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RESEARCH ARTICLE OPEN ACCESS

Curriculum Innovations: A Social Media–Based


Educational Curriculum Improves Knowledge for
Trainees in Neurocritical Care
Results of a Stratified Randomized Study
Ronald Alvarado-Dyer, MD, Faddi G. Saleh Velez, MD, Hera A. Kamdar, MD, Naomi Niznick, MD, Correspondence
Elizabeth Carroll, MD, Carlos Castillo-Pinto, MD, Melvin Parasram, DO, Dearbhla Kelly, MD, Dr. Alvarado-Dyer
Shweta Goswami, MD, Mikel S. Ehntholt, MD, Neha S. Dangayach, MD, MSCR, Marc-Alain Babi, MD, Ronald.Alvarado-Dyer@
Ahmad Riad Ramadan, MD, Christos Lazaridis, MD, Catherine Albin, MD, and Nicholas A. Morris, MD ouhealh.com

®
Neurology Education 2023;2:e200087. doi:10.1212/NE9.0000000000200087

Abstract
Introduction and Problem Statement
The Neurocritical Care (NCC) Society Resident and Fellow Task Force’s NEURON study
concluded that learners had significant concerns regarding the need for educational improve-
ment in NCC. To address these shortcomings, we identified the lack of an educational cur-
riculum for trainees in NCC and developed a Twitter-based educational curriculum for trainees
to improve knowledge in NCC.

Objectives
The objectives of this study were to describe the pathophysiology, delineate a systematic
diagnostic approach, and apply evidence-based strategies in the management of diseases in
NCC.

Methods and Curriculum Description


Ten trainees developed a Tweetorial (educational content available on Twitter)–based cur-
riculum, with individual review by at least 2 NCC faculty. Learners were recruited through
Twitter and randomized to 1 of 2 groups in a wait-list control prospective study. Group 1
completed the curriculum in the first 6 months of the 2021–2022 academic year, and group 2
completed the curriculum in the second half. Tweetorials were posted weekly on a private
Twitter account only available to the active learner group. Learners were assessed by a multiple-
choice format test (written by the trainees and reviewed by faculty) at 3 time points: before the
first Tweetorial was released (preeducational curriculum assessment), after group 1 completed
all tutorials and before group 2 started the curriculum (assessment 1), and after both groups
finished (assessment 2). The primary outcome was the mean score on the second and third
assessments.

Results and Assessment Data


One hundred forty-six learners were assigned to group 1 or 2 using stratified block randomi-
zation including 99 (68%) Neurology residents, 81 (55%) US-based. Each group was com-
posed of 73 participants. A total of 20 Tweetorials were published on a private Twitter account
(@NeurocriticalE). Completed assessments were obtained from 100, 32, and 18 learners for

From the Department of Neurology (R.A.-D., C.L.), University of Chicago Medical Center, University of Chicago, IL; Department of Neurology (F.G.S.V.), The University of Oklahoma
Health Sciences Center, Oklahoma City; Department of Neurology (H.A.K.), Massachusetts General Hospital and Brigham and Women Hospital, Harvard Medical School, Boston;
Department of Medicine (Neurology; Critical Care) (N.N.), The Ottawa Hospital, Ontario, Canada; Department of Neurology (E.C.), Columbia University Medical Center; Department
of Neurology (E.C.), Cornell University School of Medicine, New York, NY; Department of Neurology (C.C.-P.), Seattle Children’s Hospital, University of Washington, Seattle; De-
partment of Neurology (M.P.), Yale School of Medicine, New Haven, CT; Department of Intensive Care Medicine (D.K.), St. James’s Hospital, Dublin, and Global Brain Health Institute,
Trinity College Dublin, Ireland; Department of Neurology (S.G.), University of Florida, Gainesville; Department of Neurology (M.S.E.), University of Pennsylvania, Philadelphia, PA;
Department of Neurology (N.S.D.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Neurosurgery (M.-A.B.), Neurological Institute, Cleveland
Clinic Foundation (Florida), Port St. Lucie; Department of Neurology (A.R.R.), Henry Ford Health, Detroit, MI; Department of Neurology and Neurosurgery (C.A.), Emory University
School of Medicine, Atlanta, GA; and Department of Neurology (N.A.M.), Program in Trauma, University of Maryland School of Medicine, Baltimore.

Go to Neurology.org/NE for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
This is an open access article distributed under the terms of the Creative Commons Attribution License 4.0 (CC BY), which permits unrestricted use, distribution, and reproduction in any
medium, provided the original work is properly cited.

Copyright © 2023 American Academy of Neurology 1


Glossary
APP = advanced practice provider; NCC = neurocritical care; NCCU = NCC unit; NICU = neurologic intensive care unit;
REDCap = Research Electronic Data Capture.

the pre-educational curriculum assessment, assessment 1, and assessment 2, respectively. Group 1 and group 2 performed
similarly in the pre-educational curriculum assessment. A potential for knowledge improvement was observed in group 1 at
assessments 1 and 2 when compared with the learner group 2. Group 1 had more impressions, engagements, likes, URL clicks,
and media views.

Discussion and Lessons Learned


Although there was some learner attrition, our study demonstrates that social media can effectively deliver educational content
and engage a diverse group of trainees around the globe.

thousands of Twitter users. The coronavirus disease 2019


Introduction and Problem Statement pandemic accelerated the adoption of social media platforms
Physician trainees and advanced practice providers (APPs) such as Twitter, leveraging its independent, asynchronous,
often provide frontline care to critically ill neurologic and interactive, and democratic features that flatten traditional
neurosurgical patients in the neurologic intensive care unit educational hierarchies.5
(NICU). Despite the establishment of neurocritical care
(NCC) units (NCCUs) in academic centers across the Despite its growing popularity, a gap exists in showing
United States, a 2012 survey of neurology residency directors evidence-based support for the educational efficacy of this
revealed that only 56% of neurology residency programs have newly embraced platform, particularly within NCC. In this
a dedicated NCCU rotation, and even across these programs, study, we aimed to develop a social media–based NCC edu-
formal training in NCC is highly variable.1,2 When the Neu- cational curriculum for trainees and APPs with the goal of
rocritical Care Society Resident and Fellow Task Force’s improving knowledge in NCC disorders and assess the
NEURON study surveyed neurology residents across the feasibility and efficacy of a Tweetorial-based educational
United States and 1 international NCC training program, they curriculum.
found that residents had significant concerns regarding the
need for educational improvement within the NCCU.3 Given
the demanding nature of the field, complex patient care, Curriculum Objectives
and varying call schedules, there is also limited time for 1. To describe the pathophysiology of diverse condi-
and engagement with formal NCC didactics. We posited tions in NCC (Table 1).
that an on-demand, asynchronous learning solution 2. To delineate a systematic approach in the diagnosis
was needed to address educational gaps broadly across of NCC disorders through case-based learning.
NCCUs. Thus, we developed a novel Twitter-based edu- 3. To apply evidence-based strategies in the manage-
cational curriculum for trainees and APPs to improve their ment of diseases in NCC.
knowledge in NCC.
We developed and delivered a Twitter-based NCC educa-
Social media has emerged as a relevant and growing tool for tional curriculum to all the registered participants.
medical education. Twitter offers a rich interactive platform
for disseminating educational content through Tweetorials,
which are collections of threaded or consecutive tweets aimed
at teaching users who engage with them.4 Furthermore, via
Methods and Curriculum Description
Twitter analytics, Twitter also offers the possibility of gauging Curriculum Design
the interaction across followers with every individual tweet, We developed a wait-list control educational curriculum
which provides valuable insight regarding the interaction be- among the recruited participants. The educational curriculum
tween users and the educational content delivered via was staggered. The participants randomized to group 1 had
Tweetorials. Tweetorials offer several features that are well the curriculum made available to them in the first half of the
adapted to adult learners including asynchronous learning and 2021–2022 academic year. The participants randomized to
distilled points and require only a short investment of time to group 2 had the curriculum made available to them in the
read for independent learning. As such, these microteaching second half of the academic year. The educational curriculum
posts are perfectly adapted “chalk talks” that can reach was designed to be delivered over 5–6 months.

2 Neurology: Education | Volume 2, Number 3 | September 2023 Neurology.org/NE


Table 1 Educational Curriculum Topics
Topics Subtopics

Increased intracranial pressure Basics, monitoring and overview of management.

Ischemic stroke Anterior circulation ischemic stroke

Posterior circulation ischemic stroke

Intracerebral hemorrhage Supratentorial hemorrhage

Infratentorial hemorrhage

Subarachnoid hemorrhage Aneurysmal high-grade subarachnoid hemorrhage

Traumatic brain injury Blunt traumatic brain injury

Penetrating brain injury

Spinal cord injury Cervical spine injury

Status epilepticus Definition, pathophysiology, diagnosis, and treatment

Neuromuscular diseases Guillain-Barré syndrome and myasthenia gravis

Encephalitis/meningitis Etiology, diagnosis, and management

Toxic/metabolic syndromes Posterior reversible encephalopathy syndrome, serotonin syndrome, and neuroleptic malignant
syndrome.

Brain death Definition and algorithm

Ventilator management in the NCCU Basic concepts and applications in mechanical ventilation in the NICU

Basic NCCU pharmacology Anticoagulant and antiplatelet reversal, antihypertensive medications

Critical care nephrology in NCCU Diabetes insipidus

Syndrome of inadequate antidiuretic hormone secretion

Dialysis disequilibrium syndrome

Pediatric NCCU for neurology and non-neurology Pediatric stroke and pediatric traumatic brain injury
residents

Abbreviations: NCCU = neurocritical care unit; NICU = neurologic intensive care unit.

Participant’s Recruitment NCC management, several links to scientific references for


The study was advertised through the author’s Twitter ac- further review, key points of the pathology and management,
counts during the enrollment period. Trainees and APPs in- and at least 1 poll.
terested in participating in the educational curriculum
completed an initial survey (distributed through Research Educational Curriculum Outline/Syllabus
Electronic Data Capture [REDCap]), which contained basic The curriculum was based on the published core curriculum
demographic information, current level of training, location of and competencies for advanced training in neurologic in-
training, interest in NCC, prior rotation in an NCCU, if so, tensive care (Table 1).6
the duration of the rotation, and whether they would like to
participate in the educational curriculum. Curriculum Learning Outcomes: Assessments
In addition to authoring tweetorials, the participating fellows
Curriculum Content: Tweetorials also collaborated in authoring a knowledge assessment test
Ten trainees (8 NCC fellows, 1 vascular neurology fellow, and with a total of 65 multiple-choice questions on the covered
1 pediatric neurology fellow) developed the curriculum. Each topics. Each question was approved and verified by 6 board-
trainee wrote at least 1 case-based Tweetorial on an assigned certified neurointensivists prior to being included (same 6
topic that was reviewed by at least 2 of 6 NCC faculty from neurointensivists who reviewed the Tweetorials). Two of the
different academic institutions across the United States. neurointensivists (N.A.M. and C.L.) were directly assigned by
Tweetorials were posted on a private Twitter account the main investigator (R.A.-D.). The other 4 (N.S.D., M.-A.B.,
(@NeurocriticalE) on a weekly basis throughout the duration A.R.R., C.A.) were recruited through Twitter. A total of 5
of the curriculum for each learner group. Each Tweetorial questions were discarded. Any question-related discrepancy
consisted of the following: a brief case presentation, initial was resolved by N.A.M. In the process of creating the

Neurology.org/NE Neurology: Education | Volume 2, Number 3 | September 2023 3


Figure 1 Educational Curriculum’s Flowchart

assessments, we randomly sorted the questions into three 20- Statistical Analysis
question assessments. All the tests were delivered via RED- We reported participant’s tests scores and Twitter metrics
Cap to each participant. (impressions, engagements, likes, and social media views)
using standard descriptive statistics (e.g., mean and SD for
Before the initiation of the educational curriculum, all continuous normally distributed data and median and inter-
participants were expected to complete a 20-question pre- quartile range for non-normally distributed data). We com-
educational curriculum assessment to gauge baseline knowl- pared participants’ tests scores, as well as group 1 and 2
edge. Assessment 1 was expected to be completed by all Twitter metrics using student unpaired t test. Differences
participants after group 1 had finished the curriculum (but were considered significant with a p value <0.05. All analyses
before group 2 has started the curriculum), and assessment 2 were performed using Stata/MP (version 15.0; StataCorp.,
was expected to be completed by all participants after both College Station, TX) and photon 3 software. Only complete
learner groups completed the curriculum. The primary cases were analyzed at each time point. There was no
learning outcome of our curriculum was the mean score on intention-to-treat analysis, and there was no data imputation.
the second and third assessments. The wait-list design con-
trolled for the expected learning or maturation effect that Standard Protocol Approvals, Registrations,
takes place during a training program. and Patient Consents
The study was reviewed and approved by The University of
Twitter Metrics Chicago Institutional Review Board. A waiver of signed in-
The Twitter analytics website7 was used to gather Twitter formed consent was granted. Through an initial REDCap
metrics after each learner group finished the educational survey, all the participants were provided an opportunity to
curriculum. We collected the number of impressions, en- agree or decline to participate in the educational curriculum.
gagements, likes, URL clicks, and media views of all 20
Data Availability
published Tweetorials per learner group. Impressions were
Data will be made available through request directed to the
defined as the number of times users saw a Tweet on
corresponding author.
Twitter. Engagements were the number of times a user
interacted with a Tweet (clicked anywhere on the Tweet).
Likes indicated the number of times a user liked a Tweet.
URL clicks referred to the number of times a user clicked
Results
on a website link within a Tweet. Media views denoted the Participants
number of times a user interacted with images and videos in A total of 146 learners participated (Figure 1). This included
a Tweet. 99 (68%) neurology trainees and 45 (31%) trainees from

4 Neurology: Education | Volume 2, Number 3 | September 2023 Neurology.org/NE


other specialties such as anesthesia, child neurology, internal
medicine, neurosurgery, emergency medicine, and pediat- Table 3 Twitter Metricsa
rics. Two participants (1%) were APPs. Of them, 81 (55%) Group 1 Group 2
were US-based, while 65 (45%) were non-US-based. One
Impressions 1,577 (1,210–2,483) 959 (621–1,168)
hundred (69%) had a dedicated NCCU at their institution.
Ninety-two (63%) were considering pursuing an NCC fel- Engagements 182 (148–276) 81 (59–105)
lowship. When comparing both groups, there was no sta-
Likes 17 (13–28) 5 (3–6)
tistically significant difference regarding the learners’ mean
age, sex (self-identified in the first REDCap survey), interest URL clicks 8 (4–16) 2 (0–6)

in pursuing an NCC fellowship, and participants who had an Media views 151 (130–213) 7 (40–86)
NCCU at their institution. Group 1 was composed of 57
a
(78%) neurology trainees, while group 2 had 42 (58%) All data presented as median (interquartile range). Data represent the
median of all Tweetorials for each group.
neurology trainees. Similarly, group 1 had more US-based
trainees when compared with group 2 (47 [64%] vs 34
[47%]) (Table 2).
the divergence in test scores between group 1 and group 2;
Assessments and (3) wait-list control studies delivered over social media
One hundred learners completed the pre-educational curric- risk losing social media–based learners to follow-up.
ulum assessment. Thirty-two learners completed assessment
1, and 18 learners completed assessment 2. Both learner Free, global, and easily accessible, Twitter has the ability to engage
groups performed similarly in the pre-educational curriculum trainees and other healthcare providers from around the world and
assessment. A potential for knowledge improvement was serve as a platform to provide medical education through many
observed in group 1 at assessments 1 and 2 when compared formats including journal clubs, conferences, and webinars.5,8,9 Our
with that in learner group 2. study was able to recruit learners from more than 22 countries
(eTables 1 and 2, links.lww.com/NE9/A39) and from several
Twitter Metrics medical specialties as well. This diverse group of learners partici-
Learner group 1 had overall more impressions, engagements, pated in an innovative Tweetorial-based educational curriculum.
likes, URL clicks, and media views than group 2 (Table 3). As
summarized in eTable 3 (links.lww.com/NE9/A39) and pre- Tweetorial-based educational efforts lack data supporting their
sented in Figure 2, group 1 had consistently higher engage- efficacy. The divergence in tests scores between our 2 groups from
ments throughout the curriculum. the preassessment to assessment 1 suggests knowledge improve-
ments are possible, although our results should be interpreted
cautiously in light of poor participant retention. A recent study of
Discussion and Lessons Learned Tweetorials from the CardioNerds Academy analyzed 7 cardiol-
In this novel Tweetorial-based educational curriculum, we ogy Tweetorials from 4 unique authors that found that the mean
found out the following: (1) our Tweetorial-based education proportion of respondents felt comfortable with a given topic
was able to reach learners with different backgrounds around increased from 24.7% to 72.9% after completing a Tweetorial.10
the globe but lacked sustained curricular engagement; (2) the Our study builds on this work by suggesting that knowledge may
preliminary evaluation of our educational curriculum suggests actually increase, a higher-order learning outcome.11
potential for improving knowledge in NCC as evidenced by
While both groups performed similarly on the baseline as-
sessment, group 1 scored better on the second and third
assessments, showing minimal knowledge decay. By contrast,
Table 2 Participant Characteristicsa group 2 did not seem to benefit from the curriculum, possibly
Group 1 Group 2 due to poor engagement, evidenced by their Twitter metrics.
(n = 73) (n = 73) A plausible explanation for a lower engagement rate in the
Age, mean (SD) 31 (6.0) 31 (5.1) second learner group is the methodology of wait-list–
controlled studies that may lead to more attrition as other
Woman 34 (47) 25 (34)
content vies for learner attention. Malcom Knowles’ adult
US-based 47 (64) 34 (47) learning theory suggests that adults are most interested in
Neurology trained 57 (78) 42 (58) learning that has immediate relevance and impact.12 The slow
incremental deployment of our curriculum may have delayed
Dedicated NCCU 54 (74) 46 (63)
its delivery to the point that group 2 learners had moved
Interested in pursuing NCC fellowship 48 (66) 44 (60) beyond the initial engagement on social media that inspired
their participation. We had segmented the curriculum in this
Abbreviations: NCC = neurocritical care; NCCU = NCC unit.
a
All data presented as n (%) unless otherwise specified.
way to align with Mayer’s principles of multimedia learning.
According to Mayer,13 learners have limited capacity to their

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Figure 2 Engagements per Tweetorial

processing powers and learn better when messages are pre- longitudinal curriculum and how to assess outcomes. Our
sented in user-paced segments rather than as a continuous Tweetorial-based educational curriculum embraces the
unit. While this may be true, the peripatetic nature of resi- andragogy theory of adult education, which is based on self-
dency training may demand that the subspecialized curricu- directed, self-efficacious, problem-centered, independent
lum is delivered during the relevant clinical rotations lest all and constructive methods.16 In addition, these micro-
but the most intrinsically motivated learners be lost. Future teaching threads are innovations in medical education be-
studies of subspecialty education may need to account for this. cause they are a novel teaching method that involve creation,
integration, and application and thus merit inclusion within
An alternative explanation would be that group 1 was in- the Educational Scholarship through social media as defined
herently more motivated than group 2 and that this motiva- by Holmboe et al.17
tion could have led to group 1 learning more about NCC
independent of our curriculum. The imbalance in trainee Because our Twitter profile (@NeurocriticalE) and curricu-
background is another possible explanation for the difference lum was made available publicly in July 2022, it has garnered
in performance between both learner groups because group 1 1,395 followers, highlighting its expansive reach.
had more Neurology trainees compared with group 2, and the
maturation effect is expected to be greater in Neurology trainees. Our study has several limitations. There were more neurology
Another possible explanation for the difference in performance trainees in group 1 than in group 2 despite randomization,
between both learner groups is the presence of differential although this difference was not statistically significant. There
dropout, particularly given the considerable decrement in the was a dramatic reduction in the number of participants who
number of participants completing all the assessments. Last, completed each assessment; however, the reductions were
while NCC training is quite diverse throughout the world, we similar in each group. In addition, we were not able to assess
have no objective evidence to believe the country of origin or Twitter metrics at an individual participant level, which would
location of training played a substantial role in the score variation have allowed us to determine whether increased engagement
or engagement between both learner groups. with the curriculum led to more knowledge transfer. We also
lacked qualitative feedback from the participants. Regarding
Twitter has emerged as an innovative platform that can ef- our assessments, our multiple-choice–based assessments
fectively deliver educational content and engage diverse lacked measures of validity outside of internal content validity.
groups of healthcare professionals around the world. Our We also lacked international diversity in the participating
novel educational curriculum was able to reach learners from NCC faculty. Finally, our findings may have been biased to-
across 23 countries. On average, the learners accessed our ward more engagement with the platform because we
educational material multiple times as measured by the recruited our learners on Twitter and they volunteered to take
number of engagements obtained via Twitter metrics. We part. We do not know whether learners who do not already
followed expert advice in developing our Tweetorials, yet actively use Twitter would have interacted with our curricu-
best practices for Tweetorials remain to be elucidated.14,15 lum as favorably if assigned to it as part of a training program.
Future research should focus on answering important
questions to help optimize Tweetorial-based education, A Twitter-based educational curriculum disseminates teach-
including how to maintain learner engagement through a ing and improves knowledge in engaged learners. It is a low-

6 Neurology: Education | Volume 2, Number 3 | September 2023 Neurology.org/NE


resourced curriculum that worldwide neurosciences educa-
tors can design and adapt for their own learning needs and Appendix (continued)
context. Furthermore, given the educational modality, Name Location Contribution
worldwide collaborations and partnerships are possible in
curriculum design, delivery, and evaluation. Twitter may be Dearbhla Department of Intensive Drafting/revision of the
Kelly, MD Care Medicine, St James’s article for content, including
a valuable adjunct tool for learning and teaching in acade- Hospital, Dublin, and Global medical writing for content
mia. Further research is necessary to discover best research Brain Health Institute, Trinity
College Dublin, Ireland
designs for evaluating this platform. Best practices for
consistent, longitudinal learner engagement also remain to Shweta Department of Neurology, Drafting/revision of the
Goswami, University of Florida, article for content, including
be defined. MD Gainesville medical writing for content

Mikel S. Department of Neurology, Drafting/revision of the


Study Funding Ehntholt, University of Pennsylvania, article for content, including
No targeted funding reported. MD Philadelphia medical writing for content

Neha S. Department of Neurology, Drafting/revision of the


Disclosure Dangayach, Icahn School of Medicine at article for content, including
The authors report no disclosures relevant to the manuscript. MD, MSCR Mount Sinai, New York, NY medical writing for content

Go to Neurology.org/NE for full disclosures. Marc-Alain Department of Neurology Drafting/revision of the


Babi, MD and Neurosurgery, article for content, including
Neurological Institute, medical writing for content
Publication History Cleveland Clinic Foundation
Received by Neurology: Education November 20, 2022. Accepted in final (Florida), Port St. Lucie
form June 5, 2023. Submitted and externally peer reviewed. The Ahmad Riad Department of Neurology, Drafting/revision of the
handling editor was Editor Roy Strowd III, MD, MEd, MS. Ramadan, Henry Ford Health, Detroit, article for content, including
MD MI medical writing for content

Christos Department of Neurology, Drafting/revision of the


Lazaridis, University of Chicago Medical article for content, including
MD Center, University of Chicago, medical writing for content;
IL study concept or design
Appendix Authors
Catherine Department of Neurology Drafting/revision of the
Name Location Contribution
Albin, MD and Neurosurgery, Emory article for content, including
University School of medical writing for content;
Ronald Department of Neurology, Drafting/revision of the
Medicine, Atlanta, GA study concept or design
Alvarado- University of Chicago Medical article for content, including
Dyer, MD Center, University of Chicago, medical writing for content;
Nicholas A. Department of Neurology, Drafting/revision of the
IL; Current affiliation: major role in the acquisition
Morris, MD Program in Trauma, article for content, including
Department of Neurology, of data; study concept or
University of Maryland medical writing for content;
OU Health University of design; and analysis or
School of Medicine, study concept or design; and
Oklahoma Medical Center, interpretation of data
Baltimore analysis or interpretation of
Oklahoma City
data
Faddi G. Department of Neurology, Drafting/revision of the article
Saleh Velez, The University of Oklahoma for content, including medical
MD Health Sciences Center, writing for content; study
Oklahoma City concept or design; and analysis References
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