Twelve Tips for Tweeting as a Residency Program

Physicians have dramatically increased social media use in recent years. Twitter has been heralded as a means to connect a broader learning community, engage with colleagues, initiate mentorship and sponsorship, and to amplify trainees. A residency program-linked Twitter account affords unique opportunities to champion residents while promoting the program and its affiliated faculty and institutions. However, while the scholarship of Twitter usage is expanding, the current literature specific to residency programs is limited. We draw from our experience tweeting as an internal medicine program to share more broadly applicable advice. With these practical tips, creating, maintaining, and sustaining a residency program twitter account can be feasible, fulfilling, and successful.


Introduction
Social media (#SoMe) use has dramatically expanded and evolved since Facebook's creation in 2004 and Twitter's creation in 2006. More than two-thirds of American adults now use social networking sites (Duggan, 2015). Social media consists of multiple digital platforms to network, exchange information, and participate in discussions-all tasks consistent with continuing medical education. Analysis of the impact of health care social media (#hcsm) repeatedly draws attention to its educational and professional development value. Indeed, 60% of physicians surveyed believe that social media improved the quality of their patient care (McGowan et al., 2012).
Multiple social media platforms exist, though Twitter (and #medtwitter) is uniquely poised to benefit physicians at all stages of training or practice through its public, open-access format. Twitter is also heralded as uniquely suiting trainees and junior members of the profession by flattening hierarchies and democratizing education as well as giving them "access and voice" (Chretien et al., 2015). According to one study examining Twitter use within UME, "Students gained access to information, to experts, to a variety of perspectives including patient and public perspectives, and to communities of support. They also gained a platform for advocacy…and a sense of equalization O'Glasser A, Desai S, Cooney T MedEdPublish https://doi.org/10. 15694/mep.2019.000156.1 Page | 2 within the medical hierarchy" (Chretien et al., 2015). Cultivation of professional social media use fosters career exploration and identify formation for trainees and physicians (Logghe et al., 2017;Greenberg, 2017). A previously published "Twelve Tips" also focused broadly on social media use for medical educators (Kind et al., 2014), and a broad analysis of social media used in GME identified mixed benefits and variable strategies (Sterling et al., 2017).
Theoretically, Twitter provides residency programs the ability to disseminate knowledge in novel ways and to draw attention to its residents' accomplishments. Literature on the impact of social media use by residency programs is expanding, though only draws from a few different types of residency programs (St Claire et al., 2019;Xie et al., 2018;Diller and Yarris, 2018;Lamb et al., 2017;Hass et al., 2016). Focus tends to be placed on educational content, though one study from an internal medicine program twitter account analysis found that the small number of tweets highlighting resident accomplishments or social events (N=49) were rated as highly informative by the majority of residents (80%) (Bergl, Narang and Arora, 2015).
We created our Internal Medicine Residency Program's Twitter account (@OHSUIMRes) in July 2015. Approval for the account creation as a branded OHSU account was required from the OHSU Social Media Manager in accordance with the institutional social media policy, a step that may be required at other institutions. Here, we share lessons from the growth of the account, which remains active and has surpassed 1200 followers and 4900 tweets. We also share tips for successful and sustainable tweeting as a residency program.

Twelve Tips
Tip 1: Tweet early, tweet often Many individuals experience trepidation when first creating a Twitter account. Many new accounts share that they "lurk" but never write tweets. This is an appropriate means to initiate professional Twitter use as "observation is still a key part of the scientific method" (Mariano, 2016). Start by observing content, especially from other residency programs, faculty, or medicine thought leaders.
Do not "lurk" for too long. Comfort with Twitter and actual benefit to your program will only come once the tweeting starts. Practice does make perfect. Tweeting begets more tweeting, which builds momentum, comfort, and familiarity with the platform. Tweeting also helps an account gain followers. Interacting with other accounts leads to additional connections and creative collaborations with this platform.
We also found it was important for a residency-program linked account to identify a primary Tweeter in advance of creation so that frequency of tweets can be maintained. Our Twitter-account has been predominantly written by program leadership though Chief Residents have access and contribute. Other internal medicine residency accounts may be solely Chief Resident operated.
Tip 2: Know core Twitter vocabulary and use hashtags, mentions, links! At a bare minimum, a tweet is composed of text elements. The original 140-character limit has increased to 280 characters. However, we highly recommend that tweets contain more than bare text and include other elements. Hashtags allow others to discover the content even if they do not follow your account. Mentions (including another account's "handle") automatically draw others into the conversation initiated by a tweet, essentially serving as a virtual "tag, you're it". Links and media (including photos or videos) also earn more attention and engagements. #Medtwitter has been heralded by many as flattening hierarchies, democratizing education, and provides trainees "access and voice" (Chretien et al, 2015). #Medtwitter has created a new field of sponsorship and our ability to amplify those junior to us (Schillcutt and Silver, 2018). When we celebrate and champion our trainees' accomplishments it becomes a most fulfilling aspect of maintaining an active, vibrant account. We set the goal of tweeting ever resident accomplishment-publication, poster, conference presentation, award, etc. We use #OHSUscholarship to identify such tweets as well as catalogue them for ourselves for future access. Be creative with vocabulary to celebrate accomplishments-liberally use words such as "excited", "thrilled", and "proud". Sharing resident accomplishments does more than sharing enthusiasm for trainees. Tweets increase reach and dissemination of publications, and tweeted papers receive more future citations. #Medtwitter is the new channel for academic dissemination (Cabrera et al, 2017;Cabrera, Roy and Chisolm, 2018).
The potential impact of tweeting a resident publication cannot be underestimated. Fifteen months into our account, we tweeted a new resident publication and mentioned @BMJ_latest in it. The BMJ account retweeted it promptly to their audience of tens of thousands of followers. That tweet earned over 14,000 impressions. This platform allowed us to disseminate a resident accomplishment to a broad and otherwise untapped audience.
In addition to celebrating accomplishments, we recommend identifying residents' individual interests and engaging those on Twitter in this content including the humanities, history of medicine, or certain advocacy arenas. Rather than just tweet about material, "mention" an interested resident in the twitter-initiated conversation, which demonstrates respect for their interest and provides a form of introduction to national and international conversations with thought leaders.

Tip 4: Use your program's calendar of key annual events as source material
Residency program tweets sharing core annual events should form a basis for recurring material, which helps residents identify the program's ongoing investment in these activities. Such material also provides information about program structure, culture/climate, and "day in the life" for external readers, including potential medical student applicants. Use standard conferences and didactics as a source of educational content and consider using hashtags that reflect your conference names such as #NoonConference and #GrandRounds. Know when to be prepared to tweet about first and last #InterviewDay, residency #MatchDay, and #FellowshipMatchDay. We also strongly recommend being aware of major medicine and subspecialty conferences, as well as their designated hashtags. Be prepared to tweet resident accomplishments at scheduled events like these.

Tip 5: Engage faculty and fellows on Twitter
While #Medtwitter permits creation of broader communities, it can be very helpful to start by engaging your "home" community. Learn or solicit handles of residents, fellows, and faculty. We have seen an expanding number of medicine subspecialty fellowship programs create programmatic accounts, including at our institution. Engage them in conversations and bring their teaching directly to your own Twitter audience. Supporting faculty, fellows, and residents creates reciprocity and amplifies your own Twitter voice.
Local faculty and fellows also provide a source of notification of accomplishments and successes. As the number of institutional colleagues on Twitter has grown since we created our account, we have found that an increasing number of publication notifications are coming from faculty/fellow co-authors tweeting content before even learning about it from the residents themselves.
Engaged faculty and fellows also provide a very valuable source for "boots on the ground" at major academic meetings. For example, in spring 2018, we knew a large number of core pulmonology and critical care faculty would be attending American Thoracic Society. Faculty attending tweeted about resident posters and oral presentations in real-time, which was repeated in 2019 ( Figure 1). Similarly, teach residents the "art of the humblebrag". Learning to comfortably promote your own work to maximize dissemination is an emerging part of the professional development growth curve (Figure 2).

Tip 6: Define "community" in multiple ways on Twitter
In addition to defining your local community of residents, fellows, and core faculty, define other communities. Your institution may have multiple branded accounts, and in addition to engaging subspecialty fellowship accounts, broaden your Twitter connections to other specialty departments. Some of our earliest tweets involved communication with the Departments of Family Medicine (@ohsufamilymed) and Emergency Medicine (@OHSUEmergency). Our Department of Surgery (@OHSUsurgery) now has a very active account we interact with along with a newer dedicated Emergency Medicine residency program account (@OHSUEMRes). Engage with the main institution account for support and amplification. Consider also following accounts linked to rotation sites, such as an affiliated VA hospital or community partners. Identify your affiliated national and regional professional societies. Connect with as many other residency program twitter accounts as possible, especially in your area of specialty interest.
Being intentional with engaging with community on twitter is a reminder to be gracious and generous with your social media time. Be a "giver" not a "taker" on social media. Rather than aim to boost likes and tweet views only, aim to build and sustain connections via social media conversations.

Tip 7: Identify preferred content themes within medicine
In addition to maintaining tweets about resident accomplishments and local educational content, tweet about specialty updates. Advocacy is an important physician activity, including on social media (Berwick, 2017). Do not be afraid to tackle "big" or non-neutral topics, though be sure to engage program leadership (and Department leadership if appropriate) in the conversation first. During the first year of our account, we learned that tweeting about the opioid epidemic engaged faculty content experts. We also benefitted from institutional leadership being very vocal about social advocacy, and as this aligned with program values. We felt comfortable tweeting about transgender health, LGBQT rights, gun violence, and racism. However, if you feel comfortable tweeting such content, do so from a place of professionalism, knowledge, perspective, and available evidence.

Tip 8: Keep your eyes open & your chin up!
Ironically, we have found that Twitter has encouraged us to be more mindful and less buried in our smartphones while walking around campus. Be mindful of your surroundings and all the wonderful learning that may be occurring even in the "small" moments. While it is very valuable to have predictable, reliable source of regular content as highlighted earlier, it is also very important to be prepared to tweet unplanned content. This may include impromptu learning, moments of camaraderie and friendship, moments of spontaneous humor, and other surprises such as encounters with the pet therapy dogs. Scenery photos are also well received rather than distracting from more educational content. We quickly embraced a "love where you work and the work you do there" theme to our tweet content.

Tip 9: Utilize Twitter Analytics
The main objective of tweeting as a residency program should not only be to gain likes, retweets, and followers. Numerical feedback about tweet reach and effectiveness is very important to sustain ongoing twitter activity. Twitter offers analytics information which includes a variety of statistics. We view these metrics as valuable surrogate markers for impact. We have also been surprised by specific tweets which were very well received and more widely disseminated via retweets. There has been a significant reach of scholarship related tweets, which drove ongoing prioritization of these.
Tip 10: Be professional and follow the 5-second rule at all times; think first, tweet later Privacy and professionalism concerns are a valid barrier to exploring Twitter use for professional development. Consult your institution social media policy, which may entail applying for permission to launch an affiliated account. Respect patient privacy at all times-be especially cautious about this in conference/case discussion formats as protected health information may be visible on white board, radiographs, or other image content. Resources provide guidance for being intentionally vague to protect patient privacy without diluting the educational value (Crane and Gardner, 2016). Respect for all members of the healthcare teams, regardless of degrees or training, must also be respected and modeled on social media. Maintain an appropriate tone when representing your program on twitter. Tweet need not be saccharine sweet at all times, but avoid negative or condescending tones. Do not rant, and do not engage with trolls (users whose primary purpose is to provoke or inflame discussions). If you maintain your own account in addition to writing the program account, make sure you are logged in to the correct account before posting.
Tip 11: Do not be afraid to brag or toot your own horn! Social media is frequently criticized for promoting narcissism and the "look at me" culture. However, as we have shown, the "look at me" narcissism stereotype of social media can be channeled into "look at them" as it pertains to the amplification and celebration of those junior to us. In the spirit of sharing on social media, it is also appropriate to tweet about the successes of your program itself. Highlight successes (ex. Fellowship match), curricular innovations, and the work and successes of the program leadership team.

Tip 12: Have fun!
In addition to all the reasons discussed thus far, #medtwitter can be fun. Even a program account, rather than an individual account, can have a fun personality. Do not be afraid of clever, whimsical, or humorous tweets. Show that you love to learn, teach, and practice medicine. Share the fun of being part of your residency program family. Recent examples from our account include a live-tweeted "baked goods rounds" on the first week of July and livetweeted Halloween candy rounds, in which one of the Chief Residents walked around the hospital in a dinosaur outfit (Figure 3).

Conclusion
Tweeting as a residency program is feasible. Our experience shows that the creation and maintenance of account can be very rewarding and fulfilling for residents, faculty, and program leadership. Beyond measuring success by raw numbers of followers, retweets, likes, or impressions, we have defined success in terms of positive benefit to our residents and broader exposure for our program and its educational mission. Through evolution and maturation of tweet content, @OHSUIMRes became a powerful vehicle to encapsulate who we are as a residency program. We found it an interactive and dynamic process, facilitating new camaraderie and connections, ranging from local to O'Glasser A, Desai S, Cooney T international. Our Twitter account matured into a powerful voice and connector for our program and its residents and faculty. These twelve tips are shared to facilitate similar successes for other residency program Twitter accounts.

Take Home Messages
Twitter creates opportunities for residency and training programs to disseminate educational content Twitter creates unique opportunities for programs to amplify and celebrate traineers Twitter affords program opportunities to further engage local faculty Twitter creates new national and international learning and networking opportunities Maintaining a program Twitter account is possible and rewarding