The Network That Never Sleeps

Abstract

This review describes how Twitter is currently used by laboratory professionals for education, research, and networking. This platform has a global audience. It enables users to post information publicly, easily, rapidly, and free of charge. The absence of hierarchies enables interactions that may not be feasible offline. Laboratory professionals teach thousands of people using text, images, polls, and videos. Academic discussion flourishes without paywalls. Published research is shared faster than ever before, articles are discussed in online journal clubs, and research collaborations are facilitated. Pathologists network globally and make new friends within and beyond their specialty. Pathology departments and residency programs showcase trainees and faculty and celebrate graduations. As users in one time zone go to bed, others who are just waking up begin to read and tweet, creating a 24/7/365 live global online conference. We encourage others to plug into the power of Twitter, the network that never sleeps.

social media, Twitter, professional development, education, networking, collaboration

You are at a laboratory medicine conference, mingling with your colleagues and friends from other states and countries. It’s late in the evening. It’s been a long and fruitful day of learning and connecting. You have presented your research and learned what others are doing. You have taught a course and attended a few others. Subject-matter experts were everywhere…it was so exciting! You connected with old colleagues, made new friends, and shared a laugh and a meal. Now it’s time to go home.

Now imagine that instead of the doors of the conference hall closing, they remain open. To everyone. Day and night.

As you go to bed, attendees in other time zones pour in. Everyone can see all the content created during the day: text, pictures, videos, comments, praise, and critiques. New attendees see what you and your colleagues said and discussed during the daytime, and they comment on it. They add their own teaching pearls and post their own takes on what transpired during the day. They network, mingle, debate, chat, and make new friends. This exchange goes on until they go to bed and you wake up in the morning and continue the cycle.

Now imagine that this conference is free. That anyone can attend any time without leaving their home or getting dressed up. That any trainee in any country can approach a famous professor and ask a question or strike up a conversation. Imagine that this conference goes on 24 hours a day, 7 days a week, 365 days a year.

This is the field of pathology on Twitter: the network that never sleeps.

Technology to Turbocharge Your Career

Twitter is best known as a social networking service (a type of social media), but this label does not do justice to the full range of ways in which the platform is used by medical professionals today. The somewhat flippant name of the platform contributes to the feeling among some people that its raison d’être is to post frivolous, humorous, or malicious one-liners.

From the perspective of medical professionals, however, Twitter is a free, easy-to-use, widely accessible 21st-century platform for global communication, a tool to “get the word out there” with unprecedented speed. It is also home to a diverse multinational community of pathologists and laboratory professionals engaged in constant information sharing, conversation, and 24/7/365 live real-time learning, free of traditional barriers that limit access and exclude many. This review—written by pathologists and laboratory professionals who use Twitter extensively for professional purposes—will describe the many ways in which Twitter is currently used by medical professionals in general and laboratory professionals in particular.

We remind the reader that the audience on Twitter is composed not only of pathologists and laboratory professionals but also pathologists' assistants, residents, fellows, medical students, surgeons, oncologists, pediatricians, emergency-room physicians, practitioners of virtually every other specialty in medicine, basic scientists and, of course, members of the public.

The view that Twitter is conducive to academic discourse is becoming increasingly mainstream. As the scientist Alice Soragni, PhD, and the gastrointestinal pathologist and pancreatic cancer researcher Anirban Maitra, MBBS, argue in the journal Nature Reviews Cancer, “direct, unrestricted access to the biomedical community at large, together with the possibility to ask questions and obtain feedback in real time, is one of the singular advantages to using this platform for communicating published or unpublished data.” ¹ Soragni and Maitra further state, “our professional networks have become larger and more diverse thanks to Twitter, and we are better for it.”

We agree. Twitter has made our professional networks larger and more diverse as well, and in doing so, has turbocharged our careers. We hope we can show you how.

What Is Twitter?

Twitter is a microblogging platform or application (app) that allows users to post messages (information) in small portions known as tweets (≤280 characters), images (as many as 4 per tweet) and short videos (as long as 2 minutes, 20 seconds). A Twitter account is required for posting tweets but not for reading them. Tweets can be read by anyone with access to the internet and a web browser. This feature enables information to be rapidly made public and widely accessible.

Twitter is best known as a smartphone app but it can also be used on a tablet or in an internet browser on a desktop or laptop. It can be downloaded free of charge in most countries and includes a one-click translation feature to increase accessibility.

How to Get Started on Twitter

The process takes only a few minutes. You grab your cell phone, download the (free) Twitter app, and create a username and password. You are now ready to tweet. Even easier, you can like or retweet a post created by someone else (see the upcoming section on retweets). Once on Twitter, you can read a step-by step guide that describes what you can do on the platform.² We also highly recommend the tips provided in a free online guide created by Jerad Gardner, MD, a pathologist who was instrumental in bringing pathologists and laboratory professionals to the Twittersphere.³

To let others know who you are, we recommend that you add a picture to your profile and say something about yourself (for instance, “I am a cytopathologist from Utah” or even just “pathologist” or “pathology resident”). A professional headshot is ideal, but even a simple selfie is better than a profile without a picture. We recommend starting with a photograph and a one-line description of yourself, and later editing your profile to expand and improve it. Examples of strong Twitter profiles are shown in Figure 1. Readers should feel free to use these profiles as templates to construct their own.

Figure 1

Examples of well-constructed Twitter profiles for medical/laboratory professionals. A, Twitter profile of pathology resident Constantine Kanakis, MD, MSc, MLS. B, Twitter profile of hematopathologist Eve Crane, MD, PhD. Both examples include profile and banner images, hashtags, location, and links to professional/institutional or academic profiles.

Do not leave your picture and Twitter bio blank. People like to know who they are following and are less likely to engage with an anonymous, faceless entity. The anonymity provided by an account without a real name or photograph is also ripe for misuse by trolls and bots.

It is possible to make your tweets private, but doing so would contradict the point of a public platform. It would be akin to walking onto a stage in front of a huge audience and turning your microphone off.

What Does It Mean to Follow Someone on Twitter?

Unlike in real life, where following a stranger would be creepy, following people on Twitter is essential to the architecture of the platform. Following is simply a courteous gesture or an indicator of interest in someone’s tweets. When you follow someone on Twitter, their tweets appear in your timeline (feed). Likewise, your tweets appear in your followers’ feeds. Most importantly, the reach of tweets is directly proportional to the number of followers.

But I Don’t Know What a Hashtag or a Handle Is

A hashtag is a word preceded by a number symbol (#, also known as a hash or pound sign). It is a widely used, simple, and surprisingly powerful tool on Twitter. A hashtag can also precede a series of words without spaces, as in #learntousetwitter. Hashtags allow users to index tweets with labels that describe the subject or topic of the tweet. This enables tweets on any topic to be grouped together and easily retrieved in the future.⁴ For example, you could type #pulmpath in the search bar on the Twitter app and read tweets on pulmonary pathology. Twitter users worldwide are constantly indexing their tweets with hashtags for future reference. Table 1 lists a few commonly used hashtags in pathology and laboratory medicine. A list of pathology-specific hashtags has been published previously.⁵

Table 1.

Commonly Used Hashtags in Pathology and Laboratory Medicine

Hashtag	What the Hashtag Is Used For
Broad Topics
#MedEd	Medical education
#pathology	Any topic in pathology
#PathTwitter	Any topic in pathology
#pathboards and #knoworfail	Pearls for the pathology boards
#pathbugs and #crittersontwitter	Microorganisms
Clinical Pathology
#clinpath	Clinical pathology
#hemepath and #hematology	Hematopathology
#HumpDayHemepath	Weekly hematopathology tweet
#IDTwitter or #MicroRounds or #ASMClinMicro	Infectious disease/microbiology
#SHQuickByte	Pearls from the Society for Hematopathology
#Blooducation	Transfusion medicine and blood banking
#MicroMedEd	Tweets at the intersection of microbiology and medical education
Anatomic Pathology
#surgpath or #SurgPath	Surgical pathology
#CytoPath or #FNAFriday	Cytopathology
#pulmpath	Pulmonary pathology
#GIpath or #gipath	Gastrointestinal pathology
#BSTPath	Bone and soft-tissue pathology
#liverpath	Liver pathology
#breastpath	Breast pathology
#GYNpath	Gynecologic pathology
#GUpath	Genitourinary pathology
#forensicpath	Forensic pathology
#neuropath	Neuropathology
#cvpath or #cardiacpath	Cardiovascular pathology
#pedipath	Pediatric pathology
#ENTpath	Head and neck pathology
#grosspath or #grossognosis	Gross (macroscopic) pathology
Miscellaneous
#pathart	Art and pathology
#path2path	Discussion of pathology as a career
#mottirl	Met on Twitter, then in real life
#PathTweetAward	Tweets tagged as exemplary educational tweets
#PathRhymes	Tweets with rhymes about pathology diagnosis

Whether you want to add a hashtag to your tweet is entirely your choice. However, adding a hashtag helps broaden readership to those with similar interests and helps include those who may not have otherwise read the tweet. If we posted a tweet regarding this article, we might add hashtags like this: “We just wrote an article about Twitter for pathologists and laboratory professionals in Laboratory Medicine! #pathology #PathTwitter #MedLabTwitter.” People searching for posts on #pathology would then discover this tweet.

Pathology residents navigating the overwhelming ocean of posts on Twitter are encouraged to try the hashtags #Pathboards and #PathTweetAward, which index tweets on pathology board examination pearls and tweets of educational value, respectively. For medical laboratory professionals, we recommend checking out the hashtags #medlabtwitter, #Lab4Life, and #MedLabChat. Tweets related to an individual conference or event can also be found easily if a hashtag is established, such as #ASCP2020 (for the American Society for Clinical Pathology 2020 Annual Meeting).

Handle is Twitter-speak for “name.” Think of it as creating a pseudonym for yourself on Twitter. Although most professionals choose to make their real name visible on their brief Twitter profile, Twitter mandates that you create a Twitter-name that starts with the symbol “@.” For example, Kamran Mirza, MD, PhD, goes by @KMirza. Any twitter user can tag Dr Mirza with his handle, which brings the tweet to his notice (via a notification) when he logs on to the app.

We are intrigued that the use of handles dispenses with some of the formality associated with interactions in professional life. Instead of addressing the first author of this article as Dr. Mukhopadhyay, you could call him @smlungpathguy on Twitter without causing offense, even if you are a resident or medical student. Instead of referring to him as Professor Deshpande, it is acceptable etiquette to address Professor Vikram Deshpande as @Vik_deshpandeMD. Although a handle can include part of a real name (eg, @CArnold_GI or @RunjanChetty or @feldstej), it isn’t strictly necessary. Some users get quite creative with their handle, which can reflect their specialty, interests, origins, or other aspects of their life or personality. Examples include @IHC_guy, @Chucktowndoc, @infectio01, @rovingatuscap, @Mattcrophage, and @BldCancerDoc. To help facilitate interaction, Twitter handles can also be mentioned in the text of a tweet or tagged to an associated image or video without impacting the number of characters used for the tweet itself. This alerts others of your interest in their tweet, publication, or presentation, or indicates that you wish to solicit feedback on a question or idea from those with expertise in the area (Figure 2).

Figure 2

Tagging other Twitter accounts can enhance education and broaden networks. A, In this tweet, Narendra Bhattarai, MD (@Naren_ccf), a pathology resident at Cleveland Clinic, tags several hematopathologists on Twitter with a question that arose on his hematopathology rotation. This tweet yielded a concise and well-referenced answer from Sanam Loghavi, MD (B), sparking a conversation around that topic (C), with responses from Kunal Sehgal (D) and others.

Twitter’s “Secret Sauce”: The Retweet Button

The retweet button (symbol: 2 arrows curved in the shape of a rectangle) is a powerful tool that allows users to share posts tweeted by others with their own followers using a single click. It can be used in 2 ways.

One way is to simply click the retweet button without adding a comment. This method is quick and simple, and is a great way for newcomers to get started on Twitter without creating original content. Retweets build rapport because they amplify the reach of tweets, a gesture that is appreciated by the person posting the original tweet.

The other type of retweet (a quote tweet) not only reposts the original tweet but also adds a comment. Doing this takes more effort but is a great way to share a post and express one’s opinion on it at the same time.

Education on Twitter

During the past few years, a robust body of literature^1–20 has emerged addressing various aspects of social media platforms in medicine in general, and pathology and laboratory medicine in particular. These articles cover a range of issues surrounding the use of a variety of social-media platforms, including Twitter, Facebook, Instagram, YouTube, Periscope, Snapchat, and LinkedIn, among others. We will focus exclusively on Twitter because of the unique attributes that make it ideally suited for rapid, real-time global interaction and information sharing among medical professionals.

Tweets and Tweetorials

Anything you post on Twitter is a tweet. This could be a word, a sentence, a paragraph, an image, a GIF, a video, a poll, a link, or a combination of these elements. Twitter imposes a 280-character limit, but there is a simple trick to get around this: creating a thread or a Tweetorial.

A Tweetorial is a tutorial composed of tweets threaded into a linked sequence (thread). Tweetorials have become an increasingly popular teaching tool in pathology and laboratory medicine, as well as many other specialties in medicine.^4,6,21 A few examples of Tweetorials are provided in Table 2. The reader is encouraged to click the links provided and read a few Tweetorials, to get a sense of how they incorporate the tools that Twitter offers. The number of tweets in a thread is theoretically unlimited. The longest pathology Tweetorial currently contains 150 tweets.²²

Table 2.

Selected Twitter-Based Pathology Tutorials (Tweetorials)^a

Author	Topic	Link to Tweetoriala
Matthew Cecchini, MD, PhD, FRCPC	Pulmonary Pathology: pulmonary amyloidosis	https://twitter.com/Path_Matt/status/1188506020554985480
BIDMC Infectious Diseases Fellowship	Infectious Disease: cystic echinococcosis	https://twitter.com/BIDMC_IDFellows/status/1298824845673795584
Rola Ali, MD	Giant cell-rich bone tumors	https://twitter.com/DrRolaAli/status/1217839247916523520
Luis Humberto Cruz, MD	Ganglioglioma	https://twitter.com/luishcruzc/status/1230867921603198976
Samson W. Fine, MD	Prostate anatomy	https://twitter.com/rovingatuscap/status/1156317771246002177
Valerie A. Fitzhugh, MD	Synovial sarcoma	https://twitter.com/DrFNA/status/1032086422327570432
Raul Gonzalez, MD	Hepatic masses	https://twitter.com/RaulSGonzalezMD/status/1237785642148302849
Daniela Hermelin, MD	Kell blood group	https://twitter.com/HermelinMD/status/1190014347193573376
Sanjay Mukhopadhyay, MD	Aspiration pneumonia (particulate matter aspiration)	https://twitter.com/smlungpathguy/status/1058922823857696768
	Immunotherapy	https://twitter.com/smlungpathguy/status/1236376706845421568
Karen Pinto, DNB, FRCPath	Testicular masses	https://twitter.com/TheKarenPinto/status/1223188799695532032
Avraham Z. Cooper, MD	Eosinophilic depletion s/p prednisone	https://twitter.com/AvrahamCooperMD/status/1304825763984703489
David Steensma, MD	Left-shift	https://twitter.com/DavidSteensma/status/1214387521104367618

^aAll Tweetorials accessed on December 19, 2020.

Twitter also has a poll feature that allows users to answer questions anonymously and compare their answers to those of others. Polls can be posted for a limited time period (chosen by the author) before the poll is closed and replaced by the final results. This tool is incredibly effective in increasing engagement and is occasionally used as a pretutorial test in Tweetorials to engage the reader, begin the discussion, and assess baseline knowledge. Some Tweetorials also feature a post-tutorial poll to gauge whether the Tweetorial increased understanding of key teaching points (Figure 3).²³

Figure 3

Polls can enhance engagement and facilitate assessment of learning. These tweets, part of a Twitter-based tutorial (Tweetorial), show an example of a pre-Tweetorial poll (A), which is easy to create. In the image shown, the poll is closed, and viewers can see the breakdown of answers. B, Answers to the same question after the Tweetorial. Note that the percentage of people who selected the correct answer increased from 85% to 94%.

The ability to share links within tweets is a key strength of Twitter and distinguishes it from Instagram, in which links are not clickable. This enables users to post links to published journal articles, other tweets, websites, and YouTube videos, facilitating dissemination of educational content.

As mentioned earlier herein, short videos can also be embedded within tweets. Innovative educators such as Karen Pinto, DNB, FRCPath (@TheKaren Pinto) and Tristan Rutland, MBBS (@TristanRutland7) have used videos within tweets to harness the full potential of Twitter as an educational medium.

Education in the Era of COVID-19 and Social Distancing

The role of Twitter as a platform for free global education in the era of social distancing has been recently described in detail.⁴ Similar to other online platforms, Twitter was uniquely positioned to take on the challenges posed by the COVID-19 pandemic, which created an unprecedented demand for information related to SARS-CoV-2 (the coronavirus).

The usual paradigm of academic publication, which emphasizes slow, careful review, often at the expense of speed, was upended by the seriousness and rapidity of events. Medical professionals responded by using this platform to rapidly share advances in the literature, add commentary, and provide context. Although the deluge of information that ensued had mixed results, some pathologists did an exemplary job in sharing breaking information virtually instantaneously while maintaining scientific integrity.²⁴ In a remarkable example of the power of Twitter to rapidly crowdsource post-publication peer review, commentary on the platform triggered an investigative effort that resulted in retraction of 2 dubious publications in the Lancet and the New England Journal of Medicine.^25,26

Twitter was also used in synergy with other educational media during this period. For instance, live tweets were posted alongside a simulcast lecture by one of the authors of this review (C.K., @CEKanakisMD). The lecture was hosted by PathCast, an online compendium of pathology lectures. The topic of COVID-19 testing strategies and laboratory considerations registered 3900 views on YouTube; 17,100 views on Facebook Live; and 525 impressions from its initial Twitter post.²⁷

#VirtualPath

Social distancing due to COVID-19 resulted in the rise of several remarkable ventures on social media united by the hashtag #VirtualPath.⁴ Originally conceived as a label for all pathology-related activity on social media, #VirtualPath quickly morphed into virtual lectures, most prominently #CAPVirtualPath, a lecture series organized by the College of American Pathologists (CAP). Organization of this lecture series involved rapid recruitment of pathology and laboratory-medicine faculty, who agreed to give lectures that would be made freely available online by CAP. The lecture series became a massive success partly because it was promoted heavily on Twitter, attracting the attention of a large international audience that flocked to the lectures, encouraged by the unencumbered access to high-quality educational content. Christina Arnold, MD (@CArnold_GI) was awarded the 2020 CAP Distinguished Service Award for her role in organizing, promoting, recruiting for, and presenting for this lecture series.

Another project that started under the aegis of this hashtag was #VirtualPathGR (Virtual Pathology Grand Rounds: @VirtualPathGR on Twitter).⁴ The Virtual Pathology Grand Rounds provides its audience with continuing medical education (CME) credits through the American Society of Clinical Pathology (ASCP). We also witnessed the inception of a virtual pathology student interest group (@Path_SIG).

Internationally recognized organizations and institutions joined this initiative by making their in-house lectures available on social media. One example was the posting of hematopathology content from MD Anderson Cancer Center using the hashtag #virtualhemepathMDA. These hashtags saw soaring engagement (measured by metrics provided by Symplur), with millions of impressions and hundreds of thousands of tweets.

#Blooducation

There has been tremendous growth on Twitter within the area of blood banking and transfusion medicine on a global level, thanks to the efforts of the AABB, the International Society for Blood Transfusion (ISBT), and the American Society for Apheresis (ASFA). These organizations encourage and promote educational tweets within these specialties, which often use the hashtag #Blooducation. The value of Twitter for promoting online education in these specialties is increasingly recognized.²⁸

As in the world of anatomic pathology, Twitter-enabled collaborations in blood banking have taken many forms. Experts in the field with a Twitter presence are a valuable resource for laboratory professionals with questions about the standard of practice, in issues ranging from trauma resuscitation to discrepant findings on antibody panels. Blood banking technologists and specialists worldwide can provide real-time insights, advice, or additional resources when questions or challenges arise.

The speed of Twitter as a resource is illustrated by the responses to a tweet posing a question about the clinical significance of an anti-M antibody in pregnancy.²⁹ Within 60 seconds of the tweet, blood banking colleagues from around the world started sharing personal experiences and resources on this complex issue with a range of blood bank practices.

Another example of how Twitter is used in the blood-banking community is a tweet in which a question was posted in reference to a recently published article in the journal Transfusion, to gauge knowledge of the virtual platelet crossmatch.^30,31 Soon after the tweet was posted, members of the transfusion medicine community on Twitter replied, agreeing that this new technology has a role and noting that understanding how to implement it requires more information. AABB recognized this tweet as an educational opportunity, and the topic was chosen as the next journal article for the AABB Twitter-based Journal Club (#AABBjc), which took place in September 2020, generating tremendous engagement.³² In addition to free online access to global participation, this virtual journal club also provides easy access for journal authors to join, lead, or even moderate the discussion. The September #AABBjc journal club discussion saw participation from 7 countries. An coauthor of the article (@KreuterMD) participated as a moderator.

Compared with traditional journal clubs, Twitter-based journal clubs achieve far more than highlighting the main points of an article. They provide an opportunity for a vast global audience to learn from colleagues around the world without geographic boundaries or paywalls, and to network while shedding light on knowledge gaps and needed areas of research. As an additional benefit, a multi-institution research collaboration that took root from this journal club will investigate the benefit of ABO-matched platelets in suspected platelet-refractory patients in the adult population. Twitter can also be used to raise public awareness about the importance of blood donation by recruiting donors for scheduled local blood drives or requesting urgent units for rare blood types.³³

Finally, Twitter can be used to teach transfusion medicine topics beyond the traditional classroom setting. Tweetorials on these topics, freely accessible to any learner anywhere in the world, have been posted by us (D.H.).³⁴

Twitter Homework

Even before social-distancing measures shut down in-person educational activities, social media platforms were experiencing a rise in endeavors seeking to promote pathology education. One such venture was #TwitterHomework, which took educational activities that pathology faculty members had initiated in person in medical school pathology electives and brought them online to a global audience on Twitter.³⁵ This hashtag is used for a unique form of homework for medical students that encourages them to tweet about pathology-related topics. This practice can range from a retweet of a recent pathology post, to an original tweet featuring a pathology topic that the student recently learned about, to a post about their workday in pathology.

This activity encourages medical students to think for themselves, compose their thoughts on pathology-related topics into cogent posts, and learn from comments on their tweets made by others online. The exercise is helpful not only for the students but also for those viewing their tweets. #TwitterHomework has been well received, and participants report being pleasantly surprised at the warm welcome afforded to them by the pathology community in the Twitterverse.

PathElective.com

Pathology education became supercharged in the midst of the early months of COVID-19 with the development of a free, modular, interactive website curated by more than 50 volunteer pathology faculty members.³⁶ The website was conceived to bring many sources of pathology excellence together in one place and to mimic the process of an in-person pathology elective course. The website is divided into clinical pathology and anatomic pathology modules, with faculty members guiding students through different segments. Prequiz and postquiz assessments allow students to receive certificates of achievement.

Live Tweeting from Pathology and Laboratory-Medicine Conferences

Live tweeting refers to the practice of posting tweets from a medical conference while the conference is in progress. This practice enables those who cannot attend the conference in person to get a sense of the major developments occurring at the conference and to learn key take-home points. In pathology, live tweeting was first popularized at the 2015 United States and Canadian Academy of Pathology (USCAP) Annual Meeting, where it was highlighted by the hashtag #InSituPathologists. Thanks to the intense interest generated online by this activity, the 2015 USCAP meeting went viral on Twitter and founded a social media movement that continues to this day.³⁷ Live tweeting from international pathology conferences is now routine, and metrics related to online engagement continue to increase.

#PathTweetAward

#PathTweetAward is a hashtag that encourages, recognizes, and rewards pathology tweets with exceptional educational value.^4,38 The hashtag was created in April 2018. Since then, it has been used by thousands of pathologists worldwide. The underlying concept is that any pathologist anywhere in the world should be able to nominate exemplary educational tweets. This nomination is accomplished by publicly flagging the tweet with this hashtag in a reply or retweet (Figure 4). A panel of screening judges searches for tweets containing the hashtag and compiles a list of tagged tweets that is posted on Twitter every week.³⁹ The screening judges then select the best educational tweets of the month and submit them at the end of the year to a separate panel of final judges. The final judges pick the 4 best educational tweets of the year, which are then entered into a Twitter poll open to the public. The poll results decides the order of the final winners, who are given a certificate and a small cash award.

Figure 4

How to use the hashtag #PathTweetAward on Twitter. A, Pathologist Tristan Rutland, MBBS, retweets a tweet by Mark Ong, MBChB, and tags it with the hashtag #PathTweetAward. This simple action labels the tweet as a nominee for the award and brings it to the attention of the screening judges. B, In this tweet, Cullen Lilley, an MD/MA student, retweets a tweet by microbiologist Aaron Odegard, PharmD, MS, and tags it with #PathTweetAward. Note the excellent use of images in both original tweets.

In contrast to traditional awards, which are typically conferred by a few individuals behind closed doors and funded by pathology societies or large donations, #PathTweetAward is global, crowdsourced, and collaborative, with a transparent process that plays out online in full public view throughout the year. Anyone anywhere in the world can win, and everyone has a say in picking the winners. #PathTweetAward is funded by numerous small voluntary donations (crowdfunding).

Twitter for Research and Scholarly Work in Pathology

Is Anyone Reading My Paper? Disseminating Your Research

As things currently stand in academic publishing, authors seldom (if ever) learn whether anyone has read their published work. The only hard indicator is a citation by another published article. Many articles published in academic journals receive few or no citations, and it is entirely possible that many are read by few (if any) readers.

This lack of interest and engagement is mirrored by online activity measured by web-based services such as Altmetric. As shown by Altmetric data, most publications generate very little attention online, whether in the general public, in blogs, or the national news media. Journals with low impact factors and niche audiences are particularly susceptible to lackluster enthusiasm and underwhelming readership. In the past, an individual author could do little to change this dismal state of affairs.

Twitter has radically altered this paradigm.

Now, authors have a tool to publicize and showcase their scholarly work. Assuming that most authors want their work to be read widely, this is a welcome development. Authors can achieve this end in many ways, including posting a tweet or Tweetorial with a link to their article, discussing their findings with the medical community on Twitter, creating polls related to the article, and discussing their work in online journal clubs such as #PathJC.

Genuine enthusiasm for one’s scholarly work, coupled with a desire to communicate the work to others, stimulate discussion, and solicit feedback, is welcomed by the pathology community on Twitter. Discussion of articles online provides an opportunity for authors to gain perspective on their research by reading comments from a large number and variety of professionals from all over the world, some of whom may be experts in the field.

Figure 5 illustrates the impact of a tweet about an article. This tweet by the Society for Hematopathology (Figure 5A) contains a link to an article published in the American Journal of Clinical Pathology. An image from the article helps to enhance interest and draw in readers. Figure 5B shows analytics for the tweet, available on the smartphone of the person who composed it. The tweet shown here generated 9932 impressions (potential viewers) and 1183 engagements (people who liked, retweeted, replied, clicked on the link, or clicked on the image). Today, many journals and publishing houses collect and closely monitor metrics on the online impact of their articles, via tools such as Altmetric or PlumX. Figure 5C shows the countries where users were tweeting about the article and Figure 5D provides additional metrics, including the fact that the Altmetric score of this article (namely, 56) was ranked number 25 of more than 2800 articles followed for impact from this journal.

Figure 5

Promotion of manuscripts on Twitter can enhance engagement. A, A tweet from the Society of Hematopathology (@SocforHemepath). B, This tweet generated more than 300 clicks on the link to a related article. C, Geographic and demographic breakdown of people who engaged with the tweet. D, This tweet helped contribute to an Altmetric score in the top 5% of all research outputs. Metrics for the potential impact of a tweet can be readily tracked.

In the modern era, academic journals routinely track and showcase their most attention-generating articles (Figure 6). The degree of activity generated on Twitter is a contributor to the Altmetric score, which also takes into account mentions of the article on a curated list of Facebook pages, Wikipedia, blogs, and patents. Mentions in the national and international news media are weighted heavily in the scoring algorithm.

Figure 6

Academic journals use web-based scores such as Altmetric to assess impact, online attention, and readership with objective metrics. A, High-impact articles from the American Journal of Clinical Pathology. B, Altmetric scores for high-impact articles published in Laboratory Medicine.

Research Collaborations and Scholarly Work Facilitated by Twitter

In recent years, Twitter has been used in novel ways to promote scholarly collaboration. Such collaborations have resulted in several publications in peer-reviewed journals and even a few textbooks.^{1,4,9,40–50}

In many instances, pathologists have collaborated on manuscripts in which the coauthors have only met online.^1,40 Early in the COVID-19 pandemic, Oklahoma forensic pathologist Lisa Barton, MD, PhD (@LMBarton1) reached out on Twitter to one of us (S.M.) based partly on his Twitter presence and his numerous lung-pathology tweets. Dr Barton was seeking an expert pulmonary-pathology opinion on 2 COVID-19 cases, which morphed into a collaboration that produced the first published article in the English-language peer-reviewed literature on COVID-19 in complete autopsies.⁴⁰ The article generated intense interest, including coverage from the venerable magazine Scientific American, and has been highly cited in the literature (458 citations in 9 months per Google Scholar, as of February 2. 2021). Its Altmetric score (827) is the second highest of all time for the American Journal of Clinical Pathology. Additional published manuscripts also resulted from this online collaboration; to this day, the coauthors have never met in person.

In another example of the power of Twitter to rapidly create research partnerships, a tweet calling for lung-biopsy cases of vaping-related lung injury⁴¹ led to a multi-institution collaboration that resulted in a publication on this topic. This article was also highly cited, had a high Altmetric score, and remains to this day as 1 of only 2 pathologic series on this entity,⁴² to our knowledge.

The remarkable story of #EBUSTwitter has been previously described by Lepe and colleagues.⁴³ This hashtag was used for what is likely the first Twitter-enabled scholarly work in which a research idea was sparked by a tweet, fueled by another tweet, and executed almost entirely on Twitter, resulting in a peer-reviewed publication in the American Journal of Surgical Pathology⁴⁴ on a novel biologic phenomenon.

Twitter is especially well-suited for recruiting coauthors for review articles because so many experts use this platform. Potential collaborators often seek out others who write well (which is easy to judge on Twitter), work well together, and are interested in similar topics. We are aware of several published review articles^{1,4,8,10,13,45} in which the coauthors met on Twitter. Currently, journal editors also have a Twitter presence and are aware of the excellent educational content being posted online. Occasionally, a high-quality tweet or Tweetorial will catch the attention of an astute, Twitter-savvy editor, resulting in an invitation to write a review article for an academic journal.^45,48

Networking and Building a Community

Connecting With Other Professionals in Pathology

A major difference between Twitter and Facebook is that Twitter encourages interactions between individuals who may not be friends in the traditional social sense. For example, for a pathologist to appreciate or comment on an image of a fungus on Twitter, they do not need to befriend the person that posted the image. They can simply reply to the post, or like or retweet it. Because of this openness and ease of access, one can interact with virtually anyone on the platform, and they can choose to reciprocate if they wish. This structure fosters interaction between individuals who may have never met in real life, or would never have met given geographical boundaries or professional interests, or may never have approached each other. Another benefit of this environment is that it bridges gaps in seniority and experience to allow members of different experience levels to interact freely. A medical student or first-year pathology resident can easily ask a question addressed to a senior professor without the formality or barriers associated with traditional offline interactions.

A seldom-discussed variation on this theme is that Twitter is exceptionally well-suited to individuals who might be sidelined or disadvantaged in offline life due to their appearance, accent, shyness, or level of social skills. Unencumbered by these obstacles, such individuals can express themselves more freely on Twitter than they would in traditional settings. If one is to follow the adage to not judge a book by its cover, what better way than to read the book without looking at the cover?

#MOTTIRL

The hashtag #mottirl (“met on Twitter, then in real life”) captures the phenomenon of professional relationships that start online and turn into real-life meetings and lasting friendships.¹⁹ This situation typically occurs at national or international conferences, where individuals who have met, interacted, and known each other for months or even years online (but never offline) meet in person for the first time and experience the pleasure of meeting an old friend. This phenomenon is clearly a reflection of the smartphone era and the ubiquity and power of online social interactions. Individuals who meet in this way often tweet a selfie of themselves with the hashtag #mottirl to celebrate the moment they went from interacting strictly on social media to having offline interactions. Such moments cement genuine friendships and foster professional connections in a way unique to our digital generation.

Connecting With Professionals in Other Medical Specialties

Twitter makes it easy to expand one’s network beyond the narrow confines of one’s own specialty. Offline, increasing subspecialization frequently creates silos, in which people interact mainly with those in their own field, read journals catering to their own specialty, and attend national conferences tailored to the needs of a niche audience. In such an environment, it is unlikely that a pathologist will be well acquainted with the latest breaking news in, for instance, oncology, or will chat freely or frequently with oncologists. Is it equally unlikely that oncologists will be familiar with recent advances or areas of controversy in pathology.

Twitter breaks these silos by bringing everyone together on a common platform, where everyone can read everyone else’s tweets in free full text and follow anyone in any specialty. On Twitter, our clinical colleagues frequently read our posts, debates, and viewpoints, and vice versa. Updates from clinical conferences rapidly spread to the pathology world. Good teachers and facile communicators develop sizable followings and become sought after as speakers and coauthors by specialists in other fields.

The authors of this article have made scores of such connections with professionals in other fields, leading to valuable professional opportunities such as invited lectures, speaking opportunities at national conferences, podcast invitations, and invitations to coauthor scholarly publications.

Freedom of Expression

The audience on Twitter greatly values freedom of speech and authenticity. In a world where messaging is increasingly controlled by corporate interests and vetted by handlers, Twitter allows relatively unfiltered expression of the viewpoints of regular people.

Many laboratory professionals on social media celebrate personal events such as weddings and births, and share their hobbies and interests with their peers on social media. The hashtag #ILookLikeAPathologist is often used when pathologists share their interests outside of work. Members of the social-media community often join in to enjoy, congratulate, and celebrate, building a sense of community, positivity, and acceptance.

Whether you wish to share such information is entirely up to you. Many professionals prefer to keep their Twitter accounts entirely dedicated to professional purposes, whereas others prefer a blend of professional and personal purposes.

Supporting and Encouraging Others

The presence of a large group of professionals on a shared platform opens up the opportunity for mentor-mentee relationships. Finding mentors can be difficult if one is working independently, but informal mentorships are common across social media. For experienced practitioners who are social-media savvy, Twitter can be a great place to offer wisdom and career advice to younger professionals starting out in the field. Many pathologists serve as role models for others on this platform by virtue of their positive attitude and their willingness to teach.

Reaching out to a potential mentor can be as simple as tagging them in a tweet. For instance, a junior pathologist might put out a short tweet about her research or a case that she published and tag an experienced pathologist in the tweet. This practice results in instant exposure (the tagged individual might read the paper and reply with a comment) and opens up the possibility of an informal mentoring relationship.

Another way in which Twitter is used to support and encourage others is via online celebrations, which have become common during the era of COVID-19. In early 2020, a number of medical schools canceled all in-person learning and went fully online. This included cancellation of Match Day celebrations, which are a beloved tradition in medical school. To compensate, many schools started a “Virtual Match” celebration, in which students held a Zoom meeting or a YouTube live stream to announce where students in their class had matched. This activity soon moved onto Twitter, where a number of #virtual match tags were created, including some for specific fields. In this way, members of a field could congratulate incoming members and show support for an exciting life event.

Other significant life moments and professional accomplishments are also commonly celebrated on Twitter. Pathologists and laboratory professionals post about fellowships, awards, promotions, program acceptances, dissertation defenses, invited lectures, and moves to new institutions. The Twitter pathology community welcomes such posts in a collegial manner and serves as a source of constant encouragement and bonhomie. It is tempting to speculate that belonging to a welcoming community of one’s peers might reduce burnout for some individuals.

Making positive career developments public has an added benefit. It makes a vast audience (including potential future bosses or colleagues) familiar with one’s achievements and career trajectory. In this way, Twitter can function as a continuously updated curriculum vitae that is open to the public.

Group Chats

One method of building a community on Twitter is a group chat (Figure 7), a question-and-answer session that allows individuals to discuss issues related to their area of interest, expertise, or specialty. These chats encourage conversation and help to flesh out new ideas and collaborations. An example of a group chat pertinent to laboratory medicine is #MedLabChat, started in 2019 by Maria Roussakis, MLT, MSc (@MedLabMaria), Rodney E. Rohde, PhD (@RodneyRohde), and Contantine Kanakis, MD (@CEKanakisMD). #MedLabChat is a monthly group chat for medical-laboratory professionals that involves a minimum of 4 questions about a specific topic such as professional development, interdisciplinary interactions, nuances of certification, and licensure across various medical laboratory professional roles and continuing education.

Figure 7

Examples of tweets for different laboratory medicine–themed chats. A, A tweet from Nicole Riddle, MD (@NRiddleMD), asking the first question for #PathChat. B, Michael Misialek, MD (@DrMisialek) announcing the next #CAPChat topic on COVID-19 testing capabilities. C, A tweet from Maria Roussakis, MLT, MSc (@MedLabMaria), welcoming participants to the #MedLabChat for April 2020.

Another example is #PathChat, which is tailored a bit more to pathologists. The most recent #PathChat discussed coronavirus testing methodologies, supply chain constraints, and testing platforms. Pathologists, medical microbiologists, and others participated and shared laboratory testing ideas, frustrations, and solutions. #CAPChat is similar to #PathChat but is run by the CAP (@Pathologists). #PathChat and #CAPChat are moderated by members of the pathology community, who ask questions to initiate a discussion about a selected topic. The bulk of the discussion takes place during the hour that the chat is slated to occur, but discussions often continue on Twitter through the next couple of days as others log in and add their viewpoints.

Pathology Journal Clubs

A variation on a Twitter group chat is a Twitter-based online pathology journal club.^8,51 An early example of a Twitter journal club was the online nephrology Twitter journal club #NephJC, created in April 2014 to stimulate public discussion on current literature in nephrology, hypertension, and related topics across levels of training and specialties.⁵² The excitement generated around these discussions was noted by a group of pathologists active on Twitter who—with mentoring from Matthew Sparks, MD (@Nephro_Sparks), of #NephJC—launched the first pathology Twitter-based journal club, with the hashtag #PathJC.^53,54

Topics of discussion for #PathJC rotate across subspecialties, with approximately 1 topic per month. The journal club usually focuses on a recent paper with implications for diagnostic practice, such as the release of guidelines for diagnosis of acute leukemia or revised nomenclature of noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP).^55,56 These and others topics have garnered broad interest from pathologists in academia and private practice, pathology trainees, clinicians, and researchers. A #PathJC discussion on vaping-induced lung injury stimulated a robust and productive conversation that included members of the public, including the vaping community.⁴²

Given the challenges of finding a single time that works across all time zones around the world, #pathJC expanded the discussion to continue in a second time slot, adding the hashtag #eurotime to continue the conversation in Europe. These discussions typically generate impressions in the millions, provide a network for ongoing learning across practice settings, and spark collaborative research projects. In some cases, as exemplified by the vaping study, they also help raise public awareness of the role of pathologists in health care. The utility and impact of online journal clubs is increasingly recognized, and journals like Modern Pathology have granted full-text access to articles surrounding these events, to increase engagement.

Multiple subspecialty Twitter journal clubs within pathology have now been launched, including journal clubs focusing on dermatopathology (#dermpathJC), hematopathology (#hemepathJC), and gastrointestinal pathology (#GIPathJC). Setting these up is easy: all that is required is to create a hashtag and to alert potentially interested parties of when the event will occur. The #NephJC team provides a primer on their website for establishing such a journal club.⁵⁷

Twitter for Pathology Departments and Pathology Residency and Fellowship Programs

Because in-person visits to pathology departments have decreased dramatically during the COVID-19 pandemic, establishing an online presence has become increasingly important. Table 3 lists selected pathology departments and residency programs with a Twitter presence, and shows some of the ways in which these accounts post information in line with their mission.

Table 3.

Examples of Pathology Departments and Residency Programs on Twitter

Pathology Department or Residency Program	Handle	Following	Followersa	Examples of Content Posted (Tweets)
The University of Michigan Department of Pathology: Ann Arbor, MI	@UMichPath	2214	7501	Educational cases, faculty publications, showcasing research, short profiles of current residents
Mayo Clinic: Rochester, MN	@MayoClinicPath	977	6976	Showcases of resident posters at USCAP meeting
Stanford Medicine Department of Pathology: Stanford, CA	@StanfordPath	97	5391	News and interesting cases
Department of Pathology at University of Arkansas for Medical Sciences: Little Rock, AR	@PathologyUAMS	1444	4593	Profiles, cases, professional development/promotions
	@HemepathUAMS	926	1976
Massachusetts General Hospital: Boston, MA	@MGHPathology	220	3907	Mixed features of faculty staff, accolades, cases, content
University of Alabama at Birmingham, School of Medicine, Department of Pathology: Birmingham, AL	@UABPathology	1436	3456	News, interesting cases, faculty/trainee profiles
State University of New York Upstate Medical University: Syracuse, NY,	@SUNYUpstatePath	4774	2716	Pictures of residents and fellows, resident interviews, short interviews with faculty
Anatomic and Clinical Pathology Program at the University of Texas, Medical Branch; Galveston, TX	@UTMB_Pathology	531	2491	Program promotion, cases, news
Anatomic and Clinical Pathology Program at Northwestern University, Feinberg School of Medicine; Chicago, IL	@NU_Pathology	408	2438	Resident sharing, cases, professional development
	@NU_GIpath	151	1089
Loyola University Medical Center; Chicago, IL	@loyolapathology	779	2272	Educational cases, tweets promoting pathology education, tweets promoting training programs
	@loyoladermpath	238	320
	@loyolahemepath	84	718
	@hallwaypathquiz	176	303
	@MLSatLoyola	72	507
Memorial Sloan-Kettering Cancer Center Department of Pathology; New York, NY	@MSKPathology	1	2129	Educational cases, promotion, projects
University of Chicago Department of Pathology; Chicago, IL	@UChicagoPath	244	1421	Content provided by residents, who run the account
Department of Pathology at Mount Sinai West and Mount Sinai Morningside hospitals; New York, NY	@MSWPathology	247	997	News and interesting cases
Ohio State Pathology Residency; Columbus, OH	@OSUPathRes	746	905	Interesting cases, faculty/resident profiles, news
Cleveland Clinic Pathology Residency Program; Cleveland, OH	@CCFPathRes	77	609	Faculty interviews, brief resident profiles, showcasing of teaching techniques and diversity
Medical College of Wisconsin; Milwaukee, WI	@MCWPathology	77	491	Department accomplishments, publications, profiles, cases
NorthShore Pathology Residency Program; Evanston, IL	@NorthShore_Path	349	313	Profiles, cases, interdepartmental news sharing
Geisinger Pathology Residency Program; Danville, PA	@GeisingerPath	27	278	Educational material posted by faculty, pictures of residents, link to residency-program website
University of Washington Pathology Residency and Fellowship; Seattle, WA	@UWLMPathRes	39	266	Feature profiles, publications/articles, case reports
University of Arizona Pathology; Tucson, AZ	@UAzPathology	43	221	Cases, profiles, Arizona features, news, accomplishments

USCAP, United States & Canadian Academy of Pathology.

^aFollower counts change constantly. These numbers are accurate as of September 27, 2020.

These ways include showcasing the expertise, diversity, and personalities of faculty; highlighting the breadth of cases seen; and spotlighting the diversity and academic productivity of residents and fellows. Short videos featuring faculty are an excellent, no-cost, high-impact way to advertise the quality of one’s department to a large audience.⁵⁸

Such posts commonly reach thousands and help shape public perception of academic departments. As a result, these posts can potentially facilitate recruitment because they show trainees and junior faculty that your department is a supportive and productive place to build a career.

With cancellation of all National Resident Matching Program (NRMP) match celebrations across the country, the Twitterverse brought forward a virtual pathology Match celebration using the hashtag #VirtualPathMatch. With more than 4.4 million impressions and more than 1000 tweets in less than 1 month (Figure 8), this hashtag celebrated individuals involved in the Match process in 2020 and became the go-to mode for promoting and celebrating colleagues and friends.

Figure 8

#VirtualPathMatch. Tweets marking the beginning (A) and end (B) of #VirtualPathMatch, a Twitter-based celebration of the National Resident Matching Program (NRMP) Pathology Match 2019. The hashtag, created by Kamran Mirza, MD, PhD on March 14, 2020 generated more than 4.4 million impressions during a 9-day period (data shown March 1 through March 23, 2020 - the 9-day period noted is between March 14 when the hashtag was created and Match Day, March 23).

We are now living in an era in which residency applicants are increasingly familiar with faculty members who have a robust online presence. Conversely, faculty members are increasingly aware of medical students who demonstrate enthusiasm for pathology on Twitter. The residency interview season is full of opportunities for applicants and programs to connect online on Twitter. Using a public stage like Twitter to highlight an applicant’s interest, enthusiasm, or experience in the field may be potentially advantageous during interview season.

A Word of Caution

As with other technologies that have disrupted previous modes of communication—computers, the internet, and smartphones—Twitter can be used in productive and destructive ways. The potential hazards of social media use are well documented. Cell phone addiction is pervasive. The potential for misinformation and harassment exists.

There are understandable concerns about scientific integrity and expertise on Twitter. Because anyone can post freely on the platform without any type of vetting, the responsibility of deciding whether a person posting a tweet is a reliable source belongs to the reader. This situation opens up the possibility of dissemination of inaccurate or misleading information. However, because so many content experts are on the platform, fact-checking constantly occurs, and inaccurate information can be effectively debunked. We urge readers to be appropriately skeptical and (whenever possible) to cross-check published sources in the peer-reviewed literature. Caveat emptor.

Concerns about patient privacy are important and have been addressed in detail by Crane and Gardner.⁷ Legal concerns are also understandable, but as Gardner and Allen¹⁸ have pointed out, no lawsuits have been filed thus far based on misuse of social media by pathologists.

We urge everyone using Twitter and other social media platforms to never post identifiable patient information. We urge them to be mindful of Health Insurance Portability and Accountability Act (HIPAA) regulations and, above all, to strive to be supportive, kind, and collegial.

Remember that all tweets are public. Minimize clinical information in posts about cases. The time of the post, combined with location data, can make data identifiable, particularly if a tweet is related to an unusual or rare entity. An important principle in educational pathology posts is to focus on the teaching point and to remove information that is not critical to the message.

Tweet the lesson, not the patient.

The social media policies enforced by your institution may be more restrictive than HIPAA regulations. Adherence to these policies is always advisable. This practice is especially important for officially sanctioned departmental, residency, or fellowship accounts, which are more likely to be viewed as representing the organization.

Excellent guides for newcomers including Twitter dos and don’ts have been previously published.^59,60 We summarize our advice in Figure 9.²

Figure 9

Advice for Laboratory Professionals on Twitter

Summary

Twitter is a modern communication tool that puts the ability to post public messages with unprecedented speed and reach into the hands of the common person. For those in the medical professions, this tool opens up innumerable opportunities for education, research, and networking, some of which we have described in this article. We urge all laboratory professionals to take the plunge and experience first-hand the power of Twitter, the network that never sleeps.

Abbreviations

Abbreviations
 
• CAP

  College of American Pathologists

 
• CME

  continuing medical education

 
• ASCP

  American Society of Clinical Pathology

 
• ISBT

  International Society for Blood Transfusion

 
• ASFA

  American Society for Apheresis

 
• USCAP

  United States and Canadian Academy of Pathology

 
• NIFTP

  noninvasive follicular thyroid neoplasm with papillary-like nuclear features

 
• NRMP

  National Resident Matching Program

 
• HIPAA

  Health Insurance Portability and Accountability Act

Personal and Professional Conflicts of Interest

None disclosed.