The reach of Spanish-language YouTube videos on physical examinations made by undergraduate medical students

This study was conducted to evaluate the performance and reach of YouTube videos on physical examinations made by Spanish university students. We analyzed performance metrics for 4 videos on physical examinations in Spanish that were created by medical students at Miguel Hernández University (Elche, Spain) and are available on YouTube, on the following topics: the head and neck (7:30), the cardiovascular system (7:38), the respiratory system (13:54), and the abdomen (11:10). We used the Analytics application offered by the YouTube platform to analyze the reach of the videos from the upload date (February 17, 2015) to July 28, 2017 (2 years, 5 months, and 11 days). The total number of views, length of watch-time, and the mean view duration for the 4 videos were, respectively: 164,403 views (mean, 41,101 views; range, 12,389 to 94,573 views), 425,888 minutes (mean, 106,472 minutes; range, 37,889 to 172,840 minutes), and 2:56 minutes (range, 1:49 to 4:03 minutes). Mexico was the most frequent playback location, followed by Spain, Colombia, and Venezuela. Uruguay, Ecuador, Mexico, and Puerto Rico had the most views per 100,000 population. Spanish-language tutorials are an alternative tool for teaching physical examination skills to students whose first language is not English. The videos were especially popular in Uruguay, Ecuador, and Mexico.


Introduction
Physical examinations play an integral role in clinical practice despite the phenomenal advances in imaging technology and laboratory medicine over the past several decades [1]. Medical curricula include a strong focus on this core competency [2]. While formal instruction has traditionally been the primary source for learning these clinical skills [3], the Internet is becoming an important complementary resource for up-to-date, globally available information [4].
As the largest Internet video-sharing site, YouTube constitutes a promising learning resource, including for medical education and research [5]. Recent studies have evaluated the platform's potential to support English-language education on physical examinations for the cardiovascular, respiratory, and nervous systems [6], but there is scant evidence for other globally prominent languages such as Spanish, which is spoken in more than 20 countries of varying income brackets [7]. The aim of this study was to evaluate the performance and reach of video tutorials performed by medical students on physical examinations and uploaded onto YouTube.

Videos and setting
A small group (N= 7) of third-year medical students, in collaboration with 2 undergraduates in the audiovisual communications program, developed 4 videos on physical examinations during the 2013-2014 academic year at the Miguel Hernández University School of Medicine (Elche, Spain). The tutorials focused on examinations of the head and neck (7:30), the cardiovascular system (7:38), the respiratory system (13:54), and the abdomen (11:10) (Appendix 1). The medical students drafted the script under the supervision of a professor. Two students were featured in each video: one as the patient and the other as a doctor. Meanwhile, undergraduates studying

Data collection
We extracted the visualization metrics for the period from February 17, 2015 to July 28, 2017 (2 years, 5 months, and 11 days) from the YouTube channel administrator page, using the Analytics application offered by the platform to track the performance of the channel and the videos (YouTube Creator Hub. YouTube partners: guide to your YouTube analytics: https://www.youtube.com/watch?v= AU U9urHAwco&feature = youtu.be). The Analytics report is broken down into 6 cross-linked categories: performance metrics, which monitor the watch-time, views, and revenue; interaction metrics, which show data on how viewers interact with the videos (comments, likes, shares, and tags); the demographics report, which presents in- formation on viewers' sex, age, and location; the traffic sources report, which shows how viewers find the content (search terms and links from other websites); the devices report, which details the types of devices and operating systems used; and the audience retention report, with indicators related to the average view duration.

Data analysis
We collected demographic data for viewers in Spanish-speaking countries, according to watch-time per 100,000 inhabitants (using population data from 2017 [https://data.worldbank.org/country]). We also compared the 4 tutorials within the YouTube search engine ( Table 1). The Miguel Hernandez University Committee of Project Evaluation (DMC.JRR.01.17) approved the study.

Performance metrics
The total number of views, length of watch-time, and mean view duration for the 4 videos were, respectively: 164,403 views (mean, 41,101 views; range, 12,389 to 94,573 views), 425,888 minutes (mean, 106,472 minutes; range, 37,889 to 172,840 minutes), and 2:56 minutes (range, 1:49 to 4:03 minutes). The abdominal examination garnered the most views; however, viewers spent slightly more total minutes watching the respiratory system tutorial. The mean watch-time per view was 2:56 minutes (range, 1:49 [16.2% of the total video] to 4:03 minutes [40.1%]). The shorter videos (head and neck and cardiovascular system) retained viewers for more than 35% of the total playback time. Fig. 1 shows the daily and accumulated views for the 4 videos; some show seasonal differences that could correspond to academic study periods. The raw data are available in Supplement 1.

Traffic sources
The main sources of traffic by views were the "Suggested Video" thumbnails on the YouTube platform, followed by YouTube searches for key terms, and to a lesser extent embedded videos on external websites; 99% of all views took place directly on the YouTube website.

Demographics
More men watched the videos than women (range, 51% to 77%).  The most absolute views took place in Mexico, surpassing Spain and other high-population Latin American countries such as Colombia, Venezuela, Argentina, and Peru (Table 2). Ecuador (116 views per 100,000 population) and Uruguay (114 views per 100,000 population) were among the countries where the tutorials were most popular relative to the population. Spain, Bolivia, and Mexico followed (108, 92, and 90 views per 100,000 population, respectively) ( Table  2). The videos were also viewed in Puerto Rico (91 views per 100,000 population) Brazil, the United States, and Portugal. See Appendix 2 for complete data on views and playback locations.

Interaction
Our videos received 78 to 213 likes and 1 to 19 dislikes. Of the 38 total comments on the 4 tutorials, 19 were directly related to the content or quality of the videos. Seven comments were straightforward statements of support or gratitude, while 12 showed critical engagement with the content. The other 19 comments were noncontent-related (e.g., opinions on students' appearance or manner).

YouTube searches
The 4 videos under study consistently appeared among the top 5 retrieved when using Spanish search terms for the different kinds of physical examinations. Among the competing tutorials yielded by the search, one on head and neck examination had been uploaded a year before and had 25,606 views, while another was 6 years old and had 23,505 views. For the cardiac examination, the other videos in the top 5 positions had 92,000 to 124,000 views and were about 4 years old; for the respiratory system, they had 80,000 to 200,000 views and were 2 to 5 years old; and for the abdominal examination, they had 276 to 35,000 views and were 1 to 9 years old.

Conclusion
The Analytics application is integrated into the YouTube platform, allowing users to monitor the performance of their videos and channels by means of continuously updated indicators and reports [8]. This functionality has enabled studies such as ours.
As reported elsewhere [4][5][6]8], a number of high-quality tutorials on physical examinations are available in English on YouTube. Specifically investigating the reach of our university's video productions has illustrated the general relevance and importance of Spanish media in Internet medical education. It is important to promote the creation and use of these tutorials among medical students, particularly in the area of physical examinations.
The most populated Spanish-speaking country, Mexico, also showed the most views; it also ranked highly in views relative to the population, which is consistent with other studies reporting an intense interest in medical education content in Mexico [9]. More men watched the videos than women in our study, in contrast with the demographic make-up of the medical student body in Spain and Latin America, where women tend to outnumber men [9].
The views per 100,000 population were also particularly high in Ecuador and Uruguay, confirming the appeal of educational content and communications technology there [10]. Puerto Rico, a U.S. territory, also viewed the tutorials relatively frequently. Countries with limited Internet access or other communication barriers, such as Cuba, did not appear on the list of playback locations.
Our videos were filmed by and for medical students under faculty supervision. They are not professional productions, but rather an additional teaching tool, which further reinforces their academic focus. Despite the purely academic content, however, half of all comments expressed negative or clearly offensive opinions on students' appearance or manner, especially but not exclusively in relation to female students. This pattern follows general Internet trends and confirms the widespread presence of online harassment even in scientific Internet fora.
Physical examination tutorials in English are widely available, as a component of the learning materials included with medical textbooks, as content directly uploaded onto YouTube (e.g., as an aid to prepar- , or as material produced by medical schools. General physical examination apps have also been developed for medical students and doctors as a tool for practicing medicine. Despite their high quality, oral understanding can be an obstacle for non-native speakers, and some require paid subscriptions. These barriers underscore the importance of making tutorials available in different languages.
The limitations of this study include its exclusive focus on videos published by a single university in Spain. Moreover, we did not analyze the quality of the videos themselves, as has been done elsewhere [1,3,5].
The promising results achieved have encouraged us to continue producing videos of physical examinations with medical students serving as scriptwriters and actors. We are convinced that this exercise further promotes personal responsibility in the learning process.
These Spanish tutorials are an audiovisual teaching alternative to those available in English, constituting a systematic and planned element of structured teaching. They can contribute to achieving learning objectives, reinforce skills taught in other settings, and maintain students' interest in the field. Both the medical students producing the videos, and the Spanish-speaking medical education community at large, have benefitted from these materials. Further research into the details and the quality of these videos is warranted.