A Gamified Social Media–Based Head and Neck Radiology Education Initiative of the American Society of Head and Neck Radiology: Viewership and Engagement Trends at 3 Years

DISCUSSION

We report the design, implementation, and 3-year longitudinal assessment of a new social media–based educational initiative sponsored by the ASHNR. This new initiative is used by radiology learners of all levels of training (medical students, interns, residents, fellows, and practicing radiologists), as well as nonradiologist physicians (eg, otolaryngologists) and nonphysician health care providers (eg, dentists) worldwide. We found Twitter to be a highly visible and engaging tool for radiology education, as evidenced by the >2 million views and >200,000 interactions during the first 3 years of the #ASHNRCOTW initiative (Figs 2 and 3). We also found Twitter to be particularly well-suited for the delivery of education/edutainment content during the COVID-19 pandemic, as evidenced by the statistically significant increase in all viewership and engagement metrics during the pandemic compared with prepandemic levels (Online Supplemental Data). During this era of social distancing and lack of in-person societal meetings, social media provided a forum for society members to continue to interact and network, benefitting from an international form of asynchronous interactive transmedia storytelling to continue educational efforts alongside virtual conferences and online webinars. We also observed a statistically significant increase in mean new monthly followers of the @ASHNRSociety Twitter account during the pandemic compared with prepandemic levels, as well as a 5718% increase in total followers when comparing post-#ASHNRCOTW (7564 followers) to pre-#ASHNRCOTW (130 followers) levels. This growth in @ASHNRSociety Twitter followers outpaced the general growth of overall Twitter users during the same time period, which increased 41% from 122 million users in the second quarter of 2018 to 206 million users in the second quarter of 2021.²⁹ Most important, we note the potential for global radiology education outreach with this platform, as evidenced by the 7564 Twitter followers of ASHNR distributed throughout 130 countries, 66% of whom reside outside the United States.

Before the implementation of the #ASHNRCOTW, the @ASHNRSociety Twitter account was primarily used to advertise the annual meeting and provide occasional member updates regarding society news. Thus, viewership and visibility were limited, and content was directed primarily at existing society members. By establishing an ad hoc social media committee (and, subsequently, merging it with the pre-existing website committee), the ASHNR empowered a group of society members to design, implement, and oversee what has grown into a long-running, highly visible, and engaging educational initiative. This translates into an established outward-facing advertisement of the society’s educational offerings that is powered by the volunteer effort of engaged society members, incurs essentially no financial cost to the society, and uses an educational delivery vehicle that has previously been shown to appeal greatly to younger generations of learners.⁴ This initiative has also increased the society’s outreach and mentoring efforts, connecting head and neck radiologists internationally with a platform to interact and educate with novel edutainment technology.

The concept of using social media as a platform for medical education is not a new one, dating back to the first published medical literature description of a microbiology blog in 2010.³⁰ Multiple authors have previously detailed potential strengths and applications of using social media as a tool for radiology education, but these are largely limited to editorials and perspectives with few data-driven or outcomes-based investigations of this novel education tool. In a 2021 study from radiologists at Johns Hopkins, the authors found Twitter to be a useful tool for disseminating radiology education with scroll-through videos offering the highest level per tweet impressions and case images offering the highest level of per tweet engagements in their study.⁸ In a 2018 study from radiologists at Indiana University School of Medicine, the authors detailed a departmental social media–based radiology education initiative, documenting a linear growth trend of increased per-case Twitter impressions and engagements during its first year of implementation.¹³ In comparison, our study shows a growth trend in both Twitter impressions and engagements over a longer study duration (3 years), including a statistically significant increase in Twitter viewership and participation during the COVID-19 pandemic compared with prepandemic cases. The reasons for the increase in #ASHNRCOTW participation during the pandemic are not resolved by this study but may relate to the transient decrease in imaging volumes, leading to more available time for education or an increased desire for professional interaction during this time of social distancing and isolation. Similar to the results of the Indiana University study,¹³ we also found that the unknown #ASHNRCOTW case tweets had greater mean engagements than the answer tweets. This difference in overall interaction with the answer tweets is likely due to the gamified learning fostered by this educational initiative.

A key element of the #ASHNRCOTW education initiative was the explicit use of gamification, in this case, soliciting participants to submit answers to the unknown cases in the form of GIF images, to increase engagement and improve learning. Gamification refers to the integration of game elements into a nongaming environment, a concept that has increasingly been applied to medical education during the past decade with the goal of improving learning outcomes.³¹ A growing body of literature suggests that gamification is a valuable tool for medical education, contributing to increased learner engagement, increased use of education resources, increased learner satisfaction, and improved learning outcomes.^{31⇓⇓⇓-35} Gamified learning strategies have made inroads in radiology education, including such tools as in-lecture audience response systems, resident or fellow leaderboards, game fiction scenarios and role-playing, and positive reinforcement with performance rewards for trainees.^36⇓⇓-39

We intentionally gamified the #ASHNRCOTW initiative to rely on audience submission of GIF images as the primary means of participation. The benefits of using GIF images are 3-fold: 1) Participants can drop hints at the correct answer without spoiling it for other participants, 2) participants weave a storylike tapestry of memorable GIF images that combine narrative and flashbulb episodic memory with factual medical information (semantic memory) to augment learning, and 3) GIF images offer a light-hearted and often comical vehicle for approaching learning, which adds to the enjoyment of participation. This unique interactive edutainment allows participants to make connections they might not otherwise contemplate between the unknown cases and their answers using GIF images, fostering interactivity and potentially increasing the knowledge retention and understanding of complex head and neck anatomy and pathology. This asynchronous interactivity allows our educational effort to expand internationally and continuously throughout the year, expanding our audience from traditional academic radiology in-person annual conferences alone.

This study does have a few important limitations. First, we used Twitter analytics data to assess #ASHNRCOTW viewership and engagement but did not explicitly assess learning. Thus, we can demonstrate significant increases in viewership, engagement, and account followers after the establishment of the #ASHNRCOTW, but we cannot be certain that participants improved their head and neck radiology knowledge base or retention. Second, Twitter viewership data may be exaggerated due to the presence of social robots (“bots”), which are automated programs that generate or share content on social media with the intent of influencing users. Bots are estimated to account for 9%–15% of active Twitter accounts,⁴⁰ creating uncertainty in the exact number of human eyes our cases reached. The influence of bots on the niche Twitter demographic of head and neck imagers is likely small and probably has a limited effect on #ASHNRCOTW viewership. Third, we did not directly survey participants about their perceptions of this educational initiative. Thus, we cannot be certain whether participants found #ASHNRCOTW to be useful for their learning needs, though the high engagement rate (9.3%) suggests that they found it valuable. For reference, Twitter engagement rates of >1% are considered strong.⁴¹ Last, we observed a significant increase in #ASHNRCOTW Twitter viewership, engagement, and account followers corresponding with the COVID-19 pandemic. We cannot be certain whether these increases represent durable trends or a transient effect of pandemic era learning, which would require long-term studies of postpandemic viewership trends.