Family Medicine Journal Club: To Tweet or Not to Tweet?

As family medicine (FM) programs offer more distributed training sites1-3 journal clubs (JCs) are going online, with the benefit of offering distributed learners the opportunity to share their experiences.4-18 Little is known about the learning experience of online JCs.19,20 eLearning appears to be as effective in increasing knowledge levels.21 Social media also enhances learner engagement and collaboration but may be hampered by technical and privacy issues.22 Based on the studies suggesting that learners prefer e-learning as a complement to face-to-face teaching, we designed a hybrid online-traditional JC23 and explored the learner experience.

Participants from five distributed sites at the University of Toronto, including three family medicine residency teaching units (FMTU) and two medical student campuses, were recruited via email and word of mouth. Ontario Telemedicine Network (OTN) videoconferencing and Twitter were employed to connect 12 medical students and 57 residents. During the duration of the program between September 2016 and May 2017, the average age of the class for the year 1 and 2 medical students was 23.6 years, and the average age for the residents from the three sites was 31.5 years (range: 26 to 47 years).

After an introduction, four JCs were held over a 6-month period (Table 1). Using a critical appraisal worksheet, groups of two to three residents from one of the FMTUs facilitated face-to-face discussions within their group and between the other sites using OTN and Twitter.

Focus groups were conducted by an experienced, independent qualitative researcher including one focus group for the residents at each FMTU (n=33) and one focus group for all medical students (n=6). Written consent was obtained from all participants. Discussions were audio recorded for verbatim transcription. Transcripts were checked for accuracy against sound files and coded for anticipated and emergent themes using the constant comparison method including searches for disconfirming evidence.24-26 The University of Toronto REB approved the study (#33325).

Participants valued four aspects of the program: content that is relevant to practice; an effective faculty facilitator; rich discussion; and a small-group, face-to-face environment (Table 2). Participants hoped JCs would enhance their critical appraisal skills, better equipping them to practice evidence-based medicine. Articles that were contemporary and relevant to FM were preferred for their clinical implications. Participants also highlighted the integral role that facilitators play in engaging and keeping the group on track. They especially valued the facilitators’ experience in contextualizing the research discussion in terms of patient care.

While technology was intended to enrich discussion by connecting our distributed learners, most participants felt that it had the opposite effect. Videoconferencing was found to be a cumbersome medium for discussion, often hampered by technical difficulties, and failed to produce dynamic experiences or meaningful connections. Similarly, although some participants felt Twitter had the potential to connect distributed learners, the majority found that it failed to engage learners because the anonymity diminished motivation to prepare for JC and participate in the discussion. Many also felt that the use of their phones and short character limit was not conducive to fostering the social connection that is integral to effective conversations.

Most strikingly, participants raised some interesting assertions related to the role of social media in medical curricula (Table 2). Some indicated that they never used Twitter, and those who did reserved it for personal use. Many were ambivalent about overlapping their personal lives with their professional roles and were also concerned about JC discussions taking place in a public, and potentially permanent sphere. While learners valued the opportunity to draw on the experiences of peers at other sites, a small-group, face-to-face JC format was most effective in promoting engagement and fruitful discussion.

Our study provides insight into the experience of distributed learners with technology in the context of a JC. While technology connected learners, combining videoconferencing and Twitter with a face-to-face session was not found to be conducive to rich discussion. Many participants felt that technology hampered discussion as it divided participants’ attention. Since active engagement in discussion is central to learning in JCs,27-30 participants indicated that the face-to-face format provided a superior learning experience. This finding is shared by another hybrid JC employed by geriatric subspeciality trainees10 and echoes a study by McLeod et al, who noted that participation among general surgery residents was lower in the internet-based group compared to the face-to-face sessions.13 As attention is a finite resource, the advantage of face-to-face JCs may be the opportunity to be fully present whereas electronically-mediated human interactions divide our attention.31

The large-group nature of the hybrid JC also decreased the motivation of learners to participate. Research shows that although large groups can be more efficient at disseminating information, they are inferior to small groups in stimulating thinking and, as seen in our JCs, in engaging in discussion.32,33

It is noteworthy that the public nature of social media did not foster a safe learning environment. A similar fear of committing opinions to print was noted in online JCs for general surgery trainees.11,14 A private online discussion forum may have provided a more comfortable environment for learners to share differing viewpoints. Currently, there is limited role modelling of professional online physician identities or how to establish boundaries between professional and personal electronic personas. This may have further contributed to learners’ discomfort.

While this was a small-scale study limited by our inability to collect the ages of all participants, our findings suggest that the incorporation of technology in medical curricula requires careful consideration in relation to the learners, the content, the educational milieu, and the teachers.34-36 Future research can assess our hybrid model in other disciplines and with other technologies that may be better suited to discussion-based learning activities amongst distributed learners.

Our findings suggest that learners value face-to-face, small-group sessions for JCs. Learners learn best in a safe environment, and achieving a meaningful connection matters in discussion-based learning activities.