Not just cat videos

For better or worse, social media has rapidly become a popular mechanism for propagating (mis)information. Science publishing and social media are inevitable but awkward bedfellows; both share a core principle of dissemination, but also tension through issues of provenance, authenticity and quality. We are all learning how to navigate these challenges. However, social media is only the latest disruptor in the history of medical and scientific communication.

The evolution of medical journals: Index Medicus to Twitter chat

The first medical journal, Medicina Curiosa, was printed in 1684. It was in English, rather than the traditional Latin, making it accessible to those without a university education.Reference Colman¹ Three hundred years later, the internet opened up medical literature to the world. Initially, this was a simpler and easier digitisation of print media: how many reading this recall thumbing through a bulky copy of Index Medicus, then walking around a medical library trying to physically find print copies of papers in journals from a handwritten list of citations? Few mourn the passing of that and, as the internet continued to evolve, many medical organisations and research institutes were quick to establish an online presence. It provided them an opportunity to connect with a broad audience in their own communities, among patient groups and with the wider interested public; it could also be employed for promotional and educational purposes. Comparatively, academic journals have often been more hesitant, or even reluctant, partners. Although there are certainly examples of some excellent early adopters, the Twitter 280 character limit and the lack of peer review potentially runs contrary to their standard communication methods and principles.

However, clinicians, like patients, can be unsure of which sources to trust. Medical journals on social media can play a positive key role in providing, curating and signposting authentic, evidence-based content. Further, social media can extend the reach of traditional publications and engage a readership in novel ways. Twitter ‘tweet chat’ sessions have been used to open up discussions with wide audiences, and many are also using blogs and podcasts to publicise their work and provide more accessible versions – both in terms of usage of a more lay language as well as typically being free to access for non-subscribers. A study published in Journal of the American College of Radiology compared the page views of two open-access journal articles and one blog on the same subject. The blog was viewed 32 675 times within the study period. This was six times more than both journal articles combined.Reference Hoang, McCall, Dixon, Fitzgerald and Gaillard² A randomised controlled trial of tweeting about Cochrane Schizophrenia Group systematic reviews found that tweeting led to three times the number of page visits at 1 week and more time spent viewing these pages.Reference Adams, Jayaram, Bodart, Sampson, Zhao and Montgomery³ Other trials have been less positive, finding no difference in engagement if an article is the subject of tweets.Reference Fox, Bonaca, Ryan, Massaro, Barry and Loscalzo^4, Reference Fox, Gurary, Ryan, Bonaca, Barry and Loscalzo⁵ However, these trials may have been limited by a small social media presence: at the time, the journals had only modest numbers of followers on Facebook and Twitter. A study published in Journal of Medical Internet Research (JMIR) found that the number of times a JMIR article is tweeted in the first 3 days after publication predicted how highly cited it becomes.Reference Eysenbach⁶

The brave new world of scientific ‘impact’

This raises the question of what we now mean by impact. The traditional ‘impact factor’ model for journals is an average of citations received over a given period. Although the validity of this as a marker of ‘importance’ has been increasingly challenged, it is widely taken as a proxy of significance or novelty of the work a journal produces. New methods have been developed to measure the online activity surrounding scientific literature, such as those provided by the Altmetric API. These can provide quick, broad measures of public engagement, quantifying activity on social media platforms: if you are reading this (or any other paper) online, you will now see a tab opening up metrics data. It is unclear whether social media activity genuinely increases scientific awareness and citations, or simply reflects the public interest in the topic.Reference Eysenbach⁶ For example, one of the most tweeted BJPsych articles of 2018 was based on mothers singing to their infants, a topic with an obvious wider appeal that was picked up by a large number of news agencies, leading to wide coverage on social media; will this be mapped by subsequent proportionate citations?

The challenges of engaging with social media

New doctors have established digital learning and communication habits which were unimaginable to their predecessors, sometimes described as ‘Medicine 2.0.’, and many academics and clinicians have begun integrating newer social media tools like Twitter and blogs into their professional communications. The benefits to scientists and doctors in using social media include significant engagement with a very wide network. Some use Twitter to disseminate and discuss their work, both within and beyond their fields, or to rapidly hear about novel developments of others. It allows them to act as a public voice for science and medicine, to promulgate research advances and public health messages. Some may also use it as a means of developing their own professional profile.

However, many doctors – younger and older – still feel uncertain about virtual communication online. Concerns that clinicians might breach patient confidentiality or share unprofessional content are common.Reference Gholami-Kordkheili, Wild and Strech^{7, 8} Conversely, medicine, and psychiatry in particular, has often struggled with public visibility and constructive conversations with those who use services, with the common – if seemingly paradoxical – trope of the not-listening psychiatrist. Social media can facilitate communication and allows important exposure to dissonant voices. Many movements and groups are vocal on specific clinical issues and there has been hostility to research and researchers in specific fields, as well as conflict between professionals of different clinical orientations or perspectives. Perennial debates are re-enacted, such as formulation ‘versus’ diagnosis, medical model ‘versus’ social model and medication ‘versus’ therapy. The democratisation of voices is, in the round, welcomed. Reading accounts from those who have not had positive experiences in mental health services can be difficult, but it is undoubtedly important; some professionals may be less used to being challenged in so open a manner; some members of the public grateful for the opportunity to do so on a non-hierarchical playing field. However, this can add to confusion about ‘what to believe’, and one can sometimes feel there is more heat than light. The Royal College of Psychiatrist's Twitter chat organised in 2017 in response to the Panorama documentary on antidepressants may be a good learning point: a quick scan of its hashtag, #ADsMythBuster, will demonstrate both the desire for information and the variation in responses, some very hostile. Consider how an individual looking for reliable information on medication might feel wading through this.

Nevertheless, these conversations are ongoing, whether we engage or not. Observing, listening and reflecting on the distress and many opinions we see online, rather than shying from it, have to be the route to a better future for the art of psychiatry. There is a minority anti-psychiatry mindset; however, by far most people are primarily interested in improving services and care, and will put forth their own thoughts and experiences honestly. Our experience and perspective is that one can and should be positive and optimistic about this: we have had excellent, informative online discussions with patients, carers and relatives, interest groups and colleagues. Indeed it can also be an excellent mechanism for linking with individuals from think tanks, charities, and those in senior National Health Service and other managerial roles that one might not ordinarily meet in everyday clinical life. The short, ‘shouty’ nature of Twitter can sometimes seem to almost provoke unnuanced fighting; our advice is recognising its inherent limitations, avoiding heated arguments and having acceptance of differences of opinion. The art of social media is, perhaps, knowing when not to respond.

The BJPsych is becoming digitally engaged: savvy or silly?

Recognising these opportunities and challenges, the Board of the BJPsych has decided to develop the following new ways to communicate using social media.

Future horizons

We hope the BJPsych can successfully navigate online platforms, creating synergy with the journal's traditional output, balancing the risks and benefits of an extended audience. Other platforms (as yet unexplored) exist, for example Facebook, LinkedIn and Instagram. We aspire to create output that will be associated with the same authority and quality as the Journal it serves, even if each method has its own voice and unique style of contribution. The BJPsych is a publication of the College, and the College is its members. How we should proceed is a question for all of us, and undoubtedly one that we will need to refine with time: you have our Twitter handle – let us know, #BJPsychOnline.