#MedEd—The ‘TikTok’ frontier of medical education

Recent decades have seen the rapid emergence of virtual learning platforms in medical education for both synchronous remote teaching and asynchronous student learning, accelerated by the COVID-19 pandemic. Increasing focus on problem-based learning, integrated clinical teaching and outcome-based approaches in curriculum design have resulted in an increased expectation of self-directed student learning in a ‘flipped classroom’ style, with emphasis on online multimedia resources. Such approaches allow increased time for interactive, meaningful classroom teaching, associated with significant improvements in student performance, motivation and satisfaction compared with traditional lecture-based approaches. In most medical schools, students enter with often remarkable technological literacy and daily use of various personal multimedia including audio-visual and game-based content, which has translated to an expectation this is reflected in the classroom. Unfortunately, ‘Death by PowerPoint’ has persisted in clinical teaching delivery, with poor slide design, a default to didactic teaching styles and difficulties navigating online lecture platforms often resulting in learner disengagement, limiting knowledge retention. Various multimedia tools such as podcasts, videos, simulations, interactive mind mapping and flowchart software have emerged over recent decades, offering a range of options suited to different learning styles. Social media sites such as YouTube and Facebook are particularly popular with students, offering engaging and easily accessible ‘microlearning’ on familiar platforms, promoting self-directed learning, multidisciplinary interaction and engagement with curricula content.


| TIKTOK
Increasingly used in educational practice is the social media site Tik-Tok. 5TikTok is a platform where users post short form audio-visual content, with 1.8 million monthly active users and 38.5% of users in the age range 18-24. 6#learnontiktok was launched in 2020, targeting individuals whose learning was affected by the COVID-19 pandemic, as a platform for professionals, students and teachers to share and access educational resources at home using personal devices. 5edEd had 4.6 billion views at the end of 2020 and continues to expand in popularity and scope, with medical 'influencers' posting video 'shorts' with disease overviews, Objective Structured Clinical Examination (OSCE) stations or clinical skills, accompanied by audio explanations, animations and figures and patients demonstrating symptoms and signs (Figure 1). 6spite increasing use of social media such as TikTok for selfdirected student learning and popularity in current and upcoming medical school cohorts, there has been limited effective integration into curricula so far and minimal educational research into this paradigm. 5Use of social media platforms in education may be perceived as inaccessible or technologically challenging by educators unfamiliar with platforms, limiting integration into teaching practices. 7In this article, we offer a 'Toolbox' based on our experience with the use of TikTok in teaching practice, benefits observed, with pedagogical theories and practice tips behind their implementation in clinical education practice. 8

| INTEGRATING TIKTOK IN CLINICAL EDUCATION
To effectively integrate TikTok into clinical teaching, establishing overall aims of their use and considering how they will be useful within the context of the teaching environment is required. 8Covered content can include basic science, clinical revision content on diseases or presentations, OSCE cases, academic skills or ethical, economic or political debate relating to medical education and careers. 5For educators engaging face to face with students on a regular basis, producing TikToks as short-form revision material for content covered within each classroom session can provide an effective, easily accessible, repeatable resource used for revision before end-of-topic assessments. 8TikToks primarily used for asynchronous learning can focus less on personalisation to individual cohorts or session content but be contextualised within an overarching series focussing on different domains of clinical education or one-off videos on trending topics within medical education or discourse. 8oducing TikToks as short-form revision material … can provide an effective, easily accessible, repeatable resource.
TikTok also offers a valuable platform for instantaneous studentteacher collaboration and feedback.TikToks can be commented on, shared on social media and direct messages sent on the platform, encouraging student feedback on structure, content and design. 5couraging feedback from students before, during and after TikTok production can offer valuable insights into student needs and allow educators to refocus their production aims, streamline design and tailor educational content. 9

| Pedagogy
Appreciating the underlying pedagogical theories behind the use of TikToks in clinical education is helpful to effectively inform their design.Mayer's principles of multimedia learning outline the foundational assumptions of cognitive psychology and human learning underpinning the use of educational 'multimedia', designed as the concurrent use of visual, audio and interactive teaching material (Figure 2).
Cognitive load theory underpins Mayer's principles and consists of three core components (Figure 3).Overwhelming any element of cognitive load can result in increased off-task activity, lack of engagement with assessment material or inability to retain content, influenced by prior learning, environmental factors and individual student educational needs or neurodivergence. 11yer's principles suggest for sustained, effective learning, each component of cognitive load should be minimised within multimedia learning content. 10The core concepts of these theories can be synthesised to provide practical guidance to produce effective multimedia learning content (Table 1).
Integration of Mayer's principles into multimedia design has been associated with improved information retention, test scores and student engagement, highlighting the benefits of this approach in clinical education. 12I G U R E 1 Medical influencers on TikTok.#MedEd. 6ntegration of Mayer's principles into multimedia design [is] associated with improved information retention, test scores, and student engagement.

| TikTok design
Both underlying pedagogical principles and features of successful preexisting educational content on the platform can inform TikTok design.The short-form nature of TikToks translates naturally to concise coverage of core concepts, maintaining focus on overall learning outcomes and avoiding redundant material or complex analysis of content. 8Aligning TikTok material with curriculum content and specific learning outcomes increases the likelihood that content will be of value to students. 2While pre-existing subject knowledge can increase utility of TikToks as short-form revision material, assumption of prior knowledge should be avoided to promote accessibility to a wider pool of learners. 11kTok duration should be balanced between maintaining brevity and conciseness of topic coverage with relaxed pacing of page transition to allow students to appreciate each element of the storyboard without overwhelming intrinsic load. 13This translates to 5-10 s for each page depending on the amount of page material.TikToks can be paused and learner pace-controlled; hence, clear divisions between Note: Integrating Mayer's principles with the elements of cognitive load theory. 10,11ages and dividing content into subsections can be beneficial to allow breaks between pages if required.13 Maintaining consistent design principles over a topic or series including colour schemes, background music, layout and font increase the coherency of design and reduce distractors, increasing clarity, associations between and within topics and knowledge retention (Figure 4).14 Maintaining consistent design principles over a topic … increase the coherency of design and reduce distractors.

Simultaneous presentation of visual and audio features and
highlighting of content with arrows, graphics and colours create highyield outcome-focussed content, avoiding extraneous material and promoting student engagement. 8When using narrative, a relaxed tone spoken in a human voice, avoiding instructor images, increases accessibility and relatability of material and avoids unnecessary intrinsic load. 10regular publishing schedule and frequent publishing will encourage student engagement and retention to access future educational content. 8Clear titles, attention-grabbing thumbnails and instant presentation of high-yield material within the first 3 s of TikTok content consistently receive the highest viewing figures. 6The first slide of educational TikToks should therefore outline the topic and identify learning outcomes, to ensure instant clarity for students that desired learning is being accessed, increasing engagement and retention throughout the content. 8

| Producing TikToks
TikToks can be recorded and edited within the TikTok app; however, dedicated TikTok editing software on external platforms offers the best opportunity for high-yield educational content design. 5There are a range of platforms available.Canva has a variety of TikTok templates and offers in-site graphics, fonts and freehand drawing options and the ability to upload external material, useful for clinical signs, radiographic imaging or basic science diagrams. 15Such platforms allow the easy organisation of content and repeatability of templates, fonts and animation, promoting the consistency and familiarity that will engage students over multiple TikTok videos.Uploading to TikTok then allows titling and captioning of videos, including links to further reading content and adding hashtags to make content searchable within the platform, increasing the reach of educational material to the wider userbase. 8vigating external TikTok building websites requires time and practice, to increase familiarity with building videos and identifying a style and theme of educational content accessible to students and appropriate for the topic. 14Evaluation and feedback are essential for this; testing content on focus groups can identify limitations in design or technological issues that reduce the educational benefit of videos. 9its of current and future contents can then incorporate suggestions and increase the utility of material to students.Gaining feedback from a range of assessors including students, colleagues and nonclinical individuals will offer the most diverse insights on both educational content and aesthetic elements. 2With content widely available on the platform, helpful critiques from external viewers may allow further amendments to future content and allow viewers to suggest ideas for or request future content. 9

| OPPORTUNITIES AND CHALLENGES
With increasing cultural digitalisation, social media platforms such as TikTok increase student engagement and promote interactivity and peer collaboration, improving knowledge retention and learning outcomes. 13TikTok can offer an easily accessible route for patients to share their own experiences, offering valuable learning of the patient journey and promoting the development of communication skills. 13allenges remain-unfamiliarity with the platform, and time and research required to design and create educational TikToks considering the components of efficacious multimedia design may impact the practicality and feasibility of implementation. 8A structured approach to design contextualised within overall learning outcomes and objectives, directed by student feedback, will streamline production with sequential videos and offer a long-lasting educational tool accessible to a wide range of current and future learners using the TikTok platform. 9Developing educational TikToks may reduce the future burden on educators to produce revision resources when teaching the same content to multiple student cohorts and allow refining of the design and direction of subsequent content. 5Other issues including ensuring patient confidentiality on publicly accessible apps such as TikTok and awareness of copyright issues when using clinical or radiographic material are other essential components of successful and ethical use of the platform. 9With our own use of TikTok, appreciating the underlying pedagogy allowed us to summarise the key elements we should integrate within the design to maximise educational benefits.Thus, investing time to become familiar with editing software meant once the first video was produced, subsequent videos within the same series could be made with the same templates and design concepts, streamlining production and editing time.In the long term, increased use of TikTok as an educational platform will increase educator familiarity and available resources on TikTok design and allow assessment of the benefits on student learning and assessment outcomes. 8th increasing cultural digitalisation, social media platforms such as TikTok increase student engagement, promote interactivity, and peer collaboration.

| CONCLUSIONS
TikTok offers a fresh opportunity for teachers to engage with the digital zeitgeist of upcoming student cohorts and use a popular and efficacious tool within their teaching. 13TikToks allow active 'microlearning' directed by student needs that can be simultaneously tailored to specific teaching contexts but useful to a wide pool of learners on the TikTok platform. 8Effective design based on the pedagogical principles of educational multimedia and cognitive load theory can offer invaluable engagement and retention benefits, improving accessibility of and enjoyment from learning. 8Many online tools are available to aid educators in TikTok production and design, offering a range of design choices and elements. 14Exploration of these tools will allow educators to trial and test designs within their specific teaching context, with ongoing evaluation and student feedback streamlining future production.Increasing use of TikTok by educators will increase awareness and understanding of the tool and its potential educational benefits, offering opportunities for future research, support and funding in producing and implementing within structured medical teaching curricula. 5We propose a 'Toolbox' based on our own experiences and research, to support educators to integrate TikTok into their educational practice and gain the maximum potential benefits from this novel teaching tool (Table 2).
TikTok offers a fresh opportunity for teachers to engage with the digital zeitgeist of upcoming student cohorts.

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I G U R E 2 Mayer's three foundational principles of multimedia learning.10F I G U R E 3 Principles of cognitive load theory.11T A B L E 1 Mayer's principles and cognitive load theory.