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In this digital era, there is a growing tendency to use the popular Internet site YouTube as a new electronic-learning (e-learning) means for continuing medical education. Heart transplantation (HTx) remains the most viable option for patients with end-stage heart failure or severe coronary artery disease. There are plenty of freely accessible YouTube videos providing medical information about HTx.
The aim of the present study is to determine the effectiveness of YouTube as an e-learning source on HTx.
In order to carry out this study, YouTube was searched for videos uploaded containing surgical-related information using the four keywords: (1) “heart transplantation”, (2) “cardiac transplantation”, (3) “heart transplantation operation”, and (4) “cardiac transplantation operation”. Only videos in English (with comments or subtitles in English language) were included. Two experienced cardiac surgeons watched each video (N=1800) and classified them as useful, misleading, or recipients videos based on the HTx-relevant information. The kappa statistic was used to measure interobserver variability. Data was analyzed according to six types of YouTube characteristics including “total viewership”, “duration”, “source”, “days since upload”, “scores” given by the viewers, and specialized information contents of the videos.
A total of 342/1800 (19.00%) videos had relevant information about HTx. Of these 342 videos, 215 (62.8%) videos had useful information about specialized knowledge, 7/342 (2.0%) were found to be misleading, and 120/342 (35.1%) only concerned recipients’ individual issues. Useful videos had 56.09% of total viewership share (2,175,845/3,878,890), whereas misleading had 35.47% (1,375,673/3,878,890). Independent user channel videos accounted for a smaller proportion (19% in total numbers) but might have a wider impact on Web viewers, with the highest mean views/day (mean 39, SD 107) among four kinds of channels to distribute HTx-related information.
YouTube videos on HTx benefit medical professionals by providing a substantial amount of information. However, it is a time-consuming course to find high-quality videos. More authoritative videos by trusted sources should be posted for dissemination of reliable information. With an improvement of ranking system and content providers in future, YouTube, as a freely accessible outlet, will help to meet the huge informational needs of medical staffs and promote medical education on HTx.
Heart transplantation (HTx) is still the gold standard in the treatment of end-stage heart failure for appropriate candidates [
At present, the Internet has become the largest and most up-to-date source for medical information worldwide [
Some scholars have evaluated YouTube as a source of medical information on H1N1 influenza, papillomavirus vaccination, prostate cancer, and kidney stone [
This trial was conducted as a cross-sectional analysis. The website YouTube (YouTube, LLC, San Bruno, CA) was searched according to “relevance” priority for the following keywords: “heart transplantation”, “cardiac transplantation”, “heart transplantation operation”, and “cardiac transplantation operation.” All the videos containing relevant information about HTx before February 01, 2013 were included in this study. The total number of videos that appeared in the searching was 6930. However, 95% of people conducting an online search will watch no further than the first 60 videos of output, and most researchers for similar studies on YouTube videos usually chose the first 200 to 300 videos as their data sources [
First, the video was grouped under the “useful” category if it contained scientifically correct information about any aspect of HTx such as donor procurement, surgical techniques, perioperative management, rejection control, clinical follow-up, new technologies, or the issues about medical humanities (eg, history of HTx, appealing for organ donation, etc). Second, the video was categorized as “misleading” if it contained scientifically incorrect or unproven information for now (eg, self-healing from serious heart failure by the help of the God rather than medical service; asserting that mechanical circulatory support is currently a practical alternative to HTx, but without convincing proof existing in the literature; oversight during the delivery and preservation of cardiac graft; and dissemination for abandoning HTx in end-stage heart failure patients). Finally, if the video described recipients’ personal experience rather than medical information of HTx per se (eg, for raising donation, expressing gratitude, advertising hospitals, etc), it was called a “recipients video.”
In case the investigators’ designation was not identical, the video was reevaluated with both surgeons and a united assessment was conducted. The kappa statistic was used to measure interinvestigator variability.
A graphic display of the classifying process of HTx-related videos.
Videos were categorized according to the “source” into four groups: namely, hospital/university channel (H/UC), independent user channel (IUC), medical dotcom channel (MDC), and news agency channel (NAC) [
Data were analyzed with SPSS version 19.0 (SPSS Inc) and presented as mean (SD). When more than two groups of means were compared (eg, mean “duration”, mean number of “days since upload”, and mean “scores” for four source groups), data were analyzed for statistical significance using a one-way analysis of variance (ANOVA) followed by a Tukey comparison of all groups. Before running the analysis, data were checked to determine if they met the assumptions of ANOVA (homogeneity of variances and data were sampled from the Gaussian distribution).
After the first-step search with four key terms, the vast majority of the output consisted of nonmedical or minute-medical videos without meaningful and specialized information (such as live but shaking or silent videos of less than 10 seconds). For example, a YouTube search for the term “heart transplantation” returned 3750 videos, and the top 10 outcomes sorted by relevance are provided in
Of all the YouTube videos that were viewed, 342/1800 (19.00%) videos were classified into three groups containing medical information on HTx (total duration, 2373.8 minutes). Details for the inclusion of these videos are shown in
The majority of the useful videos were mainly posted by strong reputation such as H/UC (88/214, 41.1%) and NAC (64/214, 29.9%) (
Useful videos were also analyzed based on the medical information they delivered. All useful videos contained HTx-related information on at least one or more of the following aspects: (1) live demonstration of HTx, (2) brief introduction of surgeries, (3) release of new technologies, (4) scholar viewpoints by experts, or (5) medical humanities. For example, videos were categorized as “medical humanities” if the main message of the videos portrayed the history of HTx or brainstormed on the issue of organ donation after brain death. Content analysis of useful videos with respect to the above five aspects is presented in
Compared with useful videos, the misleading videos demonstrated the following characteristic: fewer numbers, shorter total and mean “duration”, but higher mean “scores” and mean “viewers/day” (
A summary of the top ten videos ranked by their “relevance”a resulting from a YouTube search for “heart transplantation” (HTx) on February 01, 2013.
Rank | Video title | Number of viewers | Days since upload | Scores | Descriptionb | Reference |
1 | Heart transplantation | 141,443 | 384 | 393 | Showing orthotopic “bicaval” technique | [ |
2 | Heart transplant surgery | 188,083 | 898 | 307 | Showing a brief scene of HTx | [ |
3 | Revived Heart Transplant Program at Batson Children’s Hospital builds on a 20-year legacy | 3052 | 265 | 5 | The revived HTx program built on a 20-year history at the University of Mississippi Medical Center | [ |
4 | Heart transplant procedure from Montefiore-Einstein, NYC | 430,349 | 1904 | 1003 | HTx with a panel discussion presented by the cardiothoracic surgeons of the Montefiore-Einstein Heart Center on an OR-Live webcast | [ |
5 | Surgical Nightmare! Heart Transplant Masterclass - Surgeon Simulator 2013 | 18,060 | 3 | 394 | Advertisement (ad) for an electronic game “Surgeon Simulator 2013” | [ |
6 | Surgeon Simulator 2013 - Successful heart transplant [Rating: A++] | 253,614 | 3 | 2469 | Ad for an electronic game “Surgeon Simulator 2013” | [ |
7 | Heart transplant surgery with live audience | 20,086 | 2 | 355 | Ad for an electronic game “Surgeon Simulator 2013” | [ |
8 | Heart transplant part 1 | 13,676 | 368 | 33 | Classical and valuable video describing HTx | [ |
9 | Implanted heart pumps keep patients in need of transplants alive | 240 | 3 | 2 | KPBS Health Reporter talked about left ventricular-assist device and heart donation | [ |
10 | Heart transplant steps simplified by Dr Sandeep Attawar | 341 | 56 | 2 | HTx live broadcast | [ |
aThe term “relevance” refers to the default ranking system for YouTube queries and is determined based on Google algorithm.
bDescription states the kind of content present in the videos.
Detailed characteristics of different categories of YouTube videos with relevant information on HTx.
Characteristics | Useful videos | Misleading videos | Recipients videos | Total HTx-related videos | |
Number of videos, n (%) | 214 (62.6) | 6 (1.7) | 122 (35.7) | 342 (100) | |
Total duration in minutes (%) | 1723.7 (72.61) | 26.0 (1.10) | 624.1 (26.29) | 2373.8 (100) | |
Mean duration in minutes (SD) | 8.05 (13.36) | 4.33 (5.33) | 5.12 (7.58) | 6.94 (11.59) | |
Mean number of days on YouTube (SD) | 582.59 (498.23) | 594.17 (519.39) | 433.16 (404.05) | 529.49 (471.27) | |
Mean scores (SD), range | 16.83 (85.73) |
46.50 (110.53) |
20.82 (120.47) |
18.77 (99.69) |
|
Total viewership, n (%) | 2,175,845 (56.09) | 1,375,673 (35.47) | 327,372 (8.44) | 3,878,890 (100) | |
Mean views/day (SD), range | 14.31 (53.74) |
202.07 (324.64) |
9.69 (38.77) |
15.95 (67.14) |
|
|
|||||
|
H/UCa | 88 | 0 | 30 | 118 |
|
IUCb | 40 | 5 | 45 | 90 |
|
MDCc | 22 | 0 | 11 | 33 |
|
NACd | 64 | 1 | 36 | 101 |
aHospital/university channel.
bIndependent user channel.
cMedical dotcom channel.
dNews agency channel.
Detailed characteristics of “useful videos” on YouTube uploaded by different sources.
Characteristics | Hospital/university channel | Independent user channel | Medical dotcom channel | News agency channel |
Useful videos, N=214 (%) | 88 (41.1) | 40 (18.7) | 22 (10.3) | 64 (29.9) |
Total duration in minutes, 1723.7 (%) | 657.05 (38.12) | 320.40 (18.59) | 263.00 (15.26) | 483.25 (28.03) |
Mean duration in minutes (SD) | 7.47 (14.04) | 8.01 (8.21) | 11.95 (21.55) | 7.55 (11.35) |
Mean number of days on YouTube (SD) | 558.67 (456.60) | 641.07 (657.85) | 412.14 (377.99) | 637.53 (456.25) |
Mean scores (SD), range | 6.70 (34.80) |
35.98 (103.36) |
6.09 (13.62) |
22.47 (126.70) |
Total viewership (n) (%) | 310,252 (14.26) | 1,036,597 (47.64) | 88,925 (4.09) | 740,071 (34.01) |
Mean views/day (SD), range | 6.02 (23.82)a
|
39.36 (107.42)a,b
|
10.08 (20.89) |
11.49 (34.40)b
|
a
b
Detailed content analysis of “useful videos” from five aspects.
Aspects | Hospital/university channel, n (%) | Independent user channel, n (%) | Medical dotcom channel, n (%) | News agency channel, n (%) | Total, n (%) |
Live demonstration of HTx | 6 (22.2) | 11 (40.7) | 5 (18.5) | 5 (18.5) | 27 (9.4) |
Brief introduction of HTx | 31 (38.7) | 17 (21.2) | 18 (22.5) | 14 (17.5) | 80 (27.9) |
Release of new technologies | 34 (49.3) | 11 (15.9) | 6 (8.7) | 18 (26.1) | 69 (23.9) |
Experts’ scholar viewpoints | 19 (52.7) | 7 (19.5) | 5 (13.9) | 5 (13.9) | 36 (12.5) |
Medical humanities | 18 (23.7) | 17 (22.4) | 6 (7.9) | 35 (46.1) | 76 (26.4) |
Coverage on the above five aspects | 108 (37.5) | 63 (21.9) | 40 (13.9) | 77 (26.7) | 288 |
The annual numbers of useful HTx-related videos.
With the rise in popularity of the website YouTube, there is now another route by which medical professionals can learn the specialized knowledge. YouTube enables physicians and institutions with strong reputation to upload multimedia clips of medical knowledge on their channels. For instance, in
YouTube videos provide us an effective way to actively engage with our worldwide colleagues, by subscribing and responding to high-quality clips from the respected individual surgeons. Although there is no information available on how many of the viewers of these videos were medical personnel, it is obvious that those high-quality videos can be used by medical staff and can improve the learning outcomes of physicians. For instance, in the live implantation video of a left ventricular assist device (LVAD, Heartmate II) as a bridge to HTx (see
However, our study demonstrated that the majority of HTx-related videos were easily available yet often without expertise information. Considering all the videos that were uploaded before February 1, 2013, YouTube had nearly 7000 videos by searching the keywords about HTx, yet only 342 of the 1800 (19.00%) videos were actually related. Furthermore, in about 40 hours of coverage of these videos, only 72.61% of them contained useful specialized information about this challenging surgery. At present, many reliable academic institutions, such as ISHLT, have not exerted their positive and dominant impacts to increase the signal-to-noise ratio of HTx-related YouTube videos, through uploading their high-quality videos for viewing by people. For example, the American Association for Thoracic Surgery (AATS) has been registered as an organizational user (AATSVideos) on November 7, 2012. However, there were only 21 videos as open resources, which contain nothing about HTx. Interestingly, the striking “Watch AATS Video” sign always stays at the top of AATS website, and there are five links to the Cardiothoracic Surgery Network (CTSNet), which deposited 159 authoritative videos of cardiac surgeries until April 12, 2013. Therefore, even with a newest video titled “Left Ventricular Aneurysm Resection and LVAD Implantation Through Median Sternotomy” (
In addition to the lack of goal-oriented contents from authoritative organizations and trustworthy individuals, there is a real risk of dissemination of misleading information by YouTube. In our study, we found that the maximum-weight misleading video (see
A screenshot of the commendable from Web viewers (on April 12, 2013).
A screenshot of the comments from Web viewers (on April 12, 2013).
A screenshot of the utterly specialized BiVAD-related discussions (on April 12, 2013).
A screenshot of the comments from web viewers about the misleading video (on April 12, 2013).
Given the problems above, two measures can be implemented by YouTube to improve its functionality with a more efficient way of providing high-quality medical videos. First, a professional community targeting at medical education can be built to inspire specialized videos uploading and consumption, just as iTunes U. Since introduced in 2007, Apple’s iTunes U courses (more than 2500) on a variety of topics have topped a billion downloads, and these courses are contributed by over 2400 educational institutions including universities, colleges, K-12 schools, and districts [
Second, more precise and personalized lists of video after searching on YouTube should be provided. When a medical practitioner wants to access HTx-related videos, the most common way is to input keywords (eg, “heart transplantation”), wait for automatic operation embedded in the YouTube search tool, and then look over the videos according to the search result list in sequence. The purposes of viewers for viewing the videos are different, in which some physicians want to look for similar experience as reference for their clinical decision-making or operative skills, and other trainees wish to look up correct and useful information just as learning materials. Though out of different purposes, they don’t expect to be distracted by irrelevant, even misleading information. To meet professional requirements with the least disturbance, YouTube ranking system should be refined and improved.
In the current YouTube ranking system, there are two comprehensive aspects of ranking factors: (1) “content”, which is out of the video self-characteristics, such as correlation between search keywords, video title, and description, and (2) “engagement”, which is contributed by viewer interaction in YouTube social community. There are 12 different detailed factors that are used to determine rank of each video (
In the present study, it was found that the “scores” of three advertisement videos of “Surgeon Simulator 2013”, an electronic game, were unexpectedly high. However, they were completely uncorrelated with HTx (
It is required to take deeper use of social network relationship among viewers. Users’ historical viewing records can be regarded as personal profile, so system can supply personalized search results according to each user’s preference, by using techniques in recommendation system [
YouTube ranking factors.a
Content | Engagement |
Title | Views |
Description | Inbound links |
Tags | Social shares |
Transcriptions | Embeds |
Channel authority | Comments |
Delivery | Likes and favorites |
aReprinted with permission from Chelaru et al [
First, our study was confined to the content analysis of HTx-related videos retrieved on February 01, 2013. This cross-sectional observation is like a snapshot of information distribution, but the actual source from YouTube is swiftly expanding as one never-ending documentary. Second, our classification method was subjective. However, the kappa coefficient demonstrated fairly high agreement between two cardiac surgeons. We did not extrapolate the percentage of “useful” and “misleading” videos in our dataset to all the HTx-related YouTube videos. Furthermore, our analysis of the comments and the social interactions of viewers and uploaders was based on pure observation without a solid methodological approach. The “scores” are based on “likes” or “dislikes”, and it may not be an excellent indication of viewer preferences or video quality on medical contents. Third, non-English language video clips were excluded, which included some valuable videos, such as many French language HTx-related videos. Fourth, we did not revalidate the results in other networking platforms, such as Baidu or Facebook. Finally, this study was limited to a direct search on YouTube, so we might have missed some valuable surgical videos that could be viewed at other available health information websites.
This study demonstrates a panoramic view of HTx-related videos on YouTube until February 1, 2013. The results of this study showed that YouTube benefits medical professionals by providing a substantial amount of specialized information. However, casting YouTube to find HTx-related videos is currently inefficient. As more young medical trainees are eagerly participating in social media and e-learning activities, it is reasonable to promote and optimize the dissemination of free and valuable medical videos via YouTube. It is clear from the results of this study that the quality of surgical specialized information in YouTube videos is very heterogeneous and the process of e-learning is not without pitfalls. The reasons include that (1) the content of most videos often lacks institutional or peer quality control, thus the specialized information shared may be not accurate; (2) finding informative and trustworthy targets is hampered by the vast amount of seemingly relevant videos via current ranking system. To solve these problems, we are expecting changes in two aspects. First, more authoritative videos by trusted sources should be posted. Second, ranking system based on present YouTube algorithm may be evolved by adding some elements like peer review, social network analysis, or NLP techniques. With the endeavors of professional individuals, academic institutions, and e-learning communities, YouTube, the leading video streaming websites, will help to meet huge informational needs of medical staffs and promote medical education on HTx.
The Revived Heart Transplant Program at Batson Children's Hospital builds on a 20-year legacy.
The heart transplant procedure from Montefiore-Einstein, NYC.
Example of a high-quality surgical educational video “Heartmate II LVAD Implantation. Arie Blitz, MD” uploaded by “Arie Blitz” channel. It was originally from the YouTube website, reproduced under Creative Commons Attribution License.
A newest video titled “Left Ventricular Aneurysm Resection and LVAD Implantation Through Median Sternotomy” available on the website of CTSNet; however, it cannot be accessed from “AATSVideos” Channel. It was reproduced under Creative Commons Attribution License.
The maximum-weight misleading video “13-year-old British girl” uploaded by “uniquerocks” Channel. It was from originally from the YouTube website, reproduced under Creative Commons Attribution License.
American Association of Thoracic Surgery
one-way analysis of variance
Cardiothoracic Surgery Network
heart transplantation
hospital/university channel
International Society for Heart and Lung Transplantation
independent user channel
left ventricular assist device
medical dotcom channel
news agency channel
natural language processing
This research was partly supported by The National Natural Science Foundation of China, under grants (No. 30900622, 81270962, and 81070159). The work of X-B Liao was sponsored by CJ Huang Medical Fellowship of Stanford University. The authors are grateful to Dr Mark Nicolls and Dr Rosen Glenn for providing superb academic environment in postdocs’ free accessing to knowledge. Furthermore, the authors got excellent guidance from Dr Dipanjan Banerjee and Jodi Halpern.
The authors XBL, HMC, XLZ, and VADJP were involved in the study design; XBL, HMC, ZBX, ZSY, KY, and MO participated in the data collection; XBL, HMC, ZKH, LQY, XLZ, and VADJP participated in the discussion and interpretation of the results; and XBL, HMC, ZKH, and VADJP led the manuscript drafting. All authors have read and approved the final manuscript.
None declared.