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Social-media-enabled learning in emergency medicine: a case study of the growth, engagement and impact of a free open access medical education blog
  1. Simon Carley1,
  2. Iain Beardsell2,
  3. Natalie May3,
  4. Liz Crowe4,
  5. Janos Baombe1,
  6. Alan Grayson1,
  7. Richard Carden5,
  8. Ashley Liebig6,
  9. Chris Gray1,
  10. Ross Fisher7,
  11. Daniel Horner8,
  12. Laura Howard1,
  13. Richard Body9
  1. 1 Emergency Department, Manchester University NHS Foundation Trust, Manchester, UK
  2. 2 Department of Emergency Medicine, University Hospital Southampton, Southampton, UK
  3. 3 Ambulance Service New South Wales Rescue Helicopter Base, New South Wales, Australia
  4. 4 Children’s Health Queensland Hospital and Health Service, Lady Cilento Children’s Hospital, South Brisbane, Queensland, Australia
  5. 5 Emergency Department, Royal London Hospital, London, UK
  6. 6 STAR Flight, Austin, Texas, USA
  7. 7 Department of Paediatric Surgery, Sheffield Children’s NHS Foundation Trust, Sheffield, UK
  8. 8 Emergency Department, Salford Royal NHS Foundation Trust, Salford, UK
  9. 9 Division of Cardiovascular Sciences, University of Manchester, Manchester, UK
  1. Correspondence to Professor Simon Carley, Emergency Department, Manchester Royal Infirmary, Manchester M13 9WL, UK; simon.carley{at}cmft.nhs.uk

Abstract

Background Clinicians are increasingly using social media for professional development and education. In 2012, we developed the St.Emlyn’s blog, an open access resource dedicated to providing free education in the field of emergency medicine.

Objective To describe the development and growth of this international emergency medicine blog.

Method We present a narrative description of the development of St.Emlyn’s blog. Data on scope, impact and engagement were extracted from WordPress, Twitter and Google Analytics.

Results The St.Emlyn’s blog demonstrates a sustained growth in size and user engagement. Since inception in 2012, the site has been viewed over 1.25 million times with a linear year-on-year growth. We have published over 500 blog posts, each of which attracts a mean of 2466 views (range 382–69 671). The site has been viewed in nearly every country in the world, although the majority (>75%) of visitors come from the USA, UK and Australia.

Summary This case study of an emergency medicine blog quantifies the reach and engagement of social-media-enabled learning in emergency medicine.

  • FOAMed
  • social media
  • medical education
  • emergency medicine

Statistics from Altmetric.com

Background

We founded the St.Emlyn’s blog in June 2012 at the International Conference of Emergency Medicine (ICEM) in Dublin. Our intention was to provide an open access platform that promotes emergency medicine learning through the use of social media. Notably, we aimed to achieve this through the use of blogs and subsequently podcasts, Twitter, Facebook and Instagram means.

This paper describes the history, growth, lessons learnt and user engagement of the decision to take emergency medicine education into the social age.1

Methods

One of the advantages of developing educational materials online is the ready access to user engagement data. The St.Emlyn’s blog is based on the WordPress platform, which provides real-time and trend data on site utilisation. Data are readily available to site owners on the number of users, page views and location of those accessing the site. In addition, we linked the WordPress to Google Analytics, which provides an even greater depth of information on real-time engagement and trends over time in usage.

Similarly, the number of users on other social media platforms such as Twitter is readily available to users of the services.

We used data available from WordPress, Twitter and Google Analytics to determine the reach and interaction of users with the blog.

We used the online National Health Service Health Research Authority decision tool to determine that this study did not need ethical approval.

Initial development

Prior to 2012, our group had embraced online learning as a mechanism to engage with a chronologically and geographically dispersed workforce. We had experience in the use of closed virtual learning environments such as Moodle where learners and educators are able to exchange and learn through asynchronous discussion of clinical cases.2 3 Online learning lends itself well to the emergency medicine workforce, and closed systems offer advantages to learners and educators who are rightly concerned about safety and confidentiality. The disadvantage of closed systems is also clear: learning can only take place among those who are registered and permitted into the system. This complicates and restricts the reach of any educational interventions to those within the system.

In contrast, social media platforms allow engagement across a much broader range of learners and teachers.4 5 They are not restricted by time, geography or permissions and thus can engage with a much wider audience.6

ICEM in 2012 was one of the first emergency medicine conferences to embrace social media as an integral part of the meeting.7 Following discussions with leaders in online education in Dublin, we were inspired to design and publish the first blog on 1 July 2012. This coincided with the creation of the Free Open Access Medical Education movement by Mike Cadogan from the Life in the Fast Lane.8 These initial blog posts and content were supported and promoted by other free, open access medical education (‘#FOAMed’) sites at the time, notably Life in the Fast Lane8 and EMCrit.9 The blog is based on the WordPress platform and is hosted on a remote server. The editorial team began with two lead editors (RB and SC) and over time has developed a multiprofessional editorial team of 12 clinicians from the USA, UK and Australia. The editorial team peer reviews and approves all content with final sign off by one of the senior editors before publication.

The team-based peer review system also acts as a sense check to maintain high professional standards and patient and clinician confidentiality on a platform that is accessible to the public. The editorial team also indexes, disseminates and curates content by linking it to the Royal College of Emergency Medicine curriculum.10

We focus on publishing content relevant to emergency medicine, which is by its nature very broad. Our approach is to publish on topics ‘that would be interesting to UK emergency physicians’ across four broad themes:

  1. evidence-based medicine reviews and critical appraisal,

  2. clinical topics,

  3. philosophy of emergency medicine,

  4. well-being.

These themes are relevant to everyone who works in emergency medicine and similarly to related specialties such as prehospital care, critical care, acute medicine and paediatrics. The process of peer review and editorial oversight is similar to that described in other emergency medicine blogs.11 12 The process from themes to postpublication review and revision is shown in figure 1.

Figure 1

Publishing process for blog posts. EBM, evidence-based medicine; EM, emergency medicine.

Results

From June 2012 to January 2017, the blog has published 510 articles, approved and published 2776 comments and has had pages viewed over 1.25 million times.

Figure 2 shows the linear growth from 2012 to 2016. In the first month of 2017, page views are averaging over 1300 per day, which if sustained predicts over half a million views in 2017.

Figure 2

Page views per annum.

Data extracted from WordPress and Google Analytics reveal the global reach of a #FOAMed-based blog. Since 2012, visits have been registered from all but a handful of the world’s countries.

The distribution of visitors reflects those countries that are primarily English speaking and with high comparative incomes. They are also those health economies that most closely resemble UK practice in emergency care. Figure 3 quantifies this distribution with over 75% of visitors coming from the UK, USA and Australia. A session represents an individual accessing the site and viewing one or more pages.

These data clearly show that the scope and reach of a #FOAMed blog extends far beyond the immediate face-to-face influence of the authors and thus offers scope to teach and learn with a global audience. Communicating the content to this audience is aided by disseminating new posts through linked Twitter, Facebook and LinkedIn accounts with summary messages and links back to original content. This blend of integrated social media platform publication and dissemination increases the reach of content and takes key selected messages to an even wider audience. For example, in January 2017, the @stemlyns Twitter account achieved 150 000 impressions (ie, delivered to a user’s account).

These data demonstrate the reach of a #FOAMed-based blog, but as with many educational interventions, the clinical impact as defined by changes to clinical care is more difficult to demonstrate. This is especially difficult with such a globally dispersed audience. However, anecdotal stories have emerged that demonstrate both the speed and impact of learning through social media. Box 1 details the impact of one particular post via various online platforms.

Box 1

Example of early clinical impact of blog post

A post based on the REVERT trial34 35 led to reports of clinicians using the technique successfully within hours of publication on the blog as communicated by reports on social media. The example given below demonstrates this with clinicians learning about the the REVERT technique through the blog and then actioning that knowledge within 12 hours of publication.36

Tweet reflecting speed of adoption of new evidence.

Examples of narratives similar to that above show how knowledge translation through social media can lead to improvements in patient care. However, examples cannot determine the breadth and overall impact of social-media-enabled learning. What is clear is that they do demonstrate the speed at which knowledge can be translated from the primary literature to the bedside through the use of social learning. This is in stark contrast to traditional models of publication where the knowledge translation cycle is measured in years rather than hours.13 14

Discussion

This case study charts the development of a #FOAMed-based medical education blog. It demonstrates a sustained growth and impact in content and engagement with a worldwide readership. This is the first paper to quantify the reach and impact of an emergency medicine blog as many bloggers are reluctant to reveal their activity data. Previous efforts to rank the impact and size of sites have used publicly available data such as Alexa rankings, Twitter followers and Facebook likes.15 However, such data, although freely available, contain significant biases, particularly against sites outside of North America. We have previously blogged on the limitations of the Social Media Index (SMi) to recognise the limitations of only having access to public datasets.16 This paper takes a different approach and uses data ordinarily only available to site publishers. This gives a more accurate and direct reporting of site use and reach.

Our belief is that the St.Emlyn’s blog is mid-large in terms of user engagement, as the latest SMi suggests,17 but without other sites and educators sharing their direct data, it is merely an estimate. We believe that these data will act as a benchmark for other sites and educators. We hope that by making these data open we will encourage others to share and thus gain a better understanding of #FOAMed resources as a whole.

The data on user engagement show how web-based learning can disseminate content to an extremely large cohort of learners unrestricted by time or geography. The location of users almost certainly reflects the language and systems familiar to the authors. However, the global reach and engagement with lower-income and middle-income countries demonstrates how knowledge can be shared without the need to travel to conferences or to subscribe to journals as the global accessibility of #FOAMed resources is essentially free to the end user.

The data show an increase in size, impact and engagement over time, which probably reflects a sustained growth in #FOAMed-based learning in general.18 19 Studies in the USA20 and Canada21 show that residents in emergency medicine increasingly value and use #FOAMed-based learning. Purdy et al demonstrated a near universal engagement with #FOAMed resources among Canadian residents and found evidence that this changed clinical practice.21 This has raised concerns about the quality of online resources and as to whether knowledge may be disseminated too quickly before it can be tested in practice.22 Efforts to define quality and impact have sought to counter these concerns through guidelines, process and scoring systems, although none of them are yet to achieve universal acceptance.15 23 24 These concerns are legitimate, although to date, they appear to be largely theoretical.

Unlike traditional medical publishing, the linked social media sites such as Facebook and Twitter allow users and authors to meet, discuss and improve content in real time. This allows authors and readers to participate in rapid and explicit updates, comments and postpublication review, which can then be incorporated into current and future blogs.25 26 Recently, traditional journals have recognised this potential and have linked with social media platforms to enhance, debate and review published content. Notably, the Canadian Journal of Emergency Medicine 27–29 and Annals of Emergency Medicine 30–32 have championed this symbiotic approach to improving the speed of knowledge translation into clinical practice. Thus, the future of medical publishing may increasingly blur the current distinction between traditional publishing and the new disruptive publishing technologies.

Limitations

This study relies on the use of statistics obtained from the routinely collected site data. There are limitations with this. Site data may be an imperfect determinant of educational engagement. Merely accessing a site does not mean that the entire content has been read, understood or acted on. Educationally, we are most interested in delivering material that changes practice, and although this can be implied from individual cases and conversations, the overall impact cannot be fully determined using these methods (although the same is true for almost all educational materials).

Data on location are determined by the internet protocol (IP) address of the user and thus can be misinterpreted if the user uses systems to hide their IP address (eg, virtual private networks).

Similarly, although sites now protect against spurious access from automated site viewing programs, it is inevitable that some traffic is not related to clinical learning.

Future directions

It is challenging to predict how social-media-enabled learning will develop in the next 5–10 years. What is clear is that new disruptive technologies can lead to significant change in how, where and when learners access educational material. The nature of interaction permitted by social platforms is allowing learners to create their own learning journeys and to construct their own knowledge from easily accessible and internationally created online resources. This has profound implications for educators and learners who must now navigate an educational world where the traditional limitations of data flowing from content creators to users are increasingly being broken down. As clinicians and educators, we have a responsibility to understand and support our teams in navigating this new social age33 of learning.

Summary

This case study of an emergency medicine blog is the first to demonstrate the quantitative reach of social-media-enabled learning. We suspect that this case study reflects the growth in social media sites in general and is a clear example of how the modern-day emergency clinician can engage and learn with a global audience.

Main messages

  • Social media technologies are increasingly used by learners to access clinical information.

  • The reach of social media technologies amplifies the reach of educators through digital technologies.

  • Free open access medical education is an emerging ethos amongst emergency medicine and critical care clinicians.

Current research questions

  • What is the clinical impact of social-media-enhanced education?

  • How will traditional models of publishing engage with independent social-media-enabled learning?

  • Can social-media-enabled learning improve patient outcomes by accelerating published evidence into bedside clinical care?

References

Footnotes

  • Contributors This paper was initially conceived and written by SC. All authors were subsequently involved in the revision and final approval of the manuscript. All authors were involved in the conception, design, publication, review and analysis of data on the St. Emlyn’s site.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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