From Cynic to Advocate: The Use of Twitter in Cardiology.

As someone who still enjoys reading books and newspapers in print, I have been admittedly slow to engage with social media. Yet it is undeniable that social media plays a critical role in facilitating the public sharing of information, ideas, and opinions. In 2019, approximately 3.5 billion people—45% of the world’s population—used some form of social media, which represented a 9% increase since 2018. The United States has seen an especially dramatic rise in the use of social media, from 7% of the population in 2005 to 70% in 2019 (1, 2,2).

While the majority of Americans continue to use social media for personal communication, individuals have increasingly begun to utilize social media as a primary source of news. As of 2018, more than two-thirds of Americans (68%) report that they access news on social media, and 20% state that they do so “often” (3). Though Facebook remains the dominant social media platform globally, Twitter has gained particular traction within the medical and scientific community. In large part, this may be attributable to Twitter’s “microblog” format, which limits posts to 280 characters instead of the free-text formats found on other platforms such as Facebook and Instagram. Twitter’s streamlined and rapid interface is thus uniquely suited to stimulate academic discussion and promote the circulation of ideas and information. In addition, Twitter users can affix hashtags to their tweets, allowing posts to be collated, grouped, and searched by topic. As an example, Dr. Sunil Rao established the #RadialFirst hashtag in January 2017 to aggregate posts related to the use of transradial cardiac catheterization; as of January 2019, the hashtag had been referenced in >60,000 tweets by >7,000 individual users (4). Hashtags are also routinely used during academic conferences to allow both attendees and nonattendees to exchange data and opinions in real time.

Yet despite Twitter’s burgeoning role as an academic forum, relatively few physicians and scientists engage with Twitter on a routine basis. In a recent survey, only 26% of scientists reported that they use Twitter in a professional capacity, and a paper published by Khan et al. (5) indicated that only 238 of 1,500 cardiologists surveyed (16%) owned Twitter accounts (6). While there are numerous potential explanations for this lack of widespread adoption among the scientific community, important concerns regarding the promotion of unsubstantiated views, data manipulation, inefficient use of time, and patient privacy are likely major contributors.

I, too, have long harbored similar reservations and have therefore been resistant to using social media for professional purposes. Recently, however, an indelible experience at the American College of Cardiology’s (ACC) Teaching Tomorrow’s Teachers (3T) program convinced me to reconsider my stance on social media and its efficacy as a tool for academic advancement and discourse.

The 3T program was established by the ACC in 2015 as an annual retreat for fellows-in-training (FITs) interested in building careers as clinician educators. Held in conjunction with the ACC’s Big Sky Cardiovascular Update course in Big Sky, Montana, the 3T program is an immersive 5-day experience during which FITs from different ACC state chapters participate in a variety of workshops to develop their skills as educators and foster a community of colleagues interested in medical education. In addition, prior to the course, each FIT is paired with an individual faculty mentor who will be presenting at the conference. Working with the mentor, the FIT is charged with writing a 5-minute case presentation that he or she will subsequently present as an introduction to the mentor’s lecture. So it was with a fair amount of trepidation that I received my topic assignment from my faculty mentor, Dr. Gina Lundberg: the use of Twitter as an academic tool within cardiology.

Given my lack of familiarity with Twitter, I was initially flummoxed. After consulting with Dr. Lundberg, however, we recognized that this, in fact, represented a unique opportunity to assess the educational impact of Twitter through an “n of 1” experiment that we designed. Specifically, I was asked to create a Twitter profile, follow the accounts of at least 10 individual cardiovascular thought leaders (e.g., Dr. Kim Eagle @keaglemd) and 10 cardiovascular organizations (e.g., the ACC @ACCinTouch), and spend 10 to 15 min per day reading posts. At the end of the study interval, which we determined to be 4 weeks, I was then tasked with analyzing my experience on Twitter and evaluating the content I found most and least useful from an educational perspective.

Though at first skeptical, once I overcame my previous reluctance to engage with social media, the results of our makeshift experiment were overwhelmingly positive. As I quickly discovered, Twitter represents a vast and diverse forum for the academic exchange of ideas and information, and the resultant educational opportunities are seemingly endless. In particular, after reviewing thousands of tweets and following >100 cardiovascular-related accounts, I identified 4 broad categories of tweets that I found to be most illuminating: content tweets, opinion tweets, instructional tweets, and live tweets (Table 1 ).

Table 1

Types of Educational Tweets

Tweet Type	Definition	Example
Content	Tweet that shares an interesting case, imaging study, or article
Opinion	Tweet that shares a personal opinion on a specific topic
Instructional: Tweetorial	Lengthy series of tweets that discusses a specific topic in detail
Instructional: Twearl	Single tweet that contains a high-yield piece of medical information or “pearl”
Live	Tweet that provides real-time updates during an academic conference or meeting

Content tweets are those in which users share interesting cases, imaging studies, and articles. These types of tweets are particularly instructive for FITs as they allow trainees to augment the breadth of cases to which they are exposed, review imaging findings, solicit advice for challenging clinical situations, and discover newly published studies. Recently, the severe acute respiratory syndrome-coronavirus-2 pandemic has demonstrated all too well the burgeoning importance of content tweets as a critical form of communication within the global academic community, as physicians have increasingly relied on Twitter to disseminate novel scientific literature and facilitate educational opportunities in the face of ongoing physical distancing policies (7). Furthermore, content tweets may give voice to underrepresented groups within the FIT community and allow them the opportunity to establish an academic reputation and participate in active scholarly discourse despite socioeconomic or logistical factors that may limit access to conferences or meetings.

Opinion tweets are those in which physicians post personal perspectives on cardiovascular topics. Like content tweets, opinion tweets represent invaluable learning opportunities for FITs, especially those written by content experts within cardiology. Moreover, the conversational nature of Twitter’s platform allows for the direct exchange of opinion tweets to occur among users, cultivating peer-to-peer, as well as peer-to-mentor, relationships.

Instructional tweets come in 2 forms: tweetorials and twearls. Tweetorials are lengthy tutorials in which a user explicates a topic over the course of multiple tweets; in contrast, twearls are single tweets that contain high-yield pieces of medical information or “pearls.” Instructional tweets are innovative tools within medical education and have become increasingly utilized by medical educators at all levels of training and clinical practice. In fact, some physicians have even begun to experiment with the use of instructional tweets on daily rounds as a way to stimulate learning and promote interconnectedness among trainees.

Finally, live tweets provide real-time updates during conferences or other academic meetings. The power of live tweeting was made manifest this past year at the annual American Heart Association Scientific Sessions after the presentation of the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial. Though the trial data had yet to be published at the time of presentation, extensive live tweeting led to immediate and thorough data review by the larger cardiology community, who dissected the trial results in a way that would certainly not have been possible via more traditional academic forums.

Through engagement with these 4 simple categories of educational tweets, my knowledge of cardiovascular medicine has expanded immeasurably since first joining Twitter—I have improved my facility with interpreting complex cardiac imaging, become more attuned to controversies within the cardiovascular literature, and made professional connections with trainees and faculty at multiple different institutions. My time on Twitter has even helped me to become a better educator myself, as I have been able to share multiple electrocardiograms and echocardiograms I discovered on Twitter in didactic sessions with medical residents.

To be sure, the use of Twitter as an essential avenue of health care communication has changed the nature of academic discourse in a number of additional ways, as well. For example, “tweetations,” or tweets mentioning a newly written article, have been shown to highly correlate with the article’s journal citation rate when sent within the first 3 days of publication and may even influence the impact factor of the journal itself (8). In addition, physicians have increasingly turned to Twitter to advertise colleagues’ achievements, disseminate public health information, and facilitate discussion with patients and the public writ large. Finally, some institutions, such as the Mayo Clinic, have begun to utilize social media portfolios and scholarship as a metric for academic promotion. Though evaluative frameworks have generally avoided the inclusion of Twitter-specific criteria such as number of followers and number of retweeted posts due to fears that such criteria may not accurately reflect true academic impact, the use of objective indices such as the “Kardashian Index,” which divides the number of a given researcher’s Twitter followers by the number of his or her peer-reviewed citations, have been proposed to better discriminate between a physician’s social media profile and his or her publication record (5,8, 9, 10).

Of course, as with any new technological advancement, social media has important limitations, and as FITs continue to engage on these platforms, it is imperative to establish a shared set of core principles to ensure the maintenance of professional decorum and patient privacy. To that end, FITs should strive for accuracy and quality within their tweets and verify that appropriate credit is given when ideas are shared or borrowed from others. The tone of each tweet should be civil, and disparaging comments should be avoided. Additionally, FITs should refrain from offering specific medical advice or posting identifiable patient information unless express permission is obtained from the patient (11).

Empowered by my newfound digital savvy, I have thus finally come to embrace social media for its educative potential. I now actively champion Twitter as a dynamic learning tool, and I consider daily Twitter use to be a critical component of my ongoing medical education. So consider this a social media call to arms. Join Twitter, start following cardiovascular thought leaders and organizations, and explore. As a former Twitter skeptic, I can attest with certitude—once you join, you will never look back.