Social Media in the Emergency Medicine Residency Curriculum: Social Media Responses to the Residents' Perspective Article UCSF UC San Francisco Previously Published Works Title Social media in the emergency medicine residency curriculum: social media responses to the residents' perspective article. Permalink https://escholarship.org/uc/item/6jj947g9 Journal Annals of emergency medicine, 65(5) ISSN 0196-0644 Authors Hayes, Bryan D Kobner, Scott Trueger, N Seth et al. Publication Date 2015-05-01 DOI 10.1016/j.annemergmed.2015.01.018 Peer reviewed eScholarship.org Powered by the California Digital Library University of California https://escholarship.org/uc/item/6jj947g9 https://escholarship.org/uc/item/6jj947g9#author https://escholarship.org http://www.cdlib.org/ EDUCATION/SPECIAL CONTRIBUTION Social Media in the Emergency Medicine Residency Curriculum: Social Media Responses to the Residents’ Perspective Article Bryan D. Hayes, PharmD*; Scott Kobner, BS; N. Seth Trueger, MD, MPH; Stella Yiu, MD; Michelle Lin, MD *Corresponding Author. E-mail: bhayes@umem.org, Twitter: @PharmERToxGuy. Volume In July to August 2014, Annals of Emergency Medicine continued a collaboration with an academic Web site, Academic Life in Emergency Medicine (ALiEM), to host an online discussion session featuring the 2014 Annals Residents’ Perspective article “Integration of Social Media in Emergency Medicine Residency Curriculum” by Scott et al. The objective was to describe a 14-day worldwide clinician dialogue about evidence, opinions, and early relevant innovations revolving around the featured article and made possible by the immediacy of social media technologies. Six online facilitators hosted the multimodal discussion on the ALiEM Web site, Twitter, and YouTube, which featured 3 preselected questions. Engagement was tracked through various Web analytic tools, and themes were identified by content curation. The dialogue resulted in 1,222 unique page views from 325 cities in 32 countries on the ALiEM Web site, 569,403 Twitter impressions, and 120 views of the video interview with the authors. Five major themes we identified in the discussion included curriculum design, pedagogy, and learning theory; digital curation skills of the 21st-century emergency medicine practitioner; engagement challenges; proposed solutions; and best practice examples. The immediacy of social media technologies provides clinicians the unique opportunity to engage a worldwide audience within a relatively short time frame. [Ann Emerg Med. 2015;-:1-11.] 0196-0644/$-see front matter Copyright © 2015 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2015.01.018 INTRODUCTION In 2013, Annals of Emergency Medicine and Academic Life in Emergency Medicine (ALiEM) began a joint social media–based global emergency medicine journal club.1-3 With this series’ increasing popularity, as well as the concurrent growing use of online resources and discussion among emergency medicine trainees, the collaboration was extended to the Annals Residents’ Perspective series.4 This article summarizes the social media–based discussion hosted by ALiEM about the 2014 article by Scott et al,5 “Integration of Social Media in Emergency Medicine Residency Curriculum.” The Accreditation Council for Graduate Medical Education Residency Review Committee now permits emergency medicine programs to fulfill up to 20% of their weekly didactic conference requirement with an average of 1 hour per week of “individualized interactive instruction,” potentially allowing programs to leverage home consumption of online resources into the formal residency curriculum.6 In a previous Residents’ Perspective, Reiter et al7 discussed the implementation of asynchronous resources into the curriculum at Mount Sinai’s emergency medicine residency, including the challenges of meeting the Residency Review Committee’s broad but vague requirements: an evaluation component, faculty oversight, monitoring for resident participation, and monitoring for effectiveness. The committee is clear that simple consumption of online -, no. - : - 2015 educational content does not suffice, and proper faculty and program leadership involvement with 2-way interaction is required.6 In addition to the accreditation challenges, program leadership is also faced with a paucity of evidence. A 2013 systematic review of the use of social media in education found only 14 relevant studies, mostly small, focused on reflective writing or using course-specific content.8 The focus in many currently published articles on social media in resident education is the risks, particularly with respect to professionalism and privacy, rather than instruction on how to develop a curriculum.9 Blog posts and podcasts previously discussing social media in emergency medicine residency educational curricula are presented in Table 1. There were 7 blog posts, 4 podcasts, and 6 news network articles. The featured Residents’ Perspective describes many of the available social media modalities that program leadership could incorporate: blogs, podcasts, videos, Twitter, and Google Hangouts. The authors provide examples of specific resources to use and descriptions of how their emergency medicine residency at the University of Pennsylvania uses each modality. They also describe their use of an innovative, debate-based, flipped classroom model. Finally, the authors address their approaches in dealing with common drawbacks in social media use for resident education, including the potential for “information overload,” which was a topic covered by Thoma et al in an accompanying Residents’ Perspective.10 Annals of Emergency Medicine 1 mailto:bhayes@umem.org mailto:@PharmERToxGuy http://dx.doi.org/10.1016/j.annemergmed.2015.01.018 Table 1. Online blog posts, podcasts, and news network articles discussing social media in emergency medicine residency educational curricula. Web Site Author Title Type Country Date American Academy of Emergency Medicine Resident and Student Association (AAEM/RSA) Meaghan Mercer FOAM—This Is Not the Future of Medicine, It Is Medical Education NOW! Blog United States July 23, 2013 ALiEM Andrew Grock New AIR Series: ALiEM AIR Blog United States July 16, 2014 ALiEM Nikita Joshi Lost in Translation: What Counts as Asynchronous Learning? Blog United States January 18, 2013 ACEP Now Jeremy Faust Tweets From Emergency Medicine–Related Conferences Relay Latest Research About Social Media and Critical Care, Resuscitation Procedures, Ultrasounds, and Toxicology News network United States May 7, 2014 ACEP Now Jeremy Faust FOAMed Appeal Is Simple: Get More, Pay Nothing News network United States February 1, 2013 Emergency Medicine Cases Anton Helman Social Media & Emergency Medicine Learning Podcast Canada June 24, 2014 Emergency Medicine Cases Anton Helman Best Case Ever 25 Rob Rogers on Social Media in EM Education Podcast Canada June 18, 2014 Emergency Medicine News Paul Bufano News: How Twitter Can Save a Life News network United States April 12, 2013 Emergency Medicine News Gina Shaw Breaking News: Don’t Call It Social Media: FOAM and the Future of Medical Education News network United States February 1, 2013 Emergency Physicians Monthly Nicholas Genes PRO/CON: Why #FOAMed Is NOT Essential to EM Education News network United States April 7, 2014 Emergency Physicians Monthly Joe Lex PRO/CON: Why #FOAMed Is Essential to EM Education News network United States April 7, 2014 iTeachEM Robert Cooney How We Are Flipping EM Education Blog United States January 15, 2014 Takeokun Jason Nomura Resident Education in Ultrasound Using Simulation and Social Media AIUM14 Blog United States April 2, 2014 The Poision Review Leon Gussow Must-Read: Getting Started in Online Emergency Medicine Education and FOAMed Blog United States June 28, 2014 The Rolobot Rambles Damian Roland #FOAMed and #SMACC: Revealing the Camouflaged Curriculum Blog United Kingdom July 1, 2014 The Skeptics Guide to Emergency Medicine Ken Milne Tiny Bubbles (#FOAMed and #MedEd) Podcast Canada April 25, 2014 Ultrasound Podcast Matt Dawson Social Media and Medical Education. #FOAMED Talk From #ACEP13 Podcast United States May 14, 2014 AIR, Approved Instructional Resources. Integration of Social Media in Emergency Medicine Residency Curriculum Hayes et al ALiEM explored these challenges and opportunities in integrating social media into a residency curriculum, using social media platforms, including a Twitter conversation, Web site discussion, and live video interview withthe authors and key subject-matter experts. This article aims to curate (ie, collect, organize, and summarize) the online discussions from the global community of practice and highlight potential challenges and strategies. We also report objective Web analytics for the various online platforms used. MATERIALS AND METHODS The Annals editors selected the Residents’ Perspectives article, and 6 facilitators were chosen by ALiEM for their expertise in medical education and active presence on social media. Two are experienced bloggers on ALiEM (B.D.H., M.L.), and all have active Twitter accounts that had 2 Annals of Emergency Medicine follower numbers greater than 100 (@SKobner), 190 (@MikeGisondi), 580 (@Stella_Yiu), 5,160 (@MDaware), 5,170 (@PharmERToxGuy), and 7,640 (@M_Lin) at the discussion. The discussion was hosted by ALiEM (http:// www.aliem.com), which is a public, WordPress-based, educational blog Web site created in 2009, with currently greater than 1 million page views annually, greater than 19,000 Facebook fans, greater than 500 Googleþ followers, and greater than 500 e-mail subscribers. Promotion of the Event Promotion for the discussion included notices on the ALiEM Web site, ALiEM Facebook page, ALiEM Googleþ page, and the Annals’ and facilitators’ individual Twitter accounts, using the #ALiEMRP hashtag. It began in the days leading up to the dialogue, which started July Volume -, no. - : - 2015 http://www.aliem.com http://www.aliem.com Figure 1. Featured ALIEM blog questions. Hayes et al Integration of Social Media in Emergency Medicine Residency Curriculum 28, 2014, and then continued several times a day during the first 5 days of the discussion period. Tweets were directed toward individuals who also follow established hashtags, such as #FOAMed (“free open access medical education,” or FOAM), as well as the followers of the facilitators. Social Media Discussion Period The facilitators’ goal during the discussion, which began July 28, 2014, was to encourage sharing and reflection on 3 preselected discussion questions (Figure 1) about social Table 2. Aggregate analytic data from various social media–based di Social Media Analytic Aggregator Metric Google Analytics: a free online service to track page views and other blog metrics Page views Numb Users Numb the Number of cities Numb Ana Number of countries Numb Goo Average time on page Averag ALiEM social media post widget: a Web- based tool embedded into each blog post, which tracks engagement metrics for multiple social media platforms Number of tweets from page Numb the Number of Facebook likes Numb Number of Googleþ shares Numb ALiEM comments section Number of site comments Comm sec Average word count per blog comment (excluding citations) Symplur Analytics: a free online service to track metrics for Twitter engagement of health-related hashtags; used to track Twitter hashtag #ALiEMRP11 Number of tweets Numb Number of Twitter participants Numb #AL Twitter impressions How m app twe follo YouTube Analytics: a free online service to track YouTube video viewing statistics Length of videocast Total d ses Number of views Numb Average duration of viewing Averag view Volume -, no. - : - 2015 media in the emergency medicine residency curriculum from the perspective of learners, educators, and programs. On July 31, 2014 (day 4), a live panel discussion was hosted on Google Hangout on Air, featuring 2 of the authors of the highlighted article, Kevin Scott, MD, and Mira Mamtani, MD (University of Pennsylvania); 2 established educators, Stella Yiu, MD (University of Ottawa), and Michael Gisondi, MD (Northwestern University); and the Annals’ assistant social media editor, Seth Trueger, MD, MPH (University of Chicago). Michelle Lin, MD (University of California, San Francisco), and Scott Kobner (New York University) participated off camera by live-tweeting the event. Bryan D. Hayes, PharmD (University of Maryland), moderated the discussion. The video interview was automatically recorded and archived into ALiEM’s YouTube account (ALiEM Interactive Videos). The discussion was hosted on the ALiEM Web site, with comments moderated on the blog Web site and Twitter. Curation of Multimodal Discussion Transcripts from Twitter, the blog Web site, and the video interview discussions were analyzed for broad scussions for the first 14 days of the event. Metric Definition Count er of times the Web page containing the post was viewed 1,222 er of times individuals from different IP addresses viewed site (previously termed “unique visitors” by Google) 1,033 er of unique jurisdictions by city as registered by Google lytics 325 er of unique jurisdictions by country as registered by gle Analytics 32 e amount of time spent by a viewer on the page 4:11 minutes er of unique 140-character notifications sent directly from blog post by Twitter to raise awareness of the post 160 er of times viewers “liked” the post through Facebook 32 er of times viewers shared the post through Googleþ 6 ents made directly on the Web site in the blog comments tion 36 311 er of tweets containing the hashtag #ALiEMRP 285 er of unique Twitter participants using the hashtag iEMRP 87 any impressions or potential views of #ALiEMRP tweets ear in users’ Twitter streams, as calculated by number of ets per participant and multiplying it by the number of wers that participant has 569,403 uration of recorded Google Hangout videoconference sion 25 min 54 s er of times the YouTube video was viewed 120 e length of time the YouTube video was played in a single ing 5 min 13 s Annals of Emergency Medicine 3 Figure 2. Geographic distribution of readers who viewed the blog post during the first 14 days of discussion. Integration of Social Media in Emergency Medicine Residency Curriculum Hayes et al emerging themes during the 14-day period (July 28 to August 10, 2014) by 3 authors (B.D.H., S.K., M.L.) independently. To ensure logical organization and comprehensiveness, and to settle any disagreements between the primary analysts, the other 2 authors subsequently reviewed these themes. Participants were self-selected, and discussants were excluded from analysis only if their commentary was blatantly inappropriate to the topic of conversation, purposefully inflammatory, or otherwise inconsistent with constructive behavior. A more purposive sampling of participants was not used because the original intent of this multimodal discussion approach was not to achieve saturation in a selected population but rather to provide a novel digital space for a virtual global community of practice to openly engage in academic discourse. Web analytics were recorded for this 14-day discussion period. Viewership and engagement were measured with such tools as Google Analytics, the ALiEM social media post widget, YouTube Analytics, and Symplur. Table 2 provides descriptions for each of these tools. The number of comments and words per comment in the Web site discussion were also calculated, excluding the initial comments by the facilitators and references. 4 Annals of Emergency Medicine RESULTS Web Analytics The 14-day analytics data for the multiplatform discussion about social media in the emergency medicine residency curriculum from July 28, 2014, to August 10, 2014, are summarized in Table 2. The Google Hangout video interview, posted on July 31, 2014, was viewed 120 times during the 14-day period—rarely in its entirety— with an average viewing time of 5 minutes 13 seconds of the full duration of 25 minutes 54 seconds. Analytics data indicate that 47.62% of page viewers were using a mobile platform (telephone or tablet) to access the video. Figure 2 displays the global geographic distribution of participants who visited the blog. A full transcript of the blog Web site discussion is archived at http://www.aliem.com/ social-media-in-the-em-curriculum-annals-em-resident- perspective-article/, all tweets with the #ALiEMRP are archived on Symplur.com at aliem.link/1tKVAdD, and the Google Hangout video can be accessed at https:// www.youtube.com/watch?v¼kyeTj7SXzCI.11 Summary of the Online Discussion Five major domains were identified, which included curriculum design, pedagogy, and learning theory; digital Volume -, no. - : - 2015 http://www.aliem.com/social-media-in-the-em-curriculum-annals-em-resident-perspective-article/ http://www.aliem.com/social-media-in-the-em-curriculum-annals-em-resident-perspective-article/ http://www.aliem.com/social-media-in-the-em-curriculum-annals-em-resident-perspective-article/ http://Symplur.com https://www.youtube.com/watch?v=kyeTj7SXzCI https://www.youtube.com/watch?v=kyeTj7SXzCI https://www.youtube.com/watch?v=kyeTj7SXzCI Hayes et al Integration of Social Media in Emergency Medicine Residency Curriculum curation skills of the 21st-century emergency medicine practitioner; engagement challenges; proposed solutions; and best practice examples. Figure 3. Tweet by Christopher Doty, MD. Figure 4. Tweet by Lauren Westafer, DO. Curriculum Design, Pedagogy, and Learning Theory Even before considering the role of social media and technology in the emergency medicine residency curriculum, several blog comments and tweets supported a broader and more scholarly thought process in addressing social media integration issues into the curriculum. Many supported the notion that pedagogy, the science and theory of teaching, should drive medical education and the role of technology. Furthermore, Javier Benítez, MD, (no affiliation) advocated that “learning theories give us a framework with which to describe how learning might happen under certain circumstances. I think the use of Social Media to engage learners in the acquisition, participation, and creation of knowledge should be explored on the basis of different learning theories. Learning theories are frameworks which help to describe how learning might occur under certain circumstances.. The use of technology should be to support effective pedagogic practices which include self-regulated learning, critical thinking, information management, and more.” As an example, Jeffrey Hill, MD, (University of Cincinnati) suggested using the community of inquiry framework, which is an instructional design model based on social constructivist education theory. This might help guide the incorporation of social media into residency education. The community of inquiry framework defines a “good” learning environment as having a cognitive, teaching, and social presence. Lin, editor-in-chief of the ALiEM blog, agreed that “you need to get buy-in from the learners about theintrinsic valueof thecontent, a strongfacilitator presence, and a ‘safe’ community to grow and learn.” Teresa Chan, BEd, MD, (McMaster University) provided a slightly different perspective, advocating that “theory and technology have to evolve side by side.” As an example, she referenced the Lave and Wenger12 theory of situated learning, which posits that learning should not be the mere transmission of noncontextualized knowledge to individuals but rather a socially driven process in which contextualized, coconstructed knowledge occurs. This may explain how clinicians in communities of practices “go from peripheral participants to experts within a community. This theory likely explains much of the FOAM community, and yet it never truly anticipated the role that online, asynchronous virtual spaces might play on developing online communities. Adaptations of these Volume -, no. - : - 2015 theories, but also being open to altering them in light of new phenomenon [sic] brought forth by the technology may be a new and intriguing merger of both curricular design and implementation.” In addition to pedagogic frameworks, Christopher Doty, MD, (University of Kentucky) also advocated faculty development on andragogy, which is the art and practice of teaching adult learners (Figure 3). Digital Curation Skills of the 21st-Century Emergency Medicine Practitioner A separate discussion examined the pervasive use of educational social media among residents but soon evolved into a dialogue about the importance of critical appraisal of information. Anand Swaminathan, MD, MPH, (New York University/Bellevue) observed that “residents have already embraced much of this [social media]. Each of them has their preferred blogs and podcasts. The information has been integrated into their general learning, and I hear things on shift that I know echo things they learned from FOAM.” Although other commentators were concerned with the possibility of information overload for residents, Benítez suggested that this use of social media represents a unique opportunity to teach a valuable skill. He argued that “medical education has always been burdened with information overload as reported by Anderson, et al. in 1980. One way to alleviate information overload and decisionmaking is by training physicians on information management with the aid of technology.” Lauren Westafer, DO, (Baystate Medical Center) resonated (Figure 4). Annals of Emergency Medicine 5 Figure 6. Tweet by Jeff Riddell, MD.Figure 5. Tweet by Jeff Riddell, MD. Integration of Social Media in Emergency Medicine Residency Curriculum Hayes et al In developing residents’ critical appraisal and information management skills, Robert Cooney, MD, MMEd, (Conemaugh Memorial Medical Center) also suggested that faculty advance their own ability to curate information alongside learners in this digital age. Discussants agreed that this would provide a more robust relationship between faculty and learners, encouraging the development of the curation skills of both. Teaching critical appraisal of online resources is a new challenge for educators who may not have robust curation skills themselves. This challenge was the impetus for the creation of the ALiEM Approved Instructional Resources series, which attempts to address observations that “residencies struggle in evaluating which blog posts and podcasts are appropriate and high quality for resident education”.13 Swaminathan contended that “programs like the ALiEM Approved Instructional Resources will make some of this easier,” in reference to lists of expert-reviewed and vetted social media content published for programs to easily integrate into their curricula. Engagement Challenges Several respondents identified engagement as the central challenge to using social media in education. Learner engagement depends on both learners and educators. From the learner perspective, the consensus seemed to be that learners are naturally gravitating toward reading and listening to online content to supplement their clinical education.14 One key obstacle identified by George Miller, MD, (Louisiana State University Health Sciences Center), however, was the issue of distraction. Because social media technologies draw in both professional and personal content to central platforms, learners may become distracted during educational sessions. Engagement with social media platforms in residency education was identified more as a problematic issue for educators and other stakeholders, such as those in key residency leadership positions. Anecdotally, skeptical faculty members have highlighted the lack of formal peer review and quality control in contrast to more established educational modalities such as textbooks and journal publications. 6 Annals of Emergency Medicine Others have questioned the need for new educational tools and the potential of this new and as yet unproven educational approach. Furthermore, several noted that the lack of published outcomes data using social media in medical education contributes to the skepticism about incorporating social media into the curricula (Figure 5). The central argument illustrating a need for a culture change with more faculty buy-in was best summarized by Shannon McNamara, MD, (St. Luke’s–Roosevelt), who stated that “As educators, we need to meet our learners where they’re at.” Jeff Riddell, MD, (UCSF-Fresno) echoed this in his tweet (Figure 6). Proponents advocated that educators embrace the digital modalities that residents are already learning from to help them navigate knowledge gaps and provide individualized feedback. Online educational content should be accepted and valued by all stakeholders (learners, educators, and administration) as a complementary resource to traditional resources, rather than as nonessential, “extra, noncore material.” In addition to a more engaged educator presence, others recommended the concept of learner agency, which is giving the learners the autonomy or power to control their own education. Educators should learn to encourage learners to initiate and invest in their own educational experience in a virtual community of practice. Multiple respondents asserted that they hope this will shift education away from the current teacher-centered, passive model to one in which learners are intrinsically motivated, are centrally involved, and develop lifelong learning skills in the process. In a more learner-centered model, educators thus may need to change their approach to teaching. Lin commented, “It is incredibly hard for educators (myself included) to shift away from giving the stock lecture that I’ve given every year. There’s a growing trend toward less ‘talking at’ (lectures) and more ‘talking with’ (facilitating) learners.” Furthermore, Hill stressed that the issue of engagement can be more difficult with online teaching compared with traditional teaching, such as classroom- based lectures. “In live teaching you can adjust your teaching style on the fly if it seems you are losing them versus when you are responding to discussion board posts Volume -, no. - : - 2015 Figure 8. Blog comment by Anand Swaminathan, MD, MPH. Figure 7. Tweet by Christopher Doty, MD. Hayes et al Integration of Social Media in Emergency Medicine Residency Curriculum or on a comment thread.” The modern educator will need to evolve to incorporate these new skills in teaching, facilitation, and engagement in online environments. Ultimately, the overarching principles remain the same as when designing nondigital educational curricula. Several individuals agreed with Hill that creation of social media– based products should still keep in mind that “the ultimate goal of any initiative should be to create a robust venue for interaction between learner and instructor” for meaningful learning experiences. Doty said that learner-centered curricula will help ensure learner engagement, as long as it is remembered that social media technologies are merely operational tools (Figure 7). Proposed Solutions Multiple suggestions were put forth to address the barriers and challenges in social media adoption for emergency medicine residency education. First, Swaminathan proposed that each residency program have faculty champions, who are active in social media and medical education, in their local departments to start the culture change from within (Figure 8). Second, multiple commentators agreed there should be more widespread faculty development efforts on learning theories, especially as they relate to digital scholarship and technologies. Third, readers said that there must be recognition that general differences exist in how technologies have played a role in our lives. Different expectations and uses cascade into generational differences with respect to educational preferences. Program leadership may even consider incorporating reverse mentoring of educators by learners on educational technologies. Fourth, there was a call for developing academic incentives to help support the efforts of digital educators. Currently, online educational efforts do not receive as much academic credibility as traditional educational endeavors in terms of academic value for promotion and tenure advancement. This may contribute to problems in recruiting and engaging faculty to join this digital educational movement. Chan challenged the academic Volume -, no. - : - 2015 norm by stating, “Just as some medical schools are giving credit for editing Wikipedia perhaps there can be some sort of ‘credit’ given to those who are engaging in KT [knowledge translation] and/or review-based scholarship in the FOAM world15? I think it is imperative that our community not only train clinicians who can be informed consumers of FOAM, but also those who can be active contributors back to the community.” Real-time Web analytic data demonstrating objective measures of viewership and engagement with social media may help educators quantify and legitimize their efforts. Fifth, Riddell also championed legitimizing social media technologies from the perspective of learners, stating, “How do we engage learners? One way is to make sure we get credit for our time.. Many in our program are regular consumers of podcasts, videocasts, and blogs and we get little to no official ‘credit’ for our hours of learning.. The easier it is for us to get ‘conference credit’ for our time, the more engaged people will be.” Best Practice Examples Throughout the course of discussion, many respondents highlighted their experience with social media in emergency medicine education. Assembled in Table 3 is a summary of their innovative examples across a diversity of settings and social media platforms. LIMITATIONS As with the previous ALiEM-Annals Residents’ Perspective discussion on multiple mini-interviews, our results may be susceptible to selection bias because voluntary participants in social media discussions may represent a distinct subset with views different from those of the broader population.4 Furthermore, the views of vocal participants may be disproportionately represented over those of stakeholders who did not participate in the public discussion. Additionally, individuals in geographic regions in which access to the social media modalities used in this study is censored could not be included in this study. Socioeconomic or technologic barriers to entry in this discussion may have also introduced sampling Annals of Emergency Medicine 7 Table 3. Summary of best social media integration practices into education mentioned by contributors to the blog discussion. Contributor Residency Program Social Media Incorporation Brian Adkins, MD University of Kentucky For medical students, uses Twitter for a quiz contest that translates toward examination bonus points and a comedic prize Robert Cooney, MD, MMEd Conemaugh Memorial Medical Center Implements wikis to redesign curriculum in real time Incorporates social media content as supplement to primary literature for flipped classroom Sean Fox, MD Carolinas Medical Center Summarizes residency conference teaching points on http://www.cmcedmasters.com/core- concepts to create a bedside resource for residents Andrew Grock, MD SUNY Downstate Cocreated ALiEM AIR series to identify expert-identified blog and podcast content for residency programs Jeffrey Hill, MD University of Cincinnati Published an online orientation curriculum for flight physician course Hosts Googleþ literature discussion forum for educator-learner discussion David Marcus, MD Long Island Jewish Medical Center Cocreated popular #EMConf hashtag on Twitter, which allows emergency medicine residency programs to share conference pearls worldwide through tweets Shannon McNamara, MD Temple University Incorporates podcasts and blogs into the emergency medicine curriculum to increase learner engagement Tamara Moores, MD University of Utah Described her residency program practices: Provides iPads to all interns, which includes downloaded textbooks, RSS setup, Twitter, and medical apps Provides automatically synchronized summaries from conference through a shared residency Evernote folder Encourages asynchronous learning using social media/multimedia resources (eg, podcast) and integration into residency conference discussion Jeff Riddell, MD UCSF-Fresno Incorporates social media discussion about timely scientific developments (eg, PEITHO and MOPETT trials), such as Twitter and blogs to trigger conversation in morning report Stephen Smith, MD University of Minnesota Incorporates his blog’s content (Smith’s ECG blog) into a 32-hour ECG course Integration of Social Media in Emergency Medicine Residency Curriculum Hayes et al bias. In addition to potentially having selection bias, our study was not designed to reach saturation, and thus some relevant themes may not have emerged. Objective Web analytics have many limitations. For instance, Twitter and Symplur data capture only Tweets that include the #ALiEMRP hashtag and may understate the number of participants and the full extent of discussion. On the other hand, the “impressions” statistic represents an upper bound of potential reach. We were able to measure 285 tweets by 87 individuals, for a total of 569,403 impressions. Furthermore, the nature of this online journal club lends itself to a potentially recursive conflict of interest because the study authors, blog editors, and journal all stand to benefit from mutual collaboration. Such inherent conflicts may be initially unavoidable in this evolving new endeavor to expand a journal article’s reach and engagement through social media technologies with trainees and practicing clinicians. DISCUSSION This article presents the results of the second ALiEM- Annals collaboration using a variety of social media approaches to explore the topic of social media integration into emergency medicine residency curricula. In analyzing the themes that emerged from the audience, some echoed the existing literature and featured article and others generated novel hypotheses for further study. 8 Annals of Emergency Medicine Emergent themes included using learning theories to develop learner-centered curricula.16 Respondents stressed that curation skills are vital for both learners and educators while remembering that social media should not be used as a sole appraisal method for primary literature.5,17 A key overarching theme throughout the discussion involved the issue of learner and educator engagement. All of the themes aligned with the current literature on the challenges and best practice strategies about collaboration, cooperative learning, engagement, and learning in a social context.18 Ultimately, a major culture shift is necessary among all stakeholders, including learners, educators, the residency leadership, and academic institutions, to accept and adopt these social media–based resources as legitimate forms of education and scholarship because learners are already independently incorporating them into their medical education.19 In the incorporation of these new technological approaches into formal curricula, it is essential to focus faculty development on teaching today’s clinician-educators about pedagogy, specifically, curriculum design and learning theories. Major educational efforts, regardless of the role of technology, can usually benefit from established instructional and curricular design approaches, such as Kern’s 6-step model for curriculum design, which includes problem identification and general needs assessment, needs assessment for targeted learners, goals and objectives, educational strategies, implementation, and evaluation and feedback.16 Volume -, no. - : - 2015 http://www.cmcedmasters.com/core-concepts http://www.cmcedmasters.com/core-concepts Hayes et al Integration of Social Media in Emergency Medicine Residency Curriculum Social Media: A New Frontier in Scholarly Discussions As described previously, our methods for scholarly discussion represent a departure from traditional approaches to critical appraisal of literature by providing a free, public, global, asynchronous forum for conversations among authors, learners, experts, clinicians, and educators.4 By continuing to explore new media for academic discourse, such as Twitter, blogs, podcasts, and YouTube, we have demonstrated the continued feasibility and potential of social media as means of meaningful discussion and engagement with primary literature. Throughout our 14-day, multiplatform discussion of the Annals’ article, we were able to reach a larger audience than in our previously reported discussions.4 As shown in Table 2, although the views and reaches on the Web site alone were consistent with the engagement observed in our previous discussion, we observed a doubling of Twitter “impressions,” which is defined as the number of potential views of all tweets by unique Twitter users. We also observed an increase in Twitter participants who used the #ALiEMRP hashtag in the discussion. This could be partially confounded by a growing Twitter user base compared with that of the previous discussion, with more followers per user, thus creating more impressions. Twitter involvement grew disproportionately to engagement with the Web site, possibly because iterative social media discussions are recruiting greater numbers of viewers from the sidelines and encouraging them to actively participate in the discussion. Alternatively, the increase in active participation may be the direct result of the subject matter. Further investigation into the engagement habits of viewers of online scholarly discussions and influx of emergency physician Twitter users should be conducted to explore these possibilities. Again, the YouTube analytics for the Google Hangout video broadcast continued to demonstrate notably less success than the blog and Twitter discussions. Similar to that of the previous installment in the series, the average viewing time was 7 minutes 8 seconds out of 22 minutes 36 seconds.4 Although the online video format is both accessible and familiar, many factors could contribute to these relatively meager statistics. For instance, mobile platforms enable viewers to engage in brief discussions in various environments (such as during commutes). These environments may be more prone to interruption and less suitable for longer-form videos. Furthermore, watching a filmed discussion is a more passive learning experience than engagement through blog comments or Twitter; therefore, participants might be less responsive to this medium of discussion. Digital scholarly discourse may be more suited to the relatively shorter time frame often associated with Volume -, no. - : - 2015 blogging and microblogging media. Whether this is due to preference of medium versus the content itself is a question for future study. Even with these incomplete viewings, we believe that the video interview with the authors and experts has unique value by connecting learners with experts more than was previously possible. In addition to the blog and Twitter discussion, the video likely reached learners who otherwise would not have become familiar with the Annals article. Some critics may be concerned that learners will increasingly depend on secondary sources instead of critically reading the primary literature. Though some viewers of our discussion might return to the original Annals article, others who might not seek out primary literature were still exposed to the discussion and critical appraisal process. We hold that this form of digital scholarship we present here exceeds traditional expectations of secondary sources by teaching learners how to critically analyze and discuss primary literature. Though this approach may not be ideal, it at least promotes scholarly inquiry among learners who might not have engaged otherwise, increasing, not substituting, engagement. As the landscape of digital scholarship evolves, our broad analytic approach to study multiple social media platforms establishes the importance of our digital, asynchronous form of academic discourse in medicine. The ability to communicate with thousands of learners, educators, and clinicians—across time, geographic barriers, and resource availability—represents a powerful opportunity that goes far beyond anything possible in traditional academic settings. CONCLUSION From an educational innovation perspective, this multimodal approach provided a novel venue for asynchronous, scholarly discussions about a controversial topic published in the journal literature. It was able to attract 1,222 unique readers from 32 countries, using social media modalities that included a medical education blog, Twitter, and live video interview. Our social media–based approach showed the power of online engagement with multiple experts and a diverse audience to detect new and emerging themes as framed by existing literature. This method may allow more rapid hypothesis generation for future research and enable more accelerated knowledge translation. However, the online community demonstrated here is only a small subset of hundreds of thousands of emergency medicine practitioners worldwide, many of whom do not engage in digital scholarly practices. As the methods presented here continue to be refined, it is hoped Annals of Emergency Medicine 9 Integration of Social Media in Emergency Medicine Residency Curriculum Hayes et al that a larger proportion of emergency medicine educators and learners will become engaged in this approach to knowledge translation. The authors acknowledge the ALiEM blog discussion participants: Brian Adkins, Javier Benitez, Teresa Chan, Robert R. Cooney, Sean M. Fox, Andrew Grock, Bryan D. Hayes, PharmD, Justin Hensley, Jeffery Hill, Scott Kobner, Michelle Lin, MD, David Marcus, Shannon McNamara, Tamara Moores, Jeff Riddell, Stephen Smith, and Anand Swaminathan; the #ALiEMRP Twitter participants (and the number of their followers): @_Drjeffy (127), @_NMay (2,764), @AAIMOnline (768), @ALiEMconf (1,499), @Alsugairmd (29), @AmosShemesh (29), @Amyjwal (62), @AnnalsofEM (4,194), @AylC1989 (76), @Bonnycastle (2,315), @Choo_ek (1,530), @CHsu1012 (99), @Damian_Roland (3,064), @DaveLew_ (78), @DavidJuurlink (3,783), @DitchDocRN14 (413), @Docamyewalsh (329), @Docmaj08 (144), @Dr_JibbaJabba (4), @drmshakeeb (80), @eAJKD (1,240), @Elghulmd (65), @EM_Educator (4,735), @EMCases (1,077), @EMEducation (2,540), @EmergencyMedBMJ (17,778), @EMinFocus (144), @EMSwami (2,756), @EMTDocAndy (27), @ErikHandberg (68), @eUSMD (271), @FelixAnkel (560), @FLTDOC1 (1,513), @Galal501 (262), @HaldunAkoglu (522), @Hp_ems (5,125), @Jameslhuffman (399), @Jeff__Riddell (24), @Jeremyfaust (2,297), @Jllaidlaw (89), @JournalofGME (307), @Jvrbntz (1,724), @K_ScottMD (302), @KasiaHamptonMD (510), @Kfontes (194), @LasVegasEM (744), @Lsaldanamd (6,206), @LWestafer (2,040), @M_Lin (7,461), @MajThagafi (761), @MayoClinicEM (560), @MDaware (4,979), @MediEditor (74), @MikeGisondi (159), @Mikepaddock (41), @MiraMamtaniPenn (21), @MKChan_RCPSC (761), @MKleinMD (213), @NickJohnsonMD (334), @Njoshi8 (1,344), @Northwesternem (264), @Nxtstop1 (4,040), @Nysuri (149), @Parzivalinc (122), @PennSoMeLab (188), @PetradMD (1,011), @PharmERToxGuy (5,086), @PoppasPearls (494), @Purdy_eve (942), @SAEMonline (2,965), @Salvo_fedele (100), @Sjpoon (58), @Skobner (), @Sono_Kids (178), @SouthernGIS (178), @Stella_Yiu (564), @TChanMD (1,674), @UChicagoEM (378), @UCMorningReport (853), @UltrasoundJelly (222), @Umanamd (1,742), @UMJacksonEM (82), @UMmedschool (2,346), @UPennEM (943), @Yaniralandaver2 (87), and @Zindoctor (154); and the Google Hangout video interview participants: Michael Gisondi, Bryan D. Hayes, PharmD, Mira Mamtani, Kevin Scott, N. Seth Trueger, MD, MPH, and Stella Yiu, MD. 10 Annals of Emergency Medicine Supervising editor: Michael L. Callaham, MD Author affiliations: From the Department of Pharmacy, University of Maryland Medical Center, and the Department of Emergency Medicine, University of Maryland, Baltimore, MD (Hayes); the New York University School of Medicine, New York, NY (Kobner); the Section of Emergency Medicine, University of Chicago, Chicago, IL (Trueger); the Department of Emergency Medicine, University of Ottawa, Ottawa, Canada (Yiu); and the Department of Emergency Medicine, University of California, San Francisco, and the MedEdLIFE Research Collaborative, San Francisco, CA (Lin). Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). Dr. Trueger reports receiving a stipend and writing fees as Social Media Editor for Emergency Physicians Monthly, and receiving a stipend and writing fees as Social Media Editor for Twitter. REFERENCES 1. Radecki RP, Rezaie SR, Lin M. Annals of Emergency Medicine Journal Club. Global Emergency Medicine journal club: social media responses to the November 2013 Annals of Emergency Medicine journal club. Ann Emerg Med. 2014;63:490-494. 2. Thoma B, Rolston D, Lin M. Global emergency medicine journal club: social media responses to the March 2014 Annals of Emergency Medicine journal club on targeted temperature management. Ann Emerg Med. 2014;64:207-212. 3. Chan TM, Rosenberg H, Lin M. Global Emergency Medicine journal club: social media responses to the January 2014 online emergency medicine journalclubonsubarachnoidhemorrhage.AnnEmergMed.2014;64:88-94. 4. Joshi NK, Yarris LM, Doty CI, et al. Social media responses to the Annals of Emergency Medicine Residents’ Perspective article on multiple mini-interviews. Ann Emerg Med. 2014;64:320-325. 5. ScottKR,HsuCH,JohnsonNJ,et al. Integrationofsocialmediainemergency medicine residency curriculum. Ann Emerg Med. 2014;64:396-404. 6. Accreditation Council for Graduate Medical Education. Frequently asked questions: emergency medicine. ACGME Emergency Medicine Web site. Available at: http://www.acgme.org/acgmeweb/Portals/0/ PDFs/FAQ/112_emergency_medical_svcs_FAQs.pdf. Published November 1, 2012. Accessed October 1, 2014. 7. Reiter DA, Lakoff DJ, Trueger NS, et al. Individual interactive instruction: an innovative enhancement to resident education. Ann Emerg Med. 2013;61:110-113. 8. Cheston CC, Flickinger TE, Chisolm MS. Social media use in medical education. Acad Med. 2013;88:893-901. 9. Chauhan B, George R, Coffin J. Social media and you: what every physician needs to know. J Med Pract Manage. 2012;28:206-209. 10. ThomaB,JoshiN,TruegerNS,etal.Fivestrategiestoeffectivelyuseonline resources in emergency medicine. Ann Emerg Med. 2014;64:392-395. 11. Symplur Analytics. Symplur analytics. Healthcare Hashtag Project. Available at: http://www.symplur.com/healthcare-hashtags/aliemrp/. Accessed September 16, 2014. 12. Lave J, Wenger E. Situated Learning, Legitimate Peripheral Participation. New York: Cambridge University Press; 1991. 13. New AIR series: ALiEM approved instructional resources. Academic Life in Emergency Medicine Web site. Available at: http://www.aliem. com/new-air-series-aliem-approved-instructional-resources/. Accessed October 1, 2014. 14. Mallin M, Schlein S, Doctor S, et al. A survey of the current utilization of asynchronous education among emergency medicine residents in the United States. Acad Med. 2014;89:598-601. Volume -, no. - : - 2015 http://www.icmje.org/ http://refhub.elsevier.com/S0196-0644(15)00035-9/sref1 http://refhub.elsevier.com/S0196-0644(15)00035-9/sref1 http://refhub.elsevier.com/S0196-0644(15)00035-9/sref1 http://refhub.elsevier.com/S0196-0644(15)00035-9/sref1 http://refhub.elsevier.com/S0196-0644(15)00035-9/sref2 http://refhub.elsevier.com/S0196-0644(15)00035-9/sref2 http://refhub.elsevier.com/S0196-0644(15)00035-9/sref2 http://refhub.elsevier.com/S0196-0644(15)00035-9/sref2 http://refhub.elsevier.com/S0196-0644(15)00035-9/sref3 http://refhub.elsevier.com/S0196-0644(15)00035-9/sref3 http://refhub.elsevier.com/S0196-0644(15)00035-9/sref3 http://refhub.elsevier.com/S0196-0644(15)00035-9/sref4 http://refhub.elsevier.com/S0196-0644(15)00035-9/sref4 http://refhub.elsevier.com/S0196-0644(15)00035-9/sref4 http://refhub.elsevier.com/S0196-0644(15)00035-9/sref5 http://refhub.elsevier.com/S0196-0644(15)00035-9/sref5 http://www.acgme.org/acgmeweb/Portals/0/PDFs/FAQ/112_emergency_medical_svcs_FAQs.pdf http://www.acgme.org/acgmeweb/Portals/0/PDFs/FAQ/112_emergency_medical_svcs_FAQs.pdf http://refhub.elsevier.com/S0196-0644(15)00035-9/sref7 http://refhub.elsevier.com/S0196-0644(15)00035-9/sref7 http://refhub.elsevier.com/S0196-0644(15)00035-9/sref7 http://refhub.elsevier.com/S0196-0644(15)00035-9/sref8 http://refhub.elsevier.com/S0196-0644(15)00035-9/sref8 http://refhub.elsevier.com/S0196-0644(15)00035-9/sref9 http://refhub.elsevier.com/S0196-0644(15)00035-9/sref9 http://refhub.elsevier.com/S0196-0644(15)00035-9/sref10 http://refhub.elsevier.com/S0196-0644(15)00035-9/sref10 http://www.symplur.com/healthcare-hashtags/aliemrp/ http://refhub.elsevier.com/S0196-0644(15)00035-9/sref12 http://refhub.elsevier.com/S0196-0644(15)00035-9/sref12 http://www.aliem.com/new-air-series-aliem-approved-instructional-resources/ http://www.aliem.com/new-air-series-aliem-approved-instructional-resources/ http://refhub.elsevier.com/S0196-0644(15)00035-9/sref13 http://refhub.elsevier.com/S0196-0644(15)00035-9/sref13 http://refhub.elsevier.com/S0196-0644(15)00035-9/sref13 Hayes et al Integration of Social Media in Emergency Medicine Residency Curriculum 15. UCSF first US medical school to offer credit for Wikipedia articles. University of California San Francisco Web site. Available at: http:// www.ucsf.edu/news/2013/09/109201/ucsf-first-us-medical-school- offer-credit-wikipedia-articles. Accessed September 19, 2014. 16. Kern DE, Thomas PA, Hughes MT. Curriculum Development for Medical Education: A Six Step Approach. 2nd ed. Baltimore, MD: Johns Hopkins University Press; 2009. Volume -, no. - : - 2015 17. Nickson CP, Cadogan MD. Free Open Access Medical education (FOAM) for the emergency physician. Emerg Med Australas. 2014;26:76-83. 18. Van der Vleuten CPM, Driessen EW. What would happen to education if we take education evidence seriously? Perspect Med Educ. 2014;3:222-232. 19. Mehta NB, Hull AL, Young JB, et al. Just imagine: new paradigms for medical education. Acad Med. 2013;88:1418-1423. Annals of Emergency Medicine 11 http://www.ucsf.edu/news/2013/09/109201/ucsf-first-us-medical-school-offer-credit-wikipedia-articles http://www.ucsf.edu/news/2013/09/109201/ucsf-first-us-medical-school-offer-credit-wikipedia-articles http://www.ucsf.edu/news/2013/09/109201/ucsf-first-us-medical-school-offer-credit-wikipedia-articles http://refhub.elsevier.com/S0196-0644(15)00035-9/sref16 http://refhub.elsevier.com/S0196-0644(15)00035-9/sref16 http://refhub.elsevier.com/S0196-0644(15)00035-9/sref16 http://refhub.elsevier.com/S0196-0644(15)00035-9/sref14 http://refhub.elsevier.com/S0196-0644(15)00035-9/sref14 http://refhub.elsevier.com/S0196-0644(15)00035-9/sref15 http://refhub.elsevier.com/S0196-0644(15)00035-9/sref15 http://refhub.elsevier.com/S0196-0644(15)00035-9/sref15 http://refhub.elsevier.com/S0196-0644(15)00035-9/sref16a http://refhub.elsevier.com/S0196-0644(15)00035-9/sref16a Social Media in the Emergency Medicine Residency Curriculum: Social Media Responses to the Residents’ Perspective Article Introduction Materials and Methods Promotion of the Event Social Media Discussion Period Curation of Multimodal Discussion Results Web Analytics Summary of the Online Discussion Curriculum Design, Pedagogy, and Learning Theory Digital Curation Skills of the 21st-Century Emergency Medicine Practitioner Engagement Challenges Proposed Solutions Best Practice Examples Limitations Discussion Social Media: A New Frontier in Scholarly Discussions Conclusion References