gms | German Medical Science

Authors Pander T and Pinilla S contributed equally.

Most of today’s medical students are part of the Net Generation [1] and even if they are not Digital Natives [2] they are likely to use digital technology and social media in one way or another [3]. They tend to have an earlier and more intense exposure to digital technologies and use them more frequently and increasingly in remote and less developed parts of the world. Consequently, these students use social media in basically every activity, whether it is communicating, learning or interacting. Social media have been defined as "a group of Internet-based applications that build on the ideological and technological foundations of Web 2.0, and that allow the creation and exchange of user-generated content" [4]. Social networks like Facebook, XING and LinkedIn, blogs, collaborative projects like Wikipedia, podcasts, video-hosting sites like YouTube, virtual game worlds and information aggregators like RSS-feeds, are some examples of social media tools. The users of social media present themselves, talk, comment, discuss, participate, share, network, create, modify and evaluate contents online [5]. The use of social media as a personal learning environment is another interesting trend in this field.

Social media changed interpersonal communication in the field of medicine and medical education. A survey of students in the health professions shows that the majority of students prefer online and social media as their primary source of information [6].

The vogue of social networks has exploded in the past several years, as the growing amount of literature and research in the field of medical education shows [7]. According to the claimed registered user numbers, the most ubiquitous and popular social network in general is Facebook [8]. It was launched in 2004 at Harvard University and was originally created for students to socialize at their university. Now it is available in over 70 languages, in 213 countries and has 1.11 billion active users worldwide - almost one seventh of the world population. In June 2013, 699 million people used Facebook actively on a daily basis, an increase of 27% year-over-year [8]. Facebook allows users to create and manage their profiles in different ways regarding their personal background, education, career, interests and everyday lives. Members can administer their own profile as well as view and comment on other members’ profiles and use in-built features like news feeds, chats, message inbox, events and groups.

In a survey of students in the health professions, Facebook was used by 91% of students aged 18–25 and 78% of students aged 26–35 [6]. Pempek et al. [9] observed that students use Facebook approximately 30 minutes per day as part of their daily routine. 25.5% of medical students use Facebook for education related reasons and another 50% said they were open to doing so [10]. In contrast, a survey among participants in continuing medical education courses showed that only 6% of surveyed individuals (average age > 50) used social media for continuing medical education purposes [11].

Facebook’s features provide potentially useful support for the education, collaboration, communication, qualification and socialization of medical students. But some new challenges and risks have to be faced. One of the biggest challenges is the integration of two opposed fields: the field of medicine with values based on a culture of privacy, confidentiality, one-to-one interactions and the field of social media, with a culture of sharing, openness, transparency and informality [12]. Legal issues need to be considered with regards to privacy regulations and file sharing activities. The German Chamber of Physicians released recommendations for physicians and medical students using social media [13]. Specific recommendations are also needed for handling learning and assessment material in the medical education context. A new reality for medical professions has thus begun. As one consequence of this trend the American Medical Association (AMA) and many other international medical schools established guidelines and policies on the professional use of Facebook and social media in general [14].

Medical educators need to know how to teach and convey the professional use of social media, in particular Facebook, as it is the predominant social media tool, to health care professionals. Moreover, the need to show how to use it effectively for educational purposes in the different phases of medical education [15]. We performed a systematic literature review to collect information on how Facebook as one of many social media tools intersects with the different phases of medical education (undergraduate, graduate and continuing medical education) and in what ways Facebook has been integrated in respective educational interventions.

To the best of our knowledge there are three previous systematic literature reviews in the broad field of social media in medical education. Hollinderbäumer et al. [6] focused on the integration of social media and Web 2.0 in medical education and emphasized the potential of social media for self-directed learning. Cheston et al. [16] reviewed the use of various social media tools in medical education and pointed out promising applications despite the lack of data on effectiveness of social media tools. Finally, Cartledge et al. [17] systematically investigated the use of social networking sites in health and bioscience professions and found that learners accepted social media tools across health professions. The fact that all reviews have been recently published shows the explosive nature and topicality of this theme.

However, with regards to the diverse affordances of each social media tool, we suggest to review the different tools individually and in a context specific way. Facebook is arguably the largest and most widely used social media tool by physicians and physicians-in-training, and affects learning and teaching processes as well as medical professionalism and mentoring activities.

One of the central aspects of these prior reviews is that social media tools become increasingly present and that there is a great potential for various ways of integrating social media in basically all medical education systems. However, there is still a need for additional research in terms of learning and teaching at the behavioral level and to better evaluate the impact of social online networks [7]. To the best of our knowledge there is no review, which exclusively and systematically reviewed the literature with regards to the use of Facebook in medical education.

The central aim of this article is to answer the following question:

Or more specifically: Of what kind are the existing studies which are concerned with the use of Facebook in the context of medical education? On which phase of medical education do these studies focus? What is their content?

A structured overview and systematical review of the current literature and empirical research is provided. Furthermore, we wanted to identify research gaps and links to prior reviews in this field and make suggestions for future research in the context of the professional and instructional use of Facebook in medical education.

To reach the listed aims and answer the research questions a systematic literature review according to Cook and West [18] was conducted. The review steps are summarized in Figure 1 [Fig. 1].

After discussing the topic with interdisciplinary collaborators and researchers, the main research questions, as cited in the aims above, were formulated.

The next step was to evaluate whether a systematic literature review would be an appropriate way of answering the research questions. The authors discussed the advantages and disadvantages of the method and came to the conclusion that for answering the question a quantitative systematic summary of the current literature and research in this field is necessary. We were particularly interested in providing a comprehensive overview of the implicit and explicit intersections of Facebook with medical education and not social media in general. The different forms of application and the strengths and weaknesses of existing studies are highlighted, structured and evaluated.

An interdisciplinary team of reviewers (TP, SP, KD, MF) was formed, consensus on important definitions and coding categories was established and a detailed research protocol was written.

Two reviewers (TP and SP) conducted the search of databases independently, carried out the initial categorization of articles and drafted the first version of the manuscript. MF and KD resolved any ambiguous cases and re-reviewed the selection of each search phase. All authors agreed to the final version of the manuscript.

Six databases (Medline, ERIC, PsycINFO, PsycArticles, PSYNDEX and EBSCOhost) were searched. We focused our search on the years since the launch of Facebook in 2004 up to August 2013 (01/2004 –08/2013).

The key search terms were medical education, undergraduate medical education, graduate medical education, continuing medical education and medical student education in combination with social media, social network, online social network and Facebook. The search term used in Medline was:

Since we wanted to focus our review exclusively on Facebook, and no other social media tools like XING, LinkedIN, Twitter, YouTube or FlickR, we narrowed our search terms subsequently to:

for searching five additional databases (ERIC, PsychINFO, PsycArticles, PSYNDEX and EBSCOhost). Three of those (PsycArticles, PSYNDEX and EBSCOhost) did not provide any relevant articles.

To identify additional studies and possible gaps of our search strategy, TP and SP hand-searched the reference lists of all articles that were included in the full-text-review. We additionally reviewed four articles.

We (TP, SP, KD, MF) defined and formulated the following inclusion and exclusion criteria:

• The studies contain empirical elements and are not statement papers, expert opinions, checklists, letters or reviews (we exempted one report [19] from this criterion because of its thematic relevance and innovative potential).
• The studies exclusively focus on medical education and not on education in the fields of nursing, pharmacy, health work, dental or veterinary medicine.
• The study participants have the status of undergraduate, graduate or continuing medical professionals and not patients or students in general.
• The studies exclusively refer to Facebook as the only or main social media tool used or evaluated and not to social media in general.

The following inclusion and exclusion process consisted of three stages. First, two reviewers (TP and SP) looked independently at the title of each article and decided whether an article would be included or not. A consensus on the results of the two independent reviewers was established, if needed a third reviewer was asked for their opinion (KD). During the next stage, two reviewers (TP and SP) independently screened the abstracts and keywords and repeated the consensus finding process mentioned above. In a last step the reviewers (TP and SP) read the full text of each article included. In a final consensus finding round with all authors the inclusion and exclusion process was completed and the final number of articles was settled.

After the studies had been selected for inclusion, the next step was to methodically abstract key information. Two reviewers (TP and SP) developed the coding categories and KD and MF validated the coding system in a separate step. TP and SP independently analyzed and coded all included articles according the categories depicted in table 1 [Tab. 1]. The subcategory “Facebook as learning and teaching environment” includes means of communication of students and faculty via and in Facebook, forms of organizing themselves in open or closed groups and modalities of learning in and with Facebook (cases, exchange of information, advising/mentoring, peer teaching, etc.).

“Facebook and digital professionalism“ codes for privacy settings of profiles, release of pictures, publication of (inadequate) comments about patients, and open association to (inadequate) Facebook groups.

“Teaching Facebook professionalism” codes methods of teaching digital professionalism through case based sessions, lectures, interdisciplinary sessions, and across phases of medical education.

After the initial coding, consensus was established for ambiguous cases among all researchers.

Finally, TP and SP synthesized the coded evidence in terms of study characteristics, study quality and key aspects of each Facebook-use category. A meta-analysis was not done because of the heterogeneity of the studies and a lack of consistent dependent variables. The relative focus of medical education research from a Facebook perspective is represented in Figure 2 [Fig. 2]. The threads and limitations of the presented systematical literature review are discussed.

Our initial database search provided us with 352 titles published between 2004 and August 2013 (see Figure 1 [Fig. 1]). After reviewing titles and abstracts, we conducted 49 full text analyses. 16 articles met our inclusion criteria. They were made part of our final review and coded according to the categories described above (see Table 1 [Tab. 1]). We compiled a descriptive overview based on the phase of medical education that Facebook was used for. Details of each included title are provided in Table 2 (see Attachment [Attach. 1]).

The main aspects of Facebook in medical education, which were reflected in the study designs and methodological approaches of the included articles, are issues with regards to Facebook and digital professionalism (n=10) and Facebook as learning and teaching environment (n=5). Only a few studies (n=2) reported on specific pedagogical techniques in order to teach Facebook professionalism and none of the studies evaluated different pedagogical or instructional designs with Facebook in a controlled study design. The majority of studies were conducted in the United States (n = 9), some in European medical education settings (n=4), one in Australia, New Zealand and in Nepal.

Almost all studies could be assigned exclusively to one of the three developed categories, except of two [20], which combined Facebook as learning and teaching environment with either digital professionalism or teaching Facebook professionalism (see Attachment [Attach. 1]).

The studies included covered the full span of medical training (divided into the three phases: undergraduate medical education, graduate medical education and continuing medical education). It is noteworthy that some studies (n = 4) combined two or all phases of medical training (see Attachment [Attach. 1]). The predominant Facebook application form in undergraduate medical education was Facebook as a virtual learning and teaching environment (n=3/5), whereas the emphasis of studies in graduate medical training was on digital professionalism (n=4/6). One study evaluated the attitude of continuing medical trainees towards Facebook as a theoretical learning and teaching environment [11].

The number of study participants in this review ranges from 25 to 1023 (1297 undergraduate medical students, 1621 interns and residents, 327 continuing medical education participants and 1483 participants in mixed settings, total of 4728) in four continents and seven countries. In terms of study design, the vast majority of studies used observational and mono-methodological designs (n=15) to assess perceptions and attitudes of study participants based on Likert-scale self-reports (n=4), quantitative analysis of Facebook profiles and characteristics (n=9) or qualitative methods (n=2). One study reported an innovative approach to use Facebook for stress management purposes, but did not provide further evaluation [19]. Only one study used a mixed-method design to evaluate the use of Facebook by undergraduate medical students for self-organized learning purposes [10].Two studies used qualitative methods to assess virtual identity perceptions [21] and Facebook as a learning and teaching environment [22].

None of the studies used a pre-posttest or controlled trial design to assess the effect of interventions via Facebook as compared to other social media tools or more traditional methods. Two studies reported on the process of developing educational materials for teaching Facebook professionalism [20] but none evaluated educational effectiveness and efficacy. None of the studies evaluated higher competence levels following an intervention in the category digital professionalism (Kirkpatrick levels 2-4) [23].

Facebook is widespread among all phases of medical training, and arguably is the predominant social media tool applied in medical education. Our review indicates that Facebook, as an element of both the hidden and the explicit curriculum of medical education processes has been mainly investigated in terms of professionalism (62%), and to a lesser extend in terms of using Facebook as learning and teaching environment (31%). Two studies reported on educational techniques to teach Facebook professionalism and no study investigated the effectiveness of the use of Facebook compared to other learning and teaching environments or in comparison to different social media tools.

Facebook is especially well accepted as a learning and teaching environment by undergraduate and graduate medical students [24]. Students used open or closed Facebook groups to prepare for exams, share online material, discuss clinical cases, organize face-to-face sessions and exchange information on clerkships.

One study reported the successful implementation of a Facebook group to support undergraduate students particularly in managing stressful situations in the first year of medical school [19]. This report did not provide any psychometric evaluations of the intervention.

At the moment, there seems to be no conclusive evidence as to which students benefit from Facebook as a learning environment for self-regulated studying. Successful use of Facebook learning groups seems to depend on preexisting social connections and academic leadership either through committed students or guiding faculty [10]. The same study however reported that undergraduate students might object to formal involvement of faculty in the informal context of Facebook. In terms of faculty offering courses via Facebook, another study reported that 30% of surveyed students would accept and participate in a formal Facebook course [25].

Although all included studies used or evaluated Facebook as the main social media tool, some had also explicitly or implicitly included other social media tools such as YouTube or Twitter [24].

The evidence presented here is based on surveys and qualitative data. No studies used quantitative measures to correlate Facebook-based learning and teaching interventions with scores in high-stakes exams or clinical competency.

Based on our review 45-96% of health care professionals in any phase of medical training have a Facebook profile, which can be publicly identified (see Attachment [Attach. 1]). The results of one study [26] indicate that the number of Facebook profiles amongst medical trainees is increasing over time.

With regards to unprofessional behavior and privacy violations the reported results ranged from 0.02% to 16% (see Attachment [Attach. 1]). Types of violations of privacy or professionalism included specific types of status postings, uploading of unprofessional profile pictures or albums with identifiable patients or questionable self-representation, and membership in Facebook groups with obvious discriminatory connotations [27].

However, there was no standardized instrument to assess professionalism of Facebook profiles. One study described the development of a professionalism score based on ACGME recommendations [28], without any further detail on validity, reliability and generalizability of the instrument. Another study developed guidelines for individual and departmental usage of Facebook considering individual freedom, medical professionalism and institutional representation [29]. Several studies indicate that Facebook profiles are used to decide on applications for residency and in a few instances they play a role in patient-physician interactions [24].

Issues with digital professionalism seem to be of particular concern in the context of international medical rotations of both undergraduate and graduate medical students [26]. Concerning the regulations of privacy settings on Facebook, undergraduate students, compared to graduate students, are less likely to actively check and adjust their privacy settings in order to protect personal information [24].

None of the studies compared digital professionalism across medical education systems and different cultures.

Two studies reported on designing pedagogical material to teach Facebook professionalism [30]. One study presented two case-vignettes, using psychiatric settings to discuss and reflect issues of digital professionalism, which were developed based on a literature review and expert opinions [20]. However there was no testing of the case-vignettes included, so that no conclusive statement about their effectiveness in the clinical teaching context can be made at this point.

The second study presented and evaluated a single session on digital professionalism for residents in radiology embedded in a series of six sessions to foster professionalism [30]. The intervention involved information material about general unprofessional online behavior as well as hypothetical cases in the setting of radiology departments, which were discussed in round-tables. Based on a pre- and post-session survey, the authors established the need for such a session as did the overall satisfaction of the participants (77% found the format suitable). No analysis of actual digital behavior of participants was included in this study.

There are some systematical reviews, which looked at social media and social networks in medical education in general [24]. However, we are not aware of a systematical literature review that summarizes the specific use of Facebook as the most important social media tool currently available.

One review provided a general overview on different types of social media in undergraduate medical education and how those have been integrated into learning and teaching [7]. Social networks seemed to be the most promising tool and further in-depth analysis was recommended. Another review analyzed the use of social media tools in UME, GME and CME. According to the authors, at this point it is not possible to reliably estimate the effect of social media on learning in medical education [16]. A third review looked at the general use of social media tools in different health sciences and also concluded that no solid evidence on the effects on learning was available. Interestingly, the authors did not find any problems with professionalism [17].

Facebook differs from other social media tools by offering a variety of different interaction tools, like communication features (e.g. walls, groups), sharing features (e.g. possibility of uploading videos, photos and documents) and information features (e.g. news, feed). In contrast, other social media focus primarily on a single element like short news feeds (Twitter), videos (YouTube) or pictures (Pinterest).

Facebook differs from other social networks –like XING and LinkedIN –mostly by the number of active users and the focus on personal versus professional activities respectively. Facebook as a predominantly personal social network however can affect a wide range of medical education domains. These include issues of online learning and teaching environments with and without faculty involvement, digital professionalism as well as pedagogical strategies to teach digital professionalism. Every aspect of social interaction that is relevant for a physician or physician-in-training is in some way or another reflected in the virtual reality of Facebook. The need to include Facebook professionalism guidelines is well established [14] and was confirmed through this review. This must be transferred to the use of all social media tools. Case-based teaching of digital professionalism seems to be feasible in terms of learners’ self-reported reactiveness.

Although Facebook is well accepted by at least a part of medical trainees in all phases, there is no conclusive evidence on the impact of the use of Facebook as a personal learning and teaching environment on higher clinical competency levels and on patient-outcomes.

For educators as well as for researchers this review started to map the different aspects of Facebook in medical education and the current state of evidence with regards to the three major areas of Facebook-based interventions: digital professionalism, teaching digital professionalism and Facebook as learning and teaching environment.

The terrain for the potential use of Facebook has started to be mapped and in some cases it has been evaluated in terms of how this social media tool is being accepted by learners in all phases of their medical education. At this point, there is no conclusive evidence on what extent Facebook specifically contributes to medical learning outcomes with regards to high-stake exams or on higher clinical performance levels and patient outcomes. Controlled trails are needed to get a better picture of the educational benefit of Facebook and social media tools in general.

In the light of national competency-based catalogues for undergraduate and graduate medical education, it is important to include a digital competence for medical professionals at each level of their training. This might be particularly relevant for newly developed competency catalogues [31] and potentially for some established ones, which have not taken up this aspect yet, such as the CanMed or Swiss competence catalogue [32], [33]. It is furthermore important to define adequate assessment tools as well as effective teaching interventions for medical educators and residency directors in terms of Facebook and social media use in general. Although some studies report on pedagogical approaches to teach Facebook and digital professionalism, we did not find studies that presented or evaluated different pedagogical frameworks to use Facebook in the most effective way, neither from a teacher’s nor a student’s perspective [10].

Even though American medical schools have a strong presence of Facebook profiles, German medical faculties have not started to use professional Facebook profiles in order to market or represent their respective schools (based on a Facebook search of the authors for the 36 German medical faculties). If medical trainees are expected to take on responsibility for their digital self, medical faculties should role model this behavior. We suggest that medical faculties should actively and explicitly address both the opportunities for teaching and learning and the challenges with regards to digital professionalism. In the light of globalizing medical education there is a need to define adequate policies for the use of Facebook – and other social media tools – across medical education systems [26].

So far, in the context of medical education, using Facebook as learning and teaching environment has been evaluated only in a limited way. However, some first studies imply that Facebook might be an effective learning and teaching environment if set up in a thoughtful and structured way [10]. Additionally, teaching digital professionalism might be a great opportunity for designing interdisciplinary and inter-professional educational interventions.

Other areas, where Facebook has not been evaluated so far, include, for instance, its role for organizing extracurricular activities of medical students in terms of international clerkships, public health projects or peer mentoring activities, which are not necessarily part of the explicit curriculum but contribute in a meaningful way to becoming a physician.

This systematic literature review has several limitations. Due to the fast evolution in this field, there might be more relevant articles, which have been published recently but are not part of our review. Additionally, the selected and included studies are heterogeneous, which makes it difficult to synthesize the data, results and implications. A meta-analysis or subgroup-comparison was not possible. Most articles were descriptive, provided only quantitative data and did not report on important parts of how medical students use Facebook, for example if their behavior changed.

The authors declare that they have no competing interests.