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Decoding Twitter: Understanding the History, Instruments, and Techniques for Success

Logghe, Heather J. MD; Boeck, Marissa A. MD, MPH; Atallah, Sam B. MD

doi: 10.1097/SLA.0000000000001824
Surgical Perspectives

*University of North Carolina, Chapel Hill

New York Presbyterian Hospital—Columbia, New York

Florida Hospital, Orlando.

Reprints: Heather J. Logghe, MD, Department of Surgery, University of North Carolina, 4001 Burnett-Womack Building CB #7050, Chapel Hill, NC 27599-7050. E-mail:

Disclosure: The authors report no conflicts of interest.

How do we, as surgeons, communicate with one another, share ideas, and advance our profession? Traditionally, this has been accomplished through peer-reviewed publications and society meetings. A significant limitation of these methods is that they do not allow for timely and interactive dialogue. They also restrict participation to those whose writing passes the editorial process or who can afford conference expenses. Social media overcomes these barriers of time delay and restrictive participation. Its benefits should be underscored and in today's era, some even argue, “social media is a necessary component of the practice of surgery.”1 Yet for surgeons who are social media-naive, the rationale to embrace its use may not be readily apparent. Social media is a tool, which must be learned. Just as in surgery, it is essential to understand its history and instrumentation, so that one can master the art.

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In the 1990s, the World Wide Web transformed medical, surgical, and continuing education, allowing instant access to millions of published resources, and the ability to query based on key words and search terms. A decade later, Web 2.0 moved beyond static web pages, emphasizing interactive, user-generated content such as blogs, wikis, and social media like YouTube, Facebook, and Twitter. Web 2.0 sites encourage users to interact, collaborate, and create dialogue within a virtual community. This became a powerful tool for disseminating research, developments, and commentary. Indeed Eysenbach2 demonstrated that tweets can “predict highly cited articles within the first 3 days of article publication.” Today, most academic journals have Twitter accounts to publicize their articles (Table 1). Many offer data from Altmetrics, which include downloads and social media mentions tabulated in real time.3 Thus, social media has evolved into an important strategy and metric to gauge the relevance of a publication before citations accrue.

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Given the ubiquity of Facebook (used by 71% of online Americans), many people unknowingly limit themselves by assuming all social media platforms are similar.4 However, the functionality and applications of each are quite diverse and inherently designed for different applications. For most, Facebook is used in the context of relative privacy, as it allows for information sharing among an established network of personal contacts, that is, “friends.” In stark contrast, Twitter is not limited to a preapproved network (with the exception of “private” Twitter accounts). Knowing every post is public can make one inherently mindful to be professional at all times. In fact, of the 5000 physician tweets analyzed by Chretien et al,5 only 3% contained unprofessional material. Although newer social media platforms have been introduced, many of their purported strengths are ill fitted to the unique needs of surgeons. For example, Health Insurance Portability and Accountability Act (HIPAA) negates the utility of platforms emphasizing photos and videography, and the transient nature of apps such as Snapchat makes them less useful to scientists.

Tweets are brief messages limited to 140 characters. Links, photos, or images may be added to convey further information. The content of your Twitter “stream” is populated with tweets from those you choose to follow. Your profile and the content you choose to share influences who decides to follow you, be it surgeons, other medical professionals, patients, family, or friends. Irrespective of who is following whom, any tweet can be retweeted or searched, with the potential to be seen by anyone. Users interact with one another by retweeting, quoting tweets, liking, or replying to tweets. Conversations can occur either in real time or asynchronously, among few or many. This asynchronicity is ideal for busy surgical schedules and international collaborations across time zones. The complex interplay between tweets and follower populations results in an open forum for learning, sharing, and engagement catered to the user's preferences. Hashtags placed before key words or phrases (without spaces) allow a tweet to be more readily found within a Twitter search (Table 2, Figs. 1 and 2). To measure the impact of hashtags, “total impressions” are often used, calculated by the number of Twitter streams the hashtag appears in.

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Just as the astute surgeon knows operations cannot be performed without risking complications, tweeting as a surgeon requires an awareness of the potential pitfalls. In addition to being public, tweets are time stamped and, if desired, the user's location can be noted. Given their increased scrutiny, health care professionals must be particularly mindful of when and where social media communications are posted. A 2016 survey suggests concerns of unsolicited patient interactions are likely unfounded, as 97% of respondents were unwilling to discuss health goals on social media.6 There also exists the fear that one poorly phrased message can cause severe side effects. Although these events are often sensationalized in the media, their actual incidence has not been studied and likely represents a small proportion of those posting on social media. Yet their existence reinforces the need to consider every message posted. Similar to how one anticipates and scrutinizes the consequences of each intraoperative move, so too should surgeons conduct themselves on social media.

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Once one decides to participate, it is best to do so with a real photo and complete profile. The first time you log in, upload a profile picture, share your geographic location, and, at a minimum, state you are a surgeon in your biography. You are going to be tweeting professionally; a well-rounded profile ascribes you credit for your contributions.

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By following leaders in your field and those who tweet high-yield content, you can read articles they find pertinent and interesting, and gain insight from their commentary. You can also learn from conferences from afar by following their designated hashtag (Fig. 2). However, it is important to read with a critical eye. Although tweets are not peer-reviewed, many contain links with further data and references to support the statements being made. If you question a shared comment or “fact,” simply reply to the tweet and ask for clarification and citation.

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Network. Lead. Connect

Take advantage of Twitter's global network by following liberally. Do not hesitate to interact. If you like or agree with a tweet, retweet it. Become a thought leader through content curation—share with others what fascinates you. If you find an article interesting or inspiring, chances are your followers will as well. Tweet to congratulate, compliment, and showcase others’ work.

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Join a Live Conversation

A tweet chat is a live Twitter discussion filtered by a hashtag and moderated at a set time on a specific topic. Twitter journal clubs are also conducted in a chat format (usually over the course of a few days). See Table 2 for popular health care tweet chats and journal clubs. This format is a powerful tool for learning and networking.7

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Educate Patients

Patients rely on digital media for education on health and disease.8 Although tweets are not HIPAA-compliant and Twitter should never be used for individualized advice or direct patient-surgeon communication, the opportunity for surgeons to educate patients via Twitter is unprecedented. Thus surgeons have taken to Twitter to provide accurate and timely information on surgical pathologies and procedures.

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Mentor and Be Mentored

The ease with which digital natives navigate social media provides a rare opportunity for “reverse mentoring” in which those traditionally in the role of “mentee”—medical students, residents, and junior faculty—are able to guide those senior to them. Furthermore Twitter's 140-character limit and level playing field irrespective of rank and degree enables all voices to be heard. This can lessen perceived hierarchical communication barriers, making experts in the field more approachable to those junior to them.

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An illustrative example of the power of social media to unite surgeons is the #ILookLikeASurgeon movement (Figs. 3 and 4). This hashtag, while initially a viral phenomenon celebrating women and diversity in surgery, rapidly evolved to an established global community with a strong message: today's surgeon might be an athlete, a parent, a leader, a person of any ethnicity, and, yes, a woman as well.9 Empowered to shape the portrayal of the profession, the hashtag drew in surgeons previously inactive on social media. The tweeted images inspired blog posts, videos, and commentary by patients, premedical students, practicing surgeons, and the lay press alike. To date there have been over 65,000 tweets containing the #ILookLikeASurgeon hashtag by over 12,000 participants, making nearly 225 million impressions worldwide.10

For many, participation in the #ILookLikeASurgeon conversation was their first social media “operation;” the first time they realized the value of Twitter-based communication. #ILookLikeASurgeon sparked a disruptive dialogue within the surgical community, and realized the potential of surgeons to unite globally to advance the profession. The impact of social media on the evolution of surgical discourse lies not within the technology, but rather within us as we generate the content and govern its quality. Ultimately, it is the surgeon-user who must find the facility to decode network media so as to learn its tools and techniques, and, in turn, apply them to perfect the art of the operation.

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We would like to thank Thomas Varghese Jr., MD of the University of Utah; Niraj Gusani, MD of Penn State Hershey: Josh Ng-Kamstra, MD, MPH of the University of Toronto; Andrew Ibrahim, MD of University Hospitals of Cleveland; and Karan Chhabra of Rutgers Robert Wood Johnson Medical School for their review and suggestions for this manuscript.

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1. Steele SR, Arshad S, Bush R, et al. Social media is a necessary component of surgery practice. Surgery 2015; 158:857–862.
2. Eysenbach G. Can tweets predict citations? Metrics of social impact based on Twitter and correlation with traditional metrics of scientific impact. J Med Internet Res 2011; 13:e123.
3. About Altmetrics on The JAMA Network. Available at: Accessed May 2, 2016.
4. Pew Research Center. Social Networking Fact Sheet. Available at: Published 2013. Accessed May 2, 2016.
5. Chretien KC, Azar J, Kind T. Physicians on Twitter. JAMA 2011; 305:566–568.
6. Jenssen BP, Mitra N, Shah A, et al. Using digital technology to engage and communicate with patients: a survey of patient attitudes. J Gen Intern Med 2016; 31:85–92.
7. Roberts MJ, Perera M, Lawrentschuk N, et al. Globalization of continuing professional development by journal clubs via microblogging: a systematic review. J Med Internet Res 2015; 17:e103.
8. Pew Research Center. Health Fact Sheet. Available at: Published 2013. Accessed May 2, 2016.
9. Hughes KA. #ILookLikeASurgeon goes viral: How it happened. Bull Am Coll Surg. 2015; 100(11):10-16. Available at: Accessed May 2, 2016.
10. #ILookLikeASurgeon—Healthcare Social Media Analytics and Transcripts. Available at: Accessed May 2, 2016.
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