Problem

Over the past 3 decades, the Internet has become a universal source of information leading to a significant increase in global connectivity and awareness. Nevertheless, medical education remains mostly unchanged in its delivery—didactic teaching in a local conference room or lecture hall, supplemented with hands-on clinical experiences. Only a few initiatives using Internet-based methods to distribute didactic lectures beyond the walls of a local academic institution to colleagues in the same city, across state lines, or internationally have been described.1–3

Limiting educational sessions solely to those who can physically attend creates missed opportunities on multiple fronts. First, educators fall short of widespread distribution of their content, which often takes the form of a computer slideshow displayed on a large screen—a format that readily lends itself to redistribution as a live broadcast or recording for on-demand access. Second, learners could save valuable clinical time by remotely attending didactic sessions. Finally, learning and practicing physicians in regions and countries with limited financial resources are often unable to bear the cost of national or international travel to attend educational conferences, which feature essential information such as updates to disease classifications and best practice guidelines.

In the past few years, there has been an unprecedented rise in the number of health care providers (HCPs) who professionally use online social networks (OSNs), including Facebook and YouTube.4 Although fundamentally different, Facebook and YouTube are the 2 largest OSNs, with 2.2 and 1.5 billion active users, respectively.5 While YouTube is considered the premiere video-sharing platform, with over 400 hours of content uploaded every minute, Facebook allows users to communicate through hyperlinks, images, plain text, and videos. In the United States alone, it is estimated that 73% and 69% of adults use YouTube and Facebook, respectively6; Twitter, another large OSN, is only used by 22% of adults in the United States.6

Recently, both Facebook and YouTube granted their users access to robust, yet easy-to-use livestreaming tools, making them platforms that could easily be used to create open-access interactive medical education lectures. Given the availability of applications that make it possible to broadcast educational content anywhere an Internet connection is available, we support the notion that physicians in resource-rich regions have a responsibility to use these tools to share relevant medical knowledge with their colleagues, particularly those in resource-poor regions.

Approach

By leveraging off-the-shelf broadcasting software, videoconferencing applications, and livestreaming features from Facebook and YouTube, in 2016, we created pathCast as a platform to broadcast pathology lectures to an international community of medical professionals. Our project was conceptualized to be a flexible medium to strengthen the pathology knowledge base and has continuously accommodated a growing collection of lecture types and topics.

Choosing topics and presenters

We developed a flexible and evolving curriculum to address a variety of challenging concepts across various pathology subspecialties (Appendix 1). Topics were selected based on several factors: (1) commonly discussed and debated issues at national and international conferences; (2) recent updates to disease classifications, diagnoses, and staging systems with impact on patient management and prognosis; (3) material considered essential for resident physician education; and (4) requested by presenters (or lecturers) and viewers. To best deliver the curriculum’s content, we invited expert pathologists to be presenters, many of whom had authored seminal literature in their respective area of expertise.

General pathCast setup

To employ the OSNs’ livestreaming functions, free channels were registered with YouTube (May 2016) and Facebook (February 2017) under the username pathCast—a portmanteau of the words pathology and broadcast. Each session (or lecture) was loosely scheduled for 60 minutes and designed as a histopathologic digital or glass slide workshop or as a traditional computer slideshow. All lectures were streamed live in high definition and archived for on-demand viewing. The lecturer decided the format and lecture style.

The sessions were either local or remote, depending on whether the lecturer was present at the site where the live feed was initiated by the moderator (Figure 1). We served as moderators by hosting and coordinating the online broadcast. By default, lecturers presented to an online audience, but the lecture could also be concurrently delivered in person to local attendees. Remote (online) attendees engaged with the presenter in real time by posting comments or questions using the broadcasts’ chat interface, prompting either verbal answers from the lecturer or written responses by the moderator. Once the broadcast ended, lectures were automatically archived as public video posts on the OSNs and were made available through the project’s website7 and as video podcasts in iTunes. Continuing medical education credits were not offered for participation.

Figure 1:

Schematic showing the 2 possible pathCast setups. pathCast is a platform to broadcast pathology lectures to an international community of medical professionals. Scenario A details a local setup where the lecturer is present at the same site as the moderator. Both use the same workstation, which contains the lecturer’s presentation along with the necessary video encoder software to distribute the livestream. Scenario B details a remote setup where the lecturer is remotely present. In this scenario, the lecturer and moderator use separate workstations, the presentation is received using web-based videoconferencing tools and is then transferred to the video encoder software for distribution on the livestream.

Minimum broadcast requirements

For both local and remote sessions, the following were the minimum requirements to broadcast a session: Internet-enabled workstation(s) with functioning audio input and output and video encoding, recording, and streaming software. If the lecturer was presenting remotely, videoconferencing software with screen sharing capabilities was also required.

Advanced livestreaming method

To simulcast a lecture to both OSNs, a live public event was first created (or scheduled) separately on both Facebook and YouTube, providing basic information such as lecture title, description, relevant categories, date, and time. Video encoding software (for which we used Open Broadcaster Software [OBS] Studio, version 0.32, distributed under GNU General Public License) was required to input custom stream settings—including, among others, video resolution, frames per second, and maximum bit rate for each session. The H.264 encoded video output (scaled) resolution was set to 1280 × 720 at 30 frames per second and a maximum bit rate of 2,700 Kbps, while the advanced audio coding was set at a bit rate of 160 Kbps. Once this information was input, each OSN generated a unique and single-use stream key for an event, which was used to set up the OBS Studio stream that was then distributed to a web-based livestream distribution service. For local setups, the presenter’s voice was captured using the microphone directly connected to the pathCast workstation. When the lecturer was remote, their voice was transmitted via the videoconferencing software and recorded using the broadcasting workstation’s soundcard.

Basic livestreaming method

To create a stream without custom settings, a public event was first created (or scheduled) on YouTube; this method was not available on Facebook. Google Hangouts, a web-based communication platform, was used natively for both videoconferencing and broadcasting. If the lecturer was locally present, their voice was directly recorded by the pathCast workstation microphone, but if they were remotely present, their voice was indirectly captured by the same microphone using the sound emanating from the workstation’s speakers.

Reach and goal

Our project aims to reach a wide audience, including resident pathologists in the United States and abroad to supplement the didactic content they receive, practicing pathologists to enhance their diagnostic skills and introduce new and emerging concepts, and pathologists in resource-poor countries who would otherwise not have the opportunity to directly learn from experts in the field. The overarching goal is to freely disseminate pathology knowledge to pathologists worldwide and thus to strengthen medical education at no extra cost.

Generating an audience

One to 2 weeks before a scheduled broadcast, promotional banners including the presenter’s name, headshot, and affiliation, along with the lecture title, date, and time were created (e.g., see Supplemental Digital Appendix 1 at https://links.lww.com/ACADMED/A787). These banners were posted on our Facebook (@pathCast) and Twitter (@pathologyCast) accounts and shared in multiple large pathology group pages on Facebook and the cross-platform messaging app, WhatsApp.

Interpreting video analytics

We explored the performance of all lectures via the OSNs’ analytics tools, which provided metrics such as minutes viewed, number of video views, geographical traffic source, viewer engagement (e.g., number of viewer comments), and viewer sentiment.

Outcomes

We reviewed analytics data from Facebook and YouTube at the end of each calendar month and in aggregate. Over the course of about 43 months (from June 2016 to December 4, 2019), a total of 87 lectures by 53 speakers and representing 18 pathology subspecialties were transmitted on YouTube (with 65 also transmitted on Facebook), using the advanced (65, 74.7%) and basic (22, 25.3%) streaming methods. Thirty (34.4%) of the sessions were local while 57 (65.5%) were remote, with presenters located across 14 different cities in the United States and 6 cities abroad (see Appendix 1). The lectures were composed of traditional computer slideshows (40, 46.0%), glass slide workshops (25, 28.7%), digital slide workshops (3, 3.5%), or a combination of these (19, 21.8%). Many pathology subspecialty topics were covered, including topics in cytopathology (15, 17.2%), gastrointestinal pathology (17, 19.5%), and neuropathology (16, 18.4%; see Appendix 1). Most lectures were presented in English only (78, 89.7%), while 8 (9.2%) were delivered in a foreign language only (1 each in Finnish, French, Italian, Japanese, Mandarin Chinese, and Portuguese and 2 in Spanish; see Appendix 1). One lecture was presented in both English and German (1, 1.1%).

As of December 4, 2019, the lectures hosted on the YouTube pathCast channel, which has 5,891 subscribers, have garnered 292,735 views for a total of 50,674 hours (~2,111 days) of watch time. Additionally, the lectures hosted on the Facebook pathCast channel, which has 8,333 followers, have received 52,171 views for a total of 386,200 minutes (~268 days) of watch time.

Using the 20 most watched sessions for a subanalysis revealed that on average livestreams peaked at 51.4 concurrent viewers. On the day of a broadcast, a lecture received an average of 220 live and on-demand views. All lectures achieved a considerable increase in on-demand views after the broadcast, with some reaching a 27-fold increase. To date, 16 (18.4%) lectures have logged > 10,000 views, 34 (39.1%) have logged 5,000–10,000 views, and 37 (42.5%) have logged 1,000–5,000 views.

Users from 1,093 unique cities across 124 countries engaged with the livestreams. Per Facebook Insights, the types of devices used to access the lectures were laptop or desktop computers (44.0%), mobile phones (42.0%), tablets (11.1%), smart televisions (2.6%), and other (1.3%). Browsing all of the publicly posted comments during and after the sessions revealed an overall positive sentiment toward the individual lectures and the pathCast channels overall, with most comments acknowledging pathCast’s value and expressing gratitude.

Next Steps Beyond the lecture hall

Previous reports have assessed the utility of on-demand YouTube videos as an educational resource for HCPs,8 and more recently Johnson and colleagues3 demonstrated the advantage of livestreaming interactive radiology seminars on Facebook. Following an initial analysis of pathCast’s viewership on YouTube in February 2017, we broadened the reach of the lectures by adding a parallel Facebook channel. Simultaneously, the advanced livestreaming method was adopted to improve performance by using a customizable external encoder capable of providing higher-quality audio–video output. To our knowledge, our project showcases the first instance of distributing medical education via simulcast on Facebook and YouTube, which could engage a large audience of HCPs who are using OSNs.

We used Twitter’s streaming platform Periscope to transmit a few sessions in May 2016; our experience with this was detailed by Fuller and colleagues.9 Briefly, Periscope only allowed users to share content captured by a smartphone’s camera; therefore, streaming a slideshow would entail videorecording a computer monitor, essentially “taking a picture of a picture.” Additionally, a local presenter’s voice was captured using the smartphone’s built-in microphone, and if they were remote, their voice was indirectly recorded as it emanated from the broadcasting workstation’s speakers, depreciating the broadcast’s audio quality. Acknowledging the platform’s shortcomings, we migrated to YouTube and later to Facebook as well. Since then, Periscope has released Producer, a version of its platform that allows users to stream high-quality broadcasts from external sources. Nevertheless, the lower number of active U.S. adult Twitter users (see above), many of who are already on Facebook and/or YouTube, made it hard to justify streaming lectures to all 3 platforms.

Introduced in 1992, CU-SeeMe is one of the earliest examples of an Internet-based videoconferencing client used to distribute education across classrooms in the United States.10 Using modern OSN tools, we have been able to disseminate an organized medical education curriculum, creating new teaching and learning opportunities for a global audience. Our project also demonstrates a paradigm shift in how online medical sessions are offered, since attendees do not need to register or be individually invited to join, rather anyone visiting the website broadcasting the livestream instantly gains access. Even if just a modest portion of a medical education curriculum is publicly transmitted as an online simulcast, both local and remote attendees can concurrently benefit from the lectures.

A valuable aspect of using Facebook’s platform is that both the lecture video and the live comments or questions are publicly archived. This creates a unique opportunity for educators and learners to continue an intellectual dialogue even after the stream has ended, since it is likely that both are already registered Facebook users.

Future directions

The field of medicine has entered a new era in which medical information can be published at a faster rate than was previously possible using traditional methods. Instead of ignoring this change, HCPs can embrace it and remain relevant by actively engaging in OSNs as content creators. As an example, pathCast hosted a multilingual (English, French, Japanese, Italian, Mandarin Chinese, and Portuguese) series introducing the Milan System for Reporting Salivary Gland Cytopathology (MSRSGC), which was presented directly by the system’s international group of editors and collaborators. This afforded the MSRSGC group an opportunity to present their seminal work to a global audience before the release of the accompanying 10-chapter atlas. It cannot be overemphasized how highly dependent the success of a new reporting system or protocol is on broad adoption and uniform utilization, which may prove challenging if the system or protocol is not well understood. It is our hope that these sessions can serve as quick introductions to the MSRSGC and amplify its global reach.

As pathCast grows, we will continue to develop the curriculum to further disseminate pathology education on a global scale. All upcoming pathCast sessions are now created as Facebook events allowing users to easily sign up for upcoming lectures and receive reminders when the livestream begins. In an effort to further disseminate the archived material, the project’s website7 and calendar of events has been shared with all pathology residency program directors across the United States. Lectures on the website7 and our YouTube channel have been organized as playlists and annotated with relevant keywords to facilitate the discovery of topics by learners. Additionally, a newsletter is now being distributed to inform users about upcoming lectures and provide them with links to archived content.

Acknowledgments:

The authors thank the lecturers for enthusiastically volunteering their time. They also thank the host institutions, notably the pathology departments at Mount Sinai West in Manhattan, The Johns Hopkins Hospital in Baltimore, Emory University in Atlanta, and Massachusetts General Hospital in Boston. The authors extend their sincere gratitude to the online audience that supports and learns from pathCast lectures.