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SGEM#72: Tiny Bubbles (#FOAMed and #MedEd)

SGEM#72: Tiny Bubbles (#FOAMed and #MedEd)

Podcast Link: SGEM72
Date:  April 25, 2014

Guest Skeptic: Dr. Nicholas Genes is an Assistant Professor in the Department of Emergency Medicine at the Mount Sinai School of Medicine in New York City.

The SGEM is always trying to cut the knowledge translation window down from 10 years to 1 year. It does this using social media to get you the best evidence, critically appraised and easily accessible. This is so you can provide the best care to emergency patients.

We usually do a critical appraisal of a recent paper. However, every so often I like to take a step back to look at the forest not the trees. In this case the beer not the bubbles. So it is time to sit back, relax and discuss a medical education issue.

Nick recently took part in a PRO/CON debate in EP Monthly. The title was Why #FOAMed is NOT Essential to EM Education. The person asked to provide the PRO side: Why #FOAMed is Essential to EM Education was Dr. Joe Lex. Joe has been referred to as the godfather of the FOAMed movement. Everyone in the FOAM community should be familiar with Joe’s famous quote.

Dr. Joe Lex

Dr. Joe Lex

  • If you want to know how we practiced medicine 5 years ago, read a textbook.
  • If you want to know how we practiced medicine 2 years ago, read a journal.
  • If you want to know how we practice medicine last year, go to a (good) conference.
  • If you want to know how we practice medicine now and in the future, use FOAMed

Free Open Access Meducation (Life in the Fast Lane)

Coined in 2012 over a pint of Guinness in Dublin by Dr. Mike Cadogan. FOAM stands for Medical education for anyone, anywhere, anytime. “FOAM should not be seen as a teaching philosophy or strategy, but rather as a globally accessible crowd-sourced educational adjunct. It proveds inline (contextual) and offline (asynchronous) content to augment traditional educational principles.”

FOAM has One Objective — to make the world a better place.


Dr. Nick Genes

Dr. Nick Genes

Nick and I discuss FOAM:

FOAM Moderation – The concept of moderation has been suggested for thousands of years. The ancient Temple of Apollo at Delphi says μηδέν άγαν (mēdén ágan = “nothing in excess“) Any learning tool used in excess could be counter productive to education. People learn using different strategies and FOAM just represents one tool that can be employed.

Twitter – I think twitter was made for the short attention span of emergency physicians (squirrel). We only get 140 characters to get our message across.

Knowledge Translation – Pathman Leaky Pipe Model demonstrates how it can take an average of 10 years for high quality, clinically relevant to reach the patient bedside.

Screen Shot 2014-04-27 at 8.21.21 PM

Retention from Podcasts – There is conflicting data on this idea in the literature. Here is an article by Schreiber et al and by Zanussi et al which discuss podcasts for medical education.

Quality of FOAM – Podcasting quality can vary. Some excellent examples are by David Newman (SmartEM) and Scott Weingart (EMCrit). Poor quality does not just happen in social media but also in traditional media used for medical education.

Screen Shot 2014-04-27 at 8.52.03 PMBEEM Process: Best Evidence in Emergency Medicine (BEEM) is a knowledge translation and dissemination project started at McMaster University by Dr. Andrew Worster. The  mission is to provide Emergency Medicine practitioners with the best clinical evidence to optimize patient care. BEEM has the only validated audience rating tool in emergency medicine continuing medical education.

  • Worster et al. Consensus Conference Follow-up: Inter-rater Reliability Assessment of the Best Evidence in Emergency Medicine (BEEM) Rater Scale, a Medical Literature Rating Tool for Emergency Physicians.Acad Emerg Med Nov 2011.
  • Carpenter CR et al. Best Evidence in Emergency Medicine (BEEM) Rater Scores Correlate With Publications’ Future Citations. Acad Emerg Med. 2013; 20:1004–1012

Referencing FOAM – It is difficult to search and reference FOAM material. However, ALiEM and LITFL are addressing this problem.

FOAM is Too Sexy and Not a Curriculum – There are excellent FOAM resources that look at the boring and fundamental aspects of emergence medicine. These include Brent Thoma (Boring EM) and Steve Carroll (EM Basic).

Finite Time of Trainees – Turn your car into a classroom. Exercise your mind while you exercise your body.

FOAM Too Good – We might get intellectually lazy if we just rely on some of the great FOAM resources (EM Literature of Note) and not dive into the data further.

Final Thoughts –  FOAM is a good way to get up to speed. It is fun to interact with emergency medicine leaders and easy to use. Ironically, without FOAM listeners to this podcast could not get up to speed, have fun and interact with a leader like Nick Genes.

Your conclusion is that you can still be an excellent physician without FOAM. I think the evidence suggests that is very difficult, expensive and time consuming to be an excellent physician without FOAM. Just look at the knowledge translation problem. We know the traditional method takes far to long for high quality, clinically relevant, evidence based information to reach the patients bedside. One definition of insanity is trying the same thing over and over again and expecting a different outcome.

FOAM offers a possible solution to the knowledge translation problem. It is definintetly not a pancea. Research is on-going and I look forward to seeing if FOAM will improve the qualty of care provided to patients. Why not try FOAM as an adjunct to traditional medical education?

KEENER KONTEST: Last weeks winner was Maja Tuta and RN from Hamilton, Ontario.  Maja knew that the Boston Marathon runs through the town of Framingham. This town is famous Framingham Hearth Study started in 1948 looking at cardiac risk factors.

Listen to this weeks podcast for the Keener question. If you know the answer then send your answer to with “keener” in the subject line. Be the first one with the correct answer and I will send you a cool SGEM skeptical prize.

Remember to be skeptical of anything you learn, even if you heard it on The Skeptics’s Guide to Emergency Medicine. 

  • Hi Ken and Nick
    Great interview – really enjoyed listening to you both bang heads.
    I pretty much agree with everything both of you say (except for textbooks… don’t waste your time reading one cover to cover, read just what you need if you can’t find a good review IMO, though I do like a well written tightly focused niche text).
    I would argue that it may be essential for every department to have at least one person – who gets some respect 😉 – who is involved in FOAM to help disseminate useful ideas, concepts and resources to those less engaged. Closely yourself off to FOAM ideas completely is a big mistake. Unless you are a rabid journal reader, it is very hard to keep up with a more moderate person who uses FOAM effectively.
    Clearly it’s not the whole answer, but used properly FOAM is an adjunct that allows you to spend more time doing things that matter and hopefully be inspired and motivated at the same time.
    Vive la FOAM!
    PS. Sadly I was not in Dublin with Mike when the FOAM acronym was coined, it was another LITFL contributor Sean Rothwell.

    • TheSGem

      Thanks, it was great to have a fellow skeptic on the show being skeptical of FOAM. It is always a good exercise to point the critical eye inward.
      I agree with your comment about txt books. Use as resource but not read cover-to-cover. I also like your suggestion about having a FOAM expert in each dept to help disseminate the FOAMy goodness.
      How can someone possibly distinguish the signal to the noise in medical literature without FOAM? It is just too much information for one person and it needs to be searched, filtered and processed.
      Sad to hear you were not in Dublin but you will be at SMACC-US in Chicago?

      • Definitely – will be helping to run the show gain at SMACC Chicago.
        See you there!

        • TheSGem

          I have a special idea we should talk about to promote SMACC Chicago…

  • Salim R. Rezaie

    Hey Ken and Nick,

    This is why FOAM is so great, you can have conversations like this where two people can disagree, have an intelligent conversation about it, and disseminate both valid points in a real time manner. As far as a curriculum for FOAM, at our institution we have an asynchronous curriculum using an online platform called Course Sites (, which is a FREE.


    1. Every four weeks our residents have a core curriculum block (i.e. cardiovascular, pulmonary, renal, ID, etc….).
    2. 2 or 3 of our faculty sift the FOAM world and find podcasts, blog posts, or PDFs of recent articles covering things in that area and upload to course sites.
    3. The residents read and/or listen to this information and then answer a set of questions developed by our faculty in order to get their one hour of credit.

    This is used as an adjunct to core curriculum content such as lectures, reading assignments, etc…..We feel this is a nice balance for our residents….4 hours of traditional learning with 1 hour of real time information.

    Thank you both for doing this podcast….important for everyone to understand the strengths and weaknesses of FOAMed.


    • TheSGem

      Appreciate the feedback. Really enjoyed discussing this with Nick.
      Thanks for sharing your curriculum which uses traditional and FOAM resources. Finding the right balance always a good thing.

    • Salim
      Do you like the coursesites stuff??
      Can we chat more about it?

  • Seth Trueger

    Ken- well done! We discussed our III curriculum in pretty good detail here:

    • TheSGem

      Thanks Seth, Check out the posting from today featuring the Godfather of #FOAMed Dr. Joe Lex.

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  • katrin hruska

    I don’t know if I got this right. As understand it Nick, who seems to be someone who enjoys reading journals, stopped reading the original articles because he enjoyed listening to podcasts more and even though he realizes that he can get a deeper understanding from articles, he doesn’t have the discipline to do so. And since he assumes that medical students are even less disciplined, he fears that they will never read any journals at all.

    Unlike Nick, social media has actually increased my reading of original articles. I want to make sure I check out the source before I comment, so of course I had to read his article in the EP monthly. That only made me more confused. It seems to me that he is pro FOAM.

    It surprises me that I got so upset about this episode of theSGEM. After all I find these discussions about social media about as interesting as a discussion about whether books are good or bad.

  • Elisha Targonsky


    This was one of my favourite SGEM episodes to date. I really enjoyed the discussion. Nick Genes had some very valid points about how non-FOAM (ie traditional textbook/journal) material is probably more essential to practicing EM. Also, that Twitter is a difficult place to have a real discussion – though I’d argue it certainly plants the seeds for discussion or gives the reader/follower a place to start by finding links to relevant material. Definitely he gives food for thought in the very least.

    However, I thought that your counterpoints regarding the similar flaws in traditional peer reviewed material were just as valid. In fact, all your counter-arguments were well thought out. I haven’t read the pro/con column yet (on the to-do list), but I think you would probably do an excellent job arguing the “pro” side.

    What I love about FOAM is the crowd-sourcing, and the immediacy of interaction/review and especially the easy accessibility/availability. I drive 45 min to/from work – that means 1.5 hours per shift where I listen to podcasts and supplement other learning/reading by turning my car into a classroom. I encourage all EM residents that I work with to turn their car into a classroom as well.

    Looking forward to Joe Lex’s appearance on the show!


  • Roger Helmers

    Just my 2 cents: Since I started listening to podcasts (SGEM, SMART EM, EM crit, Annals of Emergency Medicine) I have been reading MUCH MORE than before because every time a subject is discussed on these podcasts, it makes me want to research it myself. I have since added two more subscriptions to my monthly reading list and I am much more excited about the topic of emergency medicine than ever before! Keep up the great work! FOAMed is essential 🙂

  • Dylan Norton

    Hi Ken – I think this is a really interesting and important topic.

    I am just beginning my 4th year at a US medical school and have been an avid consumer of FOAMED for several years now. Although I can’t say whether FOAMED is essential for emergency medicine, I am certain that it is essential for me and my emergency medicine education. I believe it has made me a stronger student, and will make me a better resident and a better doctor. I think failing to fully embrace the potential that social media has to enrich and improve medical education would be a major error.

    Although I appreciate some of the points made by Dr. Genes, I believe he overstates the risks of utilizing FOAMED as opposed to traditional techniques for learning. First of all, I don’t believe we are forced to choose between traditional medical education and FOAMED. I have attended all my required classes and clerkships, and still have to pass my Shelf and board exams. I am required by my school to master the basic curriculum, and the vast majority of my time training is devoted to this. As you pointed out, however, I have down-time on my commute to the clinic or when I exercise to listen to podcasts. This amounts to 10-12 hours a week that is available for learning which would have been wasted previously. Furthermore, I find myself eager and excited about learning in this way. Who could fail to be inspired by Weingart, Newman, Reid, Swaminathan, or by you for that matter? You guys present the material in an engaging and stimulating manner that inspires me to think critically and to explore important topics further.

    I agree that listening to podcasts is not enough. If you really want to learn the material well, you have to make the effort to download the key articles that are discussed, to read them, and to try to form your own opinion. Podcasts are a fantastic way for a beginning learner to figure out what the key topics are in the field, and to learn about the seminal works that have shaped our understanding of disease processes and therapeutics. I would question the utility of a beginning learner reading the NEJM cover to cover, as Dr. Genes seems to suggest. Many of those articles are very low yield for general medical education. Learning about sepsis management and listening to a discussion of the PROCESS trial, however, is extremely productive. I would have a hard time parsing out the key points at this stage of my education, but you guys make that possible by framing the discussion and allowing me to maximize my learning.

    I also question whether Dr. Genes is correct in saying that FOAMED focuses on esoteric or rare presentations. I don’t believe that is true for the majority of podcasts or blogs. There are exceptions to this, but when it comes to the resources I use, I find myself running into the very same topics on the wards that are discussed online every day. I listen to most of the major EM podcasts, and read several blogs (ALIEM, EM Lyceum, Dr. Smith’s EKG blog, etc.), and I think they hit key topics that we must know in emergency medicine. I think it’s pretty important to know the latest on sepsis, airway management, therapeutic hypothermia in cardiac arrest, stroke management, or interpreting an elevation in troponin. These are important topics, and they are the focus of social media. Of course, you have to know the basics, such as how to work up abdominal pain or headache. As you mentioned, though, there are people like Steve Carroll who cover these topics extremely well. In addition, there is plenty of training on the basics in the existing medical school and residency curriculum.

    As for whether listeners retain the material they listening to on podcasts, I think it’s clear that passive learning, in whatever format, has limited value. This is true for traditional lecture based medical education, and it’s true for FOAMED as well. The learner must engage with the material, must push him or herself to think critically, must read, write, discuss, and eventually practice, in order to master a subject. FOAMED is no magic bullet, and it faces the same limitations as any media which conveys information. It’s only as useful if it is incorporated into a larger framework. It does, however, have the advantage of generally being stimulating and fresh. Honestly, most of the material I consume online is much more engaging and stimulating than the didactic lectures I receive at school (many of which haven’t been updated in 10 years!).

    In summary, I am a firm believer in the potential of social media to enhance and enrich medical education, both at the undergraduate and graduate level. It has helped me decide to go into emergency medicine as a specialty, it has kept me excited about medicine, and it has helped in patient care. I think all of us should be putting our efforts into embracing and improving FOAMED and to making it the best it can be. Adopting this new method of leaning has potential pitfalls, but there are tremendous opportunities as well. In any case, FOAMED is not going away, and I am certain that it will continue to become more and more integrated into medical education at all levels. We would be best served to recognize this now and put our efforts into improving social media resources, rather than trying to diminish or belittle its importance for medical education.

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