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AOA Critical Issues in Education
Orthopaedic Surgery Residency Program Social Media
Presence During the COVID-19 Pandemic
Joshua T. Bram, MD, Lori Jia, BS, William Huffman, BS, and Jaimo Ahn, MD, PhD, FACS, FAAOS, FAOA
Investigation performed at the University of Pennsylvania, Philadelphia, Pennsylvania
Background: In light of away rotation and in-person interview cancellations for the 2020 to 2021 application cycle,
social media has become a popular tool for orthopaedic surgery residency programs to highlight their strengths, curricula,
and social life to prospective applicants. The authors sought to explore the proliferation and utilization of 3 popular social
media platforms by both orthopaedic surgery departments and residencies.
Methods: Orthopaedic surgery departmental and residency program social media accounts and their creation
dates across Facebook, Twitter, and Instagram were identified using a standardized search methodology. Resi-
dency Instagram accounts were further evaluated for the number of posts, followers, likes, and comments. Both
departments and residency programs were cohorted by affiliation with a US News &World Report (USNWR) top 50
American hospital for orthopaedics or by status as a Doximity top 20 program based on reputation.
Results: Across a total of 192 residency programs included for analysis, Instagram was the most popular social media
platform (61.5%), followed by Twitter (19.8%) and Facebook (10.4%). Conversely, orthopaedic departments more fre-
quently used Facebook (33.9%) and Twitter (28.1%) over Instagram (17.2%). Of the 118 residency Instagram accounts,
102 (86.4%) were created after the onset of the COVID-19 pandemic. Larger residency programs (‡6 spots/year) and
those programs in the Doximity top 20 or affiliated with USNWR top 50 orthopaedic hospitals had a greater number of
followers as well as likes and comments per post (p < 0.05 for all).
Conclusions: Given the recruitment challenges faced by residency programs because of the COVID-19 pandemic,
Instagram has rapidly become a prominent platform for attracting orthopaedic surgery applicants. These accounts have a
large number of followers, particularly for residency programs with higher Doximity reputation rankings.
Social media has become a near ubiquitous component of
daily life, with nearly three-fourths of Americans using at
least 1 social media platform, rising to >90% of individ-
uals aged 18 to 29 years
1
. Among younger individuals, Twitter
and Instagram are popular platforms given their optimization
for mobile consumption and the ability to interact through
photos/videos. For orthopaedic surgery departments and prac-
tices, social media has become a valuable method of advertising
services and recruiting patients
2
. Social media presence is associ-
ated with easier accessibility through Google searches and higher
Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSOA/A320).
Copyright 2021 The Authors. Published by The Journal of Bone and Joint Surgery, Incorporated. All rights reserved. This is an open-access article
distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to
download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.
JBJS Open Access d2021:e21.00073. http://dx.doi.org/10.2106/JBJS.OA.21.00073 openaccess.jbjs.org 1
provider ratings
3,4
. In 2014, approximately 50% of orthopaedic
patients used social media, with younger patients up to 50·more
likely to have accounts
5
.
Although social media use is important for patient
recruitment, it has also become a popular tool for residency
applicants to access information about prospective training
programs. During the COVID-19 pandemic, the cancella-
tion of in-person away rotations and interviews forced
applicants to identify ways of obtaining program details
6
.Aside
from residency websites, which historically are variable in
content
7
, a newer avenue for obtaining information is through
program-run social media accounts. These accounts are infor-
mal platforms for advertising various components of programs,
including information on curriculum, social life, and research.
A significant rise in social media accounts over the past
year has been observed in several medical specialties
8,9
, but
these trends have not yet been reported in orthopaedics. Two
common types of social media accounts were identified as
follows: (1) “residency accounts,”which highlight residency pro-
grams and are managed by residents/graduate medical education,
and (2) “departmental accounts,”which highlight departmental
services/activities and news. The purpose of this study was to
report on the prevalence of these accounts and the timing of
account creation relative to the COVID-19 pandemic. We
hypothesized that most of the residency accounts were created after
the start of the pandemic in an effort to interface with applicants.
Furthermore, we hypothesized that programs and departments
with higher rankings would have greater numbers of social media
accounts and Instagram followers.
Materials and Methods
Alist of all US Accreditation Council for Graduate Medical
Education (ACGME)–accredited orthopaedic surgery resi-
dency programs was obtained
10
and cross-referenced with a list of
programs accepting applications through the Electronic Resi-
dency Application Service (ERAS) for the 2020 to 2021 cycle
11
.
Military residencies (N =8) and other programs (N =1) that do
accept applications through ERAS were excluded.The numberof
residency positions per class was determined through institu-
tional website review, and the 2020 to 2021 Doximity Residency
Navigator reputation rankings for programs were recorded
12
.
These are subjective evaluations of programs based on peer
reviews from board-certified orthopaedic surgeons and nomi-
nations from alumni/current residents
12
. The 2020 to 2021 US
News &World Report's (USNWR) “Best Hospitals for Orthope-
dics”rankings—ranking orthopaedic surgery departments—were
similarly collected and their affiliation to residency programs
determined (e.g., the Mayo Clinic Department Orthopedic Sur-
gery Department is affiliated with the Mayo Clinic Orthopedic
Surgery Residency Program)
13
. These rankings are more data-
driven and are based on a combination of patient outcomes
(37.5%), patient experience (5%), expert opinion (27.5%), and
other care-related indicators (30%).
The presence and activity of residency programs or
orthopaedic surgery departments and affiliated institutes (i.e.,
private groups affiliated with academic medical centers such
as OrthoCarolina) on 3 commonly used social media plat-
forms—Instagram, Facebook, and Twitter—served as the
basis for this study. Social media accounts were identified
(author J.T.B.) through (1) searching program/department
websites for accounts and (2) searches using the full and/or
abbreviated names of each program/hospital followed by the
words “orthopedic surgery,”“orthopedics,”“orthopaedics,”
“ortho,”and “residency.”All accounts since the platform
creation were searched: Facebook (2004-present), Twitter
(2006-present), and Instagram (2010-present). Accounts
focusing on orthopaedic surgery residency programs and
managed by the residents/graduate medical education office
(identified through account biographies or noted in posts) were
classified as “residency accounts”while accounts focusing on
orthopaedic departmental services/activities and news were clas-
sified as “department accounts.”Accounts with significant overlap
in content between the residency program and department were
listed under both categories to minimize the bias of arbitrarily
selecting 1 category. This overlap was defined by >25% of posts
dedicated to departmental activities/services and residency high-
lights. In addition to the presence of a corresponding social media
account, the date of page creation (Facebook page) or first post
(Facebook account, Twitter, and Instagram) was also recorded.
For residency Instagram accounts, the number of fol-
lowers, accounts followed, and total number of posts, likes,
and comments were tallied. Posts were categorized (authors
L.J. and W.H.) as being clinical, research, program informa-
tion, people spotlight, residency, social, or current events.
“Clinical”posts depicted clinical vignettes, educational topics,
and operations while “research”posts detailed publications or
conference attendance/presentations. Posts detailing the resi-
dency, city/location, and informational sessions were categorized
as “program information.”Posts highlighting specific individuals
(e.g., faculty, visiting professors, and residents/alumni) were
classified as “people spotlight.”“Day-in-the-life”posts empha-
sizing various aspects of resident experiences were placed in the
“residency”category while posts focused on life outside of the
hospital were considered “social.”Finally, images that discussed
the COVID-19 pandemic or social/political issues were cate-
gorized as “current events.”Posts featuring >50% women or
containing the hashtags “#womeninortho”or “#ilooklikea-
surgeon”were also separately tallied, as were programs using
the Instagram “highlights”feature.
All data collection occurred between March 8 and 10,
2021, after the submission of residency program rank lists
(March 3, 2021). In addition to reporting basic statistics, res-
idencies and departments were cohorted as (1) being ranked or
unranked in the USNWR top 50 and (2) being inside or outside
of the top 20 Doximity reputation rankings. Statistical analysis
was conducted using IBM SPSS Statistics for Macintosh (ver-
sion 24.0) using a threshold of p < 0.05 for significance. Cat-
egorical variables were analyzed using chi-squared and Fisher
exact tests, whereas continuous variables were analyzed using
Mann-Whitney U tests. There was no funding for this study. All
data were publicly available and did not require institutional
review board approval.
Orthopedic Residency Social Media
JBJS Open Access d2021:e21.00073. openaccess.jbjs.org 2
Results
From a total of 201 US ACGME-accredited orthopaedic
surgery residency programs, 192 met inclusion criteria.
Three programs were new for the 2020 to 2021 cycle, and 5 held
special ACGME osteopathic recognition. Twenty residency pro-
grams (10.4%) had Facebook accounts/pages, 38 (19.8%) had
Twitter accounts, and 118 (61.5%) had Instagram accounts. In
comparison, orthopaedic departments/affiliated institutes were
significantly (p < 0.001) more likely to have a Facebook (N =65,
33.9%) or Twitter (N =54, 28.1%) account but had fewer In-
stagram accounts (N =33, 17.2%). Eight, 7, and 5 programs had
combined department/residency Facebook, Twitter, and Insta-
gram accounts, respectively. A total of 125 programs (65.1%) and
83 departments (43.2%) had a social media presence on ‡1plat-
form. The most common combination of platforms for both
programs (N =26) and departments (N =24) was Twitter and
Instagram. Twenty-four departments had accounts across all 3
platforms vs. 6 residency programs.
Programs with ‡6 residents/year were more likely to have
an Instagram account (83.7% vs. 53.8%, p < 0.001) although
there was no difference based on program size regarding Face-
book (p =0.304) or Twitter (p =0.170) presence. Larger pro-
grams also had a higher number of Instagram followers, likes per
post, comments per post, and followed more accounts (all p <
0.05, Table I). In addition, 102 residency Instagram accounts
(86.4%) were created after the COVID-19 pandemic (March 11,
2021, based on the World Health Organization Declaration
14
), in
contrast to only 10 residency Facebook pages (50.0%) and 29
Twitter accounts (76.3%) (Figs. 1 and 2). The first Facebook,
Twitter, and Instagram accounts (either department or residency
TABLE I Residency Program Instagram Posts by Program Size*
‡6 Spots/Year <6 Spots/Year p
N4177—
Followers 1,095.0 (981.5-1,286.0) 781.0 (562.0-1,005.5) <0.001
Following 234.0 (133.5-375.5) 171.0 (96.5-267.0) 0.024
Posts 38.0 (19.5-69.5) 29.0 (13.0-46.0) 0.117
Likes per post 71.6 (57.3-86.7) 45.6 (24.3-65.6) <0.001
Comments per post 1.6 (1.0-2.1) 1.0 (0.6-1.7) 0.009
Use “highlights”27 (65.9) 32 (41.6) 0.012
*Statistics reported as median (interquartile range) and number (%).
Fig. 1
Orthopaedic surgery residency program social media account creation. The vertical yellow bar represents the date of the World Health Organization COVID-19
pandemic declaration (March 11, 2020). The first residency program Facebook, Twitter, and Instagram accounts were created on September 14, 2010,
August 1, 2020, and December 13, 2017, respectively.
Orthopedic Residency Social Media
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program) were created on May 15, 2009, July 7, 2009, and
September 30, 2013, respectively.
Thirty-nine residency programs were affiliated with
hospital orthopaedic departments ranked in the USNWR
top 50 for orthopaedics. Of the remaining 11 hospitals in the
top 50 hospitals, 6 were affiliated with programs that also
trained at a higher-ranking hospital (i.e., multiple affilia-
tions) and 5 were unaffiliated with a residency program.
There was no difference in the proportion of Facebook
(10.3% vs. 10.5%, p =1.000), Twitter (23.1% vs. 19.0%, p =
0.564), or Instagram (71.8% vs. 58.8%, p =0.137) accounts
for residency programs affiliated with a top USNWR ortho-
paedics department. However, orthopaedic departments ranked
by the USNWR were more likely to have Facebook (53.8% vs.
28.8%, p =0.003), Twitter (56.4% vs. 20.9%, p < 0.001), and
Instagram (38.5% vs. 11.8%, p < 0.001) accounts. When com-
paring residency programs ranked inside or outside of the Dox-
imity top 20, there were no differences in the proportion with
Facebook (15.0% vs. 9.9%, p =0.444), Twitter (30.0% vs. 18.6%,
p=0.226), or Instagram (80.0% vs. 60.0%, p =0.081) accounts.
Conversely, orthopaedic departments affiliated with residency pro-
gramsrankedintheDoximitytop20weresignificantly more likely
to have Facebook (65.0% vs. 30.2%, p =0.002), Twitter (65.0% vs.
23.8%, p < 0.001), and Instagram (45.0% vs. 14.0%, p < 0.001)
accounts.
When analyzing residency program Instagram accounts,
the median number of followers (i.e., other accounts that fol-
low the index account) and accounts followed (i.e., accounts
that the index account follows) were 992.5 (interquartile range
[IQR] 630.3-1,110.0) and 186.5 (IQR 107.5-283.5), respec-
tively. Each program posted a median 31.5 (IQR 14.0-60.3)
times, receiving a median 55.7 (IQR 31.6-74.7) likes and 1.2
Fig. 2
Orthopaedic surgery department and affiliated institution social media account creation. The vertical yellow bar represents the date of the World Health
Organization COVID-19 pandemic declaration (March 11, 2020). The first residency program Facebook, Twitter, and Instagram accounts were created on
May 15, 2009, July 7, 2009, and September 30, 2013, respectively.
TABLE II Residency Program Instagram Posts by US News &World Report's Ranking*
Top 50 Unranked p
N2890—
Followers 1,128.0 (865.8-1,415.5) 861.5 (576.6-1,044.8) <0.001
Following 220.5 (181.0-303.0) 172.0 (91.0-281.5) 0.073
Posts 39.5 (20.3-60.5) 31.0 (14.0-60.3) 0.467
Likes per post 71.9 (55.4-92.0) 53.1 (26.1-68.5) <0.001
Comments per post 1.8 (1.0-2.3) 1.0 (0.6-1.7) 0.003
Use “highlights”19 (67.9) 40 (44.4) 0.030
*Statistics reported as median (interquartile range) and number (%).
Orthopedic Residency Social Media
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(IQR 0.7-1.9) comments per post. The median likes averaged
over the last 3 posts increased to 210.5 (IQR 144.8-302.8). Fifty-nine
programs (50.0%) used the “highlights”feature. When comparing
programs based on affiliation with top USNWR orthopaedic
departments, higher-ranked programs had more followers, likes,
and comments per post (all p < 0.05, Table II). Similarly, pro-
grams ranked in the Doximity top 20 had more followers, total
posts, likes, and comments per post, and followed more accounts
(all p < 0.05, Table III). The most common posting topics were
people spotlight (30.3%), residency (23.1%), and social
(18.9%, Fig. 3). Across a total of 4,742 posts, 613 (12.9%)
focused on women in orthopaedics.
Discussion
Social media has become a popular platform for surgeons to
publicize services available to patients
15
. Residency programs,
facing the unique constraints of recruitment during the COVID-
19 pandemic, have similarly adopted social media as a way of
interacting with prospective trainees. We found that the most
popular platform for residencies was Instagram, whereas
departments were more likely to use Facebook/Twitter. These
findings are in line with data from the Pew Research Center,
where 79% of individuals aged 18 to 29 years (representing many
residency applicants) use Instagram vs. just 23% of people aged
50 to 64 years
1
. The emphasis on photo-sharing and video-
sharing by Instagram may explain its higher use among resi-
dencies, which may be seen as less formal and could facilitate
more dialogue about various program characteristics.
For orthopaedic departments and institutions, the benefits
of increased social media presence are numerous. Triemstra et al.
reported that USNWR hospital reputation scores correlate with
Twitter/Facebook follower count and total tweets, whereas total
points in the USNWR rankings correlate with social media
presence on each of Facebook, Twitter, and Instagram
16
.In
urology, increased departmental Twitter activity has been asso-
ciated with higher USNWR reputation scores
17
, and more Twitter
followers were shown to be an independent predictor of gas-
trointestinal division rankings
18
.Suchfindings have led to calls
for increased adoption of social media by orthopaedic surgeons
as a tool for publicizing services while improving reputation
2,19
.
Our results mirror these findings because departments ranked by
the USNWR or affiliated with Doximity top 20 residencies more
frequently used all 3 social media platforms. That being said, the
implication that higher social media activity leads to or is cor-
related with hospital reputation should be cause for pause
because it is not necessarily true that more prestigious insti-
tutions with a social media presence provide higher quality of
care. However, the financial implications of social media
adoption are hard to ignore because this has likely, by way of
higher reputation, led to higher patient volume.
Although orthopaedic surgeons/departments have pro-
gressively adopted social media over the past 10 years, residency
program accounts have only dramatically increased during the
COVID-19 pandemic. Although 97% of residencies had pro-
gram websites in 2015, the quality/content on these sites varied
dramatically, with <50% reporting call schedules
7
. Such vari-
ation in online presence may itself have warranted the creation
of social media accounts that allow applicants to interact with
residents
20
. This coupled with the cancellation of in-person away
rotations and interviews during the pandemic likely accelerated
the creation of resident-driven social media accounts as a means of
attracting applicants. Interestingly, our findings demonstrate that
TABLE III Residency Program Instagram Posts by Doximity Ranking*
Top 20 Outside Top 20 p
N 16 102 —
Followers 1,287.0 (1,129.5-1,578.3) 846.5 (583.5-1,047.3) <0.001
Following 287.5 (186.3-377.8) 176.5 (98.3-279.5) 0.010
Posts 57.5 (30.5-85.0) 29.0 (13.3-48.5) 0.003
Likes per post 84.5 (74.6-96.0) 53.5 (28.7-68.5) <0.001
Comments per post 1.8 (1.1-2.4) 1.1 (0.6-1.9) 0.007
Use “highlights”13 (81.3) 46 (45.1) 0.013
*Statistics reported as median (interquartile range) and number (%).
Fig. 3
Categorization of Orthopaedic Surgery Residency Program Instagram Posts.
Orthopedic Residency Social Media
JBJS Open Access d2021:e21.00073. openaccess.jbjs.org 5
orthopaedic departments were earlier adopters of social media,
perhaps as a means for attracting patients and promoting services
(demonstrated in Figs. 1 and 2). Ahmadmehrabi et al. found that
61% of otorhinolaryngology (ENT) programs had ‡1 social media
account as of June 2020, observing similarly large increases in
Instagram/Twitter accounts during the COVID-19 pandemic
9
.In
another study of ENT programs, Goshtasbi et al. found that 67%
of Instagram accounts were created after March 2020, highlighting
their increased utility during the pandemic
8
.Thesefindings are in
line with our own, where approximately two-thirds of pro-
grams had at least 1 social media account and nearly 90% of
Instagram accounts were created during the pandemic.
Because the increased number of social media accounts
among residency programs allows for more applicant-resident
interaction, we also sought to explore the impact of reputation
and rankings on account presence. As in our study, Xie et al.
(ENT) and Azoury et al. (plastic surgery) reported that
residencies with higher Doximity rankings or those affiliated
with higher-ranked USNWR hospitals were more likely to
have social media accounts with higher follower counts
and activity
21,22
. This was attributed to broader applicant
awareness of historically prestigious hospitals and the desire to
uphold their reputations through social media. Again similar to
our results, Goshtasbi et al. reported that larger residency pro-
grams more often had Instagram accounts and had more fol-
lowers/posts, which may be due to the need to recruit more
residents and increased interest in larger programs with more
positions
8
. These accounts are also windows into the more
intangible aspects of residency, including resident life, program
culture, research opportunities, and social justice initiatives
23,24
.
Social media utilization by orthopaedic surgery residencies has
likely benefited applicants tremendously. Even before COVID-19,
>95% of plastic surgery applicants had a social media presence,
and 73% followed a residency account
25
. These accounts
allow students to gain a better understanding of program
culture and fit, which could lead to a more selective appli-
cation list in line with recommendations from the American
Orthopaedic Association Council of Residency Directors for
the 2020 to 2021 application cycle
26
. However, increased
social media presence by programs must be balanced with
the awareness of applicant account content. Ponce et al.
reported that 85% of orthopaedic surgery applicants did not
restrict public access to their accounts, and 16% of indi-
viduals had unprofessional content
27
. This highlights the
importance of social media etiquette although it is impor-
tant to note that “unprofessional”content is a subjective
distinction that could be particularly damaging to women
and people of color
6
. Although the benefits of increased
social media use by residency programs likely outweigh any
negatives, this double-edged sword may be difficult for applicants to
navigate. Students should therefore be wary of their social media
presence before following specificprograms.
This study has several limitations. First, it is impossible to
know if we fully captured the social media presence of all residencies/
departments, although our systematic approach using various ver-
sions of “orthopedics”and common program acronyms (e.g.,
“PSU”for “Penn State University”)accountedforasmanypro-
grams as possible. In addition, Instagram allows for the posting of
“stories”that could not be counted toward the total number of
posts or included for content characterization, which for some
programs represented a common method of applicant interac-
tion. For social media accounts with significant equal overlap in
resident and department/patient content, we chose to tally such
accounts under both the residency and department counts rather
than arbitrarily choosing one, which minimally affected our totals.
Last, our content categorization, while partly based on groupings
used in similar studies, was not all-encompassing, although we
feel the chosen categories accurately reflected the general themes
observed.
Our study found that orthopedic surgery departments
tend to use Facebook/Twitter most frequently, although there
has been a dramatic increase in the number of Instagram
accounts used by programs to interface with prospective
applicants during the COVID-19 pandemic. In addition,
departments affiliated with hospitals ranked in the USNWR
top 50 and residencies in the Doximity top 20 were significantly
more likely to have Facebook, Twitter, and Instagram accounts.
Larger residency programs and those with higher Doximity
rankings had a greater number of followers and received more
likes and comments per post. Future studies could examine
how social media presence influences the number of residency
applications received and the quality and quantity of residents
accepted into their program. n
Joshua T. Bram, MD
1
Lori Jia, BS
1
William Huffman, BS
1
Jaimo Ahn, MD, PhD, FACS, FAAOS, FAOA
2
1
Perelman School of Medicine at the University of Pennsylvania,
Philadelphia, Pennsylvania
2
Department of Orthopedic Surgery, University of Michigan, Ann Arbor,
Michigan
E-mail address for J.T. Bram: jshbrampsu@gmail.com
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