As a third-year resident in emergency medicine, Brent Thoma was falling behind. The results of his annual exam showed that he lacked knowledge in basic areas of the specialty when compared with his cohorts across Canada. His program director at the University of Saskatchewan wanted to know: What did he plan to do about it? “Maybe I’ll start writing one of those blogs,” Thoma recounts replying in a 2015 article for International Review of Psychiatry, “Personal reflections on exploring social media in medicine.” “I’ll call it ‘BoringEM!’”
That was just over five years ago. Today, Thoma is an assistant professor at Saskatchewan, interim director of the university’s emergency medicine program, and co-author of dozens of articles published in scholarly journals. Meanwhile, BoringEM (named for the “less exciting” EM topics Thoma felt he needed to get a better handle on) is still going strong, only now it’s called CanadiEM. It has a robust editorial staff, a physician advisory board, and a wide menu of educational resources, including critical appraisal of research, creative syntheses of new standard-of-care guidelines, and posts that address common clinical dilemmas in the emergency department—when must you take a stool sample from a child with diarrhea? How can you safely administer defibrillation without interrupting chest compressions? Thoma says CanadiEM is on track to garner 1.2 million page views this year.
Both Thoma and CanadiEM are leaders in a movement called FOAM, or FOAMed: free open access medical education. The term refers to any free educational material about medicine on the Internet, and includes thousands of online resources: blogs, podcasts, videos—even Wikipedia might count as FOAM. It allows anyone to publicly weigh in on new research or share their clinical wisdom, and makes reams of information available to an audience that may never have otherwise had access to it. To some extent, FOAM is disrupting the nature and hierarchy of medical education, a change that people find both exciting and worrisome.
And then there was FOAM
The name FOAM was coined at the International Conference for Emergency Medicine in 2012, when a small group of like-minded doctors—including Mike Cadogan, (founder (in 2007) of the Australia-based EM website “Life in the Fast Lane” (LITFL)—found themselves commiserating about the “negative connotations of the term ‘Social Media’ in the laggardly minds of practicing physicians.” Cadogan later wrote that because the venue for the ICME conference was Dublin, “the answer was naturally to be found at the bottom of a pint of Guinness.” That’s where the acronym FOAM “bubbled into existence,” Cadogan wrote.
Emergency doctors were among the earliest adopters and producers of FOAM, and Thoma credits Cadogan in particular with helping to nurture a community among them. Teresa Chan, assistant professor in emergency medicine at McMaster and Thoma’s co-editor at CanadiEM, also thinks demographics played a part in how FOAM developed. “For various reasons, emergency medicine has decided this is their jam,” she says. “We’re a younger specialty, we’re a newer specialty. We have probably more millennial physicians than most other specialties because the need has just sprung up in the last two decades.”
But FOAM is not the exclusive domain of emergency doctors. There are educational blogs and podcasts in many other specialties, and several that deal with more general questions—The Rounds Table on this website is one example—though they may not always formally call themselves FOAM.
What counts as FOAM?
As far as Chan is concerned, “FOAM exists when someone learns from it.” Theoretically, if true learning is to happen, the lesson must be valid, and both Chan and Thoma have researched how to evaluate the quality of a specific FOAM resource, developing checklists that include measures for accuracy of content and credibility of sources. Social media often gets grouped with blogs in discussions about FOAM, but Thoma tends to see Twitter and the like more as vehicles for disseminating FOAM than as a place to have “a detailed and in-depth discussion.” Though sometimes the line is blurry. Chan points at a recent 22-tweet thread posted by an emergency doctor at the University of Washington challenging current thinking about cognitive bias, and surmises that it does probably qualify as FOAM. It includes citations, it’s disseminated, and people can critique it, she points out. “[It] meets a lot of the criteria.”
Increasingly, more traditional learning institutions are working with FOAM. The advisory board of Emergency Medicine Cases includes several faculty members from the University of Toronto and the website receives support from the Schwartz/Reisman Emergency Centre at Mount Sinai Hospital in Toronto. The British Medical Journal recently introduced the “Rapid Recommendations” series, partnering with a non-profit app developer to produce visually pleasing and fun-to-navigate interactive infographics that explain new, clinically relevant research.
The speed of FOAM
One of the most touted advantages of FOAM is its ability to tighten the “knowledge translation gap” in medicine, which refers to the time it takes for research to be adopted in clinical practice. An oft-cited study from 2011 found that, on average, that gap is 17 years. The process, says Thoma, involves “taking new information, figuring out where it fits in the literature, and figuring out whether it should change practice.”
Pre-FOAM, says Thoma, physicians learned about new research by reading journal articles, attending conferences, and conferring with colleagues. But “the amount of medical literature being published in a year, even in a small sub-area, is just astounding,” says Thoma. “To keep up on every possible study can be very, very difficult.” A 2004 study that asked “How much effort is needed to keep up with the literature relevant for primary care?” found the answer to be “351 hours per month or 2 full-time equivalents of physician effort.”
Today if there’s a landmark study, word gets out much faster and can spread much further, says Thoma. For example, in 2013, the New England Journal of Medicine published research that challenged a long-held post-cardiac arrest protocol known as targeted temperature management, or TTM. “Within a week, there were more than 10 blog posts and podcasts doing critical appraisals and discussing it,” says Thoma. “If you were on Twitter or social media or using any of these [FOAM] resources, you couldn’t avoid hearing about this study. And not only the study, but people with expertise in methodology writing about it, talking about it, talking about how it was going to impact their practice.”
In 2015, after the American Heart Association released its new five-year guidelines, CanadiEM (still BoringEM back then) built a series of infographics highlighting the top five changes in different areas of treatment, such as CPR and basic life support. Thoma says he saw Facebook groups where people had shared the resources 15 or 20,000 times; someone he met at a conference in Southeast Asia told Thoma he’d been sent the material via WhatsApp. “You can’t even measure how much dissemination that was,” says Thoma. “It brought a lot of attention to the changes in those guidelines very, very quickly, in a way that just the written statement doesn’t quite do.”
Thoma and Chan also see FOAM as a venue for holding research accountable. “It’s democratized science,” says Chan. “The people who are making the headlines in the NEJM—there are a lot more eyes on them. It used to be that you would have to do it old-school—find the error, write a letter, an editor or two would look it over, you’d get a reply. That would be the speed at which we could discourse about science. Now if you do something people will call you out on it that day.”
Finding the “good” FOAM
A recent Twitter poll asked: “How do you feel about the possibility that younger doctors could be persuaded by social media/blogs over peer-reviewed journals?” The results: 55 percent “terrified,” and 45 percent “reassured.” Even among FOAM users and contributors there is concern about “finding FOAM and not froth,” as Heather Murray, emergency doctor and associate professor at Queen’s, titled a recent CJEM editorial. Peter Cameron, former president of the International Federation for Emergency Medicine and a Twitter user himself, has written about the risk of “fake news” infiltrating medical education as well as the ongoing importance of careful, credible research preceding any change to clinical practice. “The traditional process of peer review publication is slow,” Cameron wrote in an email to Healthy Debate. “But there aren’t many advances in science that should be rushed into.”
Websites like CanadiEM and Academic Life in Emergency Medicine (ALiEM) have their own peer-review processes for the blogs and podcasts they publish. But Chan points out that quality filters must exist at every level—not least the level of the original research. “When things are inaccurate at the source material, that’s when we’re all screwed, and it has nothing to do with FOAM,” she says. Indeed, concern about conflict of interest in the creation and dissemination of evidence has been growing over the past two decades, says Murray, who contributes to ALiEM’s “Medical Education in Cases” (MEdiC) series. “There’s been this call about re-defining and taking another look at evidence based-medicine,” she says.
Murray thinks FOAM is at its best when tackling aspects of medicine that often don’t get taught, such as the so-called “soft skills” of the MEdiC series—dealing with a discriminatory patient, for example, or the pressure to promote your accomplishments on social media. But she worries about FOAM being used for bedside decision-making. “The freedom of FOAM is that you can have a good idea, put it out there, and see what happens,” she says. “The downside is anyone can do that, and with good graphics and a decent platform, they can look compelling… If we take examples outside of medicine, the trolls are there, the charlatans are there. There are lots of examples of Web-based hoaxes, and so I am not entirely sure why medicine would be immune to that.”
What medicine ultimately wants, she says, is “immediately accessible, valid, unbiased evidence that is available at the bedside to answer point of care questions.” For the time being, she sees FOAM as an adjunct to formal medical education. “I think there is no substitute for the one-to-one clinical mentoring apprenticeship model of medical education. And I still think there’s a role for a traditional curriculum that identifies a body of knowledge that is deemed to be essential, and delivers it. But we can improve on that too. So we’re kind of in this weird half-and-half world.”
Correction: The story has been updated to reflect that Brent Thoma was not at the ICEM conference in Dublin in 2012.