Social Media and Free Open Access Medical Education: The Future of Medical and Nursing Education?

It has become cliché to say that the Internet has changed everything, but it did, fundamentally transforming how we communicate and interact.1–6 All the world’s knowledge and experiences are available at any time with just a click of the mouse. Information is easily accessible and free to anyone with a computer, and communication across continents is as easy as e-mailing someone next door. In 1995, just 14% of American adults used the Internet, but by 2014, 87% were regular Internet users.7 Today, organizations and private citizens in all areas have taken to the Internet to entertain, to inform, and to advocate.1–6As the Internet expanded into our homes, there was a growing expectation of free and open access to information.1–3 Because information was so easily accessible on so many sites, there developed an expectation that all information should be free. In the 1990s, there was an expectation of free music downloads. In the 2000s and 2010s, there was an expectation of free videos, movies, and television shows. And in higher education, universities began offering free online courses in an effort to grow their online presence and expand reach and goodwill. Now, massive groups of online students watch the same lectures and (and in some cases take the same tests) as paying in-person students.8From this openness, people found new ways to interact online.8–10 At first this interaction was through communication in chat rooms, online message boards, and e-mail. In the beginning, these communications were relatively uncommon. Although it is hard to imagine now, in the early 2000s many people did not have computers in their homes. However, with cheaper and faster computers, and with the development of the smartphone, these interactions were easier and more convenient than ever. Currently, 64% of American adults have a smartphone equipped with Internet access, up from just 35% in spring of 2011.11 Users have the tools to communicate and interact with anyone at any time literally in the palm of their hands. With these advances in technology, digital interactions became more commonplace and more mainstream, and the social use of these tools began to explode in popularity.Social media are broadly defined as the use of platforms of electronic communication through which users create online communities.1–6 Social media use is common; 74% of Internet users spend time on social networking sites, with 71% of online adults using Facebook and 23% using Twitter.12 Women currently outpace men in social media use, with a recent survey finding 74% of women were users of social media compared with 62% of men.13These online communities are used to share information, ideas, personal messages, and other content.1–6 A variety of social media platforms comprise these communities, including Twitter, Facebook, YouTube, and blogs. Each social media platform has slightly different characteristics that depend on the nature of that platform, which result in different user bases and functions. For example, Twitter is a brief, fast-paced microblogging platform that allows just 140 characters per post and requires extreme brevity and a flair for great writing. Facebook is slower paced and visually oriented, and the communities feel more insular to the end user. Blogs are generally static forums, but allow for longer-form content. And YouTube provides a forum for videos that can entertain as well as inform. Each platform offers different services and methods for connecting, and multidisciplinary communities of providers and patients form organically within each of these spaces.1–6On some platforms including Twitter, Instagram, and Facebook, users connect through the use of “hashtags.” These searchable keywords, indicated by the # sign, allow for users of similar interests to aggregate and connect. Some examples of online communities include #hcsm for health care social media, #pulmCC for pulmonary and critical-care medicine, and #FOAMed for free open access medical education. Symplur’s Healthcare Hashtag Project has collected and organized more than 8000 health care hashtags, each representing a disease state, medical conference, or group of people interested in the topic.14Social media have also become an integral tool for medical societies, hospitals, and advocacy groups.1–6 These groups are using social media to engage, teach, and connect, and they play an important role in providing accurate, vetted health information. Additionally, organizations have realized that encouraging live-tweeting or blogging of conferences provides opportunities for wide dissemination of content that far surpasses in-person attendance.15It has been said that we are drowning in data, but starving for knowledge. The amount of knowledge and information required for health care providers today is staggering. The need for continuing education is more important than ever before. Social media platforms can help supplement traditional knowledge. Students and learners of all levels routinely check the Internet for facts about disease states, therapies, and physiology. Although these platforms can supplement and enhance learning, it is important to realize that they cannot replace fundamental education and experience.The Free Open Access Medical Education (FOAM) movement is an online community that provides medical education through a variety of social media platforms.10,16–21 The FOAM community is organized primarily around the #FOAMed hashtag but includes several other related hashtags including #FOAMcc (FOAM critical care), #FOANed (free open access nursing education) and #FOAMrn (FOAM nursing). Content is posted on blogs, YouTube videos, podcasts, Twitter feeds, and Facebook groups. Like many social media communities, FOAM has no official leader. Content is created organically by individuals in a variety of disciplines and subspecialties and from all over the world. The quality of the content is vetted in real time by the users.The story goes that the term FOAM was coined in a bar over a pint of Guinness by Mike Cadgoan in 2012.20 But the movement that was later to be called FOAM can also be traced to informal groups of multiprofessionals who joined together in e-mail listservs and chat rooms to discuss difficult cases, to learn, and to generally commiserate. Among the earliest of these was David Crippen’s CCM-L, the International Internet Critical Care Medicine Group.9 Spurred on by an increased connectivity and ease of participation through improvements in computing technology, coupled with a growing cultural expectation of free and open access in the digital age, the open access medical education movement was born.FOAM is used to communicate and educate.10,16–21 Users can search Twitter for articles, listen to podcasts for the latest in evidence-based medicine, read blogs for summaries and commentaries, and watch YouTube for video instruction. These pieces are typically more dynamic, less formal, and more conversational than traditional educational materials. All can be done at the user’s own time, or asynchronously from the author.One of the central benefits of FOAM is the low barrier to entry. Twitter accounts are free to set up and use, and by attaching an appropriate hashtag, users can join in and begin to build a community. When we consider geographic and economic barriers that currently exist in medical education, FOAM becomes even more attractive. Users share interesting content, often free of charge, seek out free content from publishers, and debate topics. Location is of little importance—in Los Angeles, London, or Laos, users are able to learn, share and contribute.Social media users follow a spectrum of involvement in social media that ranges from low to high involvement.22 Will Hill of AT&T Laboratories first outlined the idea of participation inequalities in the 1990s when reviewing early forms of social media such as Usenet newsgroups and CompuServe message boards. The 90-9-1 Rule for Participation outlines the inequality in social media and online communities and states that 90% of members of an online community exclusively lurk and never contribute; 9% contribute a little, and 1% of users account for almost all the action.22 In a Nielsen Norman blog post by Jakob Nielsen, it is noted that blogs have an even more drastic participation inequality. Nielsen estimates the rule shifts to 95-5-0.1 when applied to blogs, a major outlet for FOAM content creators.22The danger in all social media is that well-informed participants with important ideas must be strong self-promoters or risk their voices going unheard, whereas the voices of those with popular views or sponsors (or in the market for sponsorship) rise above all the others simply because of their skill at self-promotion. The problem is that sometimes ego outweighs talent, unbeknownst to the reader or listener. Thousands of followers or “likes” are not necessarily indicative of an individual who seeks to contribute to the knowledge base or refine the practice.Content producers cannot assume that their followers are erudite; they may simply be inexperienced and searching for a mentor. All who seek knowledge, regardless of the medium, must attempt to curate high-quality information and accurate content amid the din of popular content. Therein lies the conundrum. The content will only be as good as the audience demands. In much the same way that social media can claim small victories in correcting statistical errors in published studies, the same attention to detail becomes paramount when the evidence outweighs the enthusiasm for practice changes supported by the most ubiquitous voices in social media.Regarding the quality of online nursing content, we see that often, instead of talking about issues that affect the collective and the patients, the conversation revolves around products. Presumably this is because these posts trend well. However, there is a new generation of nurses who may be insecure in their practice and want access to information and knowledge beyond the very general education provided in nursing school.Whereas physicians fresh out of medical school have 3 years (at a minimum) to augment their knowledge and hone their skills, with oversight and guidance from a more experienced physician, before the full burden of patient care is theirs alone to bear, a new registered nurse (RN) will be given 12 weeks, often less, of orientation with another RN, who may also be quite inexperienced. Further, many smaller hospitals lack the resources to provide the cutting-edge education modern nurses require to adequately provide care to the patient populations they serve. Quality educational offerings, and those who curate them, are available online from many sources, only a click or a follow away, at no cost to the learner other than the time it takes to filter and process them. This is the true potential benefit of social media.Unfortunately, many nurse leaders, with years of experience in this multifaceted profession, have yet to join the conversation on social media. Therefore, the conversation is often led by novices in the field, simply because leaders are absent. As bedside nurses, we must attempt to convince nurse leaders that the conversations begun in nursing school are ongoing; they have simply relocated from the physical classroom to the burgeoning virtual classroom.But there is a potential downside to this open access. The quality of the content on social media and the Internet is dependent solely on the members of the online community. Although there may be real-time peer review to critique misleading or incorrect information, the quality of that content may be variable. Additionally, social media forums necessitate brevity. Forcing brevity is a excellent way to facilitate understanding by the author and reader. But the downside is that some things are not simple and deserve further explanation. Nuance and complexity can be lost behind pithy statements.Also, since FOAM does not follow a curriculum, there is a risk of failing to cover potentially important topics. In social media, there is a heavy focus on areas of emerging treatments such as point-of-care ultrasound, bronchoscopy, and the use of technology and data in patient care. Other less glamorous but still important basic topics may get missed by beginning learners who rely solely on social media for their educational content.Social media are here to stay. Social media platforms, and in particular the FOAM movement, have the potential to be a novel way to augment your education and to connect with other leaders in health care. But social media cannot fully take the place of traditional education methods. Health care providers have an obligation to participate in the active discussions taking place on these social media platforms. As stewards of health care, it is our responsibility to help educate the next generation of providers.