Should social media accomplishments be recognized by academia

In August, I posted this: "A paper of mine was published. Did anyone read it?"

A recent comment on it raised an interesting point. Dr. Christian Sinclair [@ctsinclair] said that a website he is helping to run called "Pallimed" has received almost 2 million views since 2005.

He then made the following calculation:

Two million views with an average of 1:30 minutes on a page = 3 million minutes = 50,000 hours = 2,083 days = 5.7 years of 24/7/365 informal learning on hospice and palliative care topics.

He said that this type of communication counts for nothing regarding academic advancement and added that writing another paper and having it published in a journal no one reads or a chapter in an expensive book no one will buy is considered worthwhile.

This reminded me of something I have talked about in recent presentations. The first laparoscopic cholecystectomy done in the United States took place in 1988. The procedure rapidly became popular due to its obvious benefits over traditional open surgery—smaller scars, shorter hospitalizations, quicker returns to normal activity.

Many academic surgeons considered the procedure radical and heretical. Opinion pieces appeared with titles like "Laparoscopic cholecystectomy: Passing fancy or legitimate treatment option?" and "Laparoscopic cholecystectomy: A new milestone or a dangerous innovation?"

Nearly all of the early adopters were community hospital surgeons who also became instructors, ran courses, and proctored others learning the procedure.

Academic surgeons were slow to take up the procedure because even back in those days they steadfastly demanded to see the results of a randomized prospective trial. The problem was that an adequately powered trial never occurred. Patients did so well after laparoscopy surgery that it became difficult to recruit anyone who would agree to be randomized.

Will most academic surgeons, who have not embraced social media, miss the boat again?

Last year, some Australians, blogging at the Intensive Care Network, found that the number needed to treat stated in a New England Journal paper on targeted vs. universal decolonization to prevent ICU infection was wrong. They blogged about it and contacted the lead author who acknowledged the error within 11 days. It took the journal 5 months to make the correction online.

Post-publication peer review is already happening on PubMed and PubPeer, a new site that allows anyone to comment on any paper.

Three years ago, I wrote "Statistical vs. Clinical Significance: They Are Not the Same," which reviewed a paper on sleep apnea. The use of compression stockings at night significantly lowered the number of apnea episodes but not enough to enable them to stop using CPAP.

That post has received over 13,400 page views, certainly far exceeding the number of people who have read my 97 peer-reviewed papers, case reports, review articles, book chapters, editorials, and letters to journal editors.

How many scientific papers published in journals have been viewed by that many people?

Since I started 4 years ago, the 565 posts on my blog have amassed 1.1 million page views, but if I still held a teaching appointment at a medical school, I would get no academic credit for that level of exposure.

Is it time to reconsider how academic promotions are determined?

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That electric hand dryer study was bogus Heres why

Just about everyone I follow on Twitter commented and/or linked to an article about a study claiming that electric hand dryers spew bacteria all over people using restrooms.

The paper, which appeared online in The Journal of Hospital Infection, said that airborne germ counts near jet air dryers were 27 times higher than counts near paper towel dispensers, and counts near warm air dryers were 4.5 times higher. The authors also coated subjects hands with black paint and measured spatter patterns on surrounding walls and persons dressed in disposable coveralls. And a photo from the study shows the dispersal pattern from a warm air dryer.

So case closed—paper towels are better, right?

Im not so sure. Instead of reading an article about the paper or just the abstract, I obtained a copy of the whole paper. I also found some comments about it from a spokesperson for a hand dryer manufacturer.

What are the flaws in the study?


From the papers Methods section: "For each test, gloved hands [not bare hands] were first coated by immersion in a suspension of lactobacilli (107 cfu/mL) that were cultured from a proprietary yoghurt." FYI, 107 cfu/mL is a lot of bacteria—certainly more than most of us would get on our hands during an average trip to the restroom. Its the equivalent of putting your hands in liquid feces, except that lactobacilli are benign bugs.

After dipping the gloved hands in bacteria, they werent washed. Stick gloved hands in bacteria, dont wash them, and then stick them in an electric dryer. No doubt there will be dispersal of bacteria around the room.

Also from the Methods section: "For [another] test, gloved hands were coated in a solution of black water-based paint." Water-based paint on gloves is not the same as water on bare hands. Have you ever seen water all over the walls next to a warm air dryer? I havent.

The study was funded by the European Tissue Symposium (ETS). Although this sounds like some kind of scientific conference, it is actually a trade organization of companies that make paper towels. The senior author of the study, Dr. M.H. Wilcox, "has received honoraria from ETS for microbiological advice and travel expenses to attend an ETS meeting." He also co-authored a consensus statement sponsored by the ETS which happened to find that paper towels are the most hygienic way to try hands.

I have always preferred paper towels. I feel that my hands can be completely dried in far less time than when I use the electric dryers. The drying process helps to reduce bacterial counts on the hands. Some studies have shown that when using electric dryers, many people do not completely dry their hands because it takes too long. See the table below.

A 2012 review of hand drying methods from the Mayo Clinic Proceedings concluded that paper towels were better than electric dryers from a hygiene standpoint, and that paper towels should be used in hospitals. [Note: One of the authors of that study had been a consultant to a paper towel manufacturer.] Thats why you dont see electric hand dryers in patient care areas of hospitals.

I also hate the noise generated by electric dryers and the faster they are, the noisier they are. You can see the decibel levels of several devices in the table above.

The paper towels vs. electric hand dryers debate has been going on for years not only about hygiene, but also about which method is better ecologically.

Although I dont believe a word of the much-tweeted European Tissue Symposium study, I still prefer paper towels.

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Should resident promotion decisions be based on a written exam

A few days ago, some surgeons on Twitter discussed the role of the American Board of Surgery In-Training Examination, a test which is given every year in January.

The test was designed to assess residents knowledge and give them an idea of where their studying should be focused. However, many general surgery program directors (PDs) use the test results in other ways. Some impose remediation programs on residents with low scores and even base resident promotion or retention on them. Some even demand that all residents in their programs maintain scores above the 50th percentile.

The Residency Review Committee (RRC) for Surgery frowns upon these practices and states in its program requirements (Section V.A.2.e) that residents knowledge should be monitored "by use of a formal exam such as the American Board of Surgery In Training Examination (ABSITE) or other cognitive exams. Test results should not be the sole criterion of resident knowledge, and should not be used as the sole criterion for promotion to a subsequent PG [postgraduate year] level."

The problem for program directors is that the RRC also mandates (Section V.C.2.c) that "as one measure of evaluating program effectiveness" 65% of a residency programs graduates must pass both the American Board of Surgerys Qualifying Examination (written) and Certifying Examination (oral) on their first attempts. I have said before that the "65% on the first attempt rule" does not seem evidence-based.

Does performance on the ABSITE predict performance on the boards examinations?

A recent paper by the staff of the American Board of Surgery states, "Although the ABSITE does not have a direct effect on board certification, it has been shown to be predictive of ABS Qualifying Examination performance." The authors cited three references.

The best is a 2010 Archives of Surgery paper that analyzed 607 graduates of 17 programs from the western US. It found "On multivariable analysis, scoring below the 35th percentile on the ABSITE at any time during residency was associated with an increased risk of failing both examinations (odds ratio, 0.23 [95% confidence interval, 0.08-0.68] for the qualifying examination and 0.35 [0.20-0.61] for the certifying examination)."

Note: The boards paper found that ABSITE scores do not correlate with passing the certifying (oral) exam. This makes sense because the oral exam is more about judgment and situational thinking than recall of facts.

A systematic review of 26 papers, published online in the Journal of Surgical Education, showed that "Structured reading programs and setting clear expectations with mandatory remedial programs were consistently effective in improving ABSITE performance, whereas the effect of didactic teaching conferences and problem-based learning groups was mixed."

However, its not so simple. Structured reading and mandatory remedial programs will only work if the deficient resident is committed to succeeding, an attitude that is not always present. [See "grit."]

A brilliant post of mine from two years ago pointed out that program size has a lot to do with being able to maintain a better than 65% board passage rate on the first attempt. Using a simple statistical fact, I explained why smaller programs may be much more likely to fail to meet the 65% standard.

A resident who, despite attempts at remediation, has single digit ABSITE percentile scores over two or three years creates a serious dilemma for the director of a small program. Should the PD keep the resident in the program which can ill afford to graduate a resident with a high risk of failure on the written board examination or dismiss the resident and try to find a competent replacement from a very small pool of available candidates?

Having been there, I can tell you its not an easy decision.

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Reaction to post on academia and social media

"Should social media accomplishments be recognized by academia?" a post of mine from October 4th, generated some lively discussion on Twitter.

Here are a few of the more interesting responses:

@ashishkjha Important question from @Skepticscalpel Should academia value impact on social media? Yes. And its coming. Slowly.

@MartinSGaynor Science comes 1st, 2nd, 3rd.. MT @ashishkjha Important Q: @Skepticscalpel Shld academia value impact on social media?

@ashishkjha agree how to measure impact a key question. Eye balls cant be enough. But too important a question to ignore.

?@DoctorTennyson Yes-I think social media has a role for #publichealth, #education, and fosters collaboration. More than obscure journals

@NirajGusani still you add value to your dept -how do/should they measure it?

?@gorskon Heck, at @ScienceBasedMed, we get 1M page views a month, but I get no credit.

@gorskon I agree though. For the most part, social media harms, not helps, academic career.

@gorskon Cranks complaining to my chair & cancer center director dont help.

@gorskon If I ever want to change jobs, Google searches will likely harm, not help, prospects

@Nadia_EMPharmD We actually asked this very question in a study we published this past year:

?@JBMatthews Academic tracks have been modernized in many places including ours; beyond # of publcns.

@JBMatthews As a journal editor and department chair, I believe its starting to "count"

?@nataliestavas We should study what has more meaningful impact, # of twitter followers or an article in the @NEJM

Most agreed that social media activity should count for something, but quantifying that something may be difficult. A certain number of followers or page views would not necessarily signify value.

Via email, Dr. Jeffrey B. Matthews, Dallas B. Phemister Professor and Chairman of the Department of Surgery at the University of Chicago, said his school of medicine created a new track for faculty that does not require traditional scholarship for academic promotion. It is non-tenure (tenure still requires traditional discovery and traditional measures of impact and importance), but there is otherwise no distinction of title.

To advance to professor requires evidence that the faculty member is outstanding. The chair and faculty committee must define what "outstanding" means, whether it is distinction in clinical practice like a high-volume, high-complexity specialty or a national draw of patients, in educational leadership such as a program director with leadership roles at APDS, ABS, RRC, or "other."

He added, "I would have ZERO trouble convincing our promotions committee that a high visibility blog with high traffic views that had evidence of thought leadership in the public domain would qualify as high impact and outstanding. And that is at the University of Chicago."

What do you think of the University of Chicagos progressive stance?

Have any other schools taken such steps?

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