Need for a new venue to foster learner-teacher relationship
The decrease in the amount of face-to-face instruction in today’s medical education weakens the learner-teacher relationship, which is important for students’ academic success (1,2), especially for students who are struggling to learn the minimum required content within the strict time constraints of the medical school. In fact, better academic performance has been correlated with face-to-face lecture attendance among medical students.(22) Poor academic performance is both a cause and effect of stress (23), and the focus on students’ physical and emotional well-being in medical education is growing.(24,25) Medical school is undoubtedly a stressful time, given the academic rigor, pressure to succeed, and personal life stressors such as social disconnectedness.(26) Social disconnectedness is associated with both lower academic performance (27) and higher risk of depression.(28)
On the other hand, rapport between students and faculty contribute to several positive student outcomes including perceived learning and motivation.(29,30) Complicated or simplified sets of questions have been asked to measure rapport in those studies (29,30), but in our study we directly asked students to gauge perceived rapport in a single question. Others described this concept as reduction of psychological distance or educational alliance that leads to improved outcomes.(31–33) Overall, fostering social connectedness, particularly rapport between students and faculty in today’s online society, was a main goal of creating the FB discussion group in this study.
An informal, convenient, and familiar platform
We chose FB as the platform for our discussion group because it allowed a means of interaction that was efficient, familiar, and comfortable for medical students.(7,8) Other discussion forums offered through online learning platforms in our previous courses simply did not generate any meaningful participation, which in part led to a formal adoption of email as the sole official communication channel at our institution. Similarly, DiVall and Kirwin found that a course FB page was used more than a Blackboard discussion board when both were used in parallel during a third-year pharmacy course.(10) Perhaps the most striking aspect of our study is that a very high percentage of students (94.1%) joined the group even though it was purely voluntary. Similarly, a high percentage of students actively participated in the group: 95.8% of respondents visited the group at least weekly and 93.3% liked/reacted to the posts. Many of the active FB group participants were not regularly attending lectures so the online interaction with the faculty was the main mode of forging learner-teacher relationship. Most respondents strongly agreed that the discussion group helped form better rapport with faculty (Fig. 2A) and that they felt more comfortable seeking help after using the discussion group (Fig. 2B). In our study, the nature of the FB group interaction was informal, highlighted by the social/fun/encouragement posts frequently created by faculty (61/214 posts, example in Supplementary Figure 4a). In fact, the informal, personal communication and enhanced relationships with faculty was the most frequent student comment (n=43 in Table 2). This informality of interaction and the usability of FB were main strengths of the group that likely helped its wide acceptance (Table 2).
Interestingly, as a platform for asking questions, FB was only slightly preferred over official email communication (Fig. 3A). The format of the FB discussion group allows all members to see any question and contribute cooperatively to the discussion. On one hand, this open forum allows a consolidated thread for discussion of a topic, which is readily accessible. On the other hand, some students may feel intimidated or exposed when asking questions in an open forum and may prefer to privately ask questions to faculty by email. Nevertheless, the improved learner-teacher relationship made students feel more comfortable asking questions in general. From the faculty perspective, better rapport with students made it easier to advise students and get a positive response to suggestions.
While all members of a closed FB group can see posts from any other user made within that closed group, they cannot see posts made on the personal FB accounts of other group members unless they are also FB “friends” with those other users. In this way, FB groups allow faculty and students to freely interact within the confines of the group while still providing a privacy barrier between their personal FB accounts. Interestingly, in contrast to an earlier survey of medical school faculty who deemed it rarely or never appropriate for faculty and students to be friends on FB (34), students in the current study answered that it was mostly appropriate to be FB friends with faculty (Fig. 3D). The discrepancy in these findings likely stems from perception of faculty versus students and changes in general attitudes about social media over the past decade.
Rapport and perceived learning - comparison to other studies
In our review of literature, we did not find other studies among health science education that evaluated the potential of FB groups to improve rapport between faculty and students. Instead, studies mainly focused on the instructional aspect, either as faculty-led or faculty-moderated student interaction.(8-18) In one related study, Alshiekhly et al. reported that 83.7% of students rated the interaction between students and the group administrators as “good” or “excellent” in a FB group designed to teach students about medical emergencies in dental practice.(13) However, only the quality of the ‘teaching’ interaction was assessed instead of the rapport those interactions may have fostered. Irwin et al. cited student comments to suggest that a FB page for several public health courses “enhanced communication and interaction between students and the course instructors,” but, similarly to Alshiekhly et al., did not address how that communication affected rapport or relationships between students and faculty.(11)
Medical students perceived overall that our FB group positively contributed to the content learning (Figure 2C). Several studies focused on the learning aspect of FB group shared similar conclusions. Pickering and Bickerdike reported that among medical school students taking an anatomy course in the United Kingdom, 85.0% of respondents reported that a faculty-student Facebook page “was an effective tool in advancing their learning,” and 88.5% responded that it “compared favorably to what was already available.”(12) The design of this site was very similar to ours, an optional, ungraded, supplemental FB site to facilitate faculty-student discussion, without redundancy in course materials otherwise available. Ravindran et al. reported similarly that 94.8% of undergraduate medical students in the clinical phase of their education who participated in a FB teaching group reported that the group “supplemented [their] learning relevant to [their] exam.”(16) However, the primary goal of that group was to increase content learning. As such, content posted by the teaching fellow who facilitated the group was limited to practice questions and discussions of those questions. In these studies, student perception of increased rapport with faculty and emotional well-being were not measured. While our study and the aforementioned studies assess student perceptions of content learning, Anwar et al. reported increased grades among a cohort of undergraduate medical students in a neuroscience course with access to a curated FB page where multiple choice questions, articles, links, and lecture notes were posted.(14) In short, several studies among undergraduate medical students support the potential, either real or perceived, of increased content learning associated with FB group use, and our study concurs.
Faculty perspective and future directions
There is now a wide body of literature on the use of social media in medicine. Social media platforms allow physicians to network with one another, share medical knowledge, interact with patient groups, advocate on behalf of rare diseases, and provide general education to the non-medical public.(35–43) Among these platforms, FB is the largest and most well-known. At the time our FB discussion group was formed (August 2016), FB use had grown to be ubiquitous, with 1.860 billion active users worldwide (Q4, 2016).(44) FB groups provide a free and easy-to-use platform for medical education that can be adapted to small local groups like ours all the way up to massive global groups with tens of thousands of members.(45) Our FB group for medical student and faculty interaction was initially created as a pilot project attempting to enhance the medical school experience for learners in our modules. It was such a positive experience both for faculty and for students that we pursued this formal survey evaluation to quantify and better understand student’s perceptions of the group. We are encouraged by these data and plan to continue using similar FB groups in future years. Future directions for study include formally evaluating our medical school faculty regarding their experiences and perceptions of using this FB group as well as evaluating faculty who chose not to participate in the group so as to better understand concerns and potential barriers to faculty participation. A prospective randomized control trial contrasting academic performance of students given the opportunity to participate in a faculty-student FB discussion group with the academic performance of students that are not offered this opportunity would be a potential method to objectively evaluate the educational impact of FB groups like this.
As the general population increasingly utilizes social media to connect with others and to share and consume information, it stands to reason that future medical students will do the same. There are significant differences between personal and professional use of social media, and as medical school faculty, we need to educate our students on how to appropriately and beneficially use social media, not only as students, but also as future practicing physicians. If faculty are not willing to learn how to use social media, and to engage and interact with students in that sphere, will we be able to effectively teach and model proper professional online conduct for our students?
We see the FB discussion group as a natural extension of medical school to a format that is familiar and convenient to the emerging generation of physicians. Even though online interactions may not be face-to-face, they can have a similar emotional and social impact, leading to the development of professional relationships that translate into “real life”.(46,47) Medical school faculty who show willingness to adapt to novel methods of teaching and student engagement stand to gain much, not only for the benefit of their students, but also their own academic careers.(48,49)
Limitations
There are several limitations to this study. First, all measures assessed by the questionnaire were the students’ perceptions of the outcomes, rather than the outcomes themselves. For example, whether the perceived help in content learning actually resulted in better exam score remains unknown. In addition to the new FB discussion group, several other changes were introduced during the 2016–17 academic year including three new module directors (WDW, SWR, and NKM), many new lectures and new in-house exam procedures. Therefore, it remains difficult to pinpoint whether the FB discussion group had a singular positive effect on student performances. Second, student responses may have been subject to biases such as social desirability and acquiescence biases.(50) Student reactions in the FB discussion group may have been influenced by the social desirability bias (51) as the identity of students were not hidden in FB interactions. Students may have wanted to appear in the best light to the faculty and to be supportive of faculty who tried to improve communications with them, rather than express what they actually liked or disliked in the discussion group. However, this social desirability bias should be minimized through the use of an anonymous survey.(52) Acquiescence bias occurs as individuals tend to provide affirmative answers to questions regardless of the content.(53) In order to minimize this bias, we presented questions in a bidirectional fashion with verbal explanations on both ends of the VAS questions.(54) The default slider appeared in the middle (neutral position) for each VAS question and students’ answers were only registered when they actually confirmed the neutral position or moved the position of the slider. Third, although a positive learner-teacher relationship is associated with positive outcomes in medical education (1,2), whether there are actual causal relationships between better rapport, feeling comfortable seeking help, content learning, and emotional well-being could not be determined in the questionnaire format of this study.
Although the FB discussion group expanded the number of students that faculty could connect with to improve the learner-teacher relationship, the faculty still could not engage all students. Because the group was purely voluntary, students who either did not have FB accounts or did not wish to actively participate in the discussion group were not reached. Unsurprisingly, students’ perceived benefit from use of the discussion group strongly correlated with frequency of use, and we posit that students’ decisions about using a particular resource are chiefly determined by their perceived helpfulness of the resource. Also, because of the voluntary nature of the discussion group, information shared in the group had to be duplicated in the form of official email to all students. This was perceived by some students as information overload and was the most common criticism.