International Journal of

Radiation Oncology
biology

physics

www.redjournal.org

Clinical Investigation

Mobile Technology and Social Media in the

Clinical Practice of Young Radiation Oncologists:
Results of a Comprehensive Nationwide
Cross-sectional Study
Jean-Emmanuel Bibault, MD, MSc,*,## Thomas Leroy, MD,*,##
Pierre Blanchard, MD,PhD,y,z Julian Biau, MD,x,##
Mathilde Cervellera, MD,jj,## Olivia Diaz, MD,{,##
Jean Christophe Faivre, MD,#,## Ingrid Fumagalli, MD, MSc,*,##
Nicolas Lescut, MD,**,## Valentine Martin, MD,yy,##
Baptiste Pichon, MD,zz,## Olivier Riou, MD, MSc,xx,##
Sebastien Thureau, MD, MSc,jjjj,## and Philippe Giraud, MD, PhD{{,***
*Academic Radiation Oncology Department, Oscar Lambret Center, Lille, France; yAcademic
Radiation Oncology Department, Gustave Roussy Institute, Villejuif Cedex, France; zBiostatistics and
Epidemiology Department, Gustave Roussy, Villejuif Cedex, France; xRadiation Oncology
Department, Jean-Perrin Center, Clermont-Ferrand cedex, France; jjRadiation Oncology Department,
Jean-Godinot Center, Reims, France; {Radiation Oncology Department, Lyon Sud University Hospital,
Pierre-Benite Cedex, France; #Academic Radiation Oncology & Brachytherapy Departement, AlexisVautrin Center, Avenue de Bourgogne, 54511 Vanduvre-le`s-Nancy, France; **Radiation Oncology
Department, BesanCon University Hospital, BesanCon Cedex, France; yyRadiation Oncology
Department, Gustave Roussy Institute, Villejuif Cedex, France; zzRadiation Oncology Department,
Rene-Gauducheau Center, Saint-Herblain, France; xxRadiation Oncology Department, Montpellier
Cancer InstituteeVal dAurelle, parc Euromedecine, Montpellier Cedex, France; jjjjRadiation Oncology
& Medical Physics Department, QuantIf, Litis, EA4108, Centre Henri-Becquerel, Rouen, France;
{{
Radiation Oncology Department, Hopital Europeen Georges Pompidou, Paris Descartes University,
Paris, France; ##French Society of Young Radiation Oncologists (SFjRO), Centre Antoine-Becle`re,
Paris, France; and ***French Society of Radiation Oncologists (SFRO), Paris, France
Received Jan 7, 2014, and in revised form Apr 24, 2014. Accepted for publication May 11, 2014.

Summary
Social media and mobile
technology are transforming

Purpose: Social media and mobile technology are transforming the way in which
young physicians are learning and practicing medicine. The true impact of such technologies has yet to be evaluated.

Reprint requests to: Jean-Emmanuel Bibault, MD, MSc, Academic

Radiation Oncology Department, Oscar Lambret Comprehensive Cancer
Center, 3 rue Frederic Combemale, 59000 Lille, France. Tel: 33 (0)3 20
29 29; E-mail: jebibault@gmail.com
Int J Radiation Oncol Biol Phys, Vol. -, No. -, pp. 1e7, 2014
0360-3016/$ - see front matter 2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ijrobp.2014.05.012

Conflict of interest: none.

Supplementary material
www.redjournal.org.

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International Journal of Radiation Oncology  Biology  Physics

Bibault et al.

the way in which young

physicians are learning and
practicing medicine. These
technologies have introduced
new decision-making tools in
the hospital. In parallel,
young physicians have
largely adopted social networks. The goal of this study
was to assess the true impact
of mobile technologies and
social media in the everyday
clinical practice of young
radiation oncologists.

Methods and Materials: We performed a nationwide cross-sectional survey to better

assess how young radiation oncologists used these technologies. An online survey was
sent out between April 24, 2013, and June 1, 2013. All residents attending the 2013
radiation oncology French summer course were invited to complete the survey. Logistic regressions were performed to assess predictors of use of these tools in the hospital
on various clinical endpoints.
Results: In all, 131 of 140 (93.6%) French young radiation oncologists answered the
survey. Of these individuals, 93% owned a smartphone and 32.8% owned a tablet. The
majority (78.6%) of the residents owning a smartphone used it to work in their department. A total of 33.5% had more than 5 medical applications installed. Only 60.3% of
the residents verified the validity of the apps that they used. In all, 82.9% of the residents had a social network account.
Conclusions: Most of the residents in radiation oncology use their smartphone to work
in their department for a wide variety of tasks. However, the residents do not consistently check the validity of the apps that they use. Residents also use social networks,
with only a limited impact on their relationship with their patients. Overall, this study
highlights the irruption and the risks of new technologies in the clinical practice and
raises the question of a possible regulation of their use in the hospital.
2014 Elsevier Inc.

Introduction
The rise of new technologies is reshaping the way in which
physicians practice medicine. The creation and use of online information sources through Internet and Web 2.0
platforms are radically changing the way in which we
consider therapeutic options. As mobile platforms have
become more powerful and readily available, medical
mobile apps have been created to perform various tasks.
Some of these new mobile apps are created to assist individuals in their own health management, but other mobile
apps are targeted to health care providers as tools to
improve and facilitate treatments.
Radiation oncology heavily relies on advanced technology, from treatment planning to delivery. Most physicians in
this field are already using online tools to write prescriptions,
to choose the best treatment options (1), or to search for
available clinical trials (2). Although residents still use
printed or online journals as a major source of information
(3), they have also embraced social media (4), smartphones,
and tablets to improve clinical care through rapid access to
the most updated information such as that available through
podcasts, apps, protocols, reference texts, recent research,
and more. The quality of information and services provided
by websites and apps greatly varies, and no certification
currently exists to check their validity (5). In parallel, social
networks have been largely adopted by young physicians,
with some of these websites allowing physicians to share
patients information and to discuss cases among colleagues
(6). However, the ways in which health professionals use
social media in daily practice remains poorly studied (7). As
a consequence, doctors are increasingly required to consider
how to protect patients interest and medical confidentiality.

In the same manner, these networks could also deeply affect

the doctorepatient relationship.
Although use of the Internet by patients has already been
reported (8), no studies have described the way that physicians use these news tools. This study was performed to
precisely assess how these new tools and new sources of
professional medical information are used, and how they
actually influence the learning and decision making of
young physicians.

Methods and Materials

A nationwide cross-sectional survey was performed between
April 24, 2013 and June 1, 2013 (Appendix A). All residents
attending the 2013 radiation oncology French summer course
had to register for the course online, and were invited to
complete the survey that was performed using the RSForm
module with the Joomla 1.5 Content Management System.
Residents were free to refuse the survey. Answers were
collected anonymously. The statistical package SPSS 13.0
(SPSS Inc, Chicago, IL) was used to perform the analysis. All
percentages were calculated using returned questionnaires.
Endpoints of the study were the use of smartphones for decision making in the hospital and use of social networks
among residents. Univariate binary logistic regressions were
used to look for statistical associations between binary (eg,
gender), ordinal (eg, age, level of training, duration of
ownership of a smartphone, and number of apps installed) or
nominal (eg, type of Operating System) variables and the
study endpoints. Multivariate logistic regression was to be
performed if more than 1 factor was associated with 1 of the
outcomes of interest with a P value of less than .2.

Volume -  Number -  2014

Mobile technology and social media use

Results
Study population
In all, 131 of 140 radiation oncology residents registered to
the national course answered the survey, corresponding to a
response rate of 93.6%. Most of them had been practicing
radiation oncology for more than 2 years (nZ72; 55%).
Repartition according to years of training is presented in
Figure 1. A total of 64 men (48.8%) and 67 women (51.1%)
answered the survey. Participants were 24 to 32 years of
age (median, 28 years).

Smartphones and tablets

The vast majority of the residents used a smartphone
(nZ122, 93%). A total of 62% (nZ82) used an iPhone
(Apple, Cupertino, CA), 26% (nZ34) used an Android
(Google, Mountain View, CA)-based smartphone, and
11.5% (nZ6) used a Windows phone (Microsoft, Seattle,
WA). Most of the responders had owned a smartphone for
more than 1 year (nZ99; 83.9%) and less than 5% had
owned one for less than 6 months (nZ5; 4.2%). In all,
78.6% (nZ103) of the residents owning a smartphone used
it for work in their department. Examples of the apps used
are shown in Table 1.
Only 32.8% (nZ43) of the surveyed residents owned a
tablet, almost half of them for less than 6 months (nZ19;
44.2%). Twenty-one percent (nZ9) had owned a tablet for
more than 6 months to 1 year and 34.9% for more than
1 year. In all, 84% (nZ36) of them were iPad (Apple,
Cupertino, CA), whereas 16.3% of the residents (nZ7)
owned an Android-based tablet. Overall, 29.4% (nZ35) of
the residents owning a tablet used it in their department.
Smartphone and tablet use according to level of training is
shown in Figure 2.
Most of the residents declared that they were using their
smartphone for work more than 5 times each day (57%;
nZ69), with 24.8% (nZ30) using it 5 times each day and

Fig. 1.

18.2% (nZ23) of them using it only 3 times each day. A

total of 33.5% (nZ44) had more than 5 medical applications (including contouring atlas, drugs repositories, and
bibliographic tools) installed on their terminal. Only 9.2%
(nZ12) of the residents owning a smartphone had no
medical applications installed. Of the residents, 60%
(nZ73) checked the validity of the apps that they were
using, whereas 39.7% (nZ48) did not. A total of 78% of
the residents (nZ102) used their smartphone to take pictures of lesions for diagnosis, follow-up, or second opinion.
In line with this, 75.2% (nZ91) of them used utility apps
for drug interactions, essential points, manufacturer contact, and so forth. Only 30% (nZ39) used their smartphone
to search and read articles. In all, 68% of the residents
(nZ82) also used their smartphone to calculate equivalent
doses for radiation treatments. Even if these applications
had been created for academic purposes only, 67.2%
(nZ80) of the residents used them for medical purposes
with direct consequences to the patients treatment, thereby
breaching the apps End-User Licence Agreement. Only
34.5% of the residents (nZ41) used apps to help them with
contouring although all of them had free access to a radioanatomy website and app. A binary logistic regression was
performed to assess factors associated with the use of applications for medical purposes. Sex, age in quartiles,
training level, duration of ownership of device, type of
operating system, and number of medical applications
installed on the device were included in the regression
model (Table 2). In the univariate analysis, only type of
operating system, duration of ownership of a smartphone,
and number of applications were significantly associated
with the use of apps for medical purpose. These covariates
were included in the multivariate analysis, in which only
the number of apps remained significantly associated with
the outcome (odds ratio [OR] Z 3.38, 95% confidence
interval [CI] Z 1.82-6.31, P<.001): the more apps they
added, the more likely they were to use their smartphone
for medical purposes. A second analysis was performed to
assess factors associated with checking for the medical
validity of the apps. The same covariates were included in

Number of participants according to level of training.

International Journal of Radiation Oncology  Biology  Physics

Bibault et al.
Table 1

Examples of available apps for medical and radiation oncologists

App

Description

ECCO, ESMO, ESTRO, ASCO, ASTRO

Each society has its own app featuring Annual

Meetings, Programs, and Schedules
Version 4.0 of the Common Terminology Criteria
for Adverse Events
Drug utility showing interactions, essential
points, manufacturer contact, and resource
center for each registered drug
Drug utility application
National Comprehensive Cancer Network
guidelines with algorithms for each cancer type
SearchPubMed on the go with a minimalistic and
efficient interface
More than 150 calculators created by clinical
experts featuring detailed references with
PubMed integration
Free medical calculator
Search and access articles on topics of choice
Radiation oncology equivalent dose calculator
Equivalent dose calculator

CTCAE-4
EpocratesRx

Medsonic
NCCN
PubMed On Tap
Calculate

FMCalc
Read
eLQ
BED

the univariate analysis. Sex, duration of ownership of a

smartphone, and number of medical apps installed were
significantly associated with the fact of checking the validity of the apps in the univariate analysis, but none in the
multivariate analysis (Table 2).

Online information
Of the residents, 92% (nZ119) declared that they were
keeping up to date on recently published studies; 50.8%
(nZ64) checked for new studies on a weekly basis; and
24.6% (nZ31) checked once a month. Only 4% checked
for new studies every day. Figure 3 shows the sources of
information used. A majority of residents searched for new
articles in English (64.8%; nZ81), whereas 35.2% used
mainly French to search for new studies (nZ44).

Social media
Only 10% of the residents (nZ13) had a Twitter account
(Twitter, Inc, San Francisco, CA), with half of them (nZ6)
using it to keep up to date on new studies. A total of 82.9%
of the residents (nZ107) had a Facebook account (Facebook, Inc, Menlo Park, CA). The most popular social networks are shown in Table 3. On Facebook, 88.6% of
residents (nZ93) used their real name, whereas 11.4%
(nZ12) changed their name for anonymity. However, only
11.2% (nZ12) of them had been contacted by one of their
patients through Facebook. Among these, a majority
(64.3%; nZ9) did not answer and simply ignored the
message; 14.3% (nZ2) did not answer and subsequently
changed their name; and 21.4% (nZ3) answered their patient through Facebook. We performed a univariate binary
logistic regression analysis to evaluate factors associated
with the likelihood of responding to a patient on Facebook.

Availability
iOS, Android
iOS
iOS, Android, Blackberry

Windows Phone
iOS, Android
iOS
iOS, Android, Blackberry

Windows Phone
iOS
iOS, Android
Windows Phone

Age in quartiles, sex, and training level were included in

the analysis, but no significant factors were found.
Only 17.1% (nZ22) of the residents had signed up for a
physician-dedicated social network. Among those, 20.8%
(nZ5) used this network to discuss anonymous patients cases,
to get a second opinion, and to find help. An analysis was
performed to evaluate the use of social media among residents.
Univariate logistic regressions were performed to assess factors associated with the use of Facebook, Twitter, or physiciandedicated social networks. For each social network, sex, age in
quartiles, and level of training were included in the logistic
regression model, but no significant factors were found.
Regarding the use of physician social networks, residents with
higher training levels were more likely to use them to share
anonymous patient data (Fisher exact test; PZ.011).

Discussion
To our knowledge, this study is the first to assess the true
impact of mobile technologies and social media on the
everyday clinical practice of young radiation oncologists on
a national scale.

Fig. 2.

Smartphone and tablet use.

Volume -  Number -  2014

Mobile technology and social media use

Table 2 Univariate and multivariate logistic regressions for factors associated with the use of a smartphone for a medical purpose and
verification of the medical validity of these apps

Covariate (reference category)

Age (OR per 1-year increase)

Sex (male)

Level of training (OR per 1

more year of training)
Type of operating system (iOS)

Duration of ownership of smartphone

(OR increases with time)
No. of installed medical apps
(OR per 1 more app installed)

OR
95% CI
P
OR
95% CI
P
OR
95% CI
P
OR
95%CI
P
OR
95% CI
P
OR
95% CI
P

Use of mobile apps for medical

purposes

Verification of validity of apps

Univariate

Multivariate

Univariate

Multivariate

1.04
0.81-1.35
.72
1.43
0.52-3.92
.48
1.01
0.69-1.47
.96
0.29
0.10-0.82
.02
1.94
1.05-3.60
.03
3.54
1.97-6.35
<.001

0.38
0.11-1.30
.12
1.24
0.56-2.73
.60
3.38
1.82-6.31
<.001

1.15
0.830-1.56
.40
0.5
0.24-1.04
.06
1.1
0.94-1.28
.25
0.89
0.40-1.97
.78
1.90
1.15-3.13
.012
1.60
1.05-2.45
.028

0.5
0.23-1.09
.08
1.66
0.97-2.84
.06
1.38
0.87-2.19
.17

Abbreviations: CI Z confidence interval; OR Z odds ratio.

Mobile app use in the hospital

The latest generation of smartphones can be viewed more
as hand-held computers than as telephones. Their economic model has fostered the development of applications
for almost every task performed by physicians in the
hospital. Mobile apps are easy to download and to use.
Several studies have evaluated the use of mobile phones
for medical education and clinical practice (1, 9). Kailas
et al counted more than 7000 smartphone health apps
(10). Others estimated this number actually to be more
than 40,000 (11), but the boundary between wellness apps
and medical apps is often very thin in the app stores. Two
other reviews by Free et al (12) and Terry (13) reported on

Fig. 3. Sources of medical information and their

respective frequencies of use.

the use of mobile phone in health care. As we showed in

this study, smartphone use in the clinical environment is
ubiquitous among residents (78.6%). However, only
60.3% of the residents using medical apps checked the
accuracy and scientific validity of the apps. Pandey et al
recently published a study identifying mobile applications
related to oncology as of July 29, 2011 (14). A search
query was performed on the iTunes App Store, using the
terms oncology and cancer. The final analysis
included 77 apps. Most of these apps (36.4%; nZ28) gave
general cancer information, and 16.9% (nZ13) were patient assistance tools. Of these apps, 24.6% were created
by health care agencies. A total of 36% of the apps were
aimed at health care professionals. Only 55.8% of the
apps provided scientifically validated data. The apps
aimed at the general population were less scientifically
validated then the those aimed at health care professionals
(P<.01). The authors concluded that there was a lack of
cancer-related applications with scientifically backed data
and a paucity of medical accuracy and relevance of a
majority of apps directed at general users (14).
Relying on smartphones to perform simple tasks such as
drug dosage or radiation equivalent dose calculation is easy
and convenient, but also poses risk for the residents to
forget how to perform these simple tasks by themselves.
Another major risk is to use inaccurate apps or apps not
functioning as intended (15). If these apps are used to adapt
treatments for patients, they could cause major medical
errors. This risk raises the questions of the minimum
quality criteria required for these apps (5, 16) and the need
for a regulation of their use in the hospital (17, 18). Local

International Journal of Radiation Oncology  Biology  Physics

Bibault et al.

Table 3 The 4 largest social networks as of November 2013 (not dedicated to physicians and not designed to discuss patient cases or
to share data)
Social network
Facebook

Google

LinkedIn

Twitter

Description

URL

Largest social networking service founded in

2004, with w1.15 billion active users as of
March 2013; many institutions and societies
have their own pages
Second largest social networking and identity
service founded in 2011, with w540 million
users as of October 2013
Largest professional social networking service
founded in 2002, with w259 million users as
of June 2013
Microblogging service with w554 million active
users as of November 2013

http://www.facebook.com

smartphone policies could be created for best practice.

These policies should describe which apps could be used, in
which context, and for which task. Such policy has been
applied since in February 2012 at the Albert Einstein
College of Medicine to minimize distraction in the hospital.
All team members must silence or turn off their phones
while attending rounds, but smartphones can be used for
matters directly related to patient care. A survey was also
performed to assess the residents opinion of this policy
(19). With an overall response rate of 65%, the majority of
residents (82%) agreed with the policy. However, enforcing
a stricter policy on medical app use inside the hospital
could prove to be quite challenging. Another solution
would consist of a strict control of the apps available to
download on the Internet (20). In line with this, the Food
and Drug Administration (FDA) has expressed the will to
oversight and control these mobile apps like medical devices. In September 2013, guidance was issued by the FDA
to announce which kinds of apps they intended to regulate
(21). Simple medical calculators or drug utility apps such
as the one described in this article will not be included in
this regulation. The results of this study show that even this
kind of app has direct consequences for the patient and
should perhaps be considered in the regulation. Some
cancer centers have already stepped forward and released
their own apps, including medical guidelines and calculators for their residents (22).

http://plus.google.com

http://www.linkedin.com

http://www.twitter.com

Another study published in 2011 reported that many patients contacted their physician through Facebook and sent
them friend requests, although very few physicians
responded back (6). Because of the widespread use of these
websites by physicians (25), national policy statements
addressing these issues are starting to appear. In December
2011, the French National Board of Physicians issued 5
general guidelines that define how French physicians
should use the Internet and social networks (26). Although
these guidelines encouraged physicians to engage in more
online interactions, they also clearly recommended refusing
any request from a patient made through social networks
because such virtual relationship could corrupt the
patientephysician relationship. In our study, only 10% of
the residents had actually been contacted on Facebook by
one of their patients, but 20% of those actually answered
the message.
The American College of Physicians and the Federation
of State Medical Boards also published a policy statement
in April 2013 (27). In this article, the authors created a
list of online activities describing potential benefits,
pitfalls, and recommended safeguards. They report that an
increasing number of organizational policy statements
discourage personal communications on social network
websites (28, 29). The creation and development of social
networks dedicated to physicians could be an interesting
solution to limit the risks existing with other general social
networks.

Social media use among radiation oncology

residents

Conclusion

Even if Twitter is widely used in other countries, mainly the

United States (23), it is still a minor trend in France, with
only 10% of the residents actually having a Twitter account.
However, our study showed that more than 80% of the
residents used Facebook. A review highlighted the potential
uses of social media in health care, and reminded the reader
that the ways in which health professionals use social
media in daily practice has remained underexamined (24).

In conclusion, a majority of the French residents in radiation oncology use their smartphone to perform a wide variety of tasks, including drug dosage, radiation dose
calculation, and literature research. However, almost half of
the residents do not check the validity of the apps that they
use. If an app is not working as intended, it could pose a
risk for patients; yet no regulation currently exists in this
field. At the same time, almost all residents had accounts on

Volume -  Number -  2014

social network websites, but only a minority of them had

been interacting with patients through these websites.
Overall, our study highlights the undeniable irruption of
these new technologies in the clinical practice and the risks
that this can create. The qualitative and quantitative benefit
of smartphone apps and social media could be evaluated in
a larger study including medical oncologists residents and
senior physicians.

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