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Can healthcare professionals use social media to enhance delivery of medical education and deliver the same educational content to a larger, more diverse, and more engaged audience? Ludwig H. Lin, MD, was joined by Nicolas M. Mark, MD, at the 2023 Critical Care Congress to discuss the role of social media in medical education. Dr. Mark is a board-certified intensivist at Swedish Medical Center First Hill in Seattle, Washington, USA.
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Dr. Lin: Hello and welcome to the 2023 Critical Care Congress edition of the Society of Critical Care Medicine podcast series. I’m your host, Dr. Ludwig Lin. Today, I’m joined by Dr. Nick Mark to discuss novel ICU education. Dr. Mark is an intensivist at Swedish Medical Center in Seattle, Washington. He is interested in novel medical education via social media and medical infographics. You can find out more about his work via his website, www.icuonepager.com. Welcome, Dr. Mark. Thank you so much for being here.
Dr. Mark: It’s a pleasure to be here.
Dr. Lin: Before we start, do you have any disclosures to report?
Dr. Mark: I don’t.
Dr. Lin: Okay. Well, this is such a timely topic. I think critical care and infectious diseases in the last few years have been buffeted by things like lack of information to the public or actually misinformation. I think the power of social media has never been more obvious, and this is good for us to be discussing. How did you come up with the idea of establishing these OnePager ICU guides?
Dr. Mark: That actually has a lot to do with the pandemic. At the very beginning of the pandemic, when there were just a handful of cases in the United States, most of them were in the Seattle area, which is where I work.
Dr. Lin: That’s right.
Dr. Mark: I was one of the first intensivists to see these patients. This was back in the early days of COVID when there were dozens of publications on this topic. It was literally possible to read everything that was known about COVID, which wasn’t that much. My learning style has always been to read and then take notes and then consolidate those notes, ideally down to less and less. What I ended up with after a week in the unit was one page of notes about COVID. Molecular biology, epidemiology, clinical presentation, what we knew about management at the time.
I took a photo of my notes, shared it on social media, and it went viral. Lots of people were interested in this, which got me thinking, “Okay, well, maybe other people want this.” So I cleaned it up a little bit. I made it not handwritten and shared that, and that went even more viral. People were inundating me with like, “Can you send us this?” So I made a website to share it because I thought, “Okay, this will be easier. I can just direct them here.” And ICU OnePager was born. Since then, I’ve made dozens of them on different critical care topics. Same sort of approach, start with a lot and whittle it down to just the bare essentials. Try to use pictures wherever possible.
Dr. Lin: Have you always been entrepreneurial? Was this more of a happenstance thing? Were you intentional about it?
Dr. Mark: It was very happenstance. I have been entrepreneurial before, but this was not that. This was just, “Oh, wow, people like this. Okay, well, if you like this, here’s my approach to ventilators. Oh, you like that? Here’s my approach to blood gases.” A lot of these were things that, when I was in academia, I had chalk talks and I would often prepare for them by writing out what the board was going to look like at the end as a one-page summary. I realized, “Okay, I can turn these into those one-pagers that people are after.” So I just started making them. Now, there’s 50 or 60 of them, still making more. Whenever I need to learn about a topic, then my followers get to learn about it too.
Dr. Lin: Very cool. I’m sure the people out there thank you. Do you design them yourself? Do you gather opinions about what to do?
Dr. Mark: I do all the work myself. All the artwork is mine, for good and for bad. The content is mine. Sometimes I’ll collaborate with people. If somebody is really passionate about a particular topic, it’s great to work together, especially when somebody’s knowledge and interest are different than mine. A friend of mine and I collaborated on a one-pager on hemophagocytic lymphohistiocytosis, HLH. My friend’s a rheumatologist, so it’s a good collaboration. Especially for diseases like that, it’s good to have different specialties collaborating together.
Dr. Lin: Yes. HLH is basically something that sends fear through a lot of us, in terms of the setting.
Dr. Mark: People’s reaction is either “Huh?” or “Oh, no.”
Dr. Lin: Yeah, that’s vast. That sounds great. Do you know who your audience is? Is it all intensive care people?
Dr. Mark: I have a mailing list. I’d asked people this question. It’s a pretty diverse audience. Most people work in an ICU or adjacent to an ICU. But the roles and titles are pretty different. There’s everything from medical students, residents, fellows, attendings. There are also a lot of critical care nurses, respiratory therapists. Then there are some people who don’t maybe work physically in an ICU but take care of critically ill patients, people who work in the ED, people who work in a surgical setting, people who work in medical wards. So it’s a pretty big audience. I would say probably the biggest consumers are either junior attendings who are using them to teach or residents and fellows who are using them to learn.
Dr. Lin: Perfect. I think this is a great tool for them. I wanted to ask you about your future goals for this. Do you have a plan? Do you have a mission?
Dr. Mark: One thing that initially I was thinking, maybe eventually I’ll turn these into a book or something. Then I thought a little bit more about it, and one of the things that I was very intentional about from the beginning was making it all open source because I realized if I had my stuff out there, people were going to steal it. If they liked an image, they were just going to take it as their own. So why not make that easier instead of harder and just make it with a reuse license, so people are allowed to take it, they’re allowed to refactor it, they’re allowed to reuse it, they just have to do two things: They have to acknowledge where they got it from, give me that little props and, more importantly, they have to share what they make. They can’t sequester it away.
That’s, I think, the beauty of open source, and something we ought to have more of in medical education. It’s always a shame when somebody makes an awesome explanation of something but it’s siloed within their teaching file or their institution. One of the cool things about this is people have taken my one-pagers and translated them. If you go on the site, there are probably about seven or eight languages represented. Not all of the one-pagers are translated, but it’s very cool to know that people are using my stuff, even in countries where I don’t speak the language.
Dr. Lin: Yes, that’s so inspiring. That’s great. You should work with the Global Health people. That’d be great.
Dr. Mark: It’s interesting too because I’m actually curious what is applicable and what isn’t. I’d love to learn more about that because everything on my site is really from the perspective of a U.S.-based intensivist. I imagine that there are people who are scratching their heads, and they’re like, “We don’t have that drug, or we do it this way.”
Dr. Lin: That sounds like a pretty good direction. I’m going to ask you a broader question. Which social media platform do you feel is the best for medical information? Which ones do you prefer?
Dr. Mark: Yeah. Maybe instead of “best,” we should say “least worst.” I think there are some that are not good, like Facebook, I don’t think is very good for this. The two that I think have the most promise, YouTube is great for video content, especially longer-form videos, and Twitter is good for the discussion debate. That was one of the core topics that I hit on today in my lecture, which is that one of the things that is really valuable that social media lets us do is to engage in professional debate with each other.
I feel like when I was a resident, I occasionally got to see an attending persuade another attending of something or react to changing literature that changes their practice, but that was rare. One thing I get to see on Twitter is some new paper gets published and somebody says, “Oh, that really will change my practice.” Or somebody disagrees, and then there’s a discussion among professionals about that. I think that’s incredibly valuable. As a trainee, I wish I’d gotten to see more of that. As an attending, it’s great to participate in that and learn from it.
Dr. Lin: It’s kind of like mini-grand rounds all the time.
Dr. Mark: Exactly. And I think the key is that it has to be a professional debate.
Dr. Lin: Not name-calling.
Dr. Mark: Not name-calling. In general, the rule that I use is that if I see somebody whose name is first name, last name, and then DO, MD, RN, you know, somebody who’s clear about who they are and what they do, I always try to assume good intentions from them that if they’re disagreeing with me, they’re doing it from a good place. I think that’s a good guiding principle.
Dr. Lin: Got it. Okay, the next question I want to ask you about is, we are discussing really the power and the reach of medical education via social media. You personally have a lot of influence in that. Has that changed the way you think about your role in medical education? Do you see your mission the same now as before you started this? Do you still design toward the same audience or the same clients, or do you feel like that’s changed?
Dr. Mark: I’ve tried not to change it. I do think, as the OnePager site has gotten more popular and as my personal number of followers has increased, it’s definitely made me try to be really careful about stuff, make sure to double- and triple-check what I say because I know a lot of people are looking at it and relying on it.
One of the strengths, I think, of social media-enhanced medical education is when you write a paper and you publish it and it gets through peer review, it’s just out there. Perfect, it’s published. Less than 0.1% of published manuscripts ever receive a correction. It doesn’t mean that less than 0.1% of published manuscripts don’t contain an error. It just means that they don’t get corrected, because that process of changing them is so onerous. One of the strengths of social media is you can put something out there and then somebody can tell you, your large audience can tell you where you made mistakes or tell you what you missed. Then you can iterate on it and improve it. And that’s what I love.
I think one of my one-pagers is about diuresis in the ICU. The nephrologists are like, “Oh man.” They are detail-oriented and they found so many things, and bless them because it made it so much better, right? They pointed out lots of details. I think that one-pager is up to like version 1.9 or something. Every time they brought something up, I updated it. I think that’s one of the unique things about med ed over social media. You have this huge audience of people who are giving you feedback in real time. You can iterate and improve. So even though there may not be a pre-peer review step, there’s this massive post-publication peer review. I think it arrives at better content ultimately, or at least it can.
Dr. Lin: Yes. I love that. I feel like you should have a stamp that says nephrologist-approved. That’d be great. Seriously though, I feel like this is a really nice segue to one of the follow-up questions I wanted to ask you. There are a lot of people who are in social media in an educator role. How do we, as a profession, make sure that the information that’s coming out through those sources is validated?
Dr. Mark: A couple of things. I think one thing that medical training teaches us is to be skeptical. The joke about journal clubs is that a new paper gets presented, and there’s only two reactions. One is, “I knew that already” and the other is, “I don’t believe it.” But I think, seriously, we’re all very good at reading the literature and appraising what are the strengths and weaknesses of this, you know, “Do I buy this?” Papers, methods, applicability, etc. That’s something that the lay public doesn’t have. Watching us do it, I think, is very valuable to them. People who don’t read medical publications don’t know the difference between a good one and a bad one. I think that’s something we can share with people. I think it’s also something that hopefully we’re careful about. Hopefully, as a profession, we’re not just sharing some random preprints, you know, conspiracy theory thing. We’re actually kind of vetting what we share.
I think the other thing too is that there is that step of debate and discussion. I remember at the beginning of the pandemic, that Surgisphere paper came out. There was that paper where this company claimed to have this amazing database and they were doing all these studies based on it. Very quickly, it turned out to be a total hoax. People around the world just jumped into their Table 1, identified every flaw. “Mathematically, this doesn’t add up with this. Statistically, this doesn’t make sense.” But also just practical stuff. You claim that you have 3000 ICU patients from Africa; which hospitals? I think the ability for this massive group of people to identify the flaws led to that paper getting retracted and that company just disappeared. That’s something that, had it been in the form of letters to the editor, would have taken years or probably never happened.
Dr. Lin: That’s true. Okay. I might be older and more cynical, so I’m going to ask you a follow-up to that. Your paradigm about a scientific research dialogue really depends on people having the patience to sit through an entire series of exchanges. Can we really assume that everybody’s going to do that?
Dr. Mark: I don’t think everybody has to. I think some people have to. I think, as long as there’s a critical mass of us on social media engaging with each other, I think that works. I think that the places where it comes undone is if there isn’t enough discussion or if the discussion isn’t professional, right? If the discussion is people shouting at each other, that doesn’t achieve the same end. That’s a back-and-forth, but it doesn’t doesn’t get you to the destination you want.
Dr. Lin: I feel like one of the really cool factoids I learned from your talk is that amplifying your message and reach through social media actually helps one’s professional information dissemination. I think you had said that papers that are cited via social media get cited like four times as much.
Dr. Mark: Right. There was a randomized study done by a collection of thoracic surgery journals, where they basically randomized papers to either be tweeted or not tweeted to their roughly 50,000 followers. They found that the papers that they tweeted out had higher Altimetrics scores and four times more citations. If you put this in context, we spend a lot of time worrying, “Am I going to publish in this journal or this slightly incrementally worse journal?” But actually, we probably should be much more worried about, “Is this thing that I published going to get amplified?” Because that difference is huge by comparison.
Dr. Lin: Yes. I think that was something very interesting to learn about. Also, the other thing is, What is the end goal? If the end goal is to have a lot of people get this information.
Dr. Mark: Right. If your goal is, as a researcher, to share what you’ve learned with other people so they can build on it, I think social media is a good way to amplify it. If your goal is you’ve learned something about clinical practice, either from research or from collecting primary sources, and you share that with others and that changes their practice, I think that’s great. Then, I think there’s this other larger objective, which is education, whether you’re educating medical learners or the lay public. I think, in the last couple of years, we’ve seen there’s a large unmet need for laypersons to learn medical things.
Dr. Lin: For sure. I would like to explore that a lot more, but I wanted to have one last question for you about the professional aspects of doing medical education via social media. In academia, there’s a lot of work that gets done to nurture one’s career to get the next promotion. The universities that I’ve been associated with have these academic portfolios where you put in your body of work. What I wanted to ask you is, do you have any thoughts about how a clinician educator or researcher can actually gain value with their own academic system by having a broader social media presence and amplifying their work that way? How does one do that? And how does one count that?
Dr. Mark: Those are great questions. How does one do that? I think the best thing that you can do is engage and amplify other people’s work related to yours, and they’ll do the same for you. Building that network of the people who you learn from and, hopefully, they echo that to you. Then when you share work that you’ve done, I think they’ll amplify it. I think that’s the best way for somebody starting out to build this network. Follow the people who you want to follow. Don’t hate-follow people. Amplify the people who you like following and, hopefully, they’ll do the same.
To the second question, which I think is a really important question, right? You spend time tweeting about your work. Does that count? Tweeting about your work might mean taking a large, complex topic and turning it into a series of tweets with graphics. It might really be an involved piece of work to concisely explain what you’ve done or what others have done. I think there’s this important question of, Is MedEd scholarship using social media scholarship? Will this be used by promotion and tenure committees to decide whether somebody should get promoted, for example? I think there’s a challenge because obviously there’s a big difference between somebody live vlogging what they eat and somebody who’s sharing really valuable, thoughtful medical information, right? You need a test for that.
This one group created a consensus definition of scholarship where they basically advocate a four-part test of whether the work meets criteria. First, is it original? Second, does it advance health professions’ education? Third, it has to be disseminated and archived. And fourth, it has to provide the community with the ability to comment. That’s a really interesting one to me because if you think about it, if you write a blog and you’re summarizing medical evidence and you’re teaching people stuff, that’s just as educational to learners as a review article, right? It’s original, it advances their knowledge, it’s disseminated. But you really have to give your audience the ability to comment, in order for it to meet this definition. I think that’s really telling, right? It has to be something where people can give you feedback in order to meet this digital scholarship definition. I really like that because I think it means that it’s kind of the same process as peer review, but writ large; more people are able to participate in it.
Dr. Lin: I like that. I do feel like a lot of work will need to get done in this to really get people the credit that they do deserve, actually.
Dr. Mark: I think it’s a field that’s changing quickly. I saw two papers on this when I was researching this talk. One found that 80% of promotion and tenure guidelines include terms that have to do with digital scholarship. Eighty percent, that sounds really great, right? That’s impressive. But then, there was another group that actually read the guidelines, and they found that it was actually only 8% that said that digital scholarship counted toward promotion. Something like a third said they included the terms but they said it doesn’t count for promotion. And the rest, it was ambiguous. I think this is something where there’s a lot of heterogeneity between institutions, whether this counts or not. I think there are a lot of questions, like how does it count?
Imagine you make a video on YouTube that educates people about vaccines, and a million people watch it. You’ve done like huge good for the world, right? That might count for the same or less than a case report, right? We need a system to quantify this and that system doesn’t exist yet. I think, as a start, we should recognize that high-quality digital scholarship is scholarship. But then, how do we compare those apples to other oranges? I have no idea.
Dr. Lin: Right. It probably can’t be something like counting the number of followers or counting the number of likes.
Dr. Mark: Yeah. I think we have this problem in general where the things that are easy to count are often the things that shouldn’t count. Likes, retweets, followers, those are not the right metrics. I think maybe a better metric is colleagues who say, “This is great. I learned something. I’m going to do this from now on.” One of those is probably worth hundreds of likes or thousands of likes.
Dr. Lin: Yeah. Definitely a work in progress. It almost sounds like we will need some type of an evaluation process or something, but we’ll see. Let’s talk about educating the general public versus medical professionals. Obviously, everybody has access to social media, I mean, that’s sort of the definition of social media. How do you we maintain the conscience of our profession and have as a priority education versus misinformation or disinformation or even monetization or advertisement?
Dr. Mark: There’s a lot there to talk about, which is great. I think it’s very easy to look at our job narrowly as: I go to work, I take care of critically ill people, I sign them out, I go home, and that’s my job. That is what I get paid to do, right? But I think, as a physician, as a healthcare professional, we have bigger responsibilities than just our job. One of those responsibilities is to advocate for the community.
There’s this great quote by Virchow, something along the lines of, The physician is the natural advocate for the poor and underserved. I think the fact that we see people from all different circumstances across all different strata of society, we’re able to comment on that. We’re also very aware of the problems faced by people across society. Our perspective is valuable and, as physicians, we should share it, and social media is a logical place for us to share it.
I think we also have credibility as physicians. Teachers and doctors and nurses are the three most trusted professions there are. We should take advantage of that to educate the public where we can. If there’s something that people are confused about, if there’s a lot of misinformation about a specific topic, our voices can make that conversation better hopefully.
Dr. Lin: I completely agree. How do we deal with those of us who have other more self-serving goals?
Dr. Mark: Right. I think it’s important to define the difference between misinformation and disinformation. Misinformation is false information. Disinformation is knowingly false information. I think that’s a really important difference because we’ve all been wrong before, right? I mean, you attend this conference and there are things that I would have told you were true two days ago, but then a new study like the Clovers trial comes out and, “Okay, maybe fluid management isn’t as crucial, right?” We’ve been wrong about stuff, we will be wrong about stuff again. But there’s a big difference between the literature changing over time and things that are deliberately false.
When people make claims that they know or ought to know are false, we as a professional society, right, SCCM and physicians in general and licensing boards ought to look at that more seriously, I think especially when there’s an ulterior profit motive. When somebody is making lots of money by selling supplements, for example, or when somebody is cashing in in other ways, I think, as a professional society, we have to say what is acceptable and what isn’t. It’s okay to be wrong, especially if you say, “Hey, I was wrong.” It’s not okay to say things that you really ought to know are not true.
Dr. Lin: Yes, I completely agree with you, and I feel like people who sort of co-opt a certain hot topic and almost leverage their subsequent fame to profit themselves in some fashion, it’s not what I went into medicine to do, for example.
Dr. Mark: Right. And I think one of the interesting things about this, there was a paper published a few days ago in PNAS that looked at, Why do people spread misinformation? Most people who spread misinformation just spread it because they want to get clicks, they want to get the attention, they want to get the dopamine. They share something, and people engage with it, and they get that as positive feedback. They, in many cases, don’t know that it’s not true. They just know that it’s getting them attention.
Dr. Lin: Are we talking physicians?
Dr. Mark: In this study, it was laypersons. But I think probably with physicians, there’s a similar sort of dopamine reward for attention. I think that people can kind of go astray when they’re getting a lot of attention for expressing what they would call controversial views, what other people might call just factually incorrect views. People seeking attention can cause a lot of harm, right? And they can get themselves into a lot of trouble, and we’ve seen examples of both.
Dr. Lin: Hear, hear! This is a call to arms for the rest of us. How do we empower our colleagues in critical care to be allies in educating people and also in making sure that it’s the truth that is out there?
Dr. Mark: A couple of things to that. Number one, I think if you work in critical care, you probably teach a couple of things, whether it’s something you tell everybody on rounds, whether it’s something you teach in a lecture hall, it doesn’t really matter. There are valuable things that you can share. I think social media is a good way to share those things. I would encourage people to share what they know, first of all.
Second of all, I think there’s a couple of ways that we can all contribute to solving this problem of misinformation on social media. I like to conceptualize this as a pyramid. The base of the pyramid is passively amplifying the voices of others. For example, you don’t want to talk about this thing, but somebody else has done a really good job of explaining why vaccines are safe. You can amplify them. You don’t have to create content yourself. You can just reinforce the content of people you consider trustworthy as a physician.
On top of that base, the middle of the pyramid is, you can share educational content. You can say, “I don’t want to touch misinformation. I don’t want to get into that mosh pit. But I will share this thing that I think is reputable. There was a great paper that was just published that shows something, and I’m going to give you my reactions to it and share it.” I think that adds a lot of value to the discussion because, as a healthcare professional, your perspective is valuable.
Then, at the apex of the pyramid, you have this actively opposing misinformation. When you see something out there, you can debunk it. When you see somebody whose motives are questionable, profiting from spreading misinformation, you can point that out. Nobody has to feel obligated to be in that tip of the pyramid, or anywhere in the pyramid, frankly. But know that, as a physician, as a healthcare professional, your voice is valuable and people will listen to you. Your contribution can be small, it can be, “I just amplify others.” It can be intermediate, “I put out things that I think are true to educate,” or it can be actively calling stuff false when it’s false.
Dr. Lin: But don’t sit it out. Don’t sit it out. Pick one of those.
Dr. Mark: Don’t sit it out. Actually, one other thing to say too is that many of our colleagues are not on Twitter or other social media because they don’t want to get embroiled in this stuff. To them, I would say, consider maybe joining anonymously or pseudonymously. You don’t have to put your name there, but you can still get the good stuff. You can still follow people who you think are good educators and learn from them. You can still amplify them. You don’t have to be first name, last name, MD, this is where I work, send hate mail here. You can protect yourself from that and still get some of the rewards.
Dr. Lin: And do the world some good. I really, really like that as our concluding thought for this. There’s so much more we can talk about and we should talk about it, but we just have to save that for a future discussion.
Dr. Mark: Another time.
Dr. Lin: Exactly. This concludes another edition of the Society of Critical Care Medicine’s podcast series. For SCCM, I’m Dr. Ludwig Lin. Thank you.
Ludwig H. Lin, MD, is an intensivist and anesthesiologist at Sutter Hospitals in northern California and is a consulting professor at Stanford University School of Medicine where he teaches a seminar on the psychosocial and economic ramifications of critical illness.
This podcast was recorded during the Society of Critical Care Medicine’s 2023 Critical Care Congress. Access essential education online through Congress Digital. More than 120 sessions are available on an easy-to-use platform. Continuing education credit is also available. Some SCCM members receive complimentary access to Congress Digital. To learn more, visit sccm.org/congressdigital.
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