Tweetorials — From Early Beginnings to Huge Growth and Beyond

Tweetorials are definitely a thing. In September of this year, they crossed over from the screens of Twitter to the pages of the New England Journal of Medicine (NEJM), and the following month, over 1700 doctors engaged with them.

From their early iterations in late 2017 to their present explosive growth, tweetorials have become a vibrant addition to the “Free Open Access Meducation” (#FOAMed) movement and the #MedEd community.

Growth of Tweetorials, Nov 2017 - Oct 2019. Data from the Healthcare Social Graph®
Growth of Tweetorials, Nov 2017 – Oct 2019. Data from the Healthcare Social Graph®

Early Beginnings

According to the #MedTwitter community, in late 2017 the tweetorial — think “tutorial” rather than “editorial” — emerged as an innovative tool in medical education and communication. In opportune timing, that December Twitter added threads as a new feature. For years, to circumvent the character limit, enterprising users had been coming up with ad-hoc solutions to go beyond the single tweet, from the clunky TwitLonger, to the Twitter Essay, via the tweetstorm. As has often been the case, Twitter innovated functionality in response to user demand.

While early physician adopters of Twitter, such as Mike Thompson, MD, PhD, FASCO were already using threads to share connected information, Professor Darrel Francis is credited with originating the tweetorial as an educational tool. The first tweet of his I found referencing the term dates to December 9, 2017, but hints at works that came before.

Vinay Prasad, MD MPH is also mentioned as an originator of the form. Some of his most famous tweetorials were already making the news in 2018. For example, in May of that year, his response to a Lancet article on alcohol research was featured on the CBC website:

“Prasad went away and prepared a seminar complete with data slides and references. He returned to Twitter two weeks later with a tweetorial — a series of tweets forming a mini-lecture — to explain why he believes this type of nutritional research is deeply flawed.”

— CBC

Tracking Tweetorials

Tweetorials began to spread widely. A total of 70,495 tweets have been shared since Nov 2017 and Oct 2019 as visualized in the graph above. Since August alone, the #tweetorial hashtag has racked up over 21 thousand tweets (“#medthread” is sometimes used to describe this genre but in the past month only appeared in 758 tweets.).

As an aside, tweets without the hashtag “#tweetorial” or the keyword “tweetorial” aren’t picked up by Symplur’s systems, hence the importance of registering a pertinent healthcare hashtag, and discipline in using it when tweeting. A benefit to users is the ability to generate transcripts and basic analytics for a given hashtag, all accessible from the hashtag’s own page, such as this one.

The Tony Breu Effect

By the summer of 2019, tweetorials were happening in Spanish, being mentioned in French, and Tony Breu, MD, a hospitalist and educator still relatively new to Twitter, had become so fascinated with the medium and its possibilities that he’d already leveled all the way up. Breu, who was by then an experienced tweetorialist, surveyed his audience in early summer 2019, and shared the results in this thread, confirming, among many other things, that his reach was global (57 countries beyond the US!):

Tweetorials in the New England Journal of Medicine

Then, in September, mainstream medicine gave Breu the nod, when the NEJM published his Perspective piece, “Why Is a Cow? Curiosity, Tweetorials, and the Return to Why.” What struck me the most about his article was his emphasis on curiosity, the tolerance of uncertainty, and the profound question “why” as the motivator for him to try his hand at his first tweetorial, versus the usual-in-medicine, mechanistic “what.” From my perspective as a patient advocate, a doctor who is willing to entertain curiosity and ask “why” is still a rarity. Those who bring that approach can make a significant difference on a spectrum from the doctor-patient relationship all the way to outcomes.

Tweetorials on Explore the Space Podcast

Also in September, Breu guested on Mark Shapiro MD’s Explore the Space podcast, as highlighted here by Mike Stevens, MD:

Interesting moments in the episode include the discussion of disclosures and peer review (or lack thereof) for tweetorials, and their potential threat to the imbalance of power in the medical education establishment. The imbalance is heightened when you consider the potential readership for a given journal article behind a paywall (sometimes in the low three figures) versus a tweetorial (upwards of six figures).

I Direct Messaged Breu, and he agreed to share this screenshot of Twitter analytics for his top tweet, the first one in his tweetorial exploring the causes of pruney fingers and their connection to neuropathy.

Twitter analytics for @tony_breu‘s highest ranking tweet. Screenshot courtesy of Tony Breu. (Key added in red for clarity).

Shapiro and Breu also highlighted the tweetorial fun factor, as in fun to create, read, interact with, and learn from. Breu’s example above shows a mastery of the great writing hook, with the intriguing cliffhanger inviting you to read on. While Breu has found that his first tweet in the thread will receive the highest engagement numbers, it doesn’t take into account those who scroll down (but don’t click) to read the entire tweetorial.

Another example, this time from Avital O’Glasser, MD FACP FHM, includes — beyond the usual polls, links, and visuals — great gifs and exudes a sense of delight:

What’s Next For Tony Breu?

When you go down the tweetorial rabbithole, you realize that the combination of fun and utility is contributing to the creation of a lively and friendly community that crosses medical disciplines. Breu has emerged as its de facto leader, inspiring fellow clinicians to dare to create tweetorials, and generously amplifying the work of others.

Breu has launched @MedTweetorials to curate and catalog them, and has promised to return to Shapiro’s podcast in 2020 to report on his findings.

Tweetorial Engagement Right Now

For the month of October 2019, we found the following usage numbers for “tweetorial” datasets in Symplur Signals:

  • Total tweets: 8,522
  • All users: 5,687
  • Unique doctors: 1,741
  • Unique patient advocates: 34

The Trending Articles widget revealed the top article shared for October, which reached an attention score of 1265, placing it “In the top 5% of all research outputs scored by Altmetric.”

Network Analysis shows a flurry of Twitter activity around tweetorials, with the many interconnected grey lines indicative of interactivity and the community mentioned above. If tweetorials were less useful and less fun this graph would likely be a lot bleaker:

Tweetorials — The Future

Innovation in internet-enabled medical education keeps iterating, for better or for worse (see Christina Farr‘s recent article on YouTube surgery videos), and Twitter has become an increasingly important tool for all healthcare stakeholders, physicians in particular. Symplur CEO Audun Utengen’s latest post Does a Physician’s Social Media Impact Belong on their CV? points to a not so distant future when tweetorials with significant, measurable impact will likely be included on those CVs.

Beyond that, I propose that next level innovation in tweetorials build bridges between clinicians and patient advocates, like the ones we advocates built with clinicians via, for example, disease-specific tweetchats in oncology. Advocates like Matthew Cortland, Esq have long been producing highly instructive threads, without calling them tweetorials, such as this recent one on HIPAA. It’s time for physicians and patient advocates to co-create relevant tweetorials.

Liza Bernstein

Liza Bernstein - @itsthebunk

Liza Bernstein, who is NED (No Evidence of Disease) after three primary cancer diagnoses, is a patient advocate serving a global audience via social media, conference attendance, live-tweeting, speaking and media engagements, and in-person mentoring. She also collaborates, co-designs, and advises across the multi-stakeholder healthcare spectrum to break down silos, foster understanding, promote education and empowerment, and accelerate change. Liza is a Stanford Medicine X founding ePatient scholar, advisor, and former board member, and is Symplur’s Consultant for Insights and Development.