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Surgery_Schwartz. these materials for improving knowledge, attitudes, skills, and outcomes.8 Social media has become a necessary component of surgical practice.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 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


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Surgery_Schwartz. 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 4real-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


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Surgery_Schwartz. 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,


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Surgery_Schwartz. 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 EDUCATIONWhat is Social Media?Social media is a term describing websites and web-based applications that enable users to share ideas, information, and Brunicardi_Ch54_p2187-p2196.indd 218813/02/19 2:37 PM 2189WEB-BASED EDUCATION AND IMPLICATIONS OF SOCIAL


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Surgery_Schwartz. websites and web-based applications that enable users to share ideas, information, and Brunicardi_Ch54_p2187-p2196.indd 218813/02/19 2:37 PM 2189WEB-BASED EDUCATION AND IMPLICATIONS OF SOCIAL MEDIACHAPTER 54@Twitteruser1@Twitteruser2A@Twitteruser1@Twitteruser2BFigure 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


Surgery_Schwartz

Surgery_Schwartz. 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


Surgery_Schwartz

Surgery_Schwartz. 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


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Surgery_Schwartz. 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


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Surgery_Schwartz. 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).Surgicaltreatment ASurgicaltreatment BOutcomesComplications15%11%MortalityAuthor A et al. Journal. Date.Journal Logo8%4%Comparison of Surgical Treatment A VersusSurgical Treatment BPatients with disease XFigure 54-3. A visual abstract is a graphical summary of the main results of a journal article.Brunicardi_Ch54_p2187-p2196.indd 218913/02/19 2:37 PM


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Surgery_Schwartz. Treatment BPatients with disease XFigure 54-3. A visual abstract is a graphical summary of the main results of a journal article.Brunicardi_Ch54_p2187-p2196.indd 218913/02/19 2:37 PM 2190SPECIFIC CONSIDERATIONSPART IIJournal ClubsJournals 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 media–based journal clubs can help to overcome these barriers by allowing for asynchronous discussion


Surgery_Schwartz

Surgery_Schwartz. time, or absence of local exper-tise in either the clinical topic or research methodology. Social 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 allow respondents to comment hours or even days later to a conversation. Multiple specialties, including surgery, 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


Surgery_Schwartz

Surgery_Schwartz. 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, 5aTable 54-1Ten tips for setting up an online journal club TIP 1Create an online home page that serves as a launching pad for your journal club discussions 2Develop and register a hashtag on Twitter 3Incorporate not only Twitter but other collaborative platforms as part of your online journal club 4Ensure that the time of the journal club is convenient for your target audience 5Help prepare participants by aggregating other online resources relevant to the article 6Consider inviting the authors of the featured article or other experts in the field 7Suggest journal club participants consider using


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Surgery_Schwartz. by aggregating other online resources relevant to the article 6Consider inviting the authors of the featured article or other experts in the field 7Suggest journal club participants consider using specific Twitter management applications during the Tweet chat 8Engage the participants to cultivate and incentivize more discussion 9Connect to the online community by following and engaging with other relevant social media accounts10Link back to the original paper by inserting a comment on PubMed CommonsData 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


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Surgery_Schwartz. 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


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Surgery_Schwartz. 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 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 ConferencesTraditionally, surgeons have attended regional and national conferences to network, learn new information relevant to their practice, and exchange ideas. However,


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Surgery_Schwartz. appraisal.Live-Tweeting ConferencesTraditionally, 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


Surgery_Schwartz

Surgery_Schwartz. (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 can also be assembled to allow a conversation thread to be organized into a cohesive discussion.Interactive Forums and CommunitiesInteractive forums and communities are another method by which both the internet and social media can be used for


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Surgery_Schwartz. thread to be organized into a cohesive discussion.Interactive Forums and CommunitiesInteractive forums and communities are another method by which both the internet and social media can be used for 5b6Brunicardi_Ch54_p2187-p2196.indd 219013/02/19 2:37 PM 2191WEB-BASED EDUCATION AND IMPLICATIONS OF SOCIAL MEDIACHAPTER 54ATimeDaily HTML Views & PDF Downloads of Featured Article During Each of 4 Monthly IGSJC Twitter Journal ClubsTweets025050075010001250Tweet Activity on #IGSJC10. Mar24. Mar7. Apr21. Apr5. May19. May2. JunB0100Number of HTML Views PDF Downloads200300400100Dates of Journal Club +/–5 DaysMarch 3-5June 4-50255075HTML ViewPDF DownloadFigure 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


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Surgery_Schwartz. (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.)@Twitteruser14 followers(3 unique, 1 shared)Reach: 7 unique usersImpressions: 8 impressionsEach user receivedtweet from@Twitteruser1:1 impression eachReceivedtweet fromboth users:2impressionsEach user receivedtweet from@Twitteruser2:1 impression each@Twitteruser24 followers(3 unique, 1 shared)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


Surgery_Schwartz

Surgery_Schwartz. 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.Brunicardi_Ch54_p2187-p2196.indd 219113/02/19 2:37 PM 2192SPECIFIC CONSIDERATIONSPART IIImpressionsTweetsParticipantsAvg Tweets/HourAvg Tweets/Participant4272298443,601The Numbers@User1 123@User2 65@User3 62@User4 46@User5 42@User6 32@User7 21@User8 19@User9 17@User10 16Top 10 by Mentions@User3 27@User11 25@User7 23@User4 23@User12 19@User13 13@User14 12@User15 11@User2 10@User1 9Top 10 by Tweets@User13 103,937@User24 80,956@User4 42,976@User3 40,911@User6 28,966@User41 22,534@User52 14,566@User72 13,514@User35 11,965@User68 9862Top 10 by


Surgery_Schwartz

Surgery_Schwartz. 12@User15 11@User2 10@User1 9Top 10 by Tweets@User13 103,937@User24 80,956@User4 42,976@User3 40,911@User6 28,966@User41 22,534@User52 14,566@User72 13,514@User35 11,965@User68 9862Top 10 by ImpressionsThe #Surgery Conference In˜uencersFigure 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.


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Surgery_Schwartz. 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


Surgery_Schwartz

Surgery_Schwartz. 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.Public EducationThe educational opportunities provided by the internet and social media are not


Surgery_Schwartz

Surgery_Schwartz. Collaborative forums such as the IHC allow for real-time, interactive, case-based, continuing education.Public EducationThe educational opportunities provided by the internet and social media are not limited to healthcare providers. The inter-net and social media are also being increasingly used to educate patients and their families. There are multiple media through which health education is spread, including, but not limited to, online or social media discussion forums run by patients, patient support groups, healthcare providers, or healthcare orga-nizations; blogs or newsrooms; or electronic and mobile health patient portals. Social media allows patients rapid access to information regardless of time or location. However, as noted in the following section, the accuracy of social media–based educational materials cannot be guaranteed, and patients should utilize caution in relying on the information to make important healthcare decisions.PITFALLS IN WEB AND SOCIAL MEDIA–BASED


Surgery_Schwartz

Surgery_Schwartz. media–based educational materials cannot be guaranteed, and patients should utilize caution in relying on the information to make important healthcare decisions.PITFALLS IN WEB AND SOCIAL MEDIA–BASED EDUCATIONDespite the many advantages of web and social media–based education, significant potential pitfalls still remain. First, 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


Surgery_Schwartz

Surgery_Schwartz. 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


Surgery_Schwartz

Surgery_Schwartz. 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,


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Surgery_Schwartz. 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 7Brunicardi_Ch54_p2187-p2196.indd 219213/02/19 2:37 PM 2193WEB-BASED EDUCATION AND IMPLICATIONS OF SOCIAL MEDIACHAPTER 54Table 54-2The 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 professionalismPosition 1Use 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


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Surgery_Schwartz. professionalismPosition 1Use 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 2The boundaries between professional and social spheres can blur online. Physicians should keep the two spheres separate and comport themselves professionally in both.Position 3Email 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 4Physicians should consider periodically “self-auditing” to assess the accuracy of information available about them on physician-ranking


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Surgery_Schwartz. should be included in the patient’s medical record.Position 4Physicians should consider periodically “self-auditing” to assess the accuracy of information available about them on physician-ranking websites and other sources online.Position 5The 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.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


Surgery_Schwartz

Surgery_Schwartz. 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


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Surgery_Schwartz. 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 multiple studies suggest that these often go unreported. Simi-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, users of social media content must be aware of the potential for bias introduced by undisclosed conflicts of interest and


Surgery_Schwartz

Surgery_Schwartz. professional obligation to disclose their conflicts of interest. Furthermore, 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


Surgery_Schwartz

Surgery_Schwartz. 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 54-3Online medical professionalism and educationPOSITIONS ON PROFESSIONALISM IN ONLINE PATIENT AND PHYSICIAN EDUCATION• The Internet can be a powerful tool for education.• Physicians should guide


Surgery_Schwartz

Surgery_Schwartz. 54-3Online medical professionalism and educationPOSITIONS 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:


Surgery_Schwartz

Surgery_Schwartz. 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.Brunicardi_Ch54_p2187-p2196.indd 219313/02/19 2:37 PM 2194SPECIFIC CONSIDERATIONSPART IILastly, 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


Surgery_Schwartz

Surgery_Schwartz. 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 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.IMPLICATIONS AND FUTURE DIRECTIONSThe 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 pace with which technology is advancing and the familiar-ity of the current generation (Generation Z) with the inter-net, surgeons have no


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Surgery_Schwartz. a necessary component of surgery practice.” Given the rapid 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 weband 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


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Surgery_Schwartz. 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.BIBLIOGRAPHYBirkmeyer JD, Finks JF, O’Reilly A, Oerline M, et al; Michigan Bariatric Surgery Collaborative. Surgical skill and complica-tion rates after bariatric surgery. N Engl J Med. 2013;369(15): 1434-1442. This study correlated blinding reviewer ratings of videotaped laparoscopic gastric bypass procedures to clinical outcomes. Greater skill was associated with lower rates of com-plications, reoperations, readmissions, and emergency


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Surgery_Schwartz. reviewer ratings of videotaped laparoscopic gastric bypass procedures to clinical outcomes. Greater skill was associated with lower rates of com-plications, reoperations, readmissions, and emergency depart-ment visits.Bresnahan ER, Huynh DTK, Jacob B. Social media and education in hernia repair. In: Hope WW, Cobb WS, Adrales GL, eds. Textbook of Hernia. Cham: Springer International Publishing; 2017:373-379. This book chapter describes the International Hernia Collaboration, which is a Facebook-based community of practicing surgeons, trainees, and industry representatives. The goals of the collaboration include exchange of ideas and advice regarding patient care, discussion and debate of controversial topics in hernia management, and dissemination of information to a global audience.Chan TM, Thoma B, Radecki R, et al. Ten steps for setting up an online journal club. J Contin Educ Health Prof. 2015; 35(2):148-154. Written by a multidisciplinary group of authors, this article provides 10


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Surgery_Schwartz. Thoma B, Radecki R, et al. Ten steps for setting up an online journal club. J Contin Educ Health Prof. 2015; 35(2):148-154. Written by a multidisciplinary group of authors, this article provides 10 helpful hints for setting up an online journal club, using examples from existing journal clubs.Cook DA, Levinson AJ, Garside S, Dupras DM, Erwin PJ, Montori VM. Instructional design variations in internet-based learn-ing for health professions education: a systematic review and meta-analysis. Acad Med. 2010;85(5):909-922. This systematic review and meta-analysis of 51 studies, including 30 random-ized trials, identified several key features of internet-based learning interventions that were associated with improved learning outcomes: interactivity, practice exercises, repeti-tion, and feedback. However, the evidence base upon which to design internet-based learning programs is limited by poor study designs, failure to use conceptual frameworks, and lack of adherence to reporting


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Surgery_Schwartz. feedback. However, the evidence base upon which to design internet-based learning programs is limited by poor study designs, failure to use conceptual frameworks, and lack of adherence to reporting standards.Cook DA, Levinson AJ, Garside S, Dupras DM, Erwin PJ, Montori VM. Internet-based learning in the health professions: a meta-analysis. JAMA. 2008;300(10):1181-1196. This meta-analysis of 201 studies reported that internet-based instruction had a positive effect on educational outcomes as compared to no intervention, but that there was similar effectiveness between internet-based instruction and traditional educational methods.Farnan JM, Synder Sulmasy L, Worster BK, Chaudhry HJ, Rhyne JA, Arora VM; American College of Physicians Ethics, Profes-sionalism and Human Rights Committee; American College of Physicians Council of Associates; Federation of State Medical Boards Special Committee on Ethics and Professionalism. Online medical professionalism: patient and public rela-tionships:


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Surgery_Schwartz. College of Physicians Council of Associates; Federation of State Medical Boards Special Committee on Ethics and Professionalism. Online medical professionalism: patient and public rela-tionships: policy statement from the American College of Physicians and the Federation of State Medical Boards. Ann Intern Med. 2013;158(8):620-627. This position statement pro-vides recommendations on issues relating to professional use of the internet and social media including but not limited to: use of social media for nonclinical purposes, patient confidentiality in online discussions, and use of web-based patient education resources.Guraya SY. The usage of social networking sites by medical stu-dents for educational purposes: a meta-analysis and systematic review. N Am J Med Sci. 2016;8(7):268-278. This review of 10 articles published between 2004 and 2014 suggested that although 75% of medical students use social networking sites, only 20% use them for academic or educational purposes.


Surgery_Schwartz

Surgery_Schwartz. This review of 10 articles published between 2004 and 2014 suggested that although 75% of medical students use social networking sites, only 20% use them for academic or educational purposes. Fur-thermore, none of these studies evaluated whether use of social media improved academic performance.Ibrahim AM, Lillemoe KD, Klingensmith ME, Dimick JE. Visual abstracts to disseminate research on social media: a prospective, case-control crossover study. Ann Surg. 2017;266(6):e46-e48. This prospective, case-control crossover study compared the impact of tweets alone versus tweets accompanied by a visual abstract on article visits; there was a threefold increase when visual abstracts accompanied the tweets.Jayakumar N, Brunckhorts O, Dasgupta P, Khan MS, Ahmed K. e-Learning in surgical education: a systematic review. J Surg Educ. 2015;72(6):1145-1157. This systematic review of 38 studies suggested that while the majority of studies evaluating electronic learning in surgical education


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Surgery_Schwartz. a systematic review. J Surg Educ. 2015;72(6):1145-1157. This systematic review of 38 studies suggested that while the majority of studies evaluating electronic learning in surgical education demonstrate a positive effect, most lack a proper control.McLeod RS, MacRae HM, McKenzie ME, Victor JC, Brasel KJ; Evidence Based Reviews in Surgery Steering Committee. A moderated journal club is more effective than an Internet journal club in teaching critical appraisal skills: results of a multicenter randomized controlled trial. J Am Coll Surg. 8Brunicardi_Ch54_p2187-p2196.indd 219413/02/19 2:37 PM 2195WEB-BASED EDUCATION AND IMPLICATIONS OF SOCIAL MEDIACHAPTER 542010;211(6):769-776. This multicenter randomized trial reported that surgical residents who participated in a journal club moderated by a faculty member scored higher on a vali-dated test of critical appraisal than those who participated in an online journal club.Pugh CM, Watson A, Bell RH Jr, et al. Surgical education in the


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Surgery_Schwartz. by a faculty member scored higher on a vali-dated test of critical appraisal than those who participated in an online journal club.Pugh CM, Watson A, Bell RH Jr, et al. Surgical education in the internet era. J Surg Res. 2009;156(2):177-182. This article describes the factors that led to a change in surgical education over the last two decades.Taveira-Gomes T, Ferreira P, Taveira-Gomes I, Severo M, Ferreira MA. What are we looking for in computer-based learning inter-ventions in medical education? A systematic review. J Med Internet Res. 2016;18(8):e204. This systematic review assessed recent studies on computer-based learning (CBL) for types of software platforms and interventions and adherence to current recommendations for CBL research.Brunicardi_Ch54_p2187-p2196.indd 219513/02/19 2:37 PM