Surgeons wield influence on social media

Social media, particularly Twitter and Instagram, has played an increasingly prominent role in medicine in recent years. For general surgery in particular, social media platforms have had a unique role in information propagation, mentorship, networking, and research dissemination.¹

With the onset of the coronavirus 2019 (COVID-19) pandemic and resultant social distancing measures broadly instituted in March 2020, the number of health care professionals using social media has grown significantly. Social media allows for near-instantaneous dissemination of information as well as discussion, both pertinent in the current education environment.

As the year progressed and social distancing became further ingrained in our daily lives, social media has become an increasingly powerful means of continuing the dialogue among surgical colleagues who want to share clinical and research findings, as well as patient-management scenarios and questions related to care. Social media also has afforded opportunities to initiate professional relationships and to guide the next generation of applicants to surgical training programs.

We evaluated the role of social media influencers prior to the onset of the COVID-19 pandemic and presented our findings at the virtual American College of Surgeons (ACS) Clinical Congress 2020. In this article, we explore the expanding role of social media in 2020 by analyzing general surgery social media influencers and how they evolved over the first 10 months of social distancing; interconnectivity at virtual conferences and through sharing and discussing research findings; and the activity of trainees and programs participating in the 2020–2021 general surgery residency match cycle.

General surgery social media influencers

Social media influencers are defined as users whose interactions create an impact in their respective fields or on topics of discussion. In an attempt to understand who is leading the conversation on Twitter, we analyzed social media influencers in the topic of general surgery using the Right Relevance Insights application programming interface technology on February 7, 2020.² The list of social media influencers was derived from a comprehensive ranking through the Right Relevance algorithm, including both connections (followers and who they are following) and engagement (“likes,” retweets, and comments) on the topic of interest.

In that study, we noted some diversity in level of training and gender among the general surgery Twitter influencers.² While most were surgeons or trainees, a few influencers were nongeneral surgeons. With approximately one-third of influencers as general surgery trainees, it is important to appreciate the utility of the platform at varying points in one’s training and career.

Most influencers were from North America, but this group included representatives from around the world, highlighting the universal accessibility of the platform.² Interestingly, the distribution of self-identified gender was not reflective of the population of practicing or training surgeons; men were likely overrepresented among practicing surgeons, whereas women were overrepresented among trainees. Of note, h-indices of influencers were similar to the means of those reported for academic general surgeons across the U.S.

Subsequently, secondary to the COVID-19 pandemic and resultant social distancing measures, we anticipated changes in general surgery social media influencers because of the increased utility that social media affords. Therefore, for this latest study, we analyzed individuals leading the conversations on Twitter in general surgery again on December 7, 2020, and noted some changes and significant growth in the number of influencers.² In this updated analysis, the number of influencers increased by 45.5 percent to 128 individuals in December 2020 from 88 individuals in February 2020. Of those influencers in February, only 49 (55.7 percent) remained influencers 10 months later and were joined by 69 new influencers in this short period of time.

The proportion of influencers who identified as general surgeons and general surgery trainees remained similar with 83 percent (n = 73) in February and 75 percent (n = 96) in December.² Most of these influencers were attending general surgeons—50 percent (n = 44) in February and 57.8 percent (n = 74) in December 2020—followed by other physicians and residents in other surgical specialties—11.4 percent (n = 10) of influencers in February and 18.8 percent (n = 24) in December.

Additional influencer categories were as follows (see Figure 1):²

• General surgery residents: 30.7 percent (n = 27) in February and 14.1 percent (n = 18) in December
• General surgery fellows: 3.4 percent (n = 3) in February and 3.1 percent (n = 4) in December
• A total of 1.6 percent (n = 2) medical students who emerged in the December rankings

FIGURE 1. PROFESSION AND FELLOWSHIP DISTRIBUTION OF GENERAL SURGERY INFLUENCERS (December 7, 2020)

Of those surgeons with fellowship training, representation among general surgeon influencers transitioned from surgical oncology at 18.4 percent (n = 9) in February 2020 to critical care at 17.9 percent (n = 14) in December, previously 14.3 percent (n = 7) of influencers.² Therefore, the overall distribution of role and rank of general surgeons was similar, with a small increase in attending general surgeons and surgeons in other specialties. Notably, influencers among general surgery residents decreased, whereas critical care surgeon influencers increased.

Regardless of the changes in the surgical disciplines of influencers, the gender distribution of general surgeons remained stable overall with slight variations by rank.² Of the residents and fellows, 72.7 percent (n = 16) in December identified as female versus 70 percent (n = 21) in February 2020. Conversely, 26.7 percent (n = 8) identified as male in December versus 22.7 percent (n = 5) in February. These data are comparable with those for attending general surgeons, with 70.3 percent (n = 52) identifying as male in December versus 79.5 percent (n = 35) in February, and with 28.4 percent (n = 21) identifying as female in December versus 20.5 percent (n = 9) in February (see Figure 2).²

FIGURE 2. GENDER DISTRIBUTION OF GENERAL SURGERY INFLUENCERS (December 7, 2020) Overall, general surgeons, and general surgery residents and fellows

Overall, 44.5 percent (n = 57) of influencers were located in the U.S. compared with the previous 47.7 percent (n = 42), with 46.1 percent (n = 59) located internationally versus 51.1 percent (n = 45).² The states with the highest number of social influencers included New York, Pennsylvania, and Ohio (see Table 1). The proportion of influencers from Canada decreased from 28.4 percent (n = 25) in February 2020 to 16.4 percent (n = 21), and the number of influencers in the U.K. increased to 13.3 percent (n = 17) in December from 5.7 percent (n = 5).²

TABLE 1. GEOGRAPHIC DISTRIBUTION OF GENERAL SURGERY INFLUENCERS (December 7, 2020) (n=128)

To further evaluate the relationship with social media and research engagement, we again compared December Twitter influence scores in the topic of general surgery to both h-index and total number of publications. The correlation with both the Twitter influence score and h-index (Pearson’s r = 0.432, p < 0.01) and total publications (Pearson’s r = 0.375, p < 0.01) remained strong (Figure 3). The academic h-indices for the December influencers in general surgery, including attendings and trainees (n = 96), ranged from 0 to 99 (mean 15.6 ± 9.8, median 7.5) and were similar to the h-indices of February influencers.²

FIGURE 3. TWITTER INFLUENCER SCORE (December 7, 2020) Compared to (A) h-index and (B) total number of publications

In summary, the number of influencers in general surgery on Twitter increased as expected, with increasing use of social media during this socially distanced pandemic. We found a higher number of influencers specializing in critical care, a decrease in resident influencers, and the appearance of two medical student influencers. The influencers were widely distributed geographically and had a correlation of publications and h-indices with the Twitter influence score in the topic of general surgery.

Unfortunately, we lacked the resources to identify topics discussed and what these influencers specifically added to the conversations; however, we believe that these influencers may have a significant impact on broad discussions in social media relevant to general surgery and health care. It is worth noting their presence and the roles they play in guiding these conversations.

Sharing information gathered at conferences

The social distancing parameters of 2020 universally transformed information sharing. Cornerstones of surgical discussion and education, including morbidity and mortality conferences and grand rounds, quickly transitioned to video platforms. Invited lectures, without the interactive opportunities provided by formal dinners, WalkRounds with the experts, and subsequent informal conversations, continued from a distance. Upcoming local, regional, national, and international conferences mostly were delayed, canceled, or transitioned to a virtual platform. On June 30, the ACS Clinical Congress 2020, scheduled for October 4–8, announced the transition to a virtual platform. The virtual meeting convened October 3–7.

The virtual ACS Clinical Congress 2020 was documented to have a record number of registered attendees (more than 30,000 people from approximately 150 countries), perhaps, in part, because registration also was free in the virtual format.³ By comparison, 12,370 surgeons, residents, medical students, affiliate health care professionals, exhibitors, staff, guests, and members of the press attended the ACS Clinical Congress 2019.⁴ Moreover, the recorded presentations from ACS Clinical Congress 2020 were available for access for an extended period of time, through March 31. Because of the positive reviews associated with this experience, Clinical Congress 2021 is likely to include some virtual components.³

Although the virtual platform increased accessibility to the information presented, it created an impediment to the conversation, discussion, and social networking stemming from presentations of interest. However, many conversations transitioned from the conference room and hallway to the chat features of the virtual platforms and onto social media. Whereas the chats often can be accessed only during the live meeting with registered attendees, social media platforms allow for the conversation to continue for those individuals unable to attend the meeting and may continue indefinitely for anyone with a social media account.

Twitter has been a particularly popular platform for sharing meeting content because it allows users to share images and key points with an open audience. In addition, tweets are searchable and identifiable via hashtags. For example, many surgeons and trainees followed ACS Clinical Congress 2020 using #ACSCC2020 and #ACSCC20 for updates on groundbreaking studies and hot topics of interest. Participants often continue to follow the current conversations through a more general identifier such as #SoMe4Surgery or another useful hashtag.⁵

Earlier studies have documented the increasing social media engagement of participants during in-person Clinical Congresses and illustrated the ripple effect of these platforms through both the structured hashtag and expansion outside of the hashtag.^6,7 Clinical Congress 2020 participants visually documented use of social media through conference hashtag use, revealing the expansive interconnectivity and reach of Twitter accounts.⁸ Tracking hashtag use through the virtual 2020 ACS Clinical Congress, the specific hashtags #ACSCC20 and #ACSCC2020 were used 13,749 and 2,083 times, respectively, since September 2020 through the time of data collection in December 2020.⁹ Symplur Healthcare Analytics has tracked 6,622 conferences through Twitter and their respective data using 14,332 conference hashtags as of December 23, 2020, with continued increase anticipated.¹⁰ With the ACS Clinical Congress as an example, Twitter use has been increasing with time and has had a great impact on dissemination of information from the ACS’ annual clinical education conference.⁶ Further analysis is needed to determine the relevance of social media in the setting of a completely virtual conference format with a greater number of participants.

The hashtag #SoMe4Surgery became a pertinent resource during and beyond conferences for those surgeons interested in remaining connected in the research community and keeping up to date on new publications and findings in general surgery, particularly during social distancing.¹¹ Overall, the hashtag was used 323,268 times from its initiation in July 2018 until the time of data collection in December 2020.⁹ The research summary in 280 characters forces brevity in relaying pertinent findings or creating visual abstracts.

The pandemic may have resulted in an increase in social media use, but its pertinence to being connected as a surgical trainee and surgeon was already increasing in recent years. Social media provides a forum for information sharing, building connections, and sharing discussions on a global level, with universal accessibility and expanding utility. Undoubtedly, social media continues to have an evolving role beyond 2020 and the pandemic.

Implications and benefits of #SoMe4Surgery for future surgeons

With the global pandemic arising during the mid-fellowship application cycle, exposure concerns and travel restrictions began to affect the interview process and many training programs quickly transitioned to a virtual format. In order to provide time for residency programs and applicants to prepare, on June 30, 2020, the Association of American Medical Colleges announced a virtual interview format for the 2020 residency application cycle.¹²

This move led to many concerns, ranging from the ability of both applicants and programs to present themselves, to assess each other, and to have the equipment and space required to participate in the virtual platform. Applicants especially worried about their ability to evaluate those somewhat intangible qualities that contribute to the culture of a program and the gut-feeling instincts gleaned from interactions during the interview experience. These and other concerns were somewhat balanced by the ease of interviewing from home or another local setting, nominal financial burden, and minimal risk of exposure to COVID-19.

To increase awareness of what they have to offer and to gain as much information possible, many residency applicants and residency programs alike turned to social media to supplement their interactions. By October 21, 2020, the date of Electronic Residency Application Service (ERAS) submission, 45 percent of Accreditation Council for Graduate Medical Education (ACGME) general surgery residency programs had a Twitter account—a 26 percent increase from March 2020—and 46 percent had an Instagram account—a 131 percent increase from March 2020 (see Figure 4). Account creation occurred across program structure (academic, hybrid, community, military) and location (Northeast, Midwest, South, West, Puerto Rico) on both Twitter and Instagram (see Tables 2 and 3, respectively).

FIGURE 4. TIMELINE OF ACGME GENERAL SURGERY RESIDENCY ACCOUNT CREATION (A) Twitter (B) Instagram

TABLE 2. ACGME GENERAL SURGERY RESIDENCY PROGRAMS WITH TWITTER ACCOUNTS (October 21, 2020)

TABLE 3. ACGME GENERAL SURGERY RESIDENCY PROGRAMS WITH INSTAGRAM ACCOUNTS (October 21, 2020)

Account creation increased significantly because of social distancing measures beginning in March 2020, as well as the decision to transition to a virtual platform, on June 30, as illustrated in Figure 4. As of December 7, 22 accounts representing the general surgery residency programs or departments of surgery and four accounts representing surgery divisions were included on the influencers list pulled mid-interview season. On February 7, 2020, only six residency programs or surgery departments and just three general surgery divisions were on that list (see Table 4).

TABLE 4. GENERAL SURGERY RESIDENCY PROGRAM ACCOUNTS: Designated influencers on Twitter (December 7, 2020)

In response to the unparalleled challenges of the application cycle, these programs worked to connect with and inform applicants through posts profiling their programs. Social media played a prominent role in representing programs in previous years, with prior studies analyzing department of surgery social media use, guidelines for content, and benefits. At the time of analysis, social media was determined to be an underused tool.¹³ In addition, attending surgeons—often including the program director and other educational faculty, as well as residents—appeared to work to engage future trainees.

Many programs offered virtual meet-and-greets or social hours via video platforms, allowing applicants, residents, and sometimes faculty to interact prior to application submission. These were largely advertised over social media accounts or by institutional e-mails to medical school representatives and program or clerkship directors for dissemination to medical students. Program personnel, including administrative staff, faculty, and residents, invested time and energy into these events, while applicants spent their evenings learning about programs and expressing their interest in a respective program. Some programs even publicly acknowledged that attendance at these events would be factored into ranking decisions.

Through the use of #MedTwitter, #SurgTwitter, and other relevant hashtags on social media, applicants found platforms to connect with one another, somewhat simulating the informal “application trail,” sharing information through likes, comments, and direct messages. Historically, many applicants favored more anonymous platforms, such as Reddit or the Student Doctor Network, to share information throughout the application cycle. Although these platforms continued to have a role, the number of applicants favoring more public social media platforms appears to have grown, making applicants’ ERAS applications more traceable and likely allowing them greater visibility and personal interaction.

By design, coincidence, or both, social media became tightly intertwined with the 2020 virtual residency application cycle as a resource for applicants to become familiar with programs outside their home institutions.

Future importance of social media engagement

Whether looking to stay informed, share data, network, or plan for upcoming education and career changes, social media has helped to close the social distancing gap. Individual and programmatic influencers have increased in 2020, likely in response to the pandemic to some extent. While the pandemic stimulated the increase in the use of social media in general surgery, its use is likely to continue growing. For those individuals who have not taken the opportunity to engage with influencers and in the social media communities such as #MedTwitter, #SurgTwitter, or #SoMe4Surgery, we recommend developing your social media presence thoughtfully and strategically. Following are some do’s and don’ts for increasing your social media presence.

Do’s

• Use a Twitter or Instagram handle that is short and memorable
• Include a professional photo; trainees should consider using their application photo
• Create a succinct account bio and mention your academic role
• May include witty, catchy details about yourself, but remember this is your public introduction
• Post content about your passions, but think carefully before engaging in discussion about potentially inflammatory or highly controversial topics
• Remember that everything posted on the Internet leaves a lasting mark, even when promptly deleted
• Review your (280 character or less) message or image at least once before sending
• Only post content you would be comfortable being read by your family, future trainee/boss, or patients
• Get involved
• Examine influencers’ profiles and content
• Create a network of colleagues by following mentors and mentees, colleagues, and programs, organizations, and associations of interest
• Follow journals to stay up to date on current research
• Read and reach out to #MedTwitter, #SurgTwitter, and other communities
• Support your colleagues on their professional social media journey; invite and promote them
• Review and understand institutional guidelines regarding use

Don’ts

• Do not risk a Health Information Portability and Accountability Act violation by referencing your patients; choose topics with care, bearing in mind that social media is a universal platform, and anything posted is viewable by anyone with Internet access
• Do not provide medical advice or guidance over a social media platform
• Do not plagiarize and ensure any non-original content is properly cited, linked, re-tweeted, or reposted

We anticipate continued growth of social media beyond 2020–2021 and the COVID-19 pandemic and continued importance in many aspects of our careers in surgery. It is vital to understand who is influencing the conversations that occur on these platforms and the environment in which they are occurring.

References

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8. @JulioMayol. The beauty of the #ACSCC20 network #SoMe4Surgery @AmCollSurgeons @JAmCollSurg @SWexner @pferrada1 @PipeCabreraV @TomVargheseJr @SeanLangenfeld @NeilFlochMD @WomenSurgeons @me4_so. https://twitter.com/juliomayol/status/1313366715737214979. Posted October 6, 2020. Accessed February 8, 2021.
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