BMUS journal club on Twitter: An analysis of the first #BMUS_JC discussions

Introduction

Journal clubs have evolved over recent years within healthcare to encourage continuing professional development (CPD) and awareness of ongoing research, service development and innovation. Traditionally within medical education, this has occurred through the reading and discussion of relevant journal articles, ¹ where this is usually facilitated by a leading practitioner who selects a relevant article and prepares the discussion points in advance of a face-to-face group meeting. ² In more recent years, journal clubs have extended to social media platforms, with varying examples of multimedia participation through online forum groups, websites and conferences. ³ Likewise, with the growing popularity of professional social media platforms such as Twitter and LinkedIn, there has been a growing number of successful journal clubs utilising these platforms.^4,5

Twitter is a free social media platform where users can share tweets alongside links, images and other multimedia forms (emoji/gif) to express their opinions and emotions. Content on the platform can be categorised and searchable through the use of hashtags which utilise the octothorp symbol ‘#'. The advantage of using Twitter for journal clubs is that it does not limit the geographical boundaries, allowing a wide range of users to participate, wherewith a character limit of 140 the communication is brief and fast-paced. ⁵

In August 2020, the British Medical Ultrasound Society (BMUS) organised an inaugural journal club (BMUS_JC) for both members and followers of the professional society of ultrasound on Twitter. A suitable article was chosen by the BMUS committee and journal editors for the journal club. The purpose of this article is to explore the discussions and narrative from the first BMUS Twitter Journal club, highlighting the key discussions and themes from the participants.

Methods

The BMUS_JC in August 2020 was led to discuss the Ultrasound article by Thomas et al. “Sonographers’ level of autonomy in communication in Australian obstetric settings: Does it affect their professional identity?” ⁶ The article was a qualitative study investigating sonographer practice and professionalism in Australia and the barriers to autonomy and practice. The journal club was a 1-hour chat on Twitter guided by three previously published discussion topics:

What situations in the UK do we have that means we may not always give full results to patients?

The journal club event was organised through BMUS, occurring on Thursday 20th August 2020 at 19.30 BST. Data were extracted from Twitter's site using the advanced search function to retrieve the tweets from the Journal club discussion using the #BMUS_JC on the 20–21st August 2020. The tweets were reviewed manually by the first author to establish whether they were related to the discussion themes (e.g. excluding social exchanges and side conversations). Any tweets before the discussion on the 20th were also excluded as they were mainly promoting the journal club. A manual process of reviewing each tweet was done to sort them into discussion groups for semantic thematic analysis. Following this, the analysis was reviewed with the second author.

Results

The initial search generated 131 tweets from 16 contributors. Following searching through the responses without the #BMUS_JC, a total number of tweets that contributed to the discussion were divided into discussion threads and any discussions not focussed on the topics were excluded from analysis, leading to a total of 123 tweets to be included for analysis.

The final analysis describes the themes from the three different discussion threads.

Discussion 1 (D1): What situations in the UK do we have that means we may not always give full results to patients? (54 tweets)

Findings from the discussion surrounding D1, situations where sonographers do not give full results, were categorised into three main themes (Table 1). Participants began by discussing which scenarios may arise where sonographers do not give full results. Examples being cases where ultrasound has diagnostic limitations and sonographers are unable to provide full diagnosis, with the more common examples including indeterminate findings. Continuing with this theme there was discussion where the participants felt that in scenarios where a new finding is discovered on ultrasound it is important to communicate that there is a finding even if the sonographer is unable to provide the full details at that time.

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Table 1.

D1 Themes derived from BMUS_JC tweet chat.

D1 Themes	Subthemes	Examples
Limitations of ultrasound	Full results not provided if findings are not definitive	When you see something but unsure what it is … although I am still honest and say something along those lines…
	Providing patients with enough information to inform them of a new finding	I think it’s important not to blindside patients and communicate that something has been found
Sonographer confidence	Sonographer confidence can influence the level of communication of results	Communication issues often come from a lack of confidence, not having the right support in place to support those less confident
	Recognition that communicating results is a difficult task	It's been assumed that communication of findings is just a skill everyone has … but this undermines the challenge of the role
	Importance of developing confidence when training sonographers	Those training need time to refine their skills … this needs as much as the practical side of the job
Barriers	Cultural barriers of sonographers communicating results	Some sonographers have been discouraged from saying too much by others

Within D1 there was further discussion regarding the difficulties observed and experienced in enabling sonographers to be confident to communicate ultrasound findings. The participants recognised that this aspect of the job is difficult to learn but important to develop in trainee sonographers. Furthermore, there was an overall agreement that with experience and support, a sonographer’s confidence in communicating results is developed.

Lastly, there was discussion to the potential barriers for sonographers delivering results in the UK, including discouragement from peers. Participants expressed surprise that there were still areas where this culture was occurring, where it was felt that providing patients with results was a key aspect of advanced practice.

Discussion 2 (D2): Based on our own experiences in the UK, how might some of the barriers to communication/disclosure of results experienced by sonographers in Australia be overcome or reduced? (54 tweets)

The conversations from the second discussion point involved reflections from sonographers in Australia and New Zealand sharing more of their experience, building from the journal article, and sonographers from the UK sharing their knowledge and advice for addressing any barriers.

Two main themes were drawn from the dialogue; approaches and barriers to developing the sonographer role to include communicating results (Table 2). Approaches included support and recognition from professional bodies in addition to demonstrating the benefits to patients for sonographers providing patients with results at the point of examination. Barriers identified the complex concerns from those from outside of the sonographer community, including protectionism from senior clinical professions and medico-legal concerns.

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Table 2.

D2 Themes derived from BMUS_JC tweet chat.

D2 Themes	Subthemes	Examples
Approaches to developing sonographer communicating results	Regulatory support for sonographers	Get it formalised by working with regulatory bodies
	Recognition of sonographers’ role	By obtaining the images you are already writing the report without words … you should be allowed to communicate that
	Patient benefit of sonographers reporting findings to patients	research strongly supports that immediate reporting is in the interests of patients
Barriers for sonographers communicating results	Protectionism from senior clinical professionals	Mature radiologists not trained by sonographers are more resistant to development of sonographers … those that have worked alongside sonographers respect and understand their skills
	Medico-legal concerns from providers	There is a fear of medico-legal implications and hierarchical management controlling who does what

Discussion 3 (D3): Is there an advantage in not giving full results to pregnant women? (15 tweets)

Findings from this thread demonstrate that the participants did believe that despite the importance of communicating results to patients there are cases where it is beneficial not to reveal every finding to the patient, with three key examples of when this is appropriate; when findings are not clinically significant, when findings have unknown implications, and to avoid unnecessary worry for patients (Table 3).

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Table 3.

D3 Themes derived from BMUS_JC tweet chat.

D3 Themes	Subthemes	Examples
Withholding full results	Findings of no clinical significance	Only if the findings are insignificant to the health and management of the pregnancy
	When the findings are indeterminate and implications of findings are unknown	If findings may have variable outcomes … sometimes it is best to say that you have found an unexpected appearance that requires an expert to discuss the implications of this
	To avoid unnecessary patient worry	Some have said that they were relieved that a fairly minor anomaly in the pregnancy had not been communicated because that would have been needless worry
Factors that influence decision making for providing patients with results	MDT participation is important to understand what is necessary to communicate results-wise.	Potentially easier for midwife sonographers who have a clinical understanding of the impact to care
	Sonographers’ experience of implications of results on management	Incidental findings that won’t change a patient's management … the sonographers' experience, communication skills and level of confidence are key factors that help a patient’s experience, even when something abnormal is seen
	Understanding how to manage incidental findings	Management of incidental findings can be really difficult
	Considering the patient preferences and expectations	What each pregnant patient wants varies so much … Some want so much detail and others don’t … taking each case individually and asking them what they want is vital

Furthermore, there were discussions around what factors can have an influence on sonographers’ decision making for providing patients with results. Multidisciplinary team (MDT) participation in both obstetric and non-obstetric ultrasound scanning was deemed important, where participants described how attending MDTs enable sonographers to understand which findings are considered to impact on a patient’s care or management. Incidental findings and the knowledge of how to manage these were discussed as a complicated aspect for sonographers due to the potential impact on patient care. Lastly an understanding and openness with patients as to what their preferences are was discussed as an important factor to consider, deciding whether the knowledge might cause undue worry for them.

Discussion

The findings from the first BMUS_JC demonstrated that an engaging professional, dynamic online discussion was fostered with support from the hosting organisation (BMUS). While journal clubs have traditionally been an effective way to engage healthcare professionals in CPD, the emergence of Twitter has the potential to revolutionise the format. ⁴ COVID-19 and its rapid onset into a global pandemic has required healthcare systems to change and adapt to often extreme conditions, impacting the usual professional activities such as CPD ⁹ which are still vital for disseminating and interrogating the rapidly growing findings relating to the pandemic. It is evident that this unprecedented scenario has had an impact on the usual professional activities of all healthcare professionals including sonographers, limiting educational, networking and teaching face-to-face opportunities. The BMUS_JC has provided sonographers and those interested in the ultrasound community the ability to engage in critical appraisal of the evidence base, supporting dynamic worldwide shared discussion, allowing the opportunity to interact with opinion leaders. A vital resource at a time where rapid publication and review of practices are essential to moving with the fluid nature of the pandemic.

The results from this study demonstrate a professional and insightful discussion led by the pre-set discussion topics. Topics such as the communication of ultrasound findings were thoroughly interrogated and due to the global reach of the discussion forum, different experiences, ideas and practices were discussed, offering a unique insight into global practice. The Twitter threads also raised how regulatory bodies work with the sonographic workforce differently in different geographical regions (D2 point 1). In the UK, sonographers report autonomously as endorsed by the Society and College of Radiographers and BMUS, who provide advice for sonographers with regard to communicating findings to patients as well as example reports. ¹⁰ There is much evidence to support the benefits to patients by the immediate reporting and communicating of results by sonographers ¹¹ ; however, this is a debated topic both in Europe and the wider global community. ¹² The ability for such in-depth and professional discussions to occur and be dissected by professionals on a global scale is unique to the online journal club and may inspire further progression with a patient-focused outlook.

In a time where social distancing is required, current literature supports the benefits of opening electronic discussion forums^1,2,4 where the involvement of overseas colleagues can help avoid localised echo-chambers and move discussion forums forward with new global insights.

The outcomes of the first BMUS_JC conform to the conventional wisdom from other articles supporting online journal clubs. Current data state that online journal clubs provide a suitable, dynamic and professional platform for informed discussion and debate.^2,3,5,13 The advantage of this journal club was that by signposting and clarifying clear discussion points prior to the event and having a group facilitator, group discussions were focussed, with clear and balanced insights into the relevant topic. Participants in the journal club demonstrated sonographers’ ability to evaluate research and apply the findings to their own clinical practice, as demonstrated through the arguments of how research supports communicating results to patients (Table 2). The outcomes from the peer-to-peer discussion within the group included a cohort of practitioners who were then able to share and apply evidence based practice examples and principles for others in the form of advice.

A notable finding from the BMUS_JC was the involvement of international participants. This feature provides insights that conventional journal clubs could not possibly achieve. The advertising and timing of the journal club was thought to have an influence on the global participation due to the time difference allowing both northern and southern hemispheres to participate, being evening for those in the UK and morning for those in Australasia. The journal club was also advertised on both the official BMUS and BMUS_JC social media accounts for 28 days prior to the event allowing adequate time for those interested to prepare. Furthermore, the Twitter discussions provided both active and ‘silent’ participants with a novel way to stay up to date with the latest literature and follow professional discussions in a socially distanced manner, thus allowing time to participate or review such information in an otherwise time-pressured environment.

The informal setting and convenience of Twitter also means that connections could be and were made with international colleagues in the form of follower relationships with those within the profession (sonographers/ultrasound practitioners) and those with an interest in the journal club topic (sonographer communication). Thus conversations included views from researchers in the area and reflections from patients' perspectives. Furthermore, because the discussions remain on Twitter following the formal club times, discussions can continue long after the formal discussion.

Twitter provided a rich, free platform to invigorate and globalise CPD and the journal club. BMUS already utilises the use of social media with 2595 followers in the main Twitter account and 138 followers to the BMUS_JC account, where the authors believe that with further promotion for ongoing journal clubs online can result in even more participation and discussion.

Limitations from this review include the fact that not all Tweets by participants used the hashtag, making it difficult to extract and include all the relevant discussions within the data sample. Although not surprising because of the English publication and host account being the British Medical Ultrasound Society, the chat is conducted in English only so non-English speakers did not participate, limiting the potential responses. The journal club discussions were timed for 19.30 BST which despite allowing participation from those in Australasia, may have limited participation from other geographical areas where this may have been an unsociable time for CPD activity. To potentially limit this, the journal club could consider alternating journal club timings to allow participation from those unable to commit to the inaugural event. Finally, this was an analysis of one online chat session and therefore included only a small sample of self-selected participants; further studies could elucidate greater data for a more detailed review.

Conclusion

The first BMUS Twitter journal club has provided a thought-provoking discussion between a number of ultrasound practitioners regarding the ongoing issues for sonographers’ professional identity worldwide, encouraging CPD participation, as well as highlighting areas for further dialogue and research going forwards. Following this review of the first event, the authors believe that pioneering #BMUS_JC is both viable and sustainable as a source of CPD activity for ultrasound professionals. With social distancing becoming a new challenge to navigate for clinicians and academics, the BMUS journal club utilising social media (Twitter) has demonstrated how this method of group discussion for ultrasound practitioners provides the potential for impactful international communication that would not be possible otherwise.