Esther Choo only had a few thousand followers on Twitter before August 2017. Choo, an emergency physician at the Oregon Health & Science University, interacted mostly with other doctors. But when she tweeted one day about the racism she had endured while practicing medicine, her posts went viral—and her follower count shot up to 20,000 almost overnight. Now, she has nearly 80,000 followers.

“The professional benefits have been so concrete,” Choo says. Twitter, for her, has helped her meet new professional colleagues and friends and has offered opportunities for advocacy around racial and gender equity in medicine. “It’s hard to imagine what my career would be like without it.”

As a high-profile physician on the platform, Choo (@choo_ek) is an outlier in the medical community terms of her number of followers—but she’s part of a large and growing community of doctors and scientists who use Twitter as part of their professional lives. A Nature survey conducted in 2014 found that 13% of scientists use Twitter, and in 2017, an analysis published in PLoS One identified over 45,000 scientists with accounts.

Most scientists and physicians do not reach as wide an audience as Choo does, but they find it has been helpful for their careers. “Twitter lowers the boundaries of our institutional silos,” says Ankeet Udani (@ankeetudani), an anesthesiologist and medical-education specialist at the Duke University School of Medicine who started a Twitter-based journal club for residents. It also helps level the scientific playing field, says Janet Han (@netta_doc), a cardiologist with the Veterans Affairs Greater Los Angeles Healthcare System and the University of California, Los Angeles, and an author on papers about social media in medicine. “Anybody can be on Twitter,” she says, from first-year students to department chairs. “Anyone can interact with anyone.”

The platform is also fundamentally reshaping the way scientists and academic physicians can discover, discuss and share research. It is not an extracurricular endeavor to those who participate—it is a critical communication tool, says Vinay Prasad (@VPrasadMDMPH), a hematologist-oncologist at Oregon Health & Science University and an active Twitter user with over 30,000 followers. But that change comes with growing pains, and everyone from individuals to major institutions is struggling to figure out the best way to incorporate social media into traditional metrics around achievements. “It’s probably one of the most disruptive—and net beneficial—things that has happened in academic medicine,” Prasad says.

Immediate analysis

Before Twitter, researchers had limited ways to respond to and critique new research in their field. They could write a letter to the editor or an opinion piece in a journal, but that response would be published only if editors of that journal agreed to it. Even if it was published, it would often not appear for weeks. They could conduct their own experiments and publish their own paper, but that avenue is also subject to the same gatekeeping and time restrictions. Blogs allow self publishing, but it is hard to direct people to them, and the PubMed Commons—which offered a way for researchers to comment directly on articles—never caught on and was discontinued in 2018.

Twitter sidesteps those roadblocks and allows conversations about new papers to happen immediately and publicly, says Jordan Gauthier (@drjgauthier), a fellow at the Fred Hutchinson Cancer Research Center. “On the day of publication people can react to it,” says Gauthier, an active Twitter user with around 2,000 followers.

Comments on Twitter remove the journal from the equation, allow anyone to discuss scholarship and have a high visibility, Prasad says: “It’s a tremendous democratization of critique of science.” The open platform allows for the possibility that some of the criticism or comments might be inaccurate, he adds. “But I trust that the community is smart enough to draw attention to what is accurate. Inaccurate comments don’t get the same retweets.”

Sometimes, feedback given on Twitter can be more pointed and critical than what might be given in person or in a formal op-ed. “You can see sharks gathering around a paper to tear it apart,” Gauthier says. But while they can bite, the trend might help push the quality of research. “I think about it—am I going to get panned by one of the statisticians online?” he says. “Maybe it’s driving excellence and improving methods, and asking people to think about what the community in the field thinks, rather than just in your own office.”

Going clubbing

Online discussion of papers is sometimes facilitated by Twitter journal clubs. Journal clubs, where researchers get together and critically examine new papers or pieces of literature, are important forums for the exchange of ideas and continuing education. But they traditionally happen in person, and participants are usually limited by location. On Twitter, however, journal clubs can expand beyond those boundaries. Udani, for example, started one for anesthesia residents. Anesthesiologists are often isolated, but using Twitter to talk about papers exposes them to approaches from all over the world. “It’s a change to the traditional journal club, which is a bit outdated,” he says.

formal analysis of the educational potential of Twitter journal clubs, centered on a medical-radiation journal club, concluded that the flexibility and accessibility of the digital environment offer benefits that in-person clubs do not—including the opportunity for more people to observe without pressure to participate, global engagement and fewer hierarchies based on seniority. In this particular journal club—the #MedRadJClub meeting—one hour of conversation could have up to 245 participants and 4,559 tweets, the analysis showed.

Twitter can offer a second chance for papers that might not have been accepted in high-impact journals, says Sharonne Hayes (@SharonneHayes), cardiologist and founder of the Women’s Heart Clinic at the Mayo Clinic Rochester, Minnesota. She was the senior author on a 2017 paper that found, for the first time, that female doctors were significantly less likely to be introduced with the professional title ‘Doctor’ than were their male colleagues during grand rounds, when clinicians describe patient cases to other physicians—male physicians introduced their female colleagues using formal titles only around half the time. The team submitted their results to three high-impact journals, but were rejected.

“The main sense I got from reviewers was that they didn’t think [the findings] were actually a thing,” Hayes says. The paper was eventually published in a lower-impact women’s health journal, but she pushed the paper out on social media and wrote a blog post describing the findings. That helped the paper reach a wider audience, even out of a less-widely-read journal. “As a result, my co-authors have been quoted in Time, and the Washington Post.”

The scientific community is still trying to figure out how to integrate social media into traditional benchmarks of success. Hayes herself says that the number of retweets and likes a paper gets should not be a surrogate for the value of the science itself.

Upending power structures

Social media offers an alternative to traditional power structures in science and research, which give high-impact journals, tenured professors and prestigious institutions the most weight. On Twitter, people who do not have tenure, or have more limited publications to their name, or are early in their career have opportunities to demonstrate their expertise. But displays of knowledge on social media, rather than in traditional forums like journals, are sometimes criticized as less relevant or rigorous. In 2014, a researcher created a metric called the “Kardashian index” to measure a scientist’s Twitter following against the number of citations their papers receive—with the implication that some had a Twitter “celebrity” that was not grounded in academic success and therefore was not justified.

The index was broadly criticized, including by those who took issue with the idea that citations are the most important metric of scientific expertise—which penalizes junior researchers, for example, who will automatically have a lower citation count. “It’s critical of people who seek to communicate more broadly, as if that’s a bad thing,” Prasad says.

Choo says that mentality has faded within the scientific community. “A few years ago, it was a very different landscape,” she says. “You don’t hear much anymore that you’re wasting your time on Twitter and should be writing a paper.”

Some institutions are starting to consider social-media activity in hiring and promotion decisions, which is a positive step, says Eric Topol (@EricTopol), a cardiologist and geneticist at the Scripps Research Institute and a high-profile figure (with over 177,000 followers) in scientific Twitter. “Increasingly, this is going to be the way the science community does exchange ideas, and it complements the typical story of a person’s citations,” he says.

However, it should be included in only a small way, says Hayes. “Being popular should not be the reason someone becomes a full professor.” Organizations have to grapple with how much weight they give social-media use and how they determine what types of usage are relevant to a person’s scientific work. “We need to systematize the way we assess validity,” Hayes says. “It’s still a bit of a Wild West out there.”

Choo did not initially think that social media should be incorporated into career-advancement decisions, but says she’s been won over. “I was sold on the quality and rigor of some of the educational information people are putting out on social media. People do tweetorials, which are really rigorous. It’s incredible medical education.” However, Choo says that rigorous, quantitative measures need to be developed to assess people’s social-media use.

Establishing a presence

With so many conversations about science and medicine happening on Twitter, people who do not use it at all are missing out on an important forum for conversations about science and medicine, Hayes says. They do not have to be as active as Prasad or Choo—or even tweet at all—but they should keep an eye on the discussion. “I think it has reached the point where academic physicians for sure should have a presence, if nothing else, just so they can see what’s going on. It’s like reading journals,” she says. “You can’t put your head in the sand. It’s another source of information.”

People who resist often have common concerns, including the brevity of tweets and the time it takes away from other work. Reshma Jagsi (@reshmajagsi), deputy chair in the Department of Radiation Oncology at the University of Michigan, shared many of those concerns before she started using Twitter this summer. “I was a Twitter resistor,” she says. She saw her concerns upended quickly, noting that threading tweets and linking out to articles allows robust conversations.

Social media can eat up a lot of time, but it is possible to use it productively and in moderation. Good science, Choo says, often takes time and space, so time management is key. “Some days I can get really caught up in it,” she says. “I definitely do think you need safeguards in place to make sure you’re staying productive.”

Sorting through the volume of information on Twitter and identifying the best ways to use it can take time as well. However, ignoring it entirely is not the right solution to that problem, and it is possible to see a slice of the information, even if someone cannot see everything, Jagsi says. “The sorting of the wheat from the chaff is, so far, worth it.”

This article is reproduced with permission and was first published on December 9 2020.