54
Web-Based Education and
Implications of Social Media
chapter Lillian S. Kao and Michael E. Zenilman
Introduction2187 Journal Clubs / 2190
Web-Based Education 2187 Live-Tweeting Conferences / 2190
Social Media–Based Education 2188 Interactive Forums and
Communities / 2190
What is Social Media? / 2188
Public Education / 2192
INTRODUCTION
Surgical education has changed significantly over the past two
decades. Disruptive forces such as work hour restrictions and
the advent of laparoscopy have forced educators to rethink how
and where to teach residents. Technologies, including the inter-
net and web-based applications, have further enabled educators
to redesign surgical education (Fig. 54-1). The internet has
become an integral tool not just in surgical education but also in
Americans’ lives by changing the way that people communicate
with each other, access information, and conduct their daily
lives. Today, almost 9 in 10 American adults use the internet.
1 Furthermore, the internet has revolutionized education by
allowing for expanded reach, asynchronous learning
whereby students and instructors do not have to be on the
2 same time schedule, and multimedia materials.
Like internet usage, social media has seen a rise in adop-
tion over the past decade. Social media is a term that encom-
passes multiple computer-mediated platforms that are used
for creating and sharing information, ideas, and other content.
Social media facilitates communication and interactions across
virtual networks. Commonly used platforms include Facebook,
Twitter, Snapchat, and Instagram. Social media can be used for
multiple purposes including social and professional network-
ing; however, this chapter will focus on its uses in surgical
education.
WEB-BASED EDUCATION
Web-based educational resources include lectures and webi-
nars, simulators, assessment tools, and interactive mentoring
and coaching. Furthermore, entire web-based curricula have
been developed that can link to online resources such as journal
articles, interactive anatomy modules, and videos of operations.
There are multiple advantages to web-based education. For sur-
gical trainees, web-based educational materials allow access
regardless of time of day or night, provide interactive tools for
learning (i.e., anatomy), and videos for viewing operations and
procedures. Furthermore, for practicing surgeons, web-based
educational resources include forums for sharing challenging
cases and procuring advice, activities for obtaining continuing
Pitfalls in Web and Social
Media–Based Education 2192
Implications and Future
Directions2194
education, and rapid access to information about new technolo-
gies and research. However, there may also be disadvantages in
terms of costs and technical problems.
Multiple studies have evaluated learning outcomes after
implementation of web-based educational interventions. In sur-
gical education, these interventions may be used to teach patient
care and decision-making via online case studies, convey
knowledge using online didactic materials, or introduce surgical
skills. However, studies evaluating these interventions tend to
be nonrandomized, small, and single center. A 2008 systematic
review and meta-analysis by Cook et al evaluated the effect of
internet-based learning across healthcare in general. The review
suggested that internet-based learning is better than no interven-
tion but has similar effectiveness as traditional educational
methods. A more recent 2015 systematic review by Jayakumar
et al focused on web-based education in surgery. They reported
a positive effect, but the majority of studies included in the
review lacked a control. Based on the current literature, the
internet should be considered one tool among many that can
facilitate learning. However, further studies are necessary to
identify the key elements that improve effectiveness. Web-
3 based educational materials should be developed keeping
adult learning theories and principles in mind.
Web-based surgical curricula have been developed both at
an institutional and at a national level. A widely-used curricu-
lum is the Surgical Council on Resident Education (SCORE)
curriculum, which is available via an online portal. Developed
in 2006, SCORE is based on the six core competencies required
of a graduating resident: patient care, medical knowledge,
professionalism, communication, practice-based learning, and
systems-based practice. SCORE is the result of an ongoing col-
laborative effort of the American Board of Surgery, American
College of Surgeons, American Surgical Association, Asso-
ciation of Program Directors in Surgery, Association for
Surgical Education, Residency Review Committee for Surgery
of the Accreditation Council of Graduate Medical Education,
and Society of American Gastrointestinal and Endoscopic
Surgeons. The SCORE curriculum provides content for topics
to be covered during a 5-year general surgery residency and
is adding fellowship-level content as well. The SCORE Portal
modules for each topic include learning objectives, discussion
 Key Points
1 The internet has become an integral tool not just in surgical
education but also in Americans’ lives by changing the way
that people communicate with each other, access informa-
tion, and conduct their daily lives.
2 The internet has revolutionized surgical education by allow-
ing for expanded reach—asynchronous learning whereby
students and instructors do not have to be on the same time
schedule—and multimedia materials such as interactive les-
sons and videos.
3 Despite the appeal of web-based education, systematic
reviews and meta-analyses have failed to identify high-
quality studies demonstrating that it is superior to standard
educational methods in improving learning outcomes.
4 Web-based and virtual reality simulators can be used
both to teach technical skills and to assess performance.
Virtual reality simulators have been effective in training
surgeons on technical skills that translate to operating room
performance.
questions, text resources and videos, and self-assessment
quizzes. Although improvements in quality examination per-
formance among residencies that subscribe to SCORE are prom-
ising, no studies have definitely demonstrated that SCORE use
improves resident knowledge, skills, or clinical performance.
Web-based education can also be used for assessing and
teaching surgical skills. In 2013, Birkmeyer et al performed a
4 study that correlated surgical skills in bariatric surgery,
based on blinded reviews of videotaped operations, to clini-
cal outcomes. The ability to discriminate surgeons with good and
poor technical skills using video-based assessments has signifi-
cant implications for training surgeons and for evaluating their
performance. With regards to training, multiple web-based and
virtual reality simulators have been developed that allow resi-
dents to practice tasks and skills repetitively at their own pace
and on their own time. These simulators can quantify efficiency
of motion and time to complete a task as well as provide
Enabling technologies
Disruptive forces
Impact
Surgical education
1995 2000 2005 2010
Figure 54-1.  The relationship between disruptive forces, enabling
technologies, and surgical education. (Reproduced with permission
from Pugh CM, Watson A, Bell RH, Jr, et al. Surgical education in
2188 the internet era. J Surg Res. 2009 Oct;156(2):177-182.)
5 Online and social media–based journal clubs can overcome
barriers associated with traditional journal clubs such as lack
of a convenient time and no local clinical or methodological
experts. However, they may require more time and commit-
ment from the leaders, and they may not be as effective as
traditional, in-person, faculty-moderated journal clubs.
6 Social media rapidly and exponentially increases the spread
of information.
7 Multiple pitfalls exist with regards to web and social media–
based education, including but not limited to: (a) need for
more widespread adoption and use, (b) lack of accuracy and
regulatory oversight over educational content, (c) issues
regarding patient confidentiality and privacy, (d) nondisclo-
sure of conflicts of interest, and (e) paucity of evidence for
effectiveness of these materials for improving knowledge,
attitudes, skills, and outcomes.
8 Social media has become a necessary component of surgical
practice.
real-time feedback. These metrics have been demonstrated to
have construct validity (in that they measure what they are sup-
posed to be measuring) and criterion validity (in that they cor-
relate with operative performance). For example, randomized
trials have demonstrated that surgical simulation training corre-
lates with decreased operative time and improves subjectively
rated performance on technical skills in the live setting. Web-
based assessments have also been used in combination with
physical simulators to provide similar metrics.
With regards to surgeons in practice, there has been
increased enthusiasm for the use of video-based coaching to
complement intraoperative teaching. In particular, postopera-
tive review of videotaped procedures allows surgeons to receive
individualized feedback about opportunities for improvement
without the time constraints or pressures of the operating room.
Randomized trials of surgical coaching in simulated settings
suggests benefits over traditional simulator training, and larger
trials in a live setting are ongoing. Although most coaching
occurs face-to-face, there are opportunities to use web-based
coaching. As an example, telementoring has been used to proc-
tor surgeons in the operating room, even across the globe.
Barriers to web-based education include the up-front costs
for development and the need for technical expertise. As already
noted, web-based education for teaching knowledge may not
be more effective than traditional methods. On the other hand,
simulation and video-based coaching hold significant prom-
ise in improving training in and assessment of surgical skills.
However, widespread implementation of video-based coaching
will require a culture shift for surgeons to accept assistance and
resources such as time, availability of coaches, and finances.
Ongoing studies will provide data regarding the effectiveness
of these educational strategies.
SOCIAL MEDIA–BASED EDUCATION
What is Social Media?
Social media is a term describing websites and web-based
applications that enable users to share ideas, information, and
 2189

@Twitteruser1 @Twitteruser2
A

CHAPTER 54 WEB-BASED EDUCATION AND IMPLICATIONS OF SOCIAL MEDIA

@Twitteruser1 @Twitteruser2
B

Figure 54-2.  Social media usage can be (a) unidirectional or (b) bidirectional. User names on Twitter are denoted by “@”. A. @Twitteruser2
is following @Twitteruser1. She is receiving all of his messages in her Twitter feed. However, @Twitteruser1 does not follow her back and
therefore does not receive her messages in return. B. @Twitteruser1 and @Twitteruser2 follow each other. Therefore, they each receive each
other’s messages in their Twitter feeds.

content through virtual networking. Although social media is
often used to interact with friends and family, social media
can also be used for educational and professional purposes.
Examples include Twitter-based journal clubs, Facebook-
based discussion forums, and professional networking sites
such as LinkedIn or ResearchGate. Social media platforms
can serve different purposes including social networking,
microblogging, blogging, photo sharing, video sharing, and
crowdsourcing.
Commonly used social media platforms in surgery include
Facebook, Twitter, and YouTube. Facebook is the most popular
social networking site; it can be accessed via desktops, laptops,
and mobile phones. It allows users to exchange information,
photos, and videos with specified contacts or “friends” with
whom there is a two-way relationship. Twitter is another popu-
lar social media platform. It is a microblogging site that, like
Facebook, allows exchange of messages and photos but limits
messages or tweets to 140 characters or less. Twitter users may
have one or two-way relationships with other users. Followers
of a user receive all of that person’s tweets in their Twitter feed.
YouTube is a social media platform that allows users to share
videos.
Social media usage in surgery may be unidirectional or
bidirectional (Fig. 54-2). For example, journals such as the
New England Journal of Medicine may have a large number of
followers but may be following very few users back. Given that
the number of journal articles published daily has risen expo-
nentially, particularly with the advent of open access journals,
keeping up with the surgical literature can be overwhelming.
Following journals on social media is one strategy for staying
updated. Although conventional media outlets such as newspa-
pers and news channels may draw attention to practice-changing
studies, social media is another platform by which such infor-
mation can be promoted and disseminated by journals. Many
surgical journals have an online and social media presence, and
many have social media editors who curate the posted materials.
Popular social media platforms for journals include Facebook
and Twitter. Both platforms allow journals to post text, figures,
and links to abstracts or journal articles. Both platforms allow
others to share information or comment on articles. However,
Twitter restricts text to 140 characters. A recent innovation that
may counteract the limited number of allowed characters is the
visual abstract, which is a concise pictorial representation of an
article’s key points (Fig. 54-3). Recently, a prospective, case-
control crossover study was performed whereby tweets about
articles from Annals of Surgery were either accompanied by a
visual abstract or tweeted with text alone. Accompaniment of
a tweet with a visual abstract resulted in a threefold increase
in article visits. Thus, the majority of journal followers may
merely receive the information about new publications (uni-
directional flow of information). However, users may also
choose to respond to posts with comments (bidirectional flow
of information).
Comparison of Surgical Treatment A Versus
Surgical Treatment B
Surgical Patients with disease X Surgical
treatment A treatment B
Outcomes
15% Complications 11%
8% Mortality 4%
Author A et al. Journal. Date. Journal Logo
Figure 54-3.  A visual abstract is a graphical summary of the main
results of a journal article.
2190 Journal Clubs
Journals may promote bidirectional flow of information by hosting
social media–based journal clubs. From an educational standpoint,
journal clubs have traditionally served not only as an adjunct to
lectures but also as a forum to teach about critical appraisal of the
literature. Furthermore, when facilitated by faculty with clinical
expertise on the subject being discussed, surgical trainees can bet-
ter evaluate how to incorporate the evidence into practice. How-
ever, barriers to traditional journal clubs may include poor
participation, lack of a convenient time, or absence of local exper-
tise in either the clinical topic or research methodology. Social
PART II
media–based journal clubs can help to overcome these barriers by
allowing for asynchronous discussion and expert moderators.
Online journal clubs can be carried out in real time, but they also
5a allow respondents to comment hours or even days later to
a conversation. Multiple specialties, including surgery,
SPECIFIC CONSIDERATIONS
have developed social media–based journal clubs. Tips for suc-
cessfully launching an online journal club can be garnered from
the expanding experience with them (Table 54-1).
Social media–based journal clubs in surgery have been
conducted via Facebook, Twitter, or a combination of the two
platforms. They have also taken the form of a blog. Although
commonly associated with personal journals or diaries, blogs
can also be found on professional websites that are updated
frequently by a person or group (i.e., by a journal or surgical
society). Conversations from journal club discussions can also
be compiled and summarized into a transcript either manually or
using web-based applications such as Storify. These transcripts
can be posted on the journal website or shared. Furthermore,
Table 54-1
Ten tips for setting up an online journal club
  TIP
 1 Create an online home page that serves as a launching
pad for your journal club discussions
 2 Develop and register a hashtag on Twitter
 3 Incorporate not only Twitter but other collaborative
platforms as part of your online journal club
 4 Ensure that the time of the journal club is convenient
for your target audience
 5 Help prepare participants by aggregating other online
resources relevant to the article
 6 Consider inviting the authors of the featured article or
other experts in the field
 7 Suggest journal club participants consider using specific
Twitter management applications during the Tweet chat
 8 Engage the participants to cultivate and incentivize
more discussion
 9 Connect to the online community by following and
engaging with other relevant social media accounts
10 Link back to the original paper by inserting a comment
on PubMed Commons
Data from Chan TM, Thoma B, Radecki R, et al. Ten steps for
setting up an online journal club, J Contin Educ Health Prof. 2015
Spring;35(2):148-154.
summaries from either in-person or online journal clubs can be
added to the PubMed citation via PubMed Commons.
Preliminary data suggests that online journal clubs
increase discussion about articles, views of the abstract, and
downloads (Fig. 54-4). For example, the International Gen-
eral Surgery Journal Club held four moderated discussions of
journal articles on Twitter between March and June 2014. The
reviewed articles covered topics relating to bariatric surgery
(March), venous thromboembolism in trauma (April), diverticu-
litis (May), and contralateral prophylactic mastectomy for breast
cancer (June). Although the authors and invited experts only
moderated discussions for 3 days, Twitter activity increased in
the days preceding and following these discussions. Further-
more, daily views of the article and downloads increased cor-
respondingly. Thus, online journal clubs are a potential strategy
for increasing surgeon education about seminal articles.
While social media–based journal clubs hold much appeal,
there is a paucity of data regarding their effectiveness in teach-
ing participants about critical appraisal skills. A multicenter
5b randomized trial compared journal clubs moderated by
a faculty member to online discussions. Surgical resi-
dents in both arms utilized modules developed by the Evidence
Based Reviews in Surgery Steering Committee; these modules
include the relevant guide to critical appraisal and a method-
ological and clinical review. Residents randomized to the mod-
erated group scored higher on a validated test evaluating critical
appraisal skills. Further study is required to assess the effective-
ness of social media–based journal clubs in disseminating new
knowledge as well as in teaching critical appraisal.
Live-Tweeting Conferences
Traditionally, surgeons have attended regional and national
conferences to network, learn new information relevant to their
practice, and exchange ideas. However, with the advent of
social media, surgeons no longer have to physically attend a
conference to perform all those activities. Live-tweeting is a
term used to describe the posting of comments on Twitter about
an event while it is ongoing. Multiple surgical and nonsurgical
societies have adopted Twitter to expand the reach of their
conferences. By denoting tweets as emanating from a specific
conference with a unique hashtag, the reach and number of
impressions can actually be measured (Fig. 54-5). The reach
refers to the number of unique recipients of messages from a
specific group of Twitterers (or people posting on Twitter).
Impressions refers to each time a message was delivered to a
recipient; a recipient may receive the same message more than
once. Neither reach nor impressions measure whether the
recipient read the tweet. As an example of how reach and
impressions can be used to provide metrics for social media, the
Healthcare Hashtag Project allows registered conference
hashtags to track the latest tweets, the most prolific Twitterers
of conference-related tweets, the most commonly mentioned
Twitterers, and the number of impressions (Fig. 54-6) (https://
www.symplur.com/healthcare-hashtags/). As noted in the
figure, social media rapidly and exponentially increases the
spread of information. Transcripts of conference-related tweets
6 can also be assembled to allow a conversation thread to
be organized into a cohesive discussion.
Interactive Forums and Communities
Interactive forums and communities are another method
by which both the internet and social media can be used for
 Tweet Activity on #IGSJC 2191
1250

1000

750

Tweets 500

250

CHAPTER 54 WEB-BASED EDUCATION AND IMPLICATIONS OF SOCIAL MEDIA

0
10. Mar 24. Mar 7. Apr 21. Apr 5. May 19. May 2. Jun
Time
A

Daily HTML Views & PDF Downloads of Featured Article During Each of 4 Monthly IGSJC Twitter Journal Clubs
100
Number of HTML Views PDF Downloads

400

75
300 HTML View
PDF Download
50
200

100 25

0 0
March 3-5 June 4-5
Dates of Journal Club +/–5 Days
B

Figure 54-4.  Impact of a social media–based journal club on Twitter activity, hypertext markup language (HTML) views, and portable
document format (PDF) downloads. A. Activity during a Twitter-based journal club such as the International General Surgery Journal Club
(IGSJC) can be tracked by denoting the journal club related tweets with a hashtag (#IGSJC). Twitter activity increased during each of four
journal clubs. B. Daily HTML views and PDF downloads of featured articles also increased around the time period of the four Twitter journal
clubs. (Unpublished data from Sarah Bryczowski and Michael E. Zenilman.)

@Twitteruser1 @Twitteruser2
4 followers 4 followers
(3 unique, 1 shared) (3 unique, 1 shared)

Reach: 7 unique users

Each user received Received Each user received

tweet from tweet from tweet from
Impressions: 8 impressions
@Twitteruser1: both users: @Twitteruser2:
1 impression each 2 1 impression each
impressions

Figure 54-5.  Difference between reach and impressions in Twitter. If there are two Twitter users and each has three unique followers and
one shared follower, then there are seven unique recipients of their combined tweets. Their total reach is seven unique users. If both users
tweet the same message, then one user will have received the message twice. However, each time the message was delivered counts as an
impression; thus, the followers will have a total of eight impressions.
2192 The #Surgery Conference Influencers Public Education
Top 10 by Mentions Top 10 by Tweets Top 10 by Impressions The educational opportunities provided by the internet and
@User1 123 @User3 27 @User13 103,937 social media are not limited to healthcare providers. The inter-
@User2 65 @User11 25 @User24 80,956 net and social media are also being increasingly used to educate
@User3 62 @User7 23 @User4 42,976 patients and their families. There are multiple media through
@User4 46 @User4 23 @User3 40,911
which health education is spread, including, but not limited
@User5 42 @User12 19 @User6 28,966
@User6 32 @User13 13 @User41 22,534 to, online or social media discussion forums run by patients,
@User7 21 @User14 12 @User52 14,566 patient support groups, healthcare providers, or healthcare orga-
@User8 19 @User15 11 @User72 13,514 nizations; blogs or newsrooms; or electronic and mobile health
@User9 17 @User2 10 @User35 11,965 patient portals. Social media allows patients rapid access to
@User10 16 @User1 9 @User68 9862
information regardless of time or location. However, as noted
The Numbers
PART II

in the following section, the accuracy of social media–based

443,601 Impressions educational materials cannot be guaranteed, and patients should
utilize caution in relying on the information to make important
298 Tweets healthcare decisions.
SPECIFIC CONSIDERATIONS

72 Participants PITFALLS IN WEB AND SOCIAL MEDIA–BASED

EDUCATION
2 Avg Tweets/Hour Despite the many advantages of web and social media–based

4 Avg Tweets/Participant 7 education, significant potential pitfalls still remain. First,

Figure 54-6.  Example of conference analytics from Healthcare
Hashtags (https://www.symplur.com/healthcare-hashtags/). Sur-
gery conferences can tag tweets by using a prespecified hashtag
(i.e., #SurgeryConference) to denote conference-related messages.
These can then be tracked. A mention occurs when a user includes
another user’s name in the tweet. Note in the example that even if
there are only a few users tweeting about a conference, the number
of impressions can be large if several of those users have a large
number of followers. For example, @User13 only tweeted 13 times
but had 103,937 impressions.
educational purposes. They are examples of crowdsourcing
whereby information is gathered by enlisting the assistance of
a large number of participants. Crowdsourcing often involves
the general public or a loosely defined group of individuals
as opposed to outsourcing, which tasks a project to a specific
company or group. For example, Wikipedia is an example of
crowdsourcing. In surgery, an example of crowdsourcing are
the web-based communities formed by the American College
of Surgeons. Members can belong to one or more communities
which are based on specialty (i.e., general surgery or endocrine
surgery), geography (i.e., Florida Chapter), level of education
(i.e., medical students or senior surgeons), special interest (i.e.,
surgeon writers), or issue (i.e., quality improvement and advo-
cacy). Members can post and respond to discussion threads that
cover a wide range of topics including advice for challenging
cases, surgical history, and political issues.
An example of a social media–based interactive forum is
the International Hernia Collaboration (IHC) which is housed
on Facebook. Participants include not only surgeons but also
healthcare providers and industry representatives interested in
improving outcomes after hernia surgery. Membership in the
IHC is limited to those who have been vetted and approved.
The forum allows members to ask for advice on difficult cases,
debate controversial topics, post step-by-step instructions on
procedures or management strategies, and disseminate informa-
tion rapidly to a wide audience. Collaborative forums such as
the IHC allow for real-time, interactive, case-based, continuing
education.
widespread adoption and utilization is a challenge.
Although internet and mobile phone usage is prevalent, effec-
tiveness of web-based educational materials is dependent upon
trainees’ and surgeons’ uptake of the technology and available
resources. Despite increasing availability of the internet and
mobile technology, not all surgeons use it for educational pur-
poses. For example, a systematic review and meta-analysis by
Guraya et al found that three out of four medical students use
social networking sites, but only one out of five uses them for
educational purposes. Furthermore, lack of utilization can
impact educational effectiveness. In the previously mentioned
multicenter trial comparing a moderated journal club to an
online version, low participation in the Internet journal club
was postulated to be a significant factor in the poorer perfor-
mance on a critical appraisal test. More attention to instruc-
tional design may improve uptake and effectiveness. A
systematic review and meta-analysis by Cook et al determined
that features such as interactivity, practice exercises, repeti-
tion, and feedback are associated with improved learning out-
comes. The authors also noted that the evidence base upon
which to design internet-based learning programs is limited by
poor study methodology, failure to use conceptual frame-
works, and lack of adherence to reporting standards. Thus,
while the aforementioned features should be considered in
designing future web and social media–based educational pro-
grams, further evidence-based guidance is needed.
Second, the quality of information available online and via
social media may not be accurate or reliable. Multiple reports
have been published regarding the inaccuracies of web-based
educational materials. Surgeons and surgical trainees should
carefully evaluate the source of educational material, search
for conflicts of interest that may result in biased information,
assess how recently the information was updated, and cross-
check references. The lay public may have more difficulty in
identifying trustworthy surgical educational materials on the
internet. Healthcare providers should guide patients to reputable
websites and to encourage discussion regarding the accuracy of
the content.
Third, useful dialog and advice about difficult cases must
be balanced with ethical considerations surrounding patient con-
fidentiality and privacy. Appropriate safeguards must be taken
to ensure that patients cannot be identified based on provided
information, that patients have consented to have their informa-
tion posted anonymously, and that all case-related comments are
appropriate and professional. While common sense should be
utilized in posting about patient cases, only a few organizations
have published guidelines for how to safeguard against potential
pitfalls. In 2013, the American College of Physicians Ethics,
Professionalism, and Human Rights Committee; the American
College of Physicians Council of Associates; and the Federa-
tion of State Medical Boards Special Committee on Ethics and
Professionalism published a position statement about online
medical education (Table 54-2). The paper stated that “Maintain-
ing trust in the profession and in patient–physician relationships
requires that physicians consistently apply ethical principles for
preserving the relationship, confidentiality, privacy, and respect
for persons to online settings and communications.”
Fourth, conflicts of interest must be clearly stated. Jour-
nals require authors to declare relevant conflicts of interest, but
Table 54-2
The American College of Physicians Ethics, Professionalism
and Human Rights Committee; the American College of
Physicians Council of Associates; and the Federation of
State Medical Boards Special Committee on Ethics and
Professionalism published a position paper on online
medical professionalism
Position 1 Use of online media can bring significant
educational benefits to patients and
physicians, but it may also pose ethical
challenges. Maintaining trust in the
profession and in patient–physician
relationships requires that physicians
consistently apply ethical principles for
preserving the relationship, confidentiality,
privacy, and respect for persons to online
settings and communications.
Position 2 The boundaries between professional and social
spheres can blur online. Physicians should
keep the two spheres separate and comport
themselves professionally in both.
Position 3 Email or other electronic communications
should only be used by physicians in an
established patient–physician relationship
and with patient consent. Documentation
about patient care communications should be
included in the patient’s medical record.
Position 4 Physicians should consider periodically “self-
auditing” to assess the accuracy of information
available about them on physician-ranking
websites and other sources online.
Position 5 The reach of the internet and online
communications is far and often permanent.
Physicians, trainees, and medical students
should be aware that online postings may have
future implications for their professional lives.
Data from Farnan JM1, Snyder Sulmasy L, Worster BK, et al: 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 Apr 16;158(8):620-627.
multiple studies suggest that these often go unreported. Simi- 2193
larly, conflicts of interest should be disclosed on social media.
However, such disclosures may be more difficult on social
media due to the limited number of allowable characters (i.e.,
140 characters for Twitter) or to the way information is propa-
gated. For example, a surgeon may disclose an industry relation-
ship on an original tweet, but the disclosure may not appear in
subsequent comments of a discussion thread. Surgeons post-
ing on social media must make it their ethical and professional
obligation to disclose their conflicts of interest. Furthermore,
CHAPTER 54 WEB-BASED EDUCATION AND IMPLICATIONS OF SOCIAL MEDIA
users of social media content must be aware of the potential
for bias introduced by undisclosed conflicts of interest and per-
form due diligence in assessing the reliability of the source.
Lastly, regulatory bodies and professional organizations should
publish standardized guidelines for disclosing on social media
or develop mechanisms by which disclosure can be publicly
accessed (such as the Open Payments database).
Fifth, professionalism must always be maintained. Sur-
geons posting content on the web or on social media must be
aware that information will be widely disseminated and avail-
able for posterity; messages posted on social media cannot be
fully retracted. As already mentioned, surgeons must strive
to maintain patient privacy, ensure accuracy of information,
and disclose conflicts of interest. Furthermore, surgeons must
be aware of unintentional interpretations of messages (i.e., as
discriminatory or unprofessional). Multiple studies of health-
care providers’ social media sites have identified potentially
and clearly unprofessional content; these studies have included
medical students, residents, and practicing surgeons. Despite the
prevalence of unprofessional content, few surgical residency
programs have formal institutional social media policies. Fur-
thermore, the American College of Physicians and Federation of
State Medical Boards position statement only addresses a few of
the issues surrounding web-based activities including for patient
and physician education (Table 54-3).
Table 54-3
Online medical professionalism and education
POSITIONS ON PROFESSIONALISM IN ONLINE PATIENT AND
PHYSICIAN EDUCATION
• The Internet can be a powerful tool for education.
• Physicians should guide patients to high quality online
resources that are accurate and objective. These sites
should have peer-reviewed content or have verifiable
mechanisms for quality control of information.
• Online resources for learning can be used by patients and
physicians.
• The internet and social networking can be used to improve
public health. Physicians engaged in online communities
should ensure the security of the networks and restriction of
participation to verified users. Clinical scenarios should not
contain any personal identifying information, and patient
consent should be obtained before sharing the vignette.
• Discussion of frustrations online undermines trust and
professionalism and should be avoided.
Data from Farnan JM1, Snyder Sulmasy L, Worster BK, et al: 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 Apr 16;158(8):620-627.
2194 Lastly, studies evaluating the effectiveness of web-based
education have had varied results. A recent systematic review
by Taveira-Gomes et al assessed 251 articles using computer-
based learning methodologies in medical education; the num-
ber of articles on this topic has increased over time. The most
commonly used metrics for evaluating the effectiveness of these
methodologies were assessments of knowledge, attitudes, and
skills. The majority of studies reported positive effects on these
outcomes, although the more rigorous studies (i.e., randomized
trials) were less likely to find a positive effect. Online activ-
ity (i.e., number of posts or views) was tracked in a few stud-
ies, but results were conflicting regarding whether increased
PART II
engagement correlated with improved performance. This review
suggests that high-quality studies are needed of web-based edu-
cational interventions and that these studies need to include
measures of clinical performance and outcomes.
SPECIFIC CONSIDERATIONS
IMPLICATIONS AND FUTURE DIRECTIONS
The Society of University Surgeons’ Social and Legislative
Committee issued a position statement entitled: “Social media
is a necessary component of surgery practice.” Given the rapid
8 pace with which technology is advancing and the familiar-
ity of the current generation (Generation Z) with the inter-
net, surgeons have no choice but to harness the power of the
internet and social media or risk being left behind. Many jour-
nals are phasing out print versions, and several journals are
already online only. Furthermore, textbooks may also become a
relic from the past as publishers move towards developing digi-
tal versions that include interactive graphics, audio, and video.
As surgical education continues to evolve, future directions
may include broader indications for utilization of web- and social
media-based resources. For example, video-based coaching with
face-to-face discussions have been used postoperatively to sup-
plement intraoperative teaching. However, preoperative crowd-
sourcing in planning a challenging case or intraoperative video
telementoring are other applications of video-based coaching.
Future research efforts should focus on identifying the
most effective formats and components of web and social
media–based educational interventions, using rigorous methods
to compare educational methods, and measuring clinical out-
comes. Moreover, standardized guidelines should be instituted in
order to safeguard against ethical and professional misconduct.
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CHAPTER 54 WEB-BASED EDUCATION AND IMPLICATIONS OF SOCIAL MEDIA