#OrthoTwitter: social media as an educational tool

Abstract

Aims

The increased use of social media creates opportunity for new, effective methods of delivering medical and clinical education. Twitter is a popular social media platform where users can post frequent updates and create threads containing related content using hashtags. This study aims to investigate and analyse the type of content relating to orthopaedic surgery that is being posted on the platform of Twitter.

Methods

A retrospective search was performed for tweets containing the words ‘orthopaedic surgery’ or ‘orthopedic surgery’ or the use of the hashtag ‘#OrthoTwitter’ between November 2018 to November 2019. A total of 5243 tweets were included.

Results

Tweets containing ‘orthopaedic surgery’ or ‘orthopedic surgery’ most frequently contained promotional or marketing content (30% promotional, 21% marketing), and private organisations were the category of author to which the greatest number of tweets belonged (30%). Tweets containing educational or research content were the least common among all tweets containing ‘orthopaedic surgery’ or ‘orthopedic surgery’ (11%). In contrast, of the tweets containing the hashtag ‘#OrthoTwitter’, 44% contained educational or research content, 15% contained promotional content and no tweets containing marketing content. Furthermore, 87% of all tweets using the hashtag ‘#OrthoTwitter’ were from orthopaedic surgeons, and the least number of tweets were from private organisations (2%).

Conclusion

Twitter is a widely used social media platform regarding orthopaedic surgery. We propose that the hashtag ‘#OrthoTwitter’ can be used to create an online community of orthopaedic surgeons where members can assist one another through sharing reliable and educational content.

INTRODUCTION

Social media has proved to be an efficient tool to use professionally in the realm of surgery, particularly for sharing health-related information and continuing the doctor–patient relationship beyond the clinical environment. ¹ Multiple studies within existing literature have demonstrated the power of social media as a medium for orthopaedic professionals to network with colleagues both locally and abroad, assist and provide advice on the management of patients, as well as promote medical education among the professional community. ^2–5

Twitter was founded in 2006 and within the last 14 years, it has rapidly gained popularity among both public and professional bodies. A study investigating the use of Twitter by plastic surgeons demonstrated how the platform has tremendous potential for being an easily accessible source of educational information relating to the speciality; however, there is a disconnect in content posted by plastic surgeons versus content the public would prefer to read. ⁶

This study aims to investigate and identify trends relating to orthopaedic surgery within the platform of Twitter. A secondary aim is to promote the use of a consistent hashtag in the tweets by forward-thinking orthopaedic surgeons that relate to research and education, whether that is aimed at patients or professionals. The inclusion of the same hashtag across these types of tweets will ultimately have the effect of creating a thread of tweets that contain quality education and research content which relates to orthopaedics. Students and colleagues using Twitter are then able to search for this particular hashtag to quickly and conveniently find quality educational content relating to orthopaedics, while filtering out much of the marketing and promotional content that tends to be commonplace across social media platforms. The authors support the use of the hashtag ‘#OrthoTwitter’ because it clearly and creatively signposts to Twitter users that the tweets with this hashtag will relate to orthopaedics, while also following the pattern of other existing and popular topical hashtags such as ‘#MedTwitter’ or ‘#CardioTwitter’.

METHODS

Using the advanced search function on Twitter, data for tweets posted between 1 November 2018 and 30 November 2019 was collected retrospectively. Tweets containing the words ‘orthopaedic surgery’ or ‘orthopedic surgery’ or the use of the hashtag ‘#OrthoTwitter’ were recorded. All tweets that were not posted in either British or American English were excluded. A total of 5243 tweets were collected and analysed.

For each tweet, the author was categorised into one of the following categories: ‘Orthopaedic Surgeon’, ‘Health Organisation’, ‘Private Organisation’, ‘Public’. The definition of each category is given in table 1. Examples of each tweet category can be found in the appendix.

Table 1.

Categories of tweet author

Category	Definition
Orthopaedic Surgeon	Any user that has mentioned in their Twitter profile (‘bio’) that they are either an orthopaedic consultant/attending or an orthopaedic registrar/resident.
Health Organisation	Any user that has mentioned in their Twitter profile that they represent a healthcare organisation, for example an NHS Trust or an orthopaedic centre.
Private Organisation	Any user that has mentioned in their Twitter profile that they represent a business that markets orthopaedic-related products, or a news company.
Public	Any user that does not fall into the other categories, including medical students and allied healthcare professionals.

NHS, National Health Service.

For each tweet, the content was categorised into one of the following categories: ‘Education or Research’, ‘Marketing or Job Advertisement’, ‘News’, ‘Promotion or Self-promotion’, ‘Miscellaneous’. The definition of each category is given in table 2.

Table 2.

Categories of tweet content

Category	Definition
Education or Research	The content of the tweet contains information pertaining to either an educational patient case, procedure or scenario or a research article.
Marketing or Job Advertisement	The content of the tweet is primarily focused on advertising products or services related to orthopaedic surgery, or advertising the availability of a job post related to orthopaedic surgery.
News	The content of the tweet contains information and links to news articles about novel developments or important actions/events that have occurred relating to orthopaedic surgery.
Promotion or Self-promotion	The content of the tweet is primarily focused on highlighting the achievements, skills or accomplishments that either the author has done themselves or that of someone else.
Miscellaneous	The content of the tweet does not fall into any of the other categories for example, jokes and humorous tweets.

To explore the potential educational and research value the hashtag ‘#OrthoTwitter’ has, all educational and research tweets by orthopaedic surgeons containing the hashtag ‘#OrthoTwitter’ were further subcategorised into one of the following: ‘Career Advice’, ‘Patient Case Studies’, ‘Questions/Answers/New Ideas’, ‘Link to Research Article’, ‘Opinions regarding Technical Expertise’. The definition of each category is given in table 3. Examples of each tweet subcategory can be found in the appendix.

Table 3.

Subcategories of educational and research tweets containing the hashtag ‘#OrthoTwitter’

Subcategory	Definition
Career Advice	The content of the tweet contains information relating to the topic of career development and progression within orthopaedics.
Patient Case Studies	The content of the tweet contains anonymised patient scenarios that can either be fictional or recalled from real experience, with the aim of providing a learning point or action.
Questions/Answers/New Ideas	The content of the tweet is primarily a question related to orthopaedics, or an answer to a previously asked question, or a proposition to other users about a new idea to share or implement.
Link to Research Article	The content of the tweet is primarily focused around a URL link to a research article related to orthopaedics.
Opinions Regarding Technical Expertise	The content of the tweet is largely on the subject of technical niches within the specialty of orthopaedics.

All tweets were manually read and categorised by one author. Another author then reviewed the tweets in each category and flagged any which may potentially belong to another category. Where tweets were flagged, all authors individually reviewed the tweet and the final category was decided according to the group consensus.

Data were stored in a Microsoft Excel (Microsoft Excel 2017) spreadsheet. Statistical analysis and production of figures were conducted using Microsoft Excel.

RESULTS

A total of 5243 tweets were included. A total of 3995 tweets included ‘orthopaedic surgery’, 1129 tweets included ‘orthopedic surgery’. A total of 119 tweets included contained the hashtag ‘#OrthoTwitter’.

Orthopaedic surgery

Figures 1 and 2 illustrate all the tweets containing the words ‘orthopaedic surgery’ or ‘orthopedic surgery’, by author type and content type, respectively. There is a roughly similar distribution between all four categories; however, the public posted the least number of tweets. The most common type of content posted was promotional tweets (of self or others). The least common type of content was tweets posted for educational or research purposes.

Figure 1.

Number and percentage of tweets posted containing ‘orthopaedic surgery’ or ‘orthopedic surgery’ per author category.

Figure 2.

Number and percentage of tweets posted containing ‘orthopaedic surgery’ or ‘orthopedic surgery’ per content category.

#OrthoTwitter

Figures 3 and 4 illustrate all the tweets containing ‘#OrthoTwitter’, by author type and content type, respectively. The overwhelming majority of tweets containing ‘#OrthoTwitter’ were posted by orthopaedic surgeons. For tweets containing ‘#OrthoTwitter’, the majority of tweets contained educational or research-related content. There were no tweets with marketing content using the hashtag ‘#OrthoTwitter’.

Figure 3.

Number and percentage of tweets posted containing ‘#OrthoTwitter’ per author category.

Figure 4.

Number and percentage of tweets posted containing ‘#OrthoTwitter’ per content category.

Tweets from orthopaedic surgeons

From the total number of tweets containing the words ‘orthopaedic surgery’ or ‘orthopedic surgery’, 23% were posted by orthopaedic surgeons (1194/5243). In comparison, from the total number of tweets containing the hashtag ‘#OrthoTwitter’, 87% were posted by orthopaedic surgeons (104/119). Figure 5 illustrates the differences in the content of the tweets posted by orthopaedic surgeons over the year, either with the words ‘orthopaedic surgery’ or ‘orthopedic surgery’ or the hashtag ‘#OrthoTwitter’.

Figure 5.

Percentage of tweets posted by orthopaedic surgeons containing ‘orthopaedic surgery’ or ‘orthopedic surgery’ versus ‘#OrthoTwitter’.

Of the educational and research tweets by orthopaedic surgeons, containing the hashtag ‘#OrthoTwitter’, figure 6 demonstrates the numbers of tweets in each subcategory. The majority of these tweets contained either questions or answers to previously asked questions, or were patient case-studies of educational value.

Figure 6.

Number and percentage of educational and research tweets posted by orthopaedic surgeons containing the hashtag ‘#OrthoTwitter’ per subcategory.

DISCUSSION

The key findings from our research suggest that while the words ‘orthopaedic surgery’ and ‘orthopedic surgery’ are used consistently in tweets from all categories of authors, the majority were posted by private organisations. The number of tweets containing the British spelling of ‘orthopaedic’ was substantially more than those containing the American spelling of ‘orthopedic’. This could imply that British users of Twitter post content relating to orthopaedics more frequently than American users. The most frequent type of content posted was promotion, of self or others. In addition, 21% of all tweets contained primarily marketing content. This aligns with what would be expected of private organisations in order to boost their online presence and scope for business, as together, promotional and marketing tweets comprised over 50% of the tweets included. This large volume of promotional and marketing tweets diluted the amount of useful and educational tweets relating to orthopaedic surgery. Conversely, within the tweets containing the hashtag ‘#OrthoTwitter’, there were no marketing tweets from orthopaedic surgeons, indicating that this hashtag is largely used for educational purposes. It is important to differentiate the tweets from orthopaedic surgeons versus those from private organisations as the content contained in them is likely to differ significantly. However, there will always be a risk that private organisations will latch onto the use of the hashtag ‘#OrthoTwitter’ and begin using it for promotional or marketing purposes. This is unavoidable and will inevitably reduce the use of the hashtag ‘#OrthoTwitter’ for predominantly educational or research purposes. The introduction of an additional academic hashtag relating to the speciality of trauma and orthopaedics might then begin; however, it would be a shame to lose the vast amount of excellent existing content using the original hashtag. Rather than use a different hashtag, it might be more appropriate for professionals using the hashtag ‘#OrthoTwitter’ in their Twitter posts to include additional hashtags, clarifying to users of the platform if their content is, for example, ‘#educational’ or ‘#research’.

A key strength of using social media is the ability to communicate and network with other like-minded individuals spread across the globe, forming online communities with members sharing their ideas, opinions and experiences. ⁷ If used properly, this can have a profoundly positive effect on all members and act as a source of support for challenges faced in clinical practice, as shown in the ‘Women Docs in Urology’ group on Facebook. ⁸ Given that female representation within orthopaedics is lower in comparison to other surgical specialities, effective use of social media, such as Twitter, can stand to improve this. ⁹ An example of how Twitter has been used to break down existing stereotypes surrounding surgery is the viral trend of the hashtag ‘#ILookLikeASurgeon’, which began in 2015. ¹⁰ This hashtag is continuously used by surgeons from all specialities to target existing prejudice surrounding surgery, for example, gender, by illustrating that a surgeon can look like ‘anyone’ and there is no set image of what a surgeon ‘should look like’. Another related hashtag is the ‘#SurgeonStrength’, which was introduced on Twitter as a means to demonstrate the physical strength that female surgeons have. The hashtag ‘#SurgeonStrength’ initially encouraged female surgeons to tweet images of themselves in a non-surgical setting while showing their strength, but it has also been adopted by users demonstrating the diversity within female surgeons.

Social media platforms such as Twitter can act as a catalyst for novel research projects that spark from discussion among collaborators that may never have met before. ¹¹ Twitter’s rapidly updating quality makes it easier for the wider professional community to remain up to date (in real-time) with any novel developments being made in research, as well as any changes to guidelines and clinical practice. ¹² Furthermore, due to the easily accessible nature of the Twitter platform across electronic devices, orthopaedic surgeons are more likely to initially discover educational and research content posted on social media rather than through formal literature searches which tend to be conducted relatively less frequently, in our experience.

Twitter can also prove beneficial with regards to promotion of education and research within orthopaedics. Our findings demonstrate that the hashtag ‘#OrthoTwitter’ was used most commonly by orthopaedic surgeons, posting educational and research content, and least commonly by private organisations. We propose that the hashtag ‘#OrthoTwitter’ can be used to gather an online community consisting of orthopaedic surgeons, trainees, other allied professionals and students within Twitter in which all members can help one another through sharing reliable educational content. The hashtag ‘#OrthoTwitter’ can be used to create a ‘virtual area’ within the platform that helps separate the high-quality educational tweets from the large volumes of non-educational tweets relating to orthopaedic surgery. Further subanalysis of the research and educational tweets using the hashtag ‘#OrthoTwitter’ demonstrated the potential for Twitter to be used as a tool for easily asking questions and receiving answers to them from other more-experienced users, for example, a medical student receiving career help from a trainee. Furthermore, the use of anonymised patient case studies also shows promise as another important learning tool, particularly for surgical trainees. New and current patient case studies posted on the platform can be used to address scenarios in practice that may not be covered in formal training. For example, if a new technology emerges or a disastrous event occurs, trainees may post specific patient scenarios relating to this and seek the collective expert opinions of more experienced orthopaedic surgeons in approaches to management.

Creation of this ‘virtual area’ may differentiate, to a degree, professional users from public users on the Twitter platform. It is likely that the majority of public users from a non-medical background may not be aware of the existence of the hashtag ‘#OrthoTwitter’. While patients can also benefit from consuming educational tweets containing the hashtag ‘#OrthoTwitter’, a potential drawback is the risk of creating ‘self-made’ patient experts, which can make delivering effective care more challenging. An example of this could be if a patient has agreed to a procedure with their surgeon, using one technique, and then sees on Twitter, via the hashtag ‘#OrthoTwitter’, research on a different technique. If the patient then requested the second technique for their surgery, this puts the orthopaedic surgeon in a less than ideal position.

If patients begin actively consuming tweets containing the hashtag ‘#OrthoTwitter’, it becomes even more imperative that orthopaedic surgeons actively consider the risk of breaking patient confidentiality through their tweets. An example of where this situation may arise is if an orthopaedic surgeon posted a well-intended educational tweet using the hashtag ‘#OrthoTwitter’, which included information that a patient then recognised as relating to themselves. According to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) in the USA, the Privacy Rule protects all individually identifiable health information of patients. ¹³ Breaking patient confidentiality would not only violate the HIPAA Privacy Rule but may also subject the ‘identified’ patient to risks of identity theft, insurance fraud and potential social consequences within their personal lives. In the European Union, the General Data Protection Regulation (GDPR) functions in a similar way, with emphasis being placed on obtaining appropriate consent for sharing any specific data. However, Recital 26 of the GDPR does state that provided the data are sufficiently anonymised then GDPR does not apply. ¹⁴ Social media platforms like Twitter are not entirely secure due to their public and online nature. Professional users of Twitter can fall victim to hacking, particularly those who have an active following. Given this, users must also remember that once posted, information can be disseminated instantly by third parties meaning it may not be possible to delete all traces of the tweet.

The lack of need for verification or peer-reviewing of any information posted on Twitter can reduce the reliability and, in some instances, accuracy of the content. ¹⁵ Additionally, the high volume and rapid turnover of tweets further accentuates the problem of inaccuracy. ¹⁶ An example could be where an orthopaedic surgeon endorses a particular approach for the management of a condition as ‘the best way to do so’, but there may not be peer-reviewed evidence that supports this opinion. Patients who are not familiar with evidence-based medicine may take this information at facevalue, thus making misinformed decisions of their own care. The convenience of easily and quickly accessing this kind of information on Twitter therefore poses a large potential risk of misinforming patients. The likelihood of a patient spending extra time to verify the information posted by a professional on Twitter is low because this goes against the time-saving strength of the platform. Furthermore, the public nature of social media platforms such as Twitter means that issues can arise with censorship guidelines. Patient cases posted for educational learning, particularly those involving images of traumatic injuries, can become problematic in one of the two ways. First, the images could be upsetting for any patients following the hashtag ‘#OrthoTwitter’, leading to complaints and the eventual removal of high-quality content that would be of genuine educational benefit to orthopaedic surgeons and trainees. The alternate issue could be the automatic censoring function Twitter has whereby tweets containing potentially sensitive content, such as images of traumatic injuries, would be ‘hidden’ from users, including orthopaedic surgeons. This would in turn reduce the strength and distribution of these educational tweets, as professional users may ‘miss’ them from their home page. For these reasons, as Twitter gains further recognition for its potential as an educational tool, it highlights the need for development and implementation of clear guidelines that will counteract all problems relating to inaccuracy and censorship. ¹⁶ Guidance on professional engagement with social media does exist (eg, GMC) and it is clear that professionals must take every precaution and full responsibility with any content that is posted online.

A further pitfall of using Twitter for education is a difference in familiarity, between younger orthopaedic trainees that likely grew up immersed in social media, and senior orthopaedic surgeons of a different generation that may not have engaged with social media as frequently. These senior surgeons are faced with overcoming the challenge of adapting to the rapid nature of social media and deciding how best to use these platforms to facilitate effective learning and education for their junior trainees. ¹² There is an increasing trend in orthopaedics in particular for X-ray discussions forming a very informal online trauma meeting and journal club to discuss cases, management strategies and outcomes. The more astute contributors frame the cases they presented with literature evidence. It is important to remain aware that social media platforms do not fully substitute for learning within traditional clinical teaching settings, as this is where aspects of the hidden curriculum such as professional characteristics are also developed. ^{12 17} Another potential risk from promoting the use of social media, despite it being for educational and research purposes, is accentuating the problem of social media addiction, as demonstrated in previous literature. ¹⁸

As engagement of orthopaedic surgeons and trainees with social media platforms like Twitter steadily increases, the requirement for guidance on remaining professional while online also increases. Professionals, particularly younger orthopaedic trainees, can be ignorant of the consequences of posting on social media irresponsibly. Instances online where patient confidentiality was unknowingly broken, or controversial and offensive statements were tweeted publically, can all have lasting harmful effects on both someone’s career and reputation. ^{12 19} A solution to counteract this risk of inappropriate social media use is to identify long-term users that adhere to a strictly professional code of online conduct and emulate their exemplary behaviour ¹⁹ while acknowledging that most licensing and indemnifying bodies as well as employing organisations maintain guidance and policies on social media utilisation. Tweets using the hashtag ‘#OrthoTwitter’ can highlight the accounts of several orthopaedic surgeons that are examples for trainees and other professionals to model their online behaviour after.

Limitations

Our findings are based on tweet data that spans a period of 13 months. After the initial 6-month period of retrospective data collection, between November 2019 and May 2019, the authors determined whether more tweet data were required, and if so continued with collection. Subsequently, all authors jointly agreed that the data which were collected for just over a 1-year period were sufficient to analyse the nature and content of the tweets. However, a limitation of this retrospective study is that it does not account for the continuously updating nature of Twitter. A future study adopting a prospective approach to data collection may be better suited to account for the changes in tweet data such as the introduction of any relevant new orthopaedic surgery-related hashtags.

The categories for tweet author and tweet content were determined by the authors prior to tweet data collection. It was necessary to assign one ‘author’ category and one ‘content’ category to each tweet for analysis. A limitation of this study is that no formal triangulation methods were used to independently review which categories tweets had been assigned to. In the instance where a tweet could have been assigned to multiple ‘author’ or ‘content’ categories, the overall consensus of the authors was used to decide how to categorise the tweet.

CONCLUSION

In conclusion, if used effectively, the hashtag ‘#OrthoTwitter’ has the potential to transform the general non-educational perception of social media into a constructive, powerful and constantly updating educational tool that stands to benefit orthopaedic surgeons in all levels of training, students and patients.

What is already known on this subject.

• Twitter has specifically, in the realm of plastic surgery, been shown as a powerful and easily accessible source of medically educational information, but no study previously has investigated Twitter usage relating to orthopaedic surgery.

What this study adds.

• This study demonstrates how Twitter provides an easily accessible platform to share educational content relating to orthopaedic surgery; this study has also shown the breakdown of content being posted on Twitter relating to orthopaedic surgery.

• The hashtag ‘#OrthoTwitter’ can be used to create a ‘virtual area’, which helps separate the high-quality educational tweets from the large volumes of promotional and marketing tweets.