Importance of Social Media Alongside Traditional Medical Publications
Social media is a new form of communication that leverages the Internet to create online or virtual communities. Within these established communities, users develop networks with friends, family, colleagues, businesses, and institutions. Within networks, users can share information, content, news, photos, and videos. These networks can be highly interactive, with users commenting, liking, and sharing posts within their own networks, resulting in the rapid dissemination of information. A central set of characteristics of social media is that the content is highly accessible and can be shared quickly. The net result of these factors is the viral potential of social media, defined as the likelihood that users will rapidly reshare content that they see in their own feeds.1
Social media has been rapidly growing in popularity and usage. Data from the 2014 Pew Internet Project2 show that 74% of adults who are online use social networking sites, including 49% of adults aged ≥65 years. The majority of adults (71%) use Facebook, 23% use Twitter, and 26% use Instagram. Two-thirds of US adults using social media receive news items through Facebook or Twitter,3 and, overall, 10% of US adults receive news reports from Twitter and 40% receive news reports from Facebook. Finally, roughly half of US adults see reports regarding health and medicine content on Twitter and Facebook.
When social media users look for information about health and health care online, they can find posts from newspapers, magazines, and even medical journals. Many medical journals are now using social media campaigns to help disseminate medical information beyond the pages of their journals to a potentially broader audience.1 In fact, the majority of top medical and cardiovascular journals all have social media campaigns.
Why is it important for medical journals to use social media? Using social media helps medical journals to disseminate medical findings. In addition, social media enables medical journals to target a different audience than traditional journal readership. Thus, the purpose of this perspective is to highlight the role of social media campaigns in the context of traditional medical publishing. By publishing this perspective in our Journal, we hope to bridge the gap between our traditional readership and our social media followers. This article will detail how social media campaigns can complement traditional methods of dissemination, what are the components of a good social media campaign, what are the strengths and limitations of social media, how the impact, value, and return on investment can be quantified, and how social media will continue to expand into the future.
Traditional Medical Publishing
The first medical journal, Philosophical Transactions, was founded in 1665 by The Royal Society.4 Nearly 150 years later, in 1812, 2 Boston physicians launched the journal that is now known as the New England Journal of Medicine (NEJM),5 and 12 years later, in 1823, British surgeon, Thomas Wakely, founded The Lancet.6 Shortly thereafter, in 1840, the Provincial Medical and Surgical Association created The Provincial Medical and Surgical Journal, known today as the British Medical Association and BMJ, respectively.7 The goal of BMJ, like so many other society journals that followed, including the Journal of the American Medical Association founded in 1883,8 was “to support medical professionals and organizations in improving the delivery of health care.”7
Many of the most successful medical journals were launched by societies, and the original readers of those journals were members of that society. As the journals grew, readership extended beyond a society’s members through the use of libraries. One of the major contributions to the scientific literature was the creation of Index Medicus in 1879 by the Surgeon General of the United States John Shaw Billings. The index was published from 1879 to 2004 and is viewed as the precursor to MEDLINE, formerly known as MEDLARS Online, which was launched nearly 100 years later in 1971. Despite this electronic advancement, access to this online database was still limited to physicians and researchers through their libraries.9
The advent of the World Wide Web in the early 1990s changed the publishing landscape forever. One of the first journals to create an online presence was The Journal of Biological Chemistry, which launched its online site in 1995 on the HighWire Press platform, created by Stanford University Libraries.10 This advancement was soon followed, in June 1996, by the launch of PubMed, a free, online version of MEDLINE.9
Although some journals, such as Nature, were founded, in part, on the principle “to place before the general public the grand results of scientific work and scientific discovery,”11 most medical journals considered their readership the physician/clinician and researcher. The dissemination of research results to the lay public was essentially a separate enterprise until 1969, when the Ingelfinger Rule was created by the editor of NEJM, Franz Ingelfinger.12 In his editorial, “Definition of Sole Contribution,” Ingelfinger expanded the Journal’s rule for prepublication as follows: “Papers are submitted to the Journal with the understanding that they, or their essential substance, have been neither published nor submitted elsewhere (including news media and controlled-circulation publications). This restriction does not apply to (a) abstracts published in connection with meetings, or (b) press reports resulting from formal and public oral presentation.”12 As Arnold Relman, another former Editor of NEJM acknowledged in 1981, the rule helped “to protect the newsworthiness” of an article. Relman noted, “our policy is no different from that of many major newspapers and news magazines, which do not publish certain medical stories already given full coverage elsewhere.”13
Since that time, consumption of the medical literature by physicians and the public has converged, and medical journals have evolved from simply being professional periodicals to publishers of research findings that can have wide interest to the general public. Journals began using the services of public relations specialists to help promote their articles and to build their brands as the preeminent sources of medical news. Several different modalities exist to help with the dissemination of medical information, including PubMed, electronic table of contents, print media, press releases, TV news, and many of the new forms of social media, which will be discussed later.
The traditional methods used to promote medical journal articles have several strengths. First, skilled public relations professionals assume responsibility for crafting a message that has broad appeal and is of interest to the general public. Second, distribution networks, such as PR Newswire, are used to disseminate the message to the lay press. Third, reputable news outlets, including newspapers, TV stations, and Web sites, promote the journal’s article to a mass market through their news stories. However, there are limitations to this approach. Substantial resources are required to implement an effective media campaign, making it impossible to implement on a large-scale basis. In addition, not every article published in a medical journal has the broad appeal required to make such an effort a worthwhile investment. Unfortunately, although an article may represent an important advancement to the medical community, it may not be newsworthy and it is unlikely that it will be disseminated through traditional media outlets. Last, the steps outlined above take time, usually several weeks, to implement from the beginning to the end of the process. Depending on the publication process, a journal may need to delay publication of the article to accommodate promotion to the public in this way. The newest modality, social media, provides journals with an opportunity to overcome many of these barriers. This will be discussed in detail in the upcoming sections.
Goals of Social Media in the Medical Journal Setting
For the publisher of a medical journal, there are many potential objectives in the use of social media. Foremost for many is the ability to disseminate information rapidly to a worldwide audience. Social media allows a journal to share portions of journal content with a readership that reaches far beyond the limited number of subscribers to the medical journal. Content shared on social media may include article abstracts or summaries, tables and figures, and headlines, as well, with links to full journal content on a separate Web site. Scientific and medical journals target select groups of researchers and physicians. Conversely, social media offers medical journals the opportunity to reach a much broader audience. The social media audience includes physicians in the developing world who may never have the opportunity to read a printed version of the journal, and many of whom have only basic English proficiency – enough to understand the social media headlines, but not to comprehend the full text of the journal articles. Of course, this has an inherent limitation of nuanced medical messaging. With social media, the audience size can quickly grow logarithmically to extend far beyond the bounds of the ivory tower.
When links to journal articles are shared on social media, readers who click on the link are generally taken to the journal’s own Web site where they can access the full version of the article. If the article is Open Access, then the reader will be able to read the full article. However, many journals require either individual or institutional subscription to access full content. This can then lead to a situation where a reader follows a link from Twitter to a journal Web site, only to be blocked by a paywall that prevents the reader from accessing the article of interest. To avoid this outcome, some medical journals choose to only share uniform resource locators (URLs) on social media for articles that are freely available. Other medical journals, such as Circulation, make all journal articles available without charge if accessed through the journal’s social media feed.
When journal research provokes opinion from readers, the traditional approach has been for the reader to write a letter to the editor. Such letters are assessed by the journal’s editorial staff and – if deemed worthy – they are published in the journal. The turnaround time between publication of the original journal article and publication of the letter to the editor is usually a few months. Now that journals also publish online, some journals allow users to post comments on their Web sites with reactions to articles or research papers. These comments are generally reviewed and curated by the journal’s editorial staff. Furthermore, publishing a comment usually requires that the user go through an online registration process in which he or she must provide demographic information, credentials, and conflict of interest information. With social media, journal readers can share opinions and comments about journal articles immediately after reading the article, with no prepublication review of the comments by the journal’s editorial staff. Such posts and comments can take place either on the social media site of the journal itself or on any individual’s private social media page. In some instances, journals have even begun inviting readers to participate in social media discussions such as tweetchats in which readers can share opinions, debate controversial issues, and sometimes even ask questions of study authors in real time. This rapid mode of dissemination can greatly increase the reach of any given article and can allow public commentary to be shared quickly. However, it does allow individuals with obvious conflicts to share their opinions without disclosure.
Social media also represents an opportunity for medical journals to increase their brand recognition. Campaigns on Twitter and Facebook can increase visibility for journals that might otherwise only be read by small numbers of academic researchers. Examples include engaging with prominent users of social media around scientific topics that have an appeal to the general public. In addition, a journal can promote itself through sponsoring content on social media sites. Sponsored posts appear prominently in the newsfeeds of users and can enhance brand recognition and increase the number of social media followers for the medical journal, as well.
Another use of social media for medical journals is to serve as an educational platform. Through social media, a journal can educate health practitioners about new research findings that may change clinical practice. Journals also use social media to educate the general public about scientific topics that are of importance to the lay public. There are numerous examples of social media feeds dedicated to medical education such as the hashtag #meded, which is used by physicians and physicians-in-training to discuss medical education topics on Twitter.
The Social Media Audience
Social media can be used to reach many different types of audiences. Although social media can function as an open forum that can break down boundaries between the scientific community and the general public, in practice, most scientific journals publish content that is oriented toward other researchers. Tweets that contain research headlines may speak to those familiar with a specific scientific field, but are often too narrow in scope to be of interest to the general healthcare practitioner, let alone the lay public. A challenge then emerges for the social media strategy: should the social media outreach efforts focus on fellow scientists in a certain field or should the strategy be to attract a larger audience, perhaps by posting on more general topics? If the journal has a core readership of scientists in a particular field, such a general outreach effort may alienate those who are most connected to the journal. Widening the audience beyond the scientific community represents an important future effort of social media dissemination for many medical journals and should be paired with targeted educational campaigns.
Features of Social Media Campaigns in the Medical Journal Setting
The 2 most widely used social media sites for general medical journals are Twitter and Facebook. Although some journals post the same content on both sites, others post different content to each. Notably, Twitter limits posts to 140 characters, whereas Facebook does not have a word or character limit. Table 1 shows some of the features of social media posts for a select group of medical journals. In general, posts highlight articles published in these journals and many posts contain URL links to the journal Web site. In addition, posts may contain images from the journals, quiz questions, or announcements of special interest to journal readers.
The medical journals with the largest followings on social media also tend to be the journals with a more general focus rather than a specialty focus (Table 2). Other features of social media programs include posting frequently, including links and hashtags (placement of the # symbol before a word which allows the post to be searchable), and usage of images and video. Encouraging users to engage with social media content is a successful tactic. This can be accomplished through posting questions or quizzes that relate to material published in the journal. An examination of Facebook posts by NEJM in 2012 found that those posts containing images were more likely to attract user interest than posts that did not contain images. Furthermore, those images that were subjectively more provocative generated higher numbers of likes and shares among Facebook users.14 Although most medical journals use Facebook and Twitter, many other social media platforms exist, including Instagram, YouTube, Snapchat, Pinterest, and Google+, to name a few. Usage of these other social media platforms by medical journals is currently limited, but this may change in the future as online behavior and social media usage patterns change.
Strengths and Limitations of Social Media
There are several strengths to using social media in the medical journal setting (Table 3). Medical journals are turning to social media because of its widespread usage and the opportunity it represents to reach a large audience. Unlike other channels of distribution, social media is open and accessible to anyone with a device that can connect to the Internet. Information can spread quickly on social media without barriers such as access to a mailing address or subscription. Finally, Twitter, in particular, allows users to tag or reach individuals with a specific post, permitting direct communication with thought leaders. Thus, social media is free, instantaneous, and global, contributing to its appeal.
Yet there are also limitations to social media. Although a medical journal can control the contents of its publication and even shape the tone of a press release, there is only limited ability to control how messages are shared on social media. Because of the 140-character limit on Twitter, journals must condense messages into brief sound bites; such truncated posts may lead to misinterpretation of a more nuanced message, although the short and succinct style that is characteristic of Twitter is quite appealing to many users. In addition, crafting a successful social media campaign can be costly in that it requires dedication of resources and time from staff. In addition, a limitation for medical journals is that the usage of social media is lower among researchers and clinicians than among the general population.2,15 This may limit the ability of a medical journal to reach a core group of academics who may be most interested in the topics posted online. Finally, a limitation of social media may be the difficulty in quantifying value, which we discuss in the next section.
Return on Investment
A critical factor regarding social media campaigns in the context of medical journal publishing is how to quantify impact, value, and return on investment. Impact metrics can be based on the overall size of the site’s following or can be postspecific. For example, on Facebook, a basic assessment is the number of likes that an overall page has. Likes occur when a person clicks the thumbs-up icon for any given page. Once a person has liked a page, they will receive posts on their Facebook feed with content that has been placed. Similarly on Twitter, an account will collect followers. Once someone follows a given feed, they receive all of the posts that are placed. Beyond account-based metrics, individual posts can be quantified. For example, on Facebook, Circulation routinely posts status updates regarding new articles that are published in Circulation. These individual posts can be liked, commented on, or shared. The sharing function is particularly important because this allows information to be disseminated beyond the followers of Circulation to the social network of the person doing the sharing. The ultimate number of individuals who view a post on Facebook is known as reach. A far-reaching post may be seen by many more people than actually follow Circulation on Facebook if it is shared multiple times. Twitter works similarly; followers can retweet a post that they see on the Circulation feed to their followers. On Twitter, the ultimate number of people who view a post is referred to as impressions. A recent study randomly selected 50 tweets from 15 different accounts during a 12-month period and identified that the 50 tweets collectively reached an average of 1 200 865 individuals.16 This highlights the true power of social networks to rapidly transmit information in a peer-to-peer way.
Altmetrics are newer metrics of journal impact that go beyond traditional metrics of impact factor and citation rate.17 Altmetrics that are used include the number of times a journal article is viewed, downloaded, mentioned, or discussed on social media, or saved by various citation manager programs. Many journals now offer altmetrics to accompany articles that have been published; for example, Circulation now offers altmetrics embedded directly in the article page. Altmetrics have been shown to correlate with the number of times an article is ultimately cited.18 However, it is unlikely that social media exposure per se increases citations, although this is an area of future enquiry.
Beyond metrics of impact that are strictly embedded within the social media sites themselves, social media can be used to bring in readers to medical journal Web sites or to the featured articles themselves. For example, most social media posts include a URL that can take a user to the featured article by clicking on the URL. The number of click-throughs can be quantified and tracked. Further downstream, the Web site traffic derived from social media sites can be broken down and quantified by using Web-based tools such as Google Analytics. Medical journals can take it 1 step further to examine how many times an article is viewed (page views) or downloaded by users coming in from social media sites. Page views are a particularly relevant metric because they are correlated with future article-level citations.19
At Circulation, we tested whether exposing original articles to social media would increase the number of page views received by each article.20 In brief, over the course of 1 year, we randomized all eligible original article manuscripts to receive social media or to the control group, which was not exposed to social media through the official Circulation accounts. Overall, we found no difference in 30-day page views among the articles randomized to Circulation in comparison with articles in the control group. We concluded that for a medical journal with a modest social media audience, standard social media tools do not increase readership of original articles. Because this is the first rigorous clinical trial in this area, it is not possible to know whether these findings will be generalizable to other social media campaigns and other medical journals in different fields. However, these findings raise the tantalizing question of how best to quantify impact and return on investment by using social media.
It is clear by the sheer number of medical journals running social media campaigns that there is a general sense that including social media is important. However, articulating and quantifying the specific value can be more difficult. At its most basic, social media serves to disseminate research findings. Because of its reach, social media can disseminate findings to individuals who are not part of the medical establishment and who would not access or read scientific and medical journals. In addition, social media can serve as more than simply a way to disseminate original research. Other aspects of content relevant to medical journals, including cases, images, clinician and patient updates, review articles, and guideline statements represent fundamental components of journal content, and content that is typically shared on social media sites. In our experience, this content generates substantial interest, as indicated by the publication of the 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, which received >1.5 million views on Circulation’s Facebook account and >100 000 click-throughs on Circulation’s social media link within 1 week following publication.
What are the pros and cons of this? Certainly, we cannot expect the general public to read, interpret, and understand today’s scientific publishing in the medical realm because of its technical nature and complexity. Thus, sharing the value of published research with the public is critically important to ensure that the value of scientific advances is recognized. However, this greatly increases the possibility of medical messaging being overly simplified and misinterpreted. Facebook and Twitter only allow for sound bites of information. It has been shown that many medical findings are misinterpreted in lay press headlines.21 Thus, the responsibility is really on those generating social media to offer fair interpretations of the findings to ensure that incorrect interpretations are not disseminated.
There are many important unanswered questions in the field of social media in the setting of medical journals. First and foremost is how value can be best quantified in this area. We typically look for return on investment that is tangible and quantifiable. For example, in our Circulation randomized clinical trial, we assessed 30-day page views on our journal Web site because this is an objective and easy to obtain metric. This outcome was hotly criticized in Twitter discussions surrounding the publication of our article given the limitations of this metric to truly quantify dissemination of information. If dissemination of information is what we are truly after, how can this be quantified? Many social media sites offer a virality index, which quantifies how frequently a post is shared. Whether the sharing of information through a social network is sufficient to justify the resources of running a medical journal social media campaign remains to be determined. Understanding the value of social media in the medical journal context is a major goal for the field to appreciate moving forward.
Most medical journals currently use Facebook and Twitter. Over time, other platforms will likely gain in popularity and be used for medical social media. Launching a new feed takes time; journals may be hesitant to add more and more social media channels to present campaigns without a clear sense of the ultimate value.
Our experience suggests that new content can help keep followers interested in a journal’s social media posts. Recently, platforms have begun to feature more visuals and images; it is likely that we will observe gravitation to more of these, with more interactive and visual imagery to accompany published articles. We envision a future with seamless integration between social media posts and videos and other interactive features. In our experience, we have not had to change the social media platforms that we use because the social media sites themselves are innovating so quickly.
In addition, social media is a great place to test out content before launching it in the main journal. For example, one of our most popular Circulation social media features is our weekly ECG Challenge; once we observed how popular this was on social media, it was launched as a recurring feature in the main journal.
As the field of medical publishing moves away from the promotion of overall issues to the promotion of individual articles, it raises the question of how medical research will be published in the future. Will we be issue free? If that is the case, will we be journal free, with mechanisms for authors to simply publish articles? Could social media sites eventually become distributors of scientific content, perhaps using an online, open peer-review process? Under such a model, the social media platform itself could one day become the publisher and the conduit of medical journal article delivery. For example, Facebook is now publishing instant articles in collaboration with several magazines in which the primary article is published and hosted on Facebook.
There is tremendous potential of social media in this realm. We envision a time when social media ultimately becomes the major delivery vehicle for all communication. Ideally, integration of social media into the everyday life of clinicians, researchers, medical educators, journal publishers, and patients will lead to better ways for healthcare providers and patients to communicate. The ultimate goal is to promote the messaging of complex topics more widely to improve health and wellness. Social media represents 1 such potential vehicle.
When this article was written, Caroline Fox served as an associate editor for Circulation and received compensation from the American Heart Association. Caroline Fox became an employee of Merck Research Labs December 14, 2015. Karen Barry is an employee of Circulation, a Journal of the American Heart Association. James Colbert receives compensation from the American Medical Association.
About the Authors
Caroline Fox is the former section editor overseeing Circulation’s social media. She oversaw the launch of the journal’s social media sites and oversaw content and development for the sites until December 2015. Karen Barry is the managing editor of Circulation, and worked with Dr Fox on the development and oversight of Circulation’s social media. James Colbert began his journal career as a fellow at the New England Journal of Medicine. This role led to a position working on the journal’s social media sites and its blog Now@NEJM. He currently serves as Web Editor for JAMA Internal Medicine.
- © 2016 American Heart Association, Inc.
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- Barry K,
- Loscalzo J