Curr Psychiatry Rep (2015) 17: 94 DOI 10.1007/s11920-015-0635-4
PSYCHIATRY IN THE DIGITAL AGE (JS LUO, SECTION EDITOR)
A Twitter Education: Why Psychiatrists Should Tweet Matthew E. Peters 1 & Elisabeth Uible 1 & Margaret S. Chisolm 1,2
Published online: 13 October 2015 # Springer Science+Business Media New York 2015
Abstract Social media tools such as blogs, microblogs, social networking sites, podcasts, and video-sharing sites are now ubiquitous. These tools enable instantaneous interactions with a global community of individuals, including medical professionals, learners, and patients. An understanding of social media tools and how they can be used by psychiatrists is increasingly important. This review defines some relevant social media terms and addresses challenges specific to the use of social media in psychiatry. Focused primarily on Twitter, one of the most commonly used social media tools, the review describes how Twitter is being used in non-psychiatric medical fields and highlights four current and/or potential uses of Twitter in psychiatry: (1) patient care and advocacy, (2) lifelong learning, (3) research data collection and collaboration, and (4) scholarly recognition and impact. Keywords Social media . Twitter . Psychiatric education . Professionalism . Career development
Introduction The term Bsocial media^ encompasses a variety of Internetbased tools that enable content sharing and rapid interactions
This article is part of the Topical Collection on Psychiatry in the Digital Age * Margaret S. Chisolm
[email protected] 1
Department of Psychiatry and Behavioral Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
2
5300 Alpha Commons Drive, Baltimore, MD 21224, USA
within and among large populations [1]. Examples of social media are blogs, microblogs, social networking sites, podcasts, and video-sharing sites. Checking social media on computers, tablets, and smartphones—and posting replies and original messages—has become part of the daily routine for many individuals, including medical professionals, learners, and patients. In recognition of this global use of social media, the 58th World Health Assembly adopted a resolution for all member states of the World Health Organization (WHO) to promote the use of eHealth in the pursuit of equality in access to healthcare services worldwide [2]. Despite social media’s increasingly prominent role in medicine, barriers exist that limit wider adoption of use by medical professionals. Although some of these barriers are relevant to anyone who might use social media (e.g., generational gaps and unfamiliarity, distraction and disruption, overreliance), other barriers are of particular relevance to medical professionals (e.g., lack of quality assurance, privacy/ professionalism concern, information overload) [1]. Privacy/ professionalism concerns may explain why psychiatry—a field in which an especially high level of patient confidentiality is vital—has been a relatively late adopter of social media compared to other medical specialties [3]. Because social media have been described as Ban amplifier that raises the volume on a message, be it good or bad^ [4], psychiatrists—forever mindful of the risks of self-disclosure when interacting with individual patients—may be additionally concerned about the amplification of such disclosure when using social media. To address such challenges, the American Medical Association advises separating personal and professional content on social media [5]. However, this recommendation is both artificial and nearly impossible to achieve. A recent review of 700 Btweets^ made by healthcare professionals [6] found that about 31 % were personal in nature and over 70 % of these personal messages were unrelated to the sender’s role as a
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healthcare professional. Thus, rather than separating social media content into personal and professional, a more realistic approach to social media use may be consideration of whether the content is appropriate for a healthcare professional to post in a public space [7]. The recommendations by Grajales III et al. [8] echo and add to this point. They suggest that healthcare professionals follow four principles, some of which may mitigate risk during interactions over social media: (1) maintain professionalism at all times; (2) be authentic, have fun, and do not be afraid; (3) ask for help; and (4) focus, grab attention, engage, and take action. Regardless of the exact approach taken, it is clear that at present most physicians receive no formal training on how to use social media in a professional manner [9] despite the need for such education, as recognized in the recently released Romanell Report [10], which states that all physicians must be trained to Bmanage ethical challenges in a number of areas,^ including social media. Some have even argued that social media should be seen as an entrustable professional activity [11]. One of the most widely used social media platforms is Twitter, a microblog whose mission is Bto give everyone the power to create and share ideas and information instantly, without barriers^ [12]. In 2015, Twitter reported 302 million monthly active users and 500 million tweets sent each day with 77 % of accounts being outside of the United States (US), making it an ideal avenue for instantaneous global communication. A few useful terms to know before diving into a conversation about Twitter are (1) tweet: a 140-character or less message; (2) hashtag: any word or phrase preceded by the B#^ symbol, which is used to tag and search tweets belonging to a specific topic; and (3) handle: one’s Twitter profile name preceded by the B@^ symbol. Although this review will cover topics relevant to all branches of medicine, it will highlight some current and potential uses of Twitter in the field of psychiatry. As mentioned previously, psychiatry has been slow to embrace social media and not all of the literature reviewed here is specific to psychiatry. Four main uses of Twitter will be covered: (1) patient care and advocacy, (2) lifelong learning, (3) research data collection and collaboration, and (4) scholarly recognition and impact. Use One: Patient Care and Advocacy Providing direct patient care and advocacy is the primary role of most psychiatrists. There is a difference between interaction with one’s own patients on Twitter and providing advice/ consultation services to other individuals. In general, the literature in this area suggests that one should ignore patient requests sent through social media. However, the question arises as to whether this could be seen as an act of omission [8]. As an example, it has become increasingly common for individuals to broadcast their suicidality on social media. An
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examination of 2000 randomly selected suicide-related tweets found that 14 % of these messages were Bstrongly concerning^ for a true threat of suicide [13]. Extrapolating this data, this would mean an average of 32 tweets are sent each day that portray a level of suicidality that may warrant further investigation. One could argue that by following patient tweets and/or assisting Twitter with improvement of its internal mechanisms for suicide-risk detection, psychiatrists could positively impact patient care and/or public health. The same could be said for using Twitter to monitor substance abuse and mood states in real time. Over 95 % of adolescents and young adults access the Internet daily, and in this particular population, it has been suggested that Twitter can be used to observe behaviors, provide health information, and improve patientprovider communication [14]. As a final example, social media content is now part of the data gathering process in legal cases, allowing forensic psychiatrists to collect information about a defendant’s mental state at the time of a crime [15]. Communication of suicidal thoughts via social media represents relatively uncharted medico-legal territory. Given its public nature, the authors do not recommend entering into clinical discussions with any individuals, including established patients, through Twitter. As in any public setting, if you encounter someone who is not your patient on Twitter who communicates thoughts of suicide, you are encouraged— as a Bgood Samaritan^—to refer the individual to the local emergency department. Additionally, you may report threats of suicide to Twitter’s internal mechanism for handling such messages (https://support.twitter.com/forms/suicide). If the person communicating thoughts of suicide is an established patient, you would take the same steps you normally do to minimize risks of self-harm. The authors do not recommend interacting around clinical topics with any individuals via Twitter’s direct messaging mode, as this has the potential to imply a patient-provider relationship where one does not exist and is not a secure mode of communication with established patients. Twitter is increasingly used as an avenue for providing advice/consultation services to non-established patients, thus Bmeeting patients where they are,^ meaning online [16]. In the US, 70–80 % of all adult Internet users seek health information online, as it is often free resource that patients can pursue discretely and at their own pace [17]. Not all potential patients have access to psychiatric care, and Twitter can increase access to specialist care, especially in low-resource settings [18]. Social media in general offer the potential for higher patient awareness of standards of care than was previously available. Access to digital technologies in developing countries has outpaced access to other basic goods and services, creating an opportunity for social media to leapfrog existing barriers to global health equity [19]. An analysis of 515 healthcarerelated tweets [20•] revealed that patients are actively seeking psychiatric advice on social media. Topics commonly queried
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were the impact of diagnosis on personal identity, the balance of power between provider and patient, pharmacotherapy and psychotherapy, and access to care. As there are more patients asking questions on Twitter than professionals responding, many of these requests go unanswered or are answered by non-healthcare professionals. With the establishment of a Twitter presence, psychiatrists could address misinformation in real time [21•]. In addition to psychiatrists establishing an online presence, it has become common for patients to organize into online social networks [17]. These online networks are rated as more helpful and more informative than static information websites. Enabling individuals to share experiences with a large audience may lead to reduced stigma and increased health-seeking behaviors [14]. Online social networks have the potential to meet patients’ needs for emotional support and accurate health information. In order for online social support networks to successfully meet these needs, however, professional responses to original posts must be timely, informative, and not superficial. Mehta and Atreja [17] describe the ideal social support network as achieving a balance between flexibility/ security, anonymity/authenticity, and openness/moderation. In addition, networks should be patient-centered and Bpatientpowered^ while encouraging appropriate participation by healthcare professionals. Psychiatrists can also learn from healthcare organizations’ use of Twitter. Healthcare organization support can be categorized as (1) informational (e.g., medical or health-related advice, guidance, news, findings), (2) emotional (e.g., encouragement, comfort, congratulations, praise, empathy, concern, gratitude), and (3) instrumental (e.g., giving a tangible aid) [22]. And such support can either be Bprovided^ unsolicited or Bsought^ by patients. A review of 1500 tweets sent by 58 health organizations within 2 months [22] found that approximately 77 % of tweets provided informational support, 12 % of tweets provided emotional support, and 8 % were responses to those seeking instrumental support. Thus, most interactions by health organizations with the public are providing general information/support rather than individualized assistance. Although these organizations are doing a better job than healthcare professionals at addressing patient needs, most of these interactions are one-way exchanges of information from the organization. By bringing clinical knowledge to bidirectional exchanges with the public on Twitter, psychiatrists can become the advocates that patients are seeking. Use Two: Lifelong Learning At first glance, it may be hard to understand how learning can occur 140 characters at a time. However, when used properly, Twitter is a powerful tool for lifelong learning. Whether providing learning for trainees or for established psychiatrists in practice, Twitter offers an ideal supplement (but not substitute)
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to traditional avenues of information exchange. The Jefferson Scale of Physician Lifelong Learning [23] identifies the following underlying factors of lifelong learning: (1) recognition of one’s own learning needs, (2) participation in research endeavors, (3) self-initiation or self-directed learning, (4) technical/computer skills, and (5) personal motivation. Twitter represents just one tool in the educational toolbox but one with the relatively unique benefit of 24-7 accessibility. It is important to remember that, just like traditional lifelong learning, there is not one ideal method for the educational use of social media tools [24]. This section will discuss the formal use of Twitter in trainee curriculum, as well as the use of Twitter for sharing various types of information. Free Open Access Meducation (FOAM) is defined as a community of open-access resources for learning in medicine, which uses social media to rapidly disseminate educational materials and expert insights [1]. Common hashtags used for this community are #FOAM and #meded [25]. The hashtag #acpsy is beginning to be used by the psychiatric education community to flag items relevant to academic psychiatrists. Hashtags can be searched for in Twitter and the displayed feed can be changed to include only those posts tagged with the specified hashtag. Of course, feeds for hashtags like #meded are not specific to a particular classroom activity or medical school. For those settings, specified hashtags can be used to create a flipped classroom experience (where fundamental knowledge is gained by the individual learner on his or her own time and the classroom becomes the setting to apply the knowledge) in which the feed for a predefined hashtag can be displayed on a monitor in the room and followed by the entire class. The literature around social media use in psychiatric graduate medical education [26] contains a general sentiment of caution regarding the use of social media in psychiatric training. However, some potential benefits have been suggested as well. Twitter is able to bring together trainees from around the world to share their diverse experiences and promote the timely dissemination of scientific, clinical, and educational innovations [27], all of which has the potential to improve patient care. One method of harnessing Twitter’s power for lifelong learning has been termed Bevidence-based tweeting^ (EBT) [28•]. More than just referencing/posting links to peerreviewed publications through Twitter, EBT encompasses activities such as Twitter journal clubs, Twitter chats, and BTweeting the Meeting^ (TtM). Twitter journal clubs are increasingly utilized by medical journals as a way of discussing recently published articles. One such journal club, a collaboration between the Annals of Emergency Medicine and the academic site Academic Life in Emergency Medicine (ALiEM), is the Global Emergency Medicine Journal Club [29]. During a 5-day event in 2014, this journal club used Twitter, a live videocast with the authors of the discussed
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article, and a comments section on the ALiEM website to collect information from 1431 individuals from 59 countries. During this event, a total of 206 tweets were sent. The Journal of General Internal Medicine (JGIM) uses a Twitter journal club to discuss recently published JGIM papers [30]. And the University of Toronto has recently launched the first International Psychiatric Twitter Journal Club, using the hashtag #psychjc (http://www.psychiatry.utoronto.ca/ international-psychiatry-twitter-journal-club/). Twitter chats are prescheduled meetings where people interested in a particular topic can follow a stream of tweets on the topic, sorted by the chat’s hashtag. By prescheduling the meetings, people from all over the globe can come together in real time. For example, a nephrology journal club meets twice monthly (each biweekly meeting occurring twice to include participants from two major time zones) using the hashtag B#NephJC^ to ensure that all participants’ tweets can be followed together, resulting in a real-time conversation [31]. TtM has become a standard part of both national and local conferences and teaching sessions. An example of TtM occurred at Kidney Week 2011 at the American Society of Nephrology. There, Twitter was used as a way to disseminate information from the meeting to fellow colleagues, as well as to educate the public about kidney disease [32]. Another example of TtM is adding a second screen during grand rounds presentations and medical school lectures, one screen showing the lecture content and the other the live Twitter stream created by all participants (both in live audience and afar) following the event’s hashtag [33]. At the event’s conclusion, Storify.com can be used to bring together all tweets marked with the relevant hashtag and compile a complete transcript of the discussion [31]. In addition to EBT, because Twitter posts remain forever— and, in fact, all US tweets are archived in the Library of Congress [34]—Twitter can be used as a place to store and curate information gleaned at academic events such as conferences, grand rounds, and training seminars. [15]. A quick search of one’s own Twitter feed can be conducted to pull up notes and ideas, which track the evolution of one’s thinking about various topics over time. In addition, a search of the entire Twitter community can track the evolution of thinking about various topics over time on a global scale. Use Three: Research Data Collection and Collaboration Twitter can be used as a research data source as well as a medium over which to find collaborators for ongoing or upcoming projects. Twitter can help researchers recruit from difficult to reach populations and facilitate collection of data in real time [19]. Psychiatrists can use Twitter to collect publically available, unsolicited data or to enable already recruited research participants to post data privately. Some organizations have used Twitter posts as a tool for tracking disease
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outbreak [6]. And the US Patient-Centered Outcomes Research Institute has funded Bpatient-powered research networks^ [17], research collaborations operated and governed by groups of patients and their partners. The use of social media for research is still in its infancy. However, there is potential for social media to be useful in all phases of research: (1) planning (e.g., identifying the research topic, potential collaborators, initial review of the literature), (2) development (e.g., detailed literature review, identifying underlying theories and methodologies, planning the project timelines), (3) implementation (e.g., enrolling participants, gathering data, analysis and interpretation of the data), and (4) dissemination (e.g., sharing of findings, engagement with the research community and the wider public) [21•]. An example of the use of Twitter as a source of research data is a study [35] in which 21,741 tweets about migraines were collected. Analysis of these tweets revealed that (1) migraine headaches had the greatest personal impact—as measured by most tweets—on mood (43.9 %), (2) the most commonly tweeted descriptor for migraine headaches was Bworst^ (14.6 %), (3) most postings occurring in the US (58.3 %), and (4) peak posting being on weekdays at 10 a.m. and 10 p.m. This study illustrates the use of unsolicited data available on Twitter to answer specific research questions, as well as Twitter’s ability to collect time-of-day information. Dinah Miller (Twitter handle @shrinkrapdinah) is one of three psychiatrists who founded the blog BShrink Rap Docs.^ Miller has used Twitter to distribute research surveys [15] by posting the survey link in her Twitter feed, along with a message requesting relevant individuals to participate. She references the handles of other psychiatrists who are active on Twitter and asks them to re-tweet the post. (Re-tweeting is a way of having another individual’s post appear on one’s Twitter feed where it will be seen by one’s followers.) Miller also sends Bdirect messages^ (less public communications via Twitter) to specific psychiatrists who are following her Twitter feed and who have large Twitter followings, asking them to tweet the survey link to their followers. Using these methods, some of Miller’s surveys have quickly resulted in over 1000 respondents, a level of rapid data collection that in the past was near impossible. Twitter can also be used to reach potential collaborators in psychiatry and other fields around the world, non-academics and academics alike. Twitter enables the identification of timely clinically relevant scientific and educational research questions via the sharing of information from all relevant stakeholders, including patients and learners. Twitter also provides a way for potential collaborators to find one another and can serve as a platform for the exchange of scientific, clinical, and educational research questions, hypotheses, and study design ideas, as well as other academic projects [3]. Twitter can be especially helpful in this regard for fields which cut across various specialties, such as medical education.
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Use Four: Scholarly Recognition and Impact The number of citations in peer-reviewed journal articles and the impact factors of those journals have been the traditional measures of scholarly impact [36]. However, it is increasingly recognized that these criteria need to be reviewed and reimagined for the digital age [21•]. Using traditional citation-based metrics, it can take decades for an academic to build a track record of publications and citations in highimpact journals (the accepted measure of national and international recognition and impact required for academic advancement). These metrics are especially challenging for clinical and medical education scholars, as evidenced by the relatively low h-indices of editorial board members of the highest impact medical education journals [37]. Altmetrics (aka Balternative metrics^ or Barticle-level metrics^) consist of a variety of relatively real-time measures of online dissemination (e.g., frequency that an article is read, saved on reference managers, discussed in all media) [38]. By going beyond citation-based metrics, altmetrics represent a more accurate reflection of past and current readership, which may be predictive of future readership [36, 39, 40] and citations [28•, 41]. Although it is clear that by sharing on social media one can have substantial influence in the absence of satisfying the traditional metrics of academic impact [4], this may have potential positive and negative downstream effects as one’s online influence may outweigh any significant impact on one’s field. At the very least, however, altmetrics are able to capture Bdisseminative impact,^ which may or may not correlate with traditional metrics of Bscholarly impact^ [42••]. The proprietary Altmetrics™ score is increasingly being adopted and reported by journals such as JAMA and Academic Medicine (http://altmetrics.org/manifesto), and one can track the Altmetrics™ score of one’s articles at http://www.altmetric. com/bookmarklet.php. In the future, it is hard to imagine that altmetrics—as indicators of disseminative impact and thus recognition—will not be relevant to consideration for academic advancement, in much the same way as citationbased metrics are now.
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learning, (3) research data collection and collaboration, and (4) scholarly recognition and impact. Compliance with Ethical Standards Human and Animal Rights and Informed Consent This article does not contain any studies with human or animal subjects performed by any of the authors. Conflict of Interest Matthew E. Peters and Elisabeth Uible declare that they have no conflict of interest. Margaret S. Chisolm has received royalties, as Co-Editor-in-Chief, from the International Review of Psychiatry and has received paid travel accommodations from the American Society of Nephrology. Funding/Support No funding or other support was received for this project.
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Conclusions Psychiatrists hold a key position at the complex crossroads of medicine, psychology, and sociology. An understanding of social media and how these resources can be used by psychiatrists is increasingly important. As with any new innovation, there are strong advocates and opponents to the use of social media in medicine, including psychiatry. Although unique concerns exist around the use of social media in psychiatry, if used wisely, the use of Twitter by psychiatrists has the potential to enhance (1) patient care and advocacy, (2) lifelong
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