stairsLast week, we launched season 3 of the ALiEM MEdIC series and it sure took off! The Case of the FOAM Promotion brought together learners, teachers, and colleagues from across many disciplines to discuss promotion and the conversation nicely evolved to include a discussion of life goals and self-evaluation. We are now proud to present to you the Curated Community Commentary and our 2 expert opinions. Thank-you again to all our experts and participants for contributing again this week to the ALiEM MEdIC series.

As always, we post the expert responses and a curated commentary derived from the community responses one week after the case was published. This time we are fortunate enough to have three experts to kick of season 3:

  • 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 the NHS Change Day website 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.
[su_spoiler title=”Expert Response 1: Dr. Damian Roland” style=”fancy” icon=”chevron”]

UnknownWhile there is a great deal of debate about the value of the Free Open Access Meducation (FOAM) movement, or the use of new educational methodologies, the majority of users of Social Media are not dependant on it for their careers. Health care practitioners are either delivering care, managing those that deliver care, educating those that will deliver care or researching care to make it better. Producing open access education in your own time or participating in twitter journal clubs has traditionally been a continuing medical education add on.

Until now…..

Chris’s dilemma is very real, but in the big scheme of academia, an only recently emerging problem. There are very few “Professors” of FOAM akin to Simon Carley, Michelle Lin, Chris Nickson or Scott Weingart etc. A note to the editor: it appears Mike Cadogan has already been granted the title of Grandfather of FOAM so he is the Professor Emeritus. There is certainly, as far as I am aware, no one with a paid academic tenure in online educational methodologies in Emergency Medicine and Critical care.

This is really an evidence-free zone and I can only speak from experience, although I suspect I am one of the few clinicians who has FOAM mentioned in their job plan:

To collaborate with the education team to disseminate high quality educational materials, particularly with a view to gaining a national profile for FOAM (Free Open Access Meducation) resources

It is with this in mind that I offer the following advice; aware that is it probably no more valid or relevant than anyone else’s!

My answer to the first question is neither. Chris should continue his focus on FOAM, but the trick is not to label Social Media as Social Media. He needs to present #FOAMed material as nothing more fancy than ‘education’. FOAM is an educational ethos which, in my opinion, is more of a social movement than a new educational methodology and #FOAMed is simply a way to identify a particular form of knowledge mobilization in a very crowded field. The dissonance between what is perceived as traditional education and newer educational opportunities via social media has not been helpful for learners or teachers. One important method of bringing educators together is recognising effective use of social media is no different than effective use of ‘traditional’ medical education approaches [1]

“Is that the FOAM stuff?” asked John is both a blessing and a curse. The blessing I will discuss shortly but the challenge Chris has here is that he is seen as doing something different. In fact, in the context of delivering education as an act of pedagogy, he probably isn’t. He needs to get the word around that he is producing and curating high quality education rather than distributing FOAM. I appreciate this sounds like a step back but I believe in stealth and guerrilla change rather than warfare. Patience is an uncomfortable but powerful ally. My advice is to dispel myths at source:

Yes John. I really enjoy the FOAM stuff. But it is just education with a different name you know. It is taking off in a big way though. Did you know that as a result of my last teaching session, which I recorded as a podcast, I have been invited to do a talk at a local conference?! I have also had a few requests from outside the area from residents keen to work here…”

The truth is that he will probably have to do both FOAM and ‘traditional’ work. The sacrifice many of those embracing the FOAM movement face, especially those in academic tracks, is that you have to deliver, for a period, content for social media, content for your students and content for publication. This can become exceptionally draining if continued over a long period of time. Attention to work-life balance is a must.

But why a blessing to be charged with the FOAM brush? Well there is an implicit assumption that you are the expert. You need to play on this. When I started as a consultant in my institution I went around the department offering to do ‘vodcasts’ with my colleagues (examples include one on leadership  and one on compassion). Not everyone took me up on this of course, but I had conducted a few interviews which were fun to make and helped spread the word about FOAM within the department. Additionally, this project provided a nice message to hospital management that our team was working together to create innovative educational tools. Collaboration is key to FOAM and its delivery is very clear evidence of being able to bring people together.

Finally, metrics other than simple hits and downloads aren’t easy. My approach has in part been to:

  1. Highlight where social media can add value to organizations who haven’t traditionally used it. Here is a webpage from our University following a recent event on Measurement for Improvement. I have a small story embedded there. It doesn’t have many hits but it has gotten good feedback. It enables the course organizers to say they are using different methods of engagement. Again, stealth and guerilla change rather than warfare…
  2. Use traditional approaches but on Social Media itself. Teresa Chan, Brent Thoma, Seth Trueger etc have all been successful at converting their social media knowledge into academic publications. In fact one particular paper recently identified criteria for social media based scholarship. So it is certainly possible to have an evidence based mechanism for judging the quality of your work!

I would also thoroughly recommend this great blog from Daniel Cabrera on how altmetrics are increasingly becoming a relevant academic impact system.

To have FOAM recognized as a relevant endeavour is going to take perseverance and hard work. Academic scholarship is hard – there is no easy route to promotion.


  1. Roland D, Brazil V. Top 10 ways to reconcile social media and ‘traditional’ education in emergency care. Emerg Med J. 2015 Aug 7. PMID 26253148. pii: emermed-2015-205024. doi: 10.1136/emermed-2015-205024
[/su_spoiler] [su_spoiler title=”Expert Response 2: Dr. Daniel Cabrera” style=”fancy” icon=”chevron”]

Resistance is futile, but patience is recommended. New Media and new metrics. 

ibQE1ZavNvzHoNx1Miwd11beuMxBL01Ic7QXU6LGRdg,NqsYgW_UAPjWp10sDdKBfqqvHL5o3yW0StaE-_bdK_gThis is a very timely topic, but as a disclaimer, most of the following discussion is matter of opinion, as the subject of new media and metrics has only scratched the surface of the academic complex and has focused exclusively in the equivalence of these benchmarks. This emphasis in homologation may be delaying the advent of robust socially-based milestones for career development.

Chris’ case rings utterly true for many of us living in a time of profound conflict between traditional academia and modern academia, where media and metrics are rapidly changing.

Most institutions around the world base promotion criteria and career appointment on the excellence and quality of the scholarly work of their faculty and in a smaller extent on their clinical and didactic activities; they aim to reward the impact of faculty in scientific, public and educational domains. This framework is constructed in the use of traditional metrics, mostly very indirect surrogates of the actual outcomes; classic examples are the Thomson Reuters Science Citation Index for publications, raw number of pedagogical hours delivered or actual numbers of patients seen at any given time. Evidently, these benchmarks are far from completely representative, but until recently, we haven’t had other parameters to evaluate.

The advent of social networks and distributed open platforms has created a small explosion of academic and educational content in the digital world; the fact you are reading this is a good example of it. Many healthcare professionals have embraced the potential of an open access and peer-reviewed realm to create and provide state-of-the-art didactic material. Slowly, but consistently, the quality and the impact of this open content is improving and making a dent in real world clinical application; creating a new culture of educators, or digital faculty, who now have expectations of similar advancement as their colleagues who contribute towards more traditional avenues of academia.

Currently, most academic centers either do not or just marginally recognize digital social activity as a criteria for promotion, leading to conflict among faculty who believe that their achievement in social media is meritorious and often more pragmatic and practice-changing than publishing a mediocre paper in an obscure journal.

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) he’s done?

I think the answer is, for the time being, to do both. Faculty interested or passionate in digital media academics are probably better off trying to kill two birds with one stone; this advice is echoed by most champions of FOAM. I’m fairly confident the P&T committees for most academic institutions will reward digital activity sooner than later, but for the foreseeable future, the creation of single content with diversified distribution (traditional and new media) is probably the best strategy. If you’re preparing a lecture for your residents or medical students, try to turn it into a blog post or infographic for your social home base; if you are writing a paper, you may want to do a podcast about it. The concept is to create content and to disseminate it in various forms to reach the greatest numbers of readers/listeners.

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 uncharted territory and the “all hands on deck” approach is probably a good idea. The main advice for scholars looking into a promotion based heavily on alternative media is to be sure that their application is extremely well crafted and documented. Faculty looking to go this route should seek advice from senior faculty who are friendly to the concept of FOAM/social media. Additionally, it is also very important to ask for guidance from national faculty involved and invested in the concept, examples such as the CORD EM Social Media Committee members, the International Clinician Educator Network or the faculty writing for ALiEM are all excellent resources. The beauty of social media collaboration is that it allows for great interaction with academics around the world! These people can be your advocates or even letter writers in your applications process. In other words, your tweeps can become your faculty mentors and sponsors in your real life academic career.

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

This is probably the holy grail of social media based promotion. First, as a word of advice for beginners in the digital academics world, be sure to activate and enable all possible analytics and metrics in your platforms (Google Analytics, WordPress JetPack, Twitter Analytics, etc.) as these will become your currency. Currently there is no standardized or universal metric for social media impact.  It’s likely, however, that metric standardization will be dependent on the context of the academic center, size of the specialty and particular niche; for example a cardiologist from a large US medical center posting about cutting edge invasive angiographic techniques (large academic center, large specialty, large topic) should not be compared with the activity of a nuclear medicine physician, in a smaller sized center, in an emerging country discussing the spin characteristics of cesium (small specialty, small academic center and very niche topic).

A composite index including social activity (Twitter, Facebook, Reddit, etc.) plus page views for the source, plus layperson activity (news websites, journals), plus downloads of material and adjusted to a reasonable peer review group is the most appropriate answer; Something like the Altmetric score for journal articles. The metric described does not exist, so my advise for Chris would be to share his raw analytic data (page views, Twitter impressions, podcast downloads) with the P&T committee and to try to obtain some benchmarks from the more conspicuous websites in his field of expertise to argue for impact in his domain.

Academic promotions and career development based heavily on social media activity and metrics is a herculean task right now, as most P&T committees base their recommendations on traditional impact metrics.  The irruption of alternative metrics, however, is creating awareness about the need to develop a more comprehensive dashboard of evaluation and reward, including not only social media but also new parameters such as quality, innovation and management, to name a few. With the right guidance, advice and sponsorship from senior figures invested in the concept and with extremely well documented metrics for impact, the paradigm can change. Resistance is futile. Eventually the walls will fall down, we just need to wait.

References and suggested reading

[/su_spoiler] [su_spoiler title=”Expert Response 3: Dr. Bryan Judge” style=”fancy” icon=”chevron”]

Bryan JudgeAs Chair of the College of Human Medicine’s Reappointment, Promotion, and Tenure Committee at Michigan State University, I appreciate Chris’s enthusiasm for seeking academic promotion. Promotion is essential for a faculty member’s professional development, can provide him with academic currency and self-satisfaction, and helps strengthen his department. This is my advice to Chris to help him better understand the expectations for promotion and navigate the road to a successful promotion.

Before initiating the promotion process, Chris should update his CV. It is essential to note that a CV, while an important part of the promotion process, only reflects the quantity of Chris’s work, not the quality. To demonstrate the quality of his work, Chris shoulddevelop an academic portfolio. The academic portfolio typically contains materials that substantiate achievement in the following areas: awards and grants, institutional services, instruction, invited lectures, media presentations, patient care, peer review activities, publications (abstracts, bulletins, monographs, online publications, peer-reviewed publications, textbooks, and chapters), and research.

Once he has developed a CV and an academic portfolio, Chris should review the university promotion criteria. He should choose a mentor to work with; one who has successfully obtained a promotion is ideal. Once he has familiarized himself with the promotion application form, he should review this form with both his mentor and a supervisor, such as the department chair. Together, they should identify areas of concern and discuss strategies for addressing these. In Chris’s situation, one area of concern is that his FOAM projects, while innovative, lack some elements of scholarship.

Scholarship, as defined by Boyer [1] comprises four separate but overlapping components: discovery, integration, application, and teaching. Chris’s FOAM projects fall under the scholarship of teaching heading. Shulman [2] states that to separate scholarly teaching from scholarship, one’s work must meet these criteria: the work must be publicized; the work must undergo peer review and critique; and the work must be reproducible and built on by other scholars. In Chris’s case, his FOAM work has been publicized, but it has not undergone peer review, and he would need to demonstrate that his work is reproducible and built upon by other scholars for it to quality as scholarship.

So in summary, I agree with Chris’ mentor that he is not ready for academic promotion yet. I would recommend that he begin his journey to promotion by reading a short article on Boyer’s expanded definitions of scholarship [3]. Finally, he needs to turn his FOAM work into scholarship as defined by Boyer [1] and Shulman [2] and continue adding to his academic portfolio to position himself for a successful promotion in the future.


  1. Boyer EL. Scholarship Reconsidered: Priorities of the Professoriate. Princeton, NJ: Carnegie Foundation for the Advancement of Teaching, 1990.
  2. Shulman L. The Scholarship of Teaching. Change 1999;31:11.
  3. Glassick, CE. Boyer’s Expanded Definitions of Scholarship, the Standards for Assessing Scholarship, and the Elusiveness of the Scholarship of Teaching. Acad Med 2000;75:877.
[/su_spoiler] [su_spoiler title=”Community Commentary: Dr. S. Luckett-Gatopoulos” style=”fancy” icon=”chevron”]

This case focussed on the role of non-traditional, social media-based activity in determining readiness (and worthiness!) for promotion within an academic institution.  Out of this discussion regarding the use of free open access medical education (FOAM) materials for the pursuit of academic promotion arose three major concerns.

The first theme that was voiced by participants was the role of the promotions committee in its evaluation of evolving avenues for scholarship. Dr. Loice Swisher quite rightly pointed out that ‘…technology is here to stay’ and she suggested that promotion and tenure ‘committees are going to have [to] become educated and develop criteria for the online resources.’ Dr. Daniel Cabrera agreed that, ultimately, ‘the media does not matter’ when it comes to academic scholarship, and that quality and impact are what is most important in determining merit; he admits that quality and impact in the digital world are moving targets that require on-going research and development to appreciate. Craig, a critical care/trauma nurse and educator, has found that his promotion board is ‘pretty open to non-traditional things’, but that he has to be able to demonstrate impact.

The second theme discussed by participants was the role of FOAM enthusiasts in furthering the cause within their own institutions. Dr. Swisher suggested that those invested in FOAM may need to pursue membership in promotion and tenure committees as an avenue to advocating for scholars who publish primarily on social media. Emergency department pharmacist Nadia Awad suggested that FOAM enthusiasts should ‘demonstrate to folks on [promotion and tenure] committees the opportunities that arise as a result of our involvement through media in ways that more traditional members of [these] committees can understand and appreciate’. She emphasised the ‘traditional’ scholarship activities that are often facilitated via FOAM involvement, including collaborations on traditional papers, and speaking opportunities.

As Dr. Cabrera and Craig both highlighted, FOAM enthusiasts must work to make less-traditional avenues of scholarship better accepted. Demonstrating impact and quality are important, but Nadia Awad reminded the group that ‘folks on [promotion and tenure] committees may be more receptive to accepting [FOAM] materials as scholarly activity if hey go through the peer review process’.

The third major concern discussed was the pathway FOAM enthusiasts tread when pursuing promotion. Initial groundwork was earmarked as centrally important. Dr. Rahul Patwari suggested that FOAMites pursuing promotion ‘start with the most progressive person on the [promotion and tenure] committee and ask [for] their perspective on how they would interpret…FOAM contributions’. Another suggestion Dr. Patwari offers is seeking out advice from trailblazer colleagues, perhaps at other institutions, who have already achieved promotion or tenure; how they convinced their promotions committees may provide direction.

Dr. Patwari suggested preparing to apply for promotion by mapping established promotions criteria to FOAM contributions. He suggests that an applicant ‘can follow the [rules of the promotion committee] to the letter, but with non-traditional materials’. Analytics showing worldwide views, comments, and other metrics can help establish impact and importance. Craig described preparing with a portfolio including measurable responses to his non-traditional scholarship, including numbers of staff and patients affected by his efforts. He has found that this concrete preparation has facilitated an acceptance of his achievements by his promotions committee.

FOAM enthusiasts may need to consider whether academic promotion is actually important to them; both Dr. Michelle Gibson and Dr. Nadim Lalani pointed out that promotion is not a priority for every educator!

List of Participants

  • Loice Swisher
  • Daniel Cabrera
  • Rahul Patwari
  • Eve Purdy
  • Teresa Chan
  • Craig, CEN, CCRN
  • Nadia Awad
  • Nadim Lalani
  • Michelle Gibson

 PDF for the case available here.

Featured Image from Pixabay

Eve Purdy, BHSc MD

Eve Purdy, BHSc MD

Queen's University in Kingston, Ontario, Canada
Student editor at
Founder of