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MEdIC Series | The Case of the FOAM Promotion


AcademiaWelcome back to season 3 of the ALiEM MEdIC series! The MEdIC team (Brent Thoma, Sarah Luckett-Gatopoulos, Tamara McColl, Eve Purdy, and Teresa Chan) are very excited to kick off the ‘school year’ again with another online discussion within the ALiEM Medical Education in Cases series.

Join us now to discuss the case of the FOAM (Free Open Access Meducation) promotion wherein Chris, the assistant professor, finds himself reflecting about whether he should incorporate his online and FOAM works into his promotions package.

MEdIC Series: The Concept

Inspired by the Harvard Business Review Cases and initially led by Dr. Teresa Chan (@TChanMD) and Dr. Brent Thoma (@Brent_Thoma), the Medical Education In Cases (MEdIC) series puts difficult medical education cases under a microscope. On the fourth Friday of the month, we pose a challenging hypothetical dilemma, moderate a discussion on potential approaches, and recruit medical education experts to provide “Gold Standard” responses. Cases and responses are be made available for download in PDF format – feel free to use them! If you’re a medical educator with a pedagogical problem, we want to get you a MEdIC. Send us your most difficult dilemmas (guidelines) and help the rest of us bring our teaching to the next level.

The Case of the FOAM promotion

by Anand Swaminathan (@EMSwami)

It was the end of another long overnight shift, and Chris was feeling good after successfully resuscitating a patient with septic shock patient and another with a gunshot wound to the chest. Sign-out was wrapping up. Looking up from his pile of completed charting, Chris noticed that his colleague and mentor Dr. John Siu was walking up towards him.

“Hey, Chris. I have a meeting in an hour, but want to grab a post-shift bite before you go home? John was one of the faculty members and had been a mentor to Chris throughout his first few years of being an attending. John was also on the university Promotion and Tenure (P&T) committee, and Chris has been thinking a lot about advancing his faculty career recently.

“Sure, why not.” Chris responds.

Walking over to the hospital café, the pair chatted and caught up about life, family, and their recent vacations. However, as they sat down, Chris stirred up the courage to chat about a dilemma that was weighing on his mind.

“So… John, I’ve been thinking a lot about getting my application together for promotion to Associate Professor. Can I pick your brain a bit?”

“Of course. Always happy to help. What have you done so far?”

“Well, I’ve been keeping my CV updated and I think it’s filling up nicely. My concern is that a lot of what I’ve worked on is non-traditional from the university’s perspective. I’ve been very active in resident- and medical student-education, and I’ve had the opportunity to publish a few peer-reviewed publications. I’m also on the hospital sepsis care committee, so that means I’m displaying some clinical involvement. Most of my non-clinical work, however, has been spent on a number of free open access medical education projects…”

“Is that the FOAM stuff?” asked John. “I’ve been noticing a lot of your stuff popping up everywhere! It seems you really enjoy it, no?”

Chris nodded. Chris had been relatively productive online and written a bunch of blog posts. He’d also participated in a couple of podcasts. More recently, he’d taken on an editorial role on a major FOAM website.

“Clearly, you’ve been busy with everything you’ve been doing but I’m not sure this is going to be enough for the P&T committee to move you up,” stated John, furrowing his brow. “It’s not that your work has not been fantastic and impactful, but our P&T committee… Well, they’re pretty old school in their perspective, and I think they’re going to want more of the standard publications and research. The truth is, I don’t know if anyone has gone up before the committee since these non-traditional forms of scholarship have been around so I don’t know how they’re going to respond.

Breakfast is served, and Chris mulled over what John was saying. Frankly, he was a bit discouraged, but as a rather disruptive and enthusiastic guy, Chris wasn’t afraid to fight an uphill battle. Chris reflected that perhaps promotion might not be daunting as John anticipated. John had no idea how his work would be received because it was quite different from the work that other people had previously done. Moreover, as there was no precedent at his institution, it did appear that he needed to think about how best to represent his work to the committee since there was no obvious pre-packaged way to present FOAM for the P&T committee.


Key Questions

  1. Given the lack of precedent with using FOAM for promotion in his institution, where should Chris go to get further advice on putting his application together?
  2. What metrics can Chris use to show his P&T committee the impact of the work he has done?
  3. Should Chris put the focus on his work in FOAM or direct attention in his promotion packet towards the traditional work (journal publications, clinical teaching, hospital committee participation) that he’s done?

Weekly Wrap Up

As always, we posted the expert responses and a curated commentary derived from the community responses one week after the case was published. This time the two experts were:

  • Damian Roland (@Damian_Roland) – Pediatric Emergency Medicine staff physician at the University Hospitals of Leicester NHS Trust. He has a special research interest in quality and process improvement, Identification of serious illness in children and medical education evaluation. Have a look at his blog and reflect on “what I learned this week” (#WILTW)!  Dr. Roland also encourages readers to check out and “pledge to do something better together”!
  • Daniel Cabrera (@cabreraERDR)- Consultant in Emergency Medicine at the Mayo Clinic in Rochester, MN, where he has been since 2005. A native of Chile, he obtained his medical degree from Pontificia Universidad Catolica de Chile where he was also part of an experimental training program in EM. He then completed an Emergency Medicine residency at Mayo Clinic. He holds the academic rank of Assistant Professor of Emergency Medicine. He is the editor- in-chief for the Mayo Clinic EM Blog and is the co-director of Mayo Hootsuite Healthcare in Social Media course. His academic interests include knowledge management, clinical decision-making, graduate education, orphan diseases, and Open Knowledge.
  • Bryan Judge – Attending emergency physician and Program Director of the Grand Rapids Michigan Emergency Medicine program. He is also the Chair of his local University P&T Committee.

On October 2, 2015 we will post the Expert Responses and Curated Community Commentary for the Case of the Backroom Blunder.  After that date, you may continue to comment below, but your commentary will no longer be integrated into the curated commentary which was released on October 2, 2015.  That said, we’d love to hear from you, so please comment below!

All characters in this case are fictitious. Any resemblance to real persons, living or dead, is purely coincidental. Also, as always, we will generate a curated community commentary based on your participation below and on Twitter. We will try to attribute names, but if you choose to comment anonymously, you will be referred to as your pseudonym in our writing.

Teresa Chan, MD
ALiEM Associate Editor
Emergency Physician, Hamilton
Assistant Professor, McMaster University
Ontario, Canada + Teresa Chan
  • Loice Swisher

    The case is written as an attending level issue, however, I am currently running into this issue with residents that have to do a scholarly project. I’ve been questioned on whether a blog publication would count? How about if it is peer reviewed?

    Technology is here to stay so it is likely that the P&T committees are going to have become educated and develop criteria for the online resources. People are going to have to take it to the committees and hear/share the responses.
    So- how to go about it.
    Perhaps seek out others who are on this path and have this interest. Ask about their experience and advice.
    Rob Rogers on Technology’s Potential for Promotion in Academic Emergency Medicine

    Look for those who are outside medicine for comparison-
    Citations are not enough? Academic promotions panels must take into account a scholar’s presence in the popular media.

    Highlight those that are peer reviewed and enduring medical education materials. If possible show the number of hits/reach of this material.
    This is blazing a new trail. Perhaps some that believe in this new path will have make it a priority to get on the P&T committee to give voice to the changes that are happening. Am looking forward to others thoughts as I struggle to navigate this path too.


    • cabreraerdr

      I think the principles that apply to promotions and tenure also apply for scholarship. I think program directors value and reward quality of the scholarly work and impact. I don’t think in the US the ACGME/RRC is very specific about what constitutes scholarly work and its rest heavily on the purview of the program director.
      In the scholarly project is of great quality and has impact, the media does not matter. The following issues are how to judge quality and impact; in terms of quality there are people working on this (Tomah, Lin, etc) and in terms of impact I believe probably regular metrics, with explanatory background, are a good way to show perspective.

      • I think that the MedEdLIFE research collaborative (lead by Thoma, Lin et al) have done on this area are probably very important to point out – as they help the P&T committees better understand impact and quality.

        Here are a few choice papers may be useful:

        1. Brent Thoma, Teresa M Chan, Natalie Desouza,
        Michelle Lin. Implementing peer review at an emergency medicine blog: bridging the gap between educators and clinical experts. Can J Emerg Med. 17(2):188-191. DOI: 10.2310/8000.2014.141393. PMID: 25927262

        2. Brent Thoma, Rohit Mohindra, Jennifer Artz, Teresa
        M. Chan. CJEM and the changing landscape of medical education and knowledge translation. Can J Emerg Med. 17(2):184-187. DOI: 10.1017/cem.2015.16 .

        3. Thoma B, Sanders JL, Lin M, Paterson QS, Steeg J, Chan TM. The Social Media Index: Measuring the impact of emergency medicine and critical care websites. Western Journal of Emergency Medicine, 0(0). DOI: . Published March 17, 2015. Retrieved from:

        4. Thoma B, Chan TM, Paterson QP, Milne K, Sanders JL & Lin M. Emergency Medicine and Critical Care Blogs and Podcasts: Establishing an International Consensus on Quality. Annals of Emergency Medicine. 66(4) 396-402. Available at:

        5. Lin, M., Thoma, B., Trueger, N. S., Ankel, F.,
        Sherbino, J., & Chan, T. (2015). Quality indicators for blogs and
        podcasts used in medical education: modified Delphi consensus recommendations
        by an international cohort of health professions educators. Postgraduate
        Medical Journal, Online First.

        Some other papers that also may be helpful:

        1. Hillman T, Sherbino J. Postgrad Med J 2015;91:544-545 Published Online First: 3 September 2015doi:10.1136/postgradmedj-2015-133686
        Available at:

        2. Jonathan Sherbino, Vineet M Arora, Elaine Van Melle, Robert Rogers, Jason R Frank, Eric S Holmboe. Criteria for social media-based scholarship in health professions education. Postgrad Med J 2015;91:551-555 Published Online First: 14 August 2015doi:10.1136/postgradmedj-2015-133300

        3. Leslie Flynn, Alirez Jalali, Katherine A. Moreau. Learning theory and its applicaiton to use of social media in medical education. Postgrad Med J. 2014; 91:445-560. oi:10.1136/postgradmedj-2015-133358

        4. Ian Pereira, Anne Marie Cunningham, Katherine Moreau, Jonathan Sherbino, Alireza Jalali. Thou shalt not tweet unprofessionally: an appreciative inquiry into the professional use of social media. Postgrad Med J 2015;91:561-564 Published Online First: 20 August 2015 doi:10.1136/postgradmedj-2015-133353

  • Rahul Patwari

    For further advice, I’d start with the most progressive person on the P&T committee and ask their perspective on how they would interpret his FOAM contributions. Is this potentially viable or will it not fly at all? Additionally, he can approach trail blazers at other institutions asking how they convinced their promotions committees. (Speaking of which… what did people do?)

    But first, I’d say, he should prepare by mapping the promotions criteria to all his FOAM contributions. He can follow their rules to the letter, but with non-traditional materials. As for metrics, perhaps FOAM analytics (showing worldwide impact, number of learners, # views or comments = peers who reviewed, and comments = impact on others).

    Though ultimately he may have to use a hybrid of contributions, hedging his bets with traditional mixed with the novel, giving the P&T committee time get used to the new media.

    • Eve Purdy

      Thanks Rahul for sharing. How do you suggest he do the map? Word document, info graphic 😉 ?

      • It sounds like this committee is pretty traditional, so go with what they are already familiar: Word. Or if you can find a typewriter… Or papyrus…

        • cabreraerdr

          Or even stone

  • Craig, CEN, CCRN

    This is an issue that hits a lot of us.
    When presenting to the board for promotion at the VA they are pretty open to non traditional things, but I have to be able to show impact. I was fortunate that I was prepared for this and had been developing a portfolio that included measurable responses.
    My focus is not producing content but curating and having access to it as needed. An updated version of” just in time” education.
    The thing that helps me is when I do presentations I make sure that although I have the disclaimer visible, I make sure people know I’m from the VA and that I’m making the organization look good.
    So I'[m presenting things with a measureable response and making the organization look good. I’ve been surprised when presented right, how open the establishment has been to non traditional.

    • Eve Purdy

      What measurable responses do you include?

      • Craig, CEN, CCRN

        At my level it’s pretty simple. # of staff affected, and when I can, patients affected. I also “curate” some study guides for nurses taking specialty certifications. My portfolio has them listed “Curated 325 online sites in a format accruable to nurses studying for specialty certification, at this time 235 nurses have achieved their goal” or similar. Most of what I’m doing is internal, although now I’m moving more outside the building.

        In my case it’s non competitive so as long as I can show benefit to staff and organization, I get credit.

  • Thank you for putting together this case for the MedIC series.

    While I do think it is essential to illustrate the importance of our work in the world of #FOAMed through the methods described in previous comments, it is also equally, if not more important, to demonstrate to folks on P & T committees the opportunities that arise as a result of our involvement through these media in ways that more traditional members of P & T committees can understand and appreciate. Many of us have been fortunate enough to engage in ‘traditional’ activities of scholarship that most members of P & T committees value due to our involvement in #FOAMed, such as collaborations on papers with (inter)national colleagues and speaking opportunities at academic and scientific conferences that would not have been otherwise possible without the work put forth through #FOAMed.

    In addition, the value of the peer-review process, whether pre- or post-publication of #FOAMed material, should not be underestimated; rather, as a community, this is one area where great strides can be made, especially when presenting our work to P & T committees. This is one area that we can improve upon, especially as the world of #FOAMed has grown and evolved over the past few years. Creators of #FOAMed resources may require any one of a number of methods for conducting peer review to meet the needs of both those composing the resource and those who may access the resource, but having an official process for this may not only enhance the accuracy and quality of the resource, but will also present the medium in such a way that members of P & T committees can relate to, as some may point out that this is an area that divides educational material presented via #FOAMed (e.g. blogs and podcasts) from traditional print publications (yes, even if there are some of the opinion that there are flaws inherent in the peer review process with the latter). Folks on P & T committees may be more receptive to accepting these materials as scholarly activity if it goes through the peer review process (Cocchio C, Awad NI. The Scholarly Merit of Social Media Use Among Clinical Faculty. Journal of Pharmacy Technology 2014 Apr; 30(2):61-68.)

    Two resources that may be helpful for those going through the process:

    1 – Guidelines for Evaluating Work in Digital Humanities and Digital Media put forth by the Committee of Information Technology of the Modern Language Association Executive Council:

    2 – The Digital Scholar: How Technology is Transforming Scholarly Practice by Martin Weller (full access to the book available below for free via Bloomsbury Collections):

    Thank you,

    • Thank you so much for your advice here Nadia! You truly are a trailblazer, and I think a lot of your materials will be helpful to all of this materials!

    • cabreraerdr

      Excellent resources

  • 1. Given the lack of precedent with using FOAM for promotion in his institution, where should
    Chris go to get further advice on putting his application together?

    This is tough one. If people work at an institution where “FOAM work” isn’t appreciated it’s going to be tough to use FOAM involvement to get promoted. Obviously, I think work in the FOAM world is a billion times more impactful than writing a traditional journal article, but what I think doesn’t matter. What matters is what the Professor of Microbiology who sits on the P&T committee thinks. If the committee really only looks at peer-reviewed journal articles in the promotion process then that’s where the focus should be when contemplating a promotion and when preparing an advancement packet. Now, what many P&T committees are now starting to pay attention to is metrics. These can be blog, podcast, or website metrics. And these folks want numbers. They want details. And frequently they need an explanation of what it means when you say your blog has 10,000 hits a day. Anyone going to a P&T committee for promotion must know the rules of their institution. If people work in an institution where this kind of involvement isn’t valued then maybe it’s time to consider changing institutions. Just saying. Talk to people who have been promoted. How did they do it? The other important point to bring up is the “FOAM alignment principle.” Ok, I just made that up, but it sounds kind of important right? What I mean by this is can you align your FOAM work with what the P&T committee wants and looks for (rule #1: know the rules)? Can you tie in blog posts to writing a short piece for a peer-reviewed journal? Can you create a video post for a journal’s online journal? (e.g. Academic Emergency Medicine journal). Have you given presentations (national and even international) on your FOAM work? In other words, you can creatively use FOAM involvement to tie in to your institutions P&T committee’s promotion requirements. But you have to know the rules and you have to plan. If you want more thoughts on this just email me.

    2. What metrics can Chris use to show his P&T committee the impact of the work he has done?

    These days it’s pretty easy to show blog and podcast metrics. This is precisely the reason I tell people that if they are going to “dive into FOAM” and make it their highway to promotion they need to make sure the sites they use have robust analytics. WordPress, for example, can generate maps of the world that demonstrate what countries people view your blog from. Colorful maps with data may very well be able to persuade the P&T committee. Maybe. Slowly but surely P&T committees will come around and realize the impact is greater than writing a stupid journal article that no one reads!

    3. Should Chris put the focus on his work in FOAM or direct attention in his promotion packet towards the traditional work (journal publications, clinical teaching, hospital committee
    participation) that he’s done?

    The most important thing about getting promoted is to know WHAT the P&T committee looks for. You have to know the rules of your institution. I am a big believer that life is short, too short to stay at an institution that doesn’t value your work in the “global classroom.” If your work isn’t valued, you may very well want to consider working in a place that does value you. Plenty of these places exist. Believe me. If you are truly dedicated to FOAM and making a difference in the world of medical education, you may need to consider a change of venue. Some institutions just don’t get it and likely won’t for the foreseeable future.

    Keep FOAMing and never give up!
    As Mel Herbert always says, “what you do matters!”

    Rob Rogers

    • These are great insights on how to cross over your talents to what the P&T committee wants/needs. Thanks for sharing Rob!

  • Nadim Lalani

    Very topical read. thanks

    I am usually not so negative, but hope that I can save a ‘clinician-educator-life’ or two so this is important for me to share.

    Before you even answer these Q’s I would invite readers and colleagues to ask why trying to ascend in their organisation is important to them? What does it give you? If it’s for external rewards then I would invite you to consider that it may not ever be something that you can control or influence.

    e.g. … I know of a standout clinician educator colleague that – due to the fact that there is no academic department of his own – has an appointment in another department. He has never been promoted despite exceeding ‘traditional’ criteria for years. It has been disheartening to watch him submit his CV every year knowing that he’s never going to get promoted until he has his own academic department.

    We are at risk of false promises that if you do ‘x, y and z’ you’ll get promoted when this is definitely not the case – due to politics or other organisational issues.

    Clinician educators are burning out at an alarming rate – part of this has to do with trying to ascend in a culture that may not reward our efforts. So before you even get on this difficult journey please pause and reflect. If you chose to move on – do so knowing the stakes and why you’re doing this.

    Please take a moment to read these insightful blog pieces



    • Great points Nadim. Thanks for sharing your thoughts!

    • Michelle Gibson

      You just said what I was about to say!. I am (thus far) lucky enough to not have external pressure to apply to be promoted (unexpected bonus of my odd academic appointment). So, I haven’t tried. it’s also hugely time-consuming, and at this point in my life, I like what I do, and I want to see my child grow up, and I’m not sure that promotion fits into either of those worlds. I feel appreciated by those I work with, and the students (why I really do the job), so for now, it’s enough. A good clinician-researcher friend told me years ago that if I didn’t need to get on the treadmill, then I should think twice about stepping on it voluntarily.

      I should be clear- I know of good clinician educators at my institution who have been promoted based on their education work. it’s just not at all a priority for me, and I’m at peace with that … for as long as that is allowed to be the case. 🙂