three “Learners Rs”: they receive by listening, respond by taking notes and regurgitate by taking the same assessments of their cohort (30). All alike, learners are receptacles, and educators provide information. This is a one way, didactic, teacher-directed (Pedagogy) educational format transferred to the student by the teacher (instructivism, cognitivism, behaviorism) aiming at instilling all learners with essential or basic academic knowledge and skills (essentialism). Similarly, Web 1.0 is the “read-only” web, a one-way source of information (31).

Education 2.0 and Web 2.0: knowledge builders and a constructivist and andragogical approach to learning

Education 2.0 focuses on three Cs—communicating, contributing, and collaborating (32). Learners are encouraged to interact with the content by commenting, remixing, sharing via social networks and re using in different contexts and additional purposes. Its foundations lie in humanistic roots (33) and emphasizes the human element and the social context (32,34) in the process of learning and teaching.

Web 2.0 or “read-write web” fosters interactivity among learners, and between learners, educators and content (31). Education 2.0 uses Web 2.0 technologies and tools to enhance project-based and inquiry learning, collaborative learning, global learning projects, Skype in the classroom, and shared wikis, blogs and other social networking in the classroom. These platforms and tools suit the rationale of Education 2.0.

While facilitating learning, the educator still develops learning activities and remains the learning orchestrator. Learning experiences should comply with principles of adult learning (Andragogy) such as active, experiential, authentic, relevant learning providing procedures and resources to learn how to learn (Constructivism). The educator should create engaging learning environments allowing shared planning upon learning needs diagnosed to formulate directed goals and objectives aligned with content, and evaluate outcomes (35). Learning experiences provide multiple representations of reality to reflect the complexity of the real world and prize knowledge building over knowledge reproduction. Learners experience authentic tasks in meaningful contexts and are encouraged to collaborate among themselves, to activate their prior knowledge, to reflect and accommodate new learning within their personal unique knowledge structure (35).

Education 3.0 and Web 3.0: self-determined learners, heutagogy, and connectivism

The central three Cs of Education 3.0 are connecting, creating and constructing. Education 3.0 differs from Education 2.0 by emphasizing self-determined learning, rather than learning facilitated by the educator (32). Learners create their knowledge by driving, authoring and assessing their own learning experiences. Self-determined learners develop a “free-agent learner” profile to create personalized learning environments and experiences. Being already skillful in informal learning by interacting with the web they adapt daily used tools to meet their personal learning needs independent of the educational venue, content, source and process (de-institutionalized learning). Learners become mentors, educators, and role models among themselves and share effective learning strategies. The role of educators shifts to that of mentors. Educational, social, technological and legal components influence the process of learning and teaching in Education 3.0 (29).

Education 3.0 embodies a heutagogical (36,37) and connectivist approach in the process of teaching and learning. Particularly for adult learners, heutagogy recognizes learners as autonomous, capable and self-efficacious, in summary, self-determined. Open, multifaceted, learner-centered, widely familiar and ready to use Web 2.0 tools and resources scaffold the heutagogical and connectivist learning environment, nurturing self-driven learning. Self-determined learners master their learning pathway and generate content with added value to the field of study.

Web 3.0 is the “read-write-execute” web (31). It makes use of semantic markup (data interchange formats) that enables software applications to understand information, speak to each other and to interpret information for humans (34). Based on self-browsing history, each individual has a unique Internet profile, which can be used by Web 3.0 to tailor future browsing experiences (31) by providing free, relevant, ready to use, interactive and networked personalized content based on individual interests.

This new approach to learning puts emphasis on creating deep, broad, and global connections, which has been described as connectivism (38). Learners enhance their capacity to know more using their ability to nurture connections and to devise links between fields, ideas and concepts. Decision making in what to learn is itself a learning experience.

Evolving role of educators

To take full advantage of SM in medical education, the role of educators must evolve. Education 1.0 educators assume a central role in the process of teaching and learning, delivering the essentials in the same manner to all the students regardless of their interests or previous experiences. Learning is dictated and occurs in classical classroom venues. Learners are dependent and have few resources of their own to learn sequentially.

In Education 2.0 learning environments, educators become facilitators. Educators are no longer required to control all variables and can adapt methods and choose tools and resources to better meet learners’ needs. Teaching is social, progressively constructed (educator to learner and learner to learner) and uses digital social applications. Learning venues can be in a building or on-line.

In Education 3.0 educators, learners, SM tools, resources, processes and connections become one entity potentially capable of meeting individual learners’, educators’, and societal needs. Teaching occurs in a co-constructivist system embracing the multiple bidirectional relations among educators, learners, ideas and technology. The role of educators is to develop learners’ capability in learning and to develop and apply their competencies in novel situations. Learners choose their educators, manage their own learning, decide and lead their own learning path. The educator is challenged to innovate and should become a connected learner with the responsibility to be a connected educator, which is the first step towards learner-driven learning (39).

Learners’ skills in Education 3.0

Learners in the new environment need to develop: (I) critical thinking and problem-solving skills; (II) collaboration across networks and leading by influence; (III) agility and adaptability; (IV) initiative and entrepreneurialism; (V) effective oral and written communication; (VI) accessing and analyzing information abilities; (VII) curiosity and imagination (40). Gerstein further adds grit, resilience, hope and optimistic vision, self-regulation, empathy and global stewardship as necessary skills (30).

Incorporating SM into medical education

Whyte and Hennessy developed a systematic review on how to effectively use SM in medical education. Their literature search informed the construction of a validated questionnaire on three factors: (I) most effective platforms and their purposes; (II) SM benefits to teaching, and (III) students’ understanding on the benefits/disadvantages of academic SM platforms. The review acknowledges the value of SM, with an emphasis for Facebook and Twitter, if used appropriately. SM has shown the potential to enable virtual learning communities and personal learning environments, to assist educators in expanding learning environments beyond the classroom, nurture a culture of continuous learning and promote learners’ autonomy and self-efficacy (41). Similarly, to incorporate SM into medical education, Kind and Patel recommend to: (I) define your goals; (II) match with appropriate tools; (III) know your community; (IV) share interaction guidelines; (V) keep patient information confidential, and (VI) share evidence-based information (42). To do this, educators need to understand the strengths and weaknesses of the various SM tools, and the use of SM tools in specific situations such as small group learning. Throughout, educators must be role models for appropriate use of SM (discussed below).

Advantages of SM in medical education

The strengths of SM tools include familiarity, accessibility, the ability to personalize user profiles, interactivity between individuals (formation of learning communities), extending the educational moments beyond in-person learning events to incidental learning, and reaching geographically remote and underserved communities.

Proposed advantages of SM in medical education include reflective writing, knowledge sharing, shared problem solving and peer-to-peer teaching (43,44). Learners may also generate new content to demonstrate their new learning. SM may also preferentially engage the millennial learner.

Effectiveness of SM in medical education

SM is becoming integral to evolving educational methods, however evidence of its effectiveness in medical education is weak, with at best outcomes expressed at a satisfaction level, and limited data on learner performance (43,45-47). Limited data supports incorporation of SM into medical education to foster interactivity (44).

There is also limited evidence on the role of individual SM tools. Twitter is the most frequently used platform to promote conference themes (via hashtags) and research content. Sterling et al. found the majority of studies on twitter were exploratory and used hashtags to analyze the frequency with which conference attendees accessed the platform and not its effect on learning (45). A systematic review of Twitter-based journal clubs concluded that these are free, time-efficient and publicly accessible means to facilitate international discussions regarding clinically important evidence-based research, but was not able to review the effect on learning (21).

Regarding SM in CPD, Flynn et al. concluded that SM has a modest impact on driving traffic to evidence-based CME options. Compared to other SM platforms and email, Facebook showed the best result on driving physician web traffic to evidence-based CME (48). McGowan et al. showed SM applications to be an efficient and effective method for physicians to keep up-to-date and to share newly acquired medical knowledge with other physicians within the medical community and concluded that further studies are necessary to examine the impact SM on physicians’ knowledge, attitudes, skills, and behaviors in practice (49).

Risks and barriers to using in SM in medical education

Many risks in use of SM in medical education have been described. These are detailed in Table 2 and include poor quality of information, damage to professional image, breaches of patient privacy, violation of the doctor-patient boundary, breach of regulatory standards and legal issues. These risks can be lessened by following codes of good conduct (recommendations follow).

It is important to note that although educators are aware of the advantages of incorporating SM into medical education, there is a lag in uptake. Barriers to uptake of SM in medical education are shown in Table 3, and include concerns regarding the educational value of material, professionalism, educator barriers, learner barriers, technological limitations and organizational barriers (11,53). Many of these barriers are similar to those occurring in self-directed CPD (54).

Potential negative health impacts are described for SM usage, with an association between increased use of SM and increased levels of anxiety and depression in young adults (55,56).

The significant risks and barriers associated with SM in medical education clearly indicate that training of learners and educators is needed to effectively incorporate SM into medical education.

Good practice guidelines

Many health care organizations and professional societies develop guidelines for appropriate use, for example the Australian Health Practitioner Regulation Agency (57).

Learning and role modeling good SM conduct should happen across the medical education continuum (58). SM guidelines can embed “offline” in-person settings useful models and should recognize platforms learning opportunities and challenges as more research substantially informs the idea of heutagogy as a theory of online and distance education (59,60). In its essence, heutagogy encapsulates self-determined learning and acknowledges CPD educators with competencies going beyond the cognitive component or medical knowledge to embrace others as learner centeredness, interpersonal and communication skills, professionalism and role model, reflective practice and system-based practice. Program design and implementation, program evaluation, leadership and mentorship/coaching are relevant competencies to develop by those also involved in curriculum development (61,62).

Guidelines for appropriate use are shown in Table 4.

Conclusions

Undergraduate, postgraduate and CPD programs and systems across specialties are increasingly using SM platforms for education, choosing online tools according to their specific applications. Incorporating SM tools and methods in medical education is thought to facilitate interactivity and engage learners in their own lifelong learning. Strengths of SM include wide accessibility and personalized user profiles that allow targeting specific audiences, encourage self-determined learning and self-efficacy, improve learning effectiveness, cost-benefit and bring the sense of accomplishment and satisfaction to the community of learning. On the other hand, SM platforms are associated with potential risks including particularly professionalism and breaches of the patient-physician relationship and patient confidentiality. SM sites and platforms offer very interesting and useful opportunities to promote individual and public health, and advance professional development as long as good practices are observed.

This is an interesting and emerging field of research in medical education and especially in CPD as there are few and modest quality studies pertaining SM in medical education that offer mixed results concerning learners’ satisfaction and knowledge attainment. Further research is necessary to optimize the use of SM in medical education.

Acknowledgments

Acknowledgments to Prof. Ivan Silver for the exciting inspiration to venture into self-determined learning; to Prof. Eduardo Mayorga for re-inventing new windows within eLearning.

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editors (Ana Gabriela Palis and Jorge E. Valdez-García) for the series “Modern Teaching Techniques in Ophthalmology” published in Annals of Eye Science. The article has undergone external peer review.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/aes.2019.07.02). The series “Modern Teaching Techniques in Ophthalmology” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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