FOAM, a deontological ethos

Michael Jasumback, arch-Devil’s Advocate of FOAM (see More on SMACC 2013), is back. He sent us this essay, in pure violation of the recommendation not to drink and write, and it would be remiss of it not to share it with the world.

Disclosure, I’ve had a drink.

FOAM (#FOAMed on Twitter) is one of the most powerful forces in medical education to come around, probably since Osler and Flexner. As such it behooves both the provider and end user to share an ethos. This essay will attempt to describe what such an ethos might look like.

One of the tenets of scientific inquiry is that a truth is reproducible. This may, in fact be the defining characteristic of science. Medicine is a science, with a reasonably poor track record for reproducibility, but nonetheless, we practitioners claim it is a science and it is from this perspective that we approach the world. This becomes the very foundation of our discussion. If we claim that medicine is a science, then our work should be, in some way, reproducible. Applying this concept to FOAM, we hope that our teaching is based on science that is reproducible. Leading us to the first proposition of the ethics of FOAM.

1. Prescriptive statements in FOAM should always be based upon truth.

What does this mean? Providers of  FOAM should be held to a high standard of truth. When stating that something is fact, or must be done, or “is the standard of care” there should be a large body of literature supporting such a statement and some nod must be made by the provider to this literature. In the interest of style, this may not be in the particular podcast, blog, tweet or other social media device used, but a reference should be easily available.

A second tenet that we might adhere to is that of fallibility. We have all heard and used the old saw “Half of what you were taught in medical school was wrong”. This quite probably applies to FOAM as well. We would be exhibiting significant hubris to think that only now, have we gotten things right. I suspect that in 30 years, the old saw will remain true, perhaps modified to read “Half of what you learned from  FOAM was wrong”.

Leading directly to the second proposition of the ethics of FOAM.

2. Providers of  FOAM should humbly accept that their information may be incorrect.

This might lead to the a third proposition rather directly when one considers the nature of social media and FOAM. That proposition might read something like,

3. Providers of  FOAM should be willing to stand corrected.

Correction might come from various directions, further studies might be done, studies that the  FOAM provider was unaware of might be uncovered, or logical arguments that disprove a claim might be developed. FOAM should not be a one way street, provider to end user. There must be a feedback loop, statements should and must be disproven on occasion. While reproducibility may be a tenet of science, Popper would suggest that disprovability is also a fundamental characteristic of science. So it should be with FOAM. My vision of  FOAM is that it should exist as a Hegelian dialectic. The abstract (however sure we are of it) must be considered flawed and the negative be considered. Then and only then might we come to the concrete that ultimately will become the new abstract. In more popular terms, thesis, antithesis and synthesis. Leading to the fourth proposition of the ethos of FOAM.

4.  FOAM must come with a mechanism for feedback.

One of the pitfalls of social media is that those who participate, tend to agree. That is, users and providers of FOAM often share similar perspectives and it is natural to gravitate towards individuals who share the same opinions and perspective. A risk that derives from this is that little disagreement will occur. This leads to stagnation of thought. The synthesis fails to become the new thesis and no progress may be made.

An example might be useful here.

I subscribe to multiple podcasts. One of the podcasts is moderated by one of the great educators in Emergency Medicine. This moderator has a particular niche in which he is regarded as THE authority. Few would have the temerity to challenge him in this niche. Unfortunately this moderator cannot stick only to his niche or he would soon run out of topics to discuss. On occasion this moderator strays from his niche into areas where he is less expert. He remains a great educator, but his expertise is somewhat lessened outside of his niche. On occasion, even he makes an error. Therein lies the problem. A recognized expert makes an error yet his authority is so profound that few exist who would challenge him. In fact a “cult of personality” exists, such that, even if one were to challenge him, one would be drowned out by cries of “how could you challenge this expert”. This crowd would be full of those who share his opinions and perspective, or are willing to subjugate their own to his expertise. A more classic fallacy of “reference to authority” could not be found.

Leading to a fifth proposition, related to the second, third and fourth.

5. Providers of  FOAM should seek perspectives or opinions that contradict their own.

This is perhaps the toughest of the propositions. Who wants to be challenged, discredited or disproven? Yet for our purposes we must seek this conflict. No progress can be made when one is certain that a certain perspective is the only correct one. This is especially challenging when one considers that often the best teachers are the ones most sure of their standing. Anyone who lectures will realize this immediately. When you are the master of your material, your skill at presenting it is recognized and the more likely you are to be regarded as correct. The more certain you are of a particular truth, the more powerful your presentation of it. And the harder you are to challenge. Religious and political leaders are made of such stuff.

An honest provider of  FOAM will recognize that they are not expert in all things. Given the massive amount of information available it is nigh on impossible to be an expert with full knowledge of even the smallest of subjects. For a provider of FOAM to be successful, they must embrace a diversity of topics, even those they are not expert upon. It is in this endeavor that the biggest challenge comes. Admitting your level of expertise might not be as high as your audience. This is especially true when offering opinions on those areas where you are not a renowned expert. Leading to what might be the most important of the propositions.

6. Opinions expressed by purveyors of FOAM, must be labeled as such.

Certainly many providers of  FOAM may be more expert than many of the consumers of FOAM in many areas, but however expert, opinion is opinion. And fallible. We would do well to remember the words of the great humorist Dennis Miller, “That’s just my opinion, I could be wrong”.

What of consumers of FOAM? While the principles of  FOAM suggest that the consumer is also the purveyor by way of response and interaction, what propositions of ethos apply to the consumer of FOAM?

I would suggest that the consumer of  FOAM be held to similar propositions that the purveyor, namely:

1. Prescriptive statements should always be based, as much as possible on truth.
2. Consumers of  FOAM must accept that the information provided might be incorrect
3. Consumers of  FOAM should be willing to correct and be corrected
4. Consumers of  FOAM must be willing to provide feedback
5. Consumers of  FOAM should seek perspectives or opinions that contradict their own
6. Opinions expressed by consumers of  FOAM should be labeled as such.

It is my belief that  FOAM is a thinly veiled attempt to achieve truth in medicine. I believe that adherence to these propositions is in keeping with our oath as providers of medical care to “first do no harm”, and will lead us rapidly to the most accurate, useful information available to help us with caring for our fellow man.

Of course, that’s just my opinion, I could be wrong.

Michael A. Jasumback, MD, FACEP

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Comments

  1. says

    Brilliant words, beer or no beer!
    We must be more transparent than the status quo of journal based and peer review (not difficult) and we must encourage and invite, and then accept and publicise comment, criticism and discussion in order to make this FOAM idea the best it can be. One cannot be an expert in everything, and recognising the limits of one’s knowledge and knowing where to go to extend it are cetral to being a FOAM educator, or indeed any educator or practitioner in medicine.

  2. says

    I agree- brilliant words indeed

    Reading this- a few things struck me. First- I am going to be more careful about using terms like “standard of care” or stating facts. While I haven’t done this a lot, I have done it in my own podcast. We do need to be careful about throwing around those terms

    I should also do a better job of providing references myself. There is a danger of the end-user accepting what is heard as fact just because you pop up in a google search, you are among “top medicine podcasts” in iTunes, etc. It can be a royal pain to start tracking down references of things that you know inherently as fact because they have been drilled into your head but I agree that you owe it to your end-user to do this.

    While your point about labeling opinions as such is a good one- I believe that most FOAM producers do a good job of doing this already. However, we should encourage these kind of disclosures and the first step to doing that is recognizing it as important. One of my biggest fears (especially this being my first year out of residency) is putting out incorrect information or strongly advocating for something that is my opinion and passing it off as something more.

    Finally- I want to echo the call for end-user feedback, correction of errors, and an overall conversation about what is produced. If you use FOAM- give feedback- PLEASE! Using my podcast as an example, I know from my download stats that there are a few thousand users that have downloaded at least 2 episodes of my podcast. Even though I have a few thousand end-users that can be counted as regular “subscribers” I average less than 1 email a week commenting on the show.

    Nothing would make me happier than to see my inbox full each morning with listeners who want to start a conversation about the topics I talked about or even correct errors that they have found. After 33 episodes I have yet to get an email pointing out a major error. I have no hubris on this whatsoever- I am sure that I have broadcasted errors but no one has called me on it. Are we hesitant to correct FOAM producers just because it is free and we feel bad for criticizing someone who is putting their time into a product that is done without compensation? Granted, I focus on “the basics” and stray away from the cutting edge controversies but after 33 episodes I must have screwed up somewhere- so call me out on it! Please!

    Great post and great conversation to get started. I look forward to where we can take this to the betterment of the FOAM producers AND FOAM end-users

    Steve
    EM Basic Podcast

  3. Manrique Umana says

    Ok, heard enough about FOAM, but what can it be said about FOAMed???
    Bad joking aside, I think we all live and die by those principals. The main reason most of us became involved in FOAM is to learn, to learn to teach and to interact actively with people that think like us and understand what we go through.
    So viva la FOAM(ed)!!!

  4. David Cheatham, MD MPH says

    Sorry Michael, you had me until you brought up Osler and Flexner. Seriously, FOAM is “one of the most powerful forces” since Osler/Flexner? So the last 100-years of medicine and medical education have been what, nothing, until it was suddenly discovered over a few pints of really crappy Irish brew? The only thing FOAM is at the moment is a bunch of people beating on their chests proclaiming something that already exists as being the ‘best thing ever.’ So far it’s hubris and nothing more, unless you account for the creepy avatars of folks hoisting a LiTFL mug.

    The breaking point of any online venture is always going to be one’s ability to take criticism. It’s brought down real online communities everywhere, and even here, in the nascent stage, there seems a general unwillingness to accept that FOAM (despite it being, quite frankly, the online equivalent of the mythical unicorn, or Acme Widget) might be all hat and no cattle. While I understand why people want it to be successful, and why people of a certain age want to feel like they’re reinventing the wheel or discovering fire, the shameless self promotion going on around a movement with no apparent roadmap to anywhere is off putting to the vast majority who sit on the fringes.

    • says

      Hi David,

      Though I think you well over-stepped the mark when you started denigrating Guinness, you have a point about the lack of a road map.

      Indeed working towards a road map, and encouraging people to talk about where this is all heading, is really what the introduction of the term FOAM is all about.

      The online content that is FOAM is not new, people have been using social media and free online resources for years now. But it is still just in its infancy and well short of its potential. Trying to pull all these like-minded people under a collaborative umbrella is difficult and nearly all non-FOAM using doctors run a mile when they hear the words ‘social media’. We hope that this recent ‘chest beating’ about FOAM helps stimulates discussion, further collaboration and leads to a road map of where all our time and efforts are heading.

      FOAM is not just LITFL, and is not about LITFL. We are fierce proponents of it and are having a lot of fun with in it, including taking the p!ss out of ourselves (or me taking it out of Mike -- hence the creepy Cadogan FOAM ‘Obama Hope’ iconography -- http://lifeinthefastlane.com/2012/09/need-hope-get-foamed/). One only needs to glimpse at Twitter to see that other people are talking about FOAM too and making it their own (http://www.symplur.com/healthcare-hashtags/foamed/), not to mention the growing number of blogposts on the subject (http://lifeinthefastlane.com/foam/).

      Your main criticism seems to be that we are engaged in “shameless self-promotion about a movement with no apparent road map”. What we are doing is trying to generate discussion and work towards this road map… if you have a better way I for one am all ears. Criticism, if it is constructive, is something we welcome. We believe in this stuff, but it is only early days yet. We spend untold hours creating these free resources and we want them to help as many people as possible in whatever way possible. I think we are entitled to shout from the rooftops so that people can hear us from time to time.

      As for criticizing a movement for not having achieved anything, well we have to start somewhere… and the beginning is a good place. The more people get involved in using, creating and discussing free online educational resources, the more likely we are to achieve something.

      David, I hope you continue to take part in ongoing discussions about FOAM, and are able in some way to participate at SMACC 2013 (http://lifeinthefastlane.com/2012/09/smacc-downunder/) -- either online or in person.

      Cheers,
      Chris

  5. John Dyett says

    Dear David,

    I am very glad you have stepped from the fringes into the cold light of the FOAM sun -- your opinion is valued! You have really highlighted the importance of FOAM by illustrating to the online medical education community how critical it is to get involved. FOAM is surely the most incredible, open forum for medical peer review since the journals starting publishing.

    As an example, I regret that I was never invited by The Lancet to comment on the IST-3 trial -- my conclusions certainly would not have agreed with the journal’s editorial staff! I do however appreciate the existence of FOAM and my ability to publish this letter highlights the power of our peer review process. Kind regards to all #FOAMed devotees!

  6. Minh Le Cong says

    hi there! Mike , you have an open invitation to record a podcast on my blog about this. Feel free to bring your own drinks to the session!

    You raise some great points as does David.
    Whilst any writing, creation of media, is a form of self promotion I feel the need to ground the debate into what I find as the most useful aspect of FOAMEd

    There is no way that without FOAMEd I would ever have discovered or met such professionals as Dr Weingart, Dr Orman, Dr Maini, Dr Herbert etcetc. I would never have had the opportunity to learn such concepts that have improved and continue to improve by daily clinical work.

    To me FOAMed is another way of disseminating medical information and having clinical debate about controversy and practice issues. Its not the only way but it allows me to use my time effectively. I fly to remote places and during these flights when otherwise I would have been playing sudoku, I now learn via podcasts ,free and subscription.

    Corridor and tea room consultations are part of professional discourse and teaching..with FOAMed they now become virtual places and asynchronous.

    I am all for having minimum standards and moderation of online learning. there should be feedback systems, declaration of conflicts, all the usual things that we would expect with traditional medical media.

    When something is free and open access it will always be viewed with some degree of cynicism and suspiscion. The greatest trick to attract paying students to a medical training course is increase the course fee..it works every time as psychologically people expect the more you pay the better it must be!

    But really what is this all for? Should it not be to improve patient care and safety? and one of the ways to do this is to improve information flow in a critical manner that encourages debate.
    Cliff Reid cites peer review material all the time and my site tries to do this as much as I can. But here is the rub..some things are beyond current research and evidence base..which is why having rigourous debate and discourse online allows us to progress our views on areas of controversy.

    The FOAMEd community allows these discussions to occur and this is good, in my opinion.

    I know of at least three cAses where a surgical airway was successfully performed by doctors who had felt more confident after learning and reviewing the teachings on this on Emcrit.org

    I put it to you that there is more to it than just information sharing..there is a community that inspires people to excellence.

  7. Richard van der Kleyn says

    True like all science/medicine you read/hear/get told you must always check it out yourself, how much medicine gets passed down from professor to student without any scientific basis. So the statements about FOAM hold true about any education media, be it text books, courses, congresses or POAM ( paid online acces meducation…yep just coined a new phrase) or FOAM, you must always be critical. Untill now there has been little feed back on podcasts, blogs etc but thanks to social media/twitter it is slowly starting….for example (even if it wasn´t about education) a post on trauma.org last night was being discussed wuithin 30 min on twitter….discussion is healty, needs to be incouraged and any good educator will be open to it.

    As for a road map, I see FOAM as 2 tierd: (referring to EM) For the countries lucky enougth to have EM residencies and a high level of EM speciality: they partake in FOAM to help educate there own residents and open up discussion and yes inspire to excellence, but also to be educators for the 70 % of countries that have no formal EM residency/education program. I myself live and work in such a country (Spain), where up untill now we have to largely self educate ourselves in emergency medicine, and this is where FOAM can be of great usefullness, as the internet allows a 2 way discussion which you can never have with a text book. Unfortunatly aswell most doctors arn´t as higely paid as our other western counterparts and can´t afford to go to endless congresses or pay for courses, but thanks to FOAM I have access to many of these resources free of charge when I need it….and if FOAM can help a western European Doc better himself and ultimatly provide better care for his patients, imagen what it can do to change medical education in the developing world…… online residency programs in the future? for developing nations.

    So yes FOAM has a future, there will be teething problems, there will be critsism, from big pharma which will see its influence waining, from doctors who may see a source of lucrative income dissapearing, from anyone who doasn´t like change. But FOAM has been out there for years…the ship has already sailed and its up to us the users and educators to give it direction and yes, make sure there are life boats onboard and hazard warning signs for the untrained and new users.

  8. says

    This commentary reaffirms my appreciation for an open, free, and receptive medical community -- which is what I see FOAM propagate continuously and I thank many of those who have already well articulated key points.

    I’m merely a medical student so I have no expertise in medical education, clinical medicine (or really much of anything). However, over the past four years, I’ve been using podcasts to aid in learning clinical information and integrating the pathophysiology of a disease or treatment with a global patient-oriented picture. Then, a year ago, I began using blogs to supplement my seemingly insatiable quest for information. Simultaneously, I attended school lectures where professors rarely received feedback and even more infrequently admitted to any sort of error or fallibility in the substance of the lecture. For me, however, FOAM coalesced in the Spring when many of the sources began interacting with one another.
    I began seeing dialogue on many of these pieces of free medical education that I used for years. On Twitter, residents and physicians alike would appraise journal articles, blog, media, etc. I realized that FOAM had cultivated (and continues to cultivate) within me a spirit of evaluating what I read/here/see because: (1) if I’m going to choose a lecture over my favorite band at the gym…it better be pretty awesome (2) I saw others critically appraise items (ex: EMLitofNote and SMART EM). Sure, the appraisal is often positive and supportive in the FOAM community but I also saw substantive, constructive feedback. Conversations and collaborations happened regarding lectures (which were happening around the world). I vividly remember the first piece of feedback I received regarding my blog (unknown to the world and written solely for myself and a few personal EM interested students). LITFL’s Chris Nickson left a comment, directing me to another source of medical education -- incredibly helpful. This only aided my learning! Then, I recall the first piece of feedback I nervously posted on Twitter regarding use of passive leg raise for fluid status. I sweated profusely when I hit submit…me, a mere student, criticizing (constructively) a few points from a lecture from a well-known doctor. However, the FOAM community is detached enough that I felt comfortable giving feedback. Many PHARM podcast conversations/debates on items from central lines sites to benzos serve as an example of FOAM’s own natural response to feedback -- nearly immediate and global.
    I have a cornucopia of anecdotes regarding feedback I’ve seen given and received, but I only anticipate that this will grow and improve. As an end-user, I know I should provide more feedback. However, as any clinical educator will say -- feedback can be extremely tough to give. meaningful feedback even more so! As a student, I feel I always get inadequate feedback -- even in the real-life clinical setting, where I’m paying thousands of dollars to receive such.

    Most importantly, my patients and attendings evaluate FOAM on a daily basis when I am able to employ skills, perspective, and knowledge I learned via FOAM in the clinical setting. I have daily anecdotes that affirm this point and, for my end goal, that’s the most clear demonstration that FOAM is more than a shameless self promotion act by “people beating on their chests.”

  9. Michael Jasumback says

    Thank you to all who took the time to read and comment. This particular essay has been rattling around my head for the last year or more. The FOAMed projects have merely brought it out into the open. The best part is, by responding, disagreeing or merely noticing, you have all contributed to the success of FOAMed.

    I certainly respect Dr. Cheatham’s point of view, and to some degree I agree with him. We are in the equivalent of the wild west, no map and no sheriff in town. Yet, whether he likes it or not, he has contributed. He has established an antithesis. FOAM and POAM, must combine his antithesis with their thesis and form synthesis, that is, the future of open access medical education.

    Of course, that’s just my opinion, I could be wrong.

  10. says

    I am not sure where the “shameless self promotion” enters into all of this -- when one writes a textbook, one doesn’t hide it and hope noone ever reads it. Why would FOAM be any different? And if a platform for a democratic, free and level playing field for education also has a sense of humour, can accept criticism, and laugh at itself, well, that’s damn good too.
    I created the FOAMed/HOPE image of Mike, in secret collusion with Chris Nickson and without Mike’s knowledge, to poke fun at and promote the exciting venture that seems to be carrying us all along at the moment. I HOPE we can continue not to take ourselves to seriously while attempting to do something quite serious….
    Regardless of what one’s opininon is of what we are trying to achieve with this “movement” of FOAM, there is certainly no justification for personal attacks on people who are throwing considerable energies, time and money into providing such education for all. Just my tuppence.

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