Administration and Leadership, Equipment & Gear, Industry News, News, Training

Free Open-Access Medical Education in Emergency Medicine

Issue 7 and Volume 40.

Over the past 20 years the Internet has spawned a huge number of blogs, podcasts, videos and wikis on a countless number of topics and emergency medicine has been no exception.1

At the intersection of social media and critical care, the astoundingly popular Free Open-Access Medical Education (FOAM), or #FOAMed, movement has emerged as a force to be reckoned with.2

According to Symplur, which tracks healthcare-related hashtags, there were almost 900 million Twitter impressions containing the #FOAMed hashtag in 2014. (See Figure 1.)

At the June 2015 Social Media and Critical Care Conference in Chicago, the “tribes” of critical care providers from prehospital, emergency, intensive care and anesthesia converged from around the world to share their passion for emergency medicine, resuscitation and critical care.

But not everyone was happy.

Around the world, attending physicians have complained their residents are questioning authority. They complain FOAM isn’t peer reviewed3 and can even be dangerous.4

Ironically this is a frequently discussed topic among those who participate in FOAM.

Some counter that peer review is highly political and susceptible to appeals to authority, and that guideline-writing panels can be “stacked” with physicians of a particular viewpoint or industry funding.

An interesting comparison can be found in Nobel Laureate Paul Krugman’s explanation about why the real action in economics is happening in the blogosphere and not in peer-reviewed journals:5

“The overall effect is that we’re having a conversation in which issues get hashed over with a cycle time of months or even weeks, not the years characteristic of conventional academic discourse. Is that a problem?

“OK, first point: Many people seem to have a much-idealized vision of the academic process, in which wise and careful referees peer-review papers to make sure that they are rock-solid before they go out. In reality, while many referees do their best, many others have pet peeves and ideological biases that at best greatly delay the publication of important work and at worst make it almost impossible to publish in a refereed journal. Gans and Shepherd wrote about this almost 20 years ago, and the situation has surely not improved.

“I’m told by younger colleagues, in particular, that anything bearing on the business cycle that has even a vaguely Keynesian feel can be counted on to encounter a very hostile reception; this creates some big problems of relevance for proper journal publication under current circumstances.

“A second point is that events are moving fast, and the long lead times of conventional publication essentially guarantee that it will be irrelevant to current policy issues.”

Others are hopeful FOAM will emerge as the ultimate peer review because the online dialog is robust, timely, multi-national, transparent and largely apolitical.

Many point to ACEP’s recent decision to lower the level of evidence for tPA in acute stroke from level A (recommended with a high degree of clinical certainty) to level B (recommended with a moderate degree of clinical certainty) as a huge win for emergency physicians who publically voiced their concerns, along with their reviews of existing evidence, in blogs and podcasts around the world.

Assessing Quality

There’s no doubt FOAM is disruptive to the status quo. On the other hand, in the absence of traditional peer review, it’s fair and appropriate to ask how one might assess the quality of a medical blog or podcast.

A group of researchers are in the initial phases of attempting to answer this question with a recent publication that’s just been published in Annals of Emergency Medicine.6

The researchers used an aggregate of social media indicators to identify a population of editors from a defined list of emergency medicine and critical care blogs and podcasts that participate in the FOAM movement.

A survey was then conducted to develop an expert consensus of quality indicators for blogs and podcasts in the areas of credibility, content and design.

The results showed a high level of agreement with > 90% of bloggers and podcasters including the following quality indicators:

  • Is the resource credible?
  • Is the editorial process independent from sponsors, conflicts of interest and other sources of bias?
  • Does the resource cite its references?
  • Is the content of this education resource of good quality?
  • Is the information presented in the resource accurate?
  • Is the content of the resource presented in a logical, clear and coherent way?
  • Is the resource transparent about who was involved in its creation?
  • Is the identity of the resource’s author clear?
  • Are the authorities (e.g., author, editor, publisher) who created the resource free of financial conflict of interest?

The authors freely acknowledge that this isn’t the end of the conversation but only a beginning. It’s the first collaborative effort by experts in the field to develop a consensus around quality for the communication tools of the 21st century.

It may not win the hearts and minds of some academics but it proves that bloggers and podcasters, while sometimes critical of the status quo, welcome self-analysis.  

Tom Bouthillet, NREMT-P (@tbouthillet), is editor-in-chief of (@EMS12Lead), chief content architect of (@ECGTraining) and a member of the JEMS Editorial Board.


1. Cadogan M, Thoma B, Chan TM, et al. Free open access meducation (FOAM): The rise of emergency medicine and critical care blogs and podcasts (2002–2013). Emerg Med J. 2014;31(e1):e76–e77.

2. Nickson CP, Cadogan MD. Free Open Access Medical education (FOAM) for the emergency physician. Emerg Med Australas. 2014;26(1):76–83.

3. Thoma B, Chan T, Desouza N, et al. Implementing peer review at an emergency medicine blog: Bridging the gap between educators and clinical experts. CJEM. 2014;16(0):1–4.

4. Purdy E, Thoma B, Bednarczyk J, et al. The use of free online educational resources by Canadian emergency medicine residents and program directors. CJEM. 2015;17(2):101–106.

5. Krugman P. (May 11, 2013.) In praise of econowonkery. The New York Times. Retrieved May 26, 2015, from

6. Thoma B, Chan TM, Paterson QS, et al. Emergency medicine and critical care blogs and podcasts: Establishing an international consensus on quality. Ann Emerg Med. March 25, 2015. [Epub ahead of print.]