An invisible knife to add to your toolkit: a narrative review of how podcasts have audibly shaped, styled, and sharpened surgical education

Aims and audience

The aims, audiences and content of surgical podcasts are varied, ranging from cross-disciplinary comprehensive podcasts aimed at all surgical healthcare providers, such as BTK, to podcasts developed for a particular surgical specialty, such as First Incision or Audible Bleeding.^10-12

Other surgical podcasts were specifically designed to supplement an academic journal or boost recruitment at particular hospitals.^{10-13, 17, 18} There is also a subset of podcasts that aim to simultaneously educate and entertain, termed ‘edutainment’ podcasts.^{6, 16} The target audience for surgical podcasts are likewise varied, ranging from surgical learners, to multidisciplinary allied health professionals, as well as patients, and the general public.^{10, 19} The broadest audience is often achieved by ‘edutainment’ podcasts, as they garner popularity with both healthcare professionals and the general public.¹⁶

Structure, presenters, content creators and content

A consistent structure of the most downloaded surgical podcasts is a presentation format that starts with learning objectives, followed by content delivery, and ending with defined take-home messages.^{1, 5, 11, 20} Many producers deliver a spectrum of podcast formats, including interviews, didactic lectures, mock exams, and conversational discussions.^{2, 14, 15, 21, 22} Furthermore, podcasts disseminating research often follow a journal article structure of introduction, methods, results and discussion.^{2, 14, 15, 21, 22} Larger producers such as BTK and First Incision establish multiple podcast series that have consistent formats within the same series, but vary between series depending on the target audience and focus.^{10, 11} While the general structure of most podcasts aligns with these key formats, it is noteworthy that the flow can be variable, even within a distinct series.

There is marked diversity of surgical experience among content creators and presenters, ranging from medical students to trainee and consultant surgeons, as well as multidisciplinary health professionals and members of the public.^{1, 3, 23} For example, among plastic surgery related podcasts in 2021, Clarke et al., found that 62% were presented by surgeons or residents, 27% by other varied medical professionals and 11% by non-medical professionals and were primarily targeted to prospective cosmetic surgery patients.¹⁹ Multiple presenters are a common feature of surgical podcasts, often employing the interview format, with junior team members questioning experts on a particular topic or case.²⁴

Podcast content varied greatly depending on the aim and target audience, as summarized in Table 1, with educational content being most common. Nonetheless, surgical podcasts also included topics not explicitly taught in surgical training, such as professional and non-technical skills.^{2, 10, 25} Episodes that were more conversational in format tended to focus more on contemporary themes relevant to surgery, less likely to be taught in conventional surgical texts, such as discrimination and representation in surgery, emerging technologies in surgery, war zone surgery, mental health, global health and the international impact of Covid-19 on surgical practice.^{10, 12, 14}

Issues with the use of surgical podcasts

This article identified key issues with the use of surgical podcasts in surgical education; the questionable credibility of podcasts, the domination of the podcast landscape by a few producers, and the questionable efficacy of the audio medium for meaningful learning.

Podcasts currently exist outside the regulatory parameters of more traditional mediums of publication, such as peer-reviewed journal articles. There is no requirement to make explicit the scientific objectives of the podcast, any conflicts of interest among creators or producers, or to clarify if the podcast is for education or edutainment.

Success and quality

The success of surgical podcasts remains difficult to define, and specific metrics are lacking in the area. The most common metrics used to define success and impact are longevity, number of downloads and overall listenership.²⁶ As it stands, responsibility for assessment of content, quality and validity of any information provided in surgical podcasts rests with the listener, and this seems unlikely to change in the currently unregulated podcast development space. Furthermore, given that podcast production is not regulated, issues arise in terms of dissemination of potentially inaccurate and non-peer-reviewed information. This said, many podcasts, such as BTK, are evolving to include references for each episode either in the podcast description (‘show-notes’) or on their respective webpages.¹⁰ As podcasts strive to become more reputable, the authors of this review suggest that there should be a standardized approach to development of surgical podcasts to ensure the credibility and quality of information being disseminated to surgical learners. We propose this should include information on the content creators' backgrounds and surgical experience, involved parties' conflicts of interest, the use of clear objectives, and communication of the reputability of information either verbally or with associated text references.^{26, 27} A suggested approach to critical appraisal of surgical podcast content is detailed in Table 2. However, the quality of the discussion in each podcast varies significantly based on presenters, format and content. As such, a judgement regarding the quality of a surgical podcast remains a decision that each listener must make.

Educational utilization of podcasts

This narrative review has revealed a thriving surgical podcast landscape dominated by several reputable podcast producers with large listenerships. Although smaller producers do exist, many fail to gain traction and continue to produce content past six-months, a phenomenon termed ‘pod-fade’, disappearing from active production.^{28, 29} A summary of active and inactive surgical podcasts is provided in Table 3 adapted from Little et al.²⁹ Pod-fade may in turn contribute to the apparent oligopoly of podcast producers, with 48% of all general surgery podcast episodes produced by two producers as identified by Little et al.²⁹ Similarly, 61% of otolaryngology podcasts were produced by just two producers. For orthopaedic and neurosurgery podcasts, 52% and 84% of episodes were produced by a single producer, respectively.²⁹ With such large listenerships, the oligopoly of podcast production and the non-peer reviewed nature of podcast content are two key concerns educators are likely to have when considering implementing surgical podcasts into their curriculum. Unfortunately, metrics on surgical learners using surgical podcasts to learn about surgery are lacking, including data on how useful surgical podcasts are for surgeons everyday practice, exam preparation or research.

Educational strengths and limitations of podcasts

The varied strengths and weaknesses of podcasts as an educational tool are depicted in Table 4. Surgical students and doctors have limited dedicated study time, so the ability to combine podcast learning with routine tasks, such as cooking or commuting, is a key advantage.^{1, 30-32, 38} Podcasts can also be used for focused learning, as they have been found to improve junior doctor knowledge acquisition, retention and exam performance, including as an adjunct to other, traditional teaching methods.^{35-37, 39} Conversely, a key criticism of podcasts in general is that they are often used while multitasking which can be detrimental to the efficacy of podcasts learning, through limiting knowledge acquisition; with medical examination scores found to be impaired with multitasking compared with focused, active learning.^{33, 34} Although podcast listening while conducting other activities reduces understanding of topics and knowledge retention, if podcast learning is supplementary to other forms of learning, it can be argued that any time spent listening to podcasts during routine tasks would otherwise be lacking in any learning benefit, which may therefore represent an overall learning advantage.³⁰ As such, podcasts represent a medium for surgical learning that maximizes time-efficiency, as they can be combined with routine tasks to create time for learning which otherwise might not exist.^{1, 30-32, 38} The authors of this article propose that podcasts can in fact promote education seeking behaviours, where a podcast suggests or references key articles or topics to review in more detail later.

This benefit is likely to be twofold—the audio medium of the podcast has allowed for time otherwise spent not learning to gain some level of education on a topic, and referencing articles to review later consolidates learning in a spiral learning fashion.^{30, 32} This also addresses the issue of the audio-only format of podcasts, a key flaw identified by a number of articles in this literature review.³⁸ Similar to how producers are evolving their format and references to make their podcasts more credible, several podcasts produced by high-volume producers are incorporating images, video content, or dedicated resource lists to supplement educational outcomes for particular episodes, especially on topics of anatomy, procedures, and pathologies.^{10, 12, 14, 15, 38} Surgical podcasts are likely to be most effective as an adjunct to traditional learning methods such as journal reading, clinical learning and didactic material. The capacity to pause, rewind and revisit podcasts allows learners to gain new appreciation of topics following further experience and may help to consolidate knowledge gained from other mediums.^{1, 10, 19, 34-36, 44} Furthermore, some of the most listened-to surgical podcasts make notable efforts to provide an enjoyable format that aids listener engagement and promotes podcast longevity.^{30, 39, 45} While still not standardized, these modifications highlight the responsive and versatile nature of surgical podcasts, which are likely to become more credible, applicable and responsive to the needs of listeners as time goes on.

Role for surgical podcasts in surgical education

While the relative ease of production compared to traditional surgical education mediums raises the issues mentioned above, it also means they are widely and freely available to download by anyone with internet access.^{27, 46} Our pooled results found that surgical podcasts have achieved wide uptake across all levels of surgical learners.^{30, 45, 47} Surgical trainees primarily use podcasts to improve core content and contemporary literature knowledge.³⁰ An assessment of otolaryngology trainees identified ~75% utilized podcast education and over half of these changed clinical or consulting practice secondary to podcast use.³⁰ Podcasts can also support pre-operative preparation by describing technical procedure steps, and considering nuances prior to procedures, providing scaffolding for intraoperative learning and discussion.⁴⁸ Additionally, trainee surgeons may utilize podcast-based exam preparation, with multiple podcasts specifically catered to formal examinations.^{10-12, 45, 47} Podcasts aimed at medical students have predominantly been used as a surgical study adjunct, and to supplement specific regional surgical curricula, including assessment preparation.^{1, 23} For example, Surgery 101 episodes were explicitly created to cover specific surgical topics within a 15–20 min podcast format.^{1, 3} Consultant surgeons were found to use podcasts that were more research-related, innovative or optimize professional skills.^{2, 30} Surgeons without research affiliations or regular conference attendance use podcasts to acquire up-to-date knowledge, and can also use podcast learning for continuing professional development which aligns with standards for surgical trainers.^{10, 49}

It is also notable that podcasts provide a medium that overcomes some logistical limitations of face-to-face teaching, such as the need for physical attendance, and difficulties with reproducibility across content delivery for educators.^{36, 41} In this way it has been used as a ‘safe space’ for under-discussed issues such as gender diversity, racial and social disparity, mental health, burnout, and suicide in surgical contexts.^{2, 10, 12, 38} Not only do podcasts provide learners access to information they may not feel safe to receive in person, it overcomes the geographical boundaries of access to information. Arguments that a lack of consistent internet access, geographically-limited access to streaming platforms, or financial limitations to access paid content limit the applicability of podcasts, however, the majority of podcasts remain free, and a review of social media for plastic surgery education in Sub-Saharan Africa suggests that podcasts can be an effective means to counter endemic financial and resource limitations.^{36, 46} Accordingly, Delphi consensus recommendations for graduate medical education podcasts contend these should contain universal accessibility as well as accurate information, professionalism and relevant material.²⁶

Another major practical advantage of the podcast medium is that they can be rapidly created to meet specific needs. For example, the 2015 French-established Traumacast was developed for civilian and military medical trauma management in response to terrorist threats, which rapidly provided important information nationwide.⁴³ The COVID pandemic highlighted this further; podcasts covering COVID-19 in surgical patients were able to rapidly disseminate research and emerging practice principles in 2020.^{10, 19, 50}