gms | German Medical Science

Fifteen years ago, medical students used to look up technical terms in encyclopaedias, nowadays, they turn straight to websites such as Wikipedia. Standard textbooks which for decades were the constant companion of every future doctor have now been replaced by electronic versions, for instance smartphone apps. And whereas ten years ago students used to phone each other to organize study groups, these days this is normally done using the invitation functions of various social networks like Facebook. Even the obligatory discussion of past papers before every examination is now increasingly taking place in local Internet forums or by using online office programs like Google Drive. A student survey at the Faculty of Medicine in Leipzig found that on average, the Internet is used for study purposes alone for 8.3 hours every week by the some 200 respondents in the third and seventh semesters who took part [1]. As in many other walks of life, times have changed, and even the study of medicine has been altered by technical progress [2], [3]. However, the extent to which teaching staff have caught up with the changes and how they will be table to take students’ altered learning behaviour into account in the future are currently uncertain.

Before the benefits of Web 2.0 can be debated, we first need to establish what the term Web 2.0 actually means. Although it first cropped up in 2004 at various developers’ conferences in the USA, it has still not yet been clearly defined. Sir Timothy Berners-Lee, who is regarded as the inventor of the World Wide Web, stated the following in an interview he gave in 2006: “I think Web 2.0 is of course a piece of jargon, nobody even knows what it means.” [http://www.ibm.com/developerworks/podcast/dwi/cm-int082206.txt].

In the authors’ opinion, the term Web 2.0 can now be defined more clearly. Web 2.0 marks a clear advance on ‘Web 1.0’ – a concept not actually defined as such – in which just a few providers made information available to users for passive consumption. In Web 2.0, the Internet user is no longer primarily a consumer but is increasingly playing an active role. Supported by interactive applications, users create, edit and distribute content largely by themselves. The various Web 2.0 platforms enable any user to share information without the need for advanced programming skills. As a result, projects can be developed whose value increases as more and more users take part (e.g. Wikipedia). Web 2.0 applications are ultimately nothing but platforms made available by a single operator whose content is, however, written and updated by contributors.

In the meantime, the term Web 2.0 is being gradually replaced by the terms ‘social web’ and ‘social media’, which refer to all the media employed by users to interact with each other. Emphasis is placed on communication and sharing user-generated content [http://wirtschaftslexikon.gabler.de/Archiv/569839/soziale-medien-v2.html], [http://wissen.harvardbusinessmanager.de/wissen/fak/dok.pdf?id=73314406]. Drawing a clear distinction between the social media and Web 2.0 is difficult.

Below, online portals which are used by students of medicine at Universität Leipzig are described. Both current and possible future uses in connection with the study of medicine are discussed (see attachment 1 [Attach. 1]).

Wikipedia [http://de.wikipedia.org] is an online encyclopaedia which has been in existence since 2001 and which is undeniably one of the pioneers of Web 2.0. In addition to reading its content, any user can also write new articles and edit existing ones. Although Wikipedia is by no means acclaimed on all sides in the scientific community, it is widely used by medical students and even doctors taking further training. In fact studies have shown that 80% of doctors use wikis like Wikipedia to obtain medical information. Over 90% of these doctors say they do so because accessing them is quick and easy [4]. And the level of usage among medical students is probably even higher.

Teaching staff have relatively little influence on the use of Wikipedia. Although they can of course actively take part in writing content, there are no figures recording how many lecturers actually do so. One main criticism levelled at Wikipedia (and which has already been researched on several occasions) is the lack of references and the errors contained in some medical articles. This is the downside of one of the big advantages of Web 2.0 – the possibility for any user to actively change content, regardless of their knowledge. With not every article being reviewed by experts, errors can slip through, causing problems in not just medicine but also potentially any other field [5].

YouTube [http://www.youtube.com] is a portal where users can make their own video files available to everyone. It is mainly used by the general public to host a huge quantity of short video clips. In the meantime, however, exclusive music videos, TV shows and podcasts created especially for YouTube have been posted there as well. Users can interact with makers in various ways. As far as the study of medicine is concerned, both simple podcasts (such as lectures) and specific instructional videos (e.g. for practical medical skills) can be published online. However, the former possibility is beset by serious limitations compared to other platforms and independent developments. For example, only simple lecture recordings can be published simply. There is no way of subdividing videos into individual chapters or adding supplementary literature (such as pdf files, scripts or learning objectives). For this reason, the lecture podcasts made available by Universität Leipzig’s Faculty of Medicine since the 2011/12 winter semester have been published in a proprietary player, which provides these additional options and so enables more effective learning. It makes more sense to use YouTube to augment lectures by posting training videos on certain diseases or medical skills. Videos on, say, how to correctly obtain peripheral venous access would be conceivable, as would events which can only be displayed poorly (if at all) in a lecture setting (e.g. a picture of a specific convulsion or the initiation of anaesthesia).

Recent studies have shown that being able to watch these streamed film clips from any web-enabled device at any time is very popular with students, and is also more advantageous than conventional methods such as handing out DVDs [6]. In addition to the videos themselves, YouTube’s comments feature can be for small discussions. This aspect can be expanded by integrating the YouTube player into a separate portal; a forum/upload feature can be used to allow a more detailed debate about the embedded video. Integration of this nature is for example planned for the student portal in Leipzig. Moreover, this is something which could also be employed outside a study environment. For instance, many hospitals have already begun to post information films for patients online. And at the Faculty of Medicine at Universität Leipzig, video posts are augmented by educational videos for the general public dealing with, say, relevant aspects of first aid (stable lateral position, cardiopulmonary resuscitation, etc). Then again, studies have shown that the quality of such instructional videos often varies enormously, and that those viewed the most often are not necessarily the best ones in terms of their medical content [7].

Apart from YouTube itself, there are now a number of other video sharing sites with different target groups. One example is Vimeo [http://www.vimeo.com/], which is being increasingly aimed at professional filmmakers and ambitious amateur filmmakers, but whose functions mean it could well be a suitable alternative for use in medical training. Compared to YouTube, more attention is paid to the quality of the film clips posted at Vimeo than to their quantity. The proportion of HD films on Vimeo is higher than on YouTube. And there are hardly any commercial contributions from the private sector etc at Vimeo. Instead, it hosts independent productions, all of which are characterized by excellent visual and audio clarity – an essential element of good medical training videos.

Similar to YouTube, many hospitals and medical schools have been increasingly present in social networks in recent years. At the top of the pile is Facebook, which, according to recent studies, is used these days especially frequently by healthcare institutions in the UK [8].

Facebook is by far the biggest social network with more than 900 million active users worldwide [http://www.facebook.com]. Starting from a small network of students at Harvard University, since its inception in 2004 it has evolved into a global company that is now much more than a simple website thanks to the provision of a variety of apps for smartphones, scripts for administrators and a large marketing department. It can be used in various ways in medicine. On the one hand, hospitals and universities use their own Facebook pages to raise their profile and hence attract new patients or prospective students. Moreover, members of staff can publicly associate themselves with their place of work by linking their employer’s Facebook page to their own. Take-up is very high. A recent study from the US shows that up to 96% of medical students regularly use Facebook. And following graduation, nearly 50% of clinicians continue to use it frequently [9]. At Universität Leipzig, the StuRaMed student council of the Faculty of Medicine has its own Facebook page (see Figure 1 [Fig. 1]), which students can subscribe to in order to obtain up-to-date information. Upcoming events, for example, are announced by using built-in Facebook features.

The experience of the student council shows that by taking this new approach, it is now possible to notify more students in less time than used to be the case via the regular website. In recent months, the university’s use of Facebook has also grown. Universität Leipzig now has its own official Facebook page [http://www.facebook.com/unileipzig] which is updated regularly by the press office. Apart from current students, the main target groups are prospective students and alumni. Facebook also gives the latter a simple way to stay in touch with former classmates once they’ve graduated. The Faculty of Medicine of Universität Leipzig currently only operates one official Facebook page; the page of ‘LernKlinik Leipzig’ is in effect the website of the Leipzig Skills Lab [http://www.facebook.com/LernKlinikLeipzig]. Alongside general information, attention is drawn to new courses – a feature which is very popular among students since they can often enrol more quickly and don’t need to keep watching the relevant section of the student portal.

Social networks like Facebook can also be significant for postgraduates. Groups of specialists have begun using social networks to interest medical students in certain fields of medicine. This is done by means of for instance local campaigns, congresses announced on Facebook, and small competitions for which entrants have to subscribe to the Facebook page concerned. One example is ‘My pulse’ – a campaign by the German Association of Anaesthesiologists [http://www.facebook.com/BDAeV].

StudiVZ [http://www.studivz.net/] was set up in 2005 as the answer to Facebook in the German-speaking countries and – like Facebook – was originally only intended for students. In its early years, the platform’s membership grew by leaps and bounds. Subsequently, offshoots were soon founded for school students (SchülerVZ) and non-students (MeinVZ). As a result, StudiVZ and its associated networks developed into easily the largest social network in the German-speaking part of Europe.

StudiVZ/MeinVZ also allow separate fan pages to be started. Furthermore, they enable private or public groups to be set up – a feature which was frequently used by Leipzig students during the network’s heyday (see Figure 2 [Fig. 2]).

Since then, however, its significance has declined sharply. The networks have been clearly overtaken by Facebook regarding both the numbers of users and visit duration. This highlights one of the risks of such projects in Web 2.0 – for despite becoming so successful so quickly, they can disappear just as rapidly. This is an aspect which must be borne in mind when planning integration into the curriculum. Since students’ user behaviour can only be influenced by lecturers to a very limited extent, sometimes well thought-out Web 2.0 educational projects which have been meticulously planned may come to nothing simply because not enough students actively use the relevant platform. Because StudiVZ and its related networks are now only used rarely by students, they play a far smaller role in medical training. Accordingly, there are currently no projects afoot at Leipzig to integrate StudiVZ/MeinVZ into the curriculum.

XING [http://www.xing.com/] is a social network that was founded in 2003 under the name openBC. XING currently has 12 million users. Unlike networks like Facebook and StudiVZ, at XING the main emphasis is on professional contacts. What’s more, XING offers premium accounts – which is why it isn’t used much by medical students. In medicine, it’s mainly employed by graduates to keep in touch with former classmates and to build up their own professional networks. However, this idea of networking is less pronounced and not as important for professional success among salaried doctors in hospitals as in the business sector. Therefore, at Universität Leipzig, XING is mainly used by the alumni network (see Figure 3 [Fig. 3]).

Apart from the Alumni Newsletter with information on current university life, XING is used to notify ex-students of reunions and other events at Universität Leipzig.

Another prototype and one of the earliest representatives of Web 2.0 was Internet forums. Following registration (generally free) and the creation of an account, anyone can discuss specific issues with other interested users in a variety of forums and make their own contributions to fuel the debate. Such online forums are widespread among medical students. The two main ones in Germany are Medi-Learn.de and DocCheck Campus (previously Medizinstudent.de), both of which evolved from a forum into successful businesses. Apart from a simple forum, many other useful things for medical students are to be found there such as oral examination records and a database of scripts for the various phases of medical degree courses. These two large providers are joined by a large number of smaller local projects, which are often run by student organizations or individual enthusiastic students. Studies at the Faculty of Medicine of Universität Leipzig have shown that local projects among medical students are usually the best known and also the most used by far. And when students start studying, they are far better known that the common medical search portals such as MEDLINE (see Figure 4 [Fig. 4]).

Since 2003, the local platform Leipzig-Medizin.de [http://www.leipzig-medizin.de] has become an integral part of studying medicine in Leipzig, with awareness reaching 95% (see Figure 4 [Fig. 4]). Leipzig-Medizin.de is now a portal which, apart from the forum itself, also posts current news and a variety of downloads such as past exam papers, scripts and oral examination records. The platform was founded by a medical student who wanted to enable his fellow students and himself to share their experience and swap files. It’s still run by the original founder, who is now a lecturer involved in training students. Students use the forum to discuss various study problems (see Figure 5 [Fig. 5]). They often benefit from reading the experience of students in higher years posted on this site.

In addition to current problems, past examination questions are discussed and tackled, particularly in the revision period. With each individual student benefiting from others’ knowledge, in a short time almost all outstanding questions can be jointly solved. For teaching staff, a platform like this enables them to contact students directly. This possibility is used by lecturers both overtly (i.e. they say they are faculty members) and ‘covertly’. Lecturers can see from the discussions where the problems lie and what aspects should in future be taught differently. By the way, all the content of Leipzig-Medizin.de is available to teaching staff, too, once they have registered. As a result, more and more lecturers have joined the portal in recent years so that they can benefit as well.

In addition to the examples of Web 2.0 discussed, there is a whole raft of other well-known and less well-known portals and applications. One platform which is fundamentally different from the others is Google Drive [http://drive.google.com]. Google Drive (formerly Google Docs) is a service which allows users to back up files online and to automatically synchronize them between different Internet-enabled devices. Besides, all popular office applications (word processing, spreadsheets, presentations, etc) can be carried out online – not just individually, but in teams, with all changes displayed to the other users in real time. This platform has really caught on at Universität Leipzig in recent months. Students come together to form teams and create joint student scripts for series of lectures or comment on and deal with existing teaching materials and past exam papers. Google Drive could well be used increasingly by teaching staff as a way of improving coordination and contact with each other as well as communicating with students in connection with elective subjects and workshops or when supervising, say, doctoral theses [10], [11]. In fact keen use is made of these possibilities both within the Medical Education and Research Training Team at the Department of Anaesthesiology and Intensive Care Medicine and the E-Learning and New Media Working Group at the Faculty of Medicine of Universität Leipzig. Google Drive provides a simple way to make large files available to all the members of a workgroup without overloading their individual email inboxes. The files can also be accessed by teaching staff anywhere in the world, ensuring that everyone is always up to date. Google Drive is also used in Leipzig to develop curricula and project papers, the ability to have documents edited and commented on simultaneously online by different lecturers being especially popular. At present, it’s being successfully used to for example prepare the syllabus for the new interdisciplinary field QSB 14 ‘Pain Medicine’, including the necessary coordination between the various disciplines.

Apart from its many benefits, Web 2.0 also contains a number of risks that many users aren’t initially aware of. These include the validity of data freely available on the Web, the commercial interests of some listed companies, the potential leak of sensitive data (such as student data, patient data) and the volatility of the Internet (as epitomized by the face of StudiVZ). As studies have found that many university lecturers are unaware of both the risks and the possibilities of Web 2.0 or do not know how to use the various portals [12], they need to undergo regular training. This is done annually in Leipzig during university teacher training. However, it is apparent that the need for training on how to work effectively yet safely with Web 2.0 will grow.

One worry for university teachers considering the use of Web 2.0 in medical training concerns the validity of the information found in various online sources. Different studies (e.g. by Wikipedia) have failed to provide a uniform picture. However, a survey conducted among students in the Faculty of Medicine at Universität Leipzig revealed that students are well aware of this problem and only a small proportion of users trust the information they find unquestioningly (see Figure 6 [Fig. 6]).

Another important aspect is that most social networks pursue commercial objectives. Although this may not be apparent at first glance, large companies are responsible for all platforms, and their primary aim is to maximize their profits. This may prompt decisions that are not in their users’ best interests. Therefore, commercial platforms should not be used without reservation in curricular teaching. Once again, appropriate training for lecturers would make sense. The issue of data ownership has not been clarified when non-university networks are used. Each medical faculty manages huge quantities of confidential student data (e.g. their enrolment number, dates of birth and home addresses). Within each faculty, it is possible to influence the degree of data protection and data backup. However, this is no longer the case regarding social networks. When faculties forward sensitive data to social networks (and hence to the companies behind them), what happens to this data is beyond their control. This is one of the main reasons why social networks have not yet found their way into curricular teaching and are only used in optional courses, where students can decide themselves what information to provide. Although this approach is not without its problems, at least no students are forced to register with a social network against their will during their compulsory training.

One problem which is set to become even more significant in the future is the protection of patient data. The possibilities offered by Web 2.0 in conjunction with mobile technology such as smartphones raise the risk of sensitive patient data being leaked. In future, students and staff at healthcare facilities must at all costs be alerted to the dangers [13], [14]. At present, for example, very few medical schools in the United States have suitable guidelines in place governing behaviour in the social web [15].

The volatility of the World Wide Web could also prove to be problematic. Something which on the one hand is an advantage could also be a disadvantage if, say, sizeable teaching projects or even entire curricula were geared to certain Web 2.0 applications – and hence dependent on them. If the application in question is closed down (e.g. for commercial reasons as mentioned above) or students stop using it (as was the case with StudiVZ), a painstakingly compiled project will have to be abandoned. The answer could be for institutions to create their own portals which integrate various external Web 2.0 applications and possibilities and are adapted to local conditions. Platforms tailored to the interests of the medical faculties behind them would enable the creation of concepts which enjoy long-term success without having to be dependent on external providers. In-house portals also have the advantage that students are not forced to register with external providers like Facebook in connection with their studies. Teaching staff need to accept the fact that there are still students who refuse to join social networks on principle for privacy reasons.

Open-source systems like Moodle^® or ILIAS^® make a suitable alternative to complete in-house developments. They integrate several Web 2.0 components and can be freely be adapted to users’ requirements. In addition, personal adaptations can also be made available to other users.

For these reasons, the Faculty of Medicine at Universität Leipzig is currently extensively expanding the existing student portal to include various Web 2.0 services in an effort to improve not just teaching but also interaction among students and with teaching staff. The aim is to harness the benefits of Web 2.0 in order to advance curricular teaching.

So far, social networks have only influenced curricular teaching ‘off the record’. Communication among students about courses in the platform Leipzig Medizin.de acts as a form of feedback for lecturers which bypasses the official evaluation carried out by the Faculty of Medicine but still reaches interested teaching staff directly and hence affects the development of courses and exams. Two direct examples are the fact that past questions circulating on the platform aren’t reused in multiple choice exams while oral examiners find out what questions students are expecting from them.

An online survey is going to be carried out into the needs and requests of medical students and teaching staff in Leipzig with respect to the integration of Web 2.0 components so that the benefits can be fully tapped by them. Run by the E-Learning and New Media Working Group at the Faculty of Medicine, the project will also evaluate how these target groups use Web 2.0 depending on various parameters (semester/job, age, gender, online access, etc). Working on the basis of a few smaller surveys already completed at the Faculty of Medicine, this study is intended to lay the basis for all future projects in the field of Web 2.0 and e-learning. This is the only way to correctly integrate the corresponding Web 2.0 components into the existing student portal and to maximize the benefits for students and teachers.

Web 2.0 and the social web have already considerably influenced life in recent years. Looking to the future, the opportunities that have arisen now need to be incorporated into the teaching of medicine.

The authors declare that they have no competing interests.