1. Introduction

In the last decade, medicine has evolved and has increasingly utilized the digital social media arena to connect physicians with their colleagues and patients. Various social media platforms now exist that make sharing, disseminating, and consuming medical knowledge free and convenient [1]. Patients and physicians now have access to an abundance of content in the palm of their hands, accessible 24 h a day, seven days a week.

In addition to sharing information with others, social media has been strategically utilized to brand physicians, promote individual physician’s medical practice, and educate trainees [2], [3], [4]. The advantage of social media lies in its ability to disseminate the most pertinent medical information in a concise and succinct fashion to an exponentially large audience. Each platform has its own unique advantages and target audiences [1]. For example, Instagram relies heavily on visual content to disseminate information and YouTube utilizes video content to disseminate information [5]. Twitter utilizes concise take home messages as content for their users. In a sea of information, succinct information presented with visual appeal garners the most positive response.

While academic publications have and always will remain a benchmark for “productivity” of an individual physician, social media “influence” is becoming increasingly relevant in this digital age. An “influencer” is someone who carries a large following and carries impact within the digital community. The skill sets required to become an “influencer” are similar yet different from those used to become academic productive in the traditional sense. In this current age of digital content consumption, it is important to consider an individual’s social media “influence” as well.

Neurosurgery is a highly technical field with a large amount of specialized information that can be difficult for other health care professionals and patients to understand. In this respect, social media in neurosurgery has made dissemination of relevant information easier for patients and has connected physicians with each other in an unparalleled way [2].

It stands to reason that identifying the top social media users in neurosurgery will help guide other health care professionals and patients in following legitimate individuals who are the most active. In this study, we identify the top 100 social media influencers in neurosurgery, analyze their demographic information, and compare their social media productivity with their academic productivity, as represented by the “h-index”. We purposely chose Twitter as the social media platform to study because, compared to other platforms, it has been well studied in other surgical disciplines and because it encourages more expert educational dialogue rather than self-marketing or promotion [2], [4], [6], [7], [8]. This is the first study to highlight the top social media influencers within neurosurgery.

2. Methods

Twitter influence scores for the topic “neurosurgery” were determined using the Right Relevance API (www.rightrelevance.com, San Francisco, CA, US) on August 8th, 2021. Right Relevance provides numerical rankings of influence by qualifying users’ connections (followers/following) and engagement, such as views, likes, and retweets. This software utilizes graph partitioning techniques to determine influence scores relevant to specific topic searches, allowing the top 100 most influential Twitter accounts belonging to individuals to be ranked. Accounts belonging to organizations were excluded from this study. The names of the individuals, their account handles, specialty, subspecialty, board certification/status (verified by the American Board of Neurological Surgery, American Board of Psychiatry and Neurology, American Board of Radiology, National Commission on Certification of Physician Assistants, and National Council of State Boards of Nursing online databases) practice location, and academic h-index scores (Scopus, Reed Elsevier, London, UK) were collected. Information not available within individuals’ Twitter profiles were found via institutional websites. Board certification verification was limited to physicians based in the United States. Data analyses and figures were performed/generated using Microsoft Excel (Seattle, WA, US). The Pearson correlation coefficient (r) was calculated to compare two sets of data. P < 0.05 was considered statistically significant. Descriptive statistics were used for summarizing the data.

3. Results

85% percent of the top Twitter influencers are neurosurgeons; 9.0% are neurologists; 4.0% were neuroradiologists; and 2.0% are non-physician individuals (Fig. 1).

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Fig. 1. Breakdown of the professional backgrounds of the Top 100 Twitter influencers in Neurosurgery.

All but two of the neurosurgeon influencers are practicing physicians; the remaining two were trainees in a United States Allopathic neurosurgery residency training program. 81.8% of influencers were located in the United States while the remaining influencers were international. Of the influencers in the United States, the top five states represented were; New York (17.3%), Arizona (8.6%), Massachusetts (8.6%), Florida (7.4%), and Texas (7.4%) (Fig. 2).

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Fig. 2. Geographic distribution of the top 100 Twitter influencers in Neurosurgery in the United States.

Of the international Twitter influencers, the top two countries represented were; United Kingdom (36.8%) and Canada (15.8%) (Fig. 3).

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Fig. 3. International distribution of the top 100 Twitter influencers in Neurosurgery.

The average h-index among the top 100 Twitter influencers (n = 100) was 27.6 ± 19.7 with a median of 24 (range 1 – 104). The Pearson correlation coefficient (r) is 0.35 with a p-value of 0.0003 (Fig. 4).

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Fig. 4. Correlation between Twitter influence rank and h-index.

One hundred percent of the practicing United States neurosurgeons were board certified by the American Board of Neurological Surgery. All United States neuroradiologists and neurologists were board certified. Information about board certification of international physicians was difficult to ascertain.

4. Discussion

Social media has changed the way medicine is being practiced. The various social media platforms are continuing to grow at an exponential rate and have created online communities where knowledge is shared and exchanged among health care professionals [1]. Other potential benefits of social media include public health surveillance, exponential dissemination of information, peer and emotional support, and the ability to influence health policy [5].

Because of the importance of social media in this current digital age of medicine, our aim was to learn who the most active Twitter users are in neurosurgery. By knowing who these Twitter users are, other health care professionals and patients will know who to follow for their neurosurgical content consumption.

We found that the majority of these influencers are board-certified neurosurgeons practicing within the United States who have shown a track record of academic productivity. It is important to note that the ranking system for social media influence does not represent a physician’s ability to carry out and produce great quality research. Nor does the ranking have any bearing on a surgeon’s ability to practice neurosurgery effectively.

For a physician to garner a high influence score, it requires that the individual not only produce high quality content consistently but also engage with and interact with a larger network of experts within the field of neurosurgery. To become an influencer, the individual must be similarly vetted by other influencers within the network, which happens for well-known established board-certified physicians [6]. Supporting our list is the statistically significant positive correlation (r) between a Twitter influencer’s rank and their academic h-index score.

We chose Twitter as the social media platform to study because of its intended purpose and target audience. Unlike other platforms that are more visually based and directed more towards self-branding and marketing, Twitter focuses more on technical and educational content [9], [10]. Additionally, Twitter’s platform allows a more intuitive exchange of dialogue between physicians. Lastly, the character limitations set by Twitter (280 characters) allows only the most important take home messages to be posted in a succinct way.

Traditional ways of assessing influence in neurosurgery is largely measured by scientific publications, impact factors and citations. These factors are summarized by a physician’s h-index. We found a positive correlation between a Twitter influencer’s rank and their h-index that was statistically significant, supporting the idea that these two numerical systems may go hand in hand. This is not too surprising when one considers that both measures inherently rely on an individual to consistently produce quality content whether in a manuscript format or as a concise digital post. It is likely that very established and well-known neurosurgeons will generate more followers as a natural consequence of their positions. For example, medical students interested in applying to a neurosurgery residency, residents looking for academic positions and all the staff and faculty in the departments or divisions under those already well-known neurosurgeons will become twitter followers, inflating the ranks of followers [11].

The primary limitation of this study is in understanding the proprietary algorithm used by Right Relevance. The authors of this study attempted to contact Right Relevance to better understand the algorithm but did not receive a reply. We cross searched the top 100 influencers generated by Right Relevance on two other social media platforms, Instagram and LinkedIn, and found that these same influencers were equally active on those other platforms. Given our anecdotal knowledge of the influencers on this list as physicians who are active at national neurosurgery conferences, publish prolifically, and are on the cutting edge of advancing neurosurgical technique, we are confident that this list represents an accurate picture of the top influencers in neurosurgery. Additionally, our study is of a cross sectional nature and represents the ranking of physicians at one point in time, namely August 2021 when the search was conducted. Posting on social media is a fluid and dynamic process and so the ranking on Twitter is ever changing. Because of this, our study does not capture any longitudinal trends in Twitter rankings. However, similar to the h-index in which the academic productivity is an accumulation of academic publications, social media “influence” is built over time through consistent posting of quality content. It stands to reason then that the current rankings will remain consistent over time. Lastly, this study focuses on Twitter alone. There exist a multitude of other social media platforms such as Facebook, YouTube, Instagram, LinkedIn, each with its own purpose and target audience [2], [4]. Individual physicians may prefer one platform over another and so this study may not capture the comprehensive list of all the influencers in neurosurgery.

5. Conclusion

Social media has taken on an increasingly important role for physicians to connect with each other and advance neurosurgical knowledge to the general public. By knowing who the top Twitter influencers are in neurosurgery, other physicians and patients can follow the appropriate individuals with confidence and ensure they are consuming legitimate information. Although social media has its benefits, physicians need to be aware of its potential misuse and follow ethical guidelines when posting on social media. Physicians should embrace the current digital age and utilize the various social media platforms to share the neurosurgery specialty with others.