FOAM, free open access medical education, is an online movement taking place across social media, blogs, and podcasts that is challenging traditional methods of medical education.^1,2 Its acronym coined in 2012, FOAM represents more than just the content of the learning resources; it is considered to be an ethos, a dedication to the learning and teaching of medicine in a collaborative environment made easily accessible by online platforms.¹ These new educational platforms are changing the way learners engage with educational resources and how research is translated into practice.³ Recent studies have demonstrated that 97.7 percent of American medical residents are spending at least one hour per week supplementing their traditional academic curricula with podcasts.⁴ This rapid expansion and increasing influence of FOAM in emergency medicine suggests a need for ethical analysis. Pros and cons of FOAM from an ethical perspective are outlined in Table 1. The ensuing discussion elaborates on these key issues emergency physicians should consider when utilizing or participating in FOAM.

Patient Confidentiality

Our responsibility to protect patient privacy and health care information takes on new complexity in the FOAM and social media environment. The risks, especially when discussing clinical case vignettes or sharing radiographic or electrocardiographic content, are well described.⁵ Attentive care to “de-identification” of publicly shared content requires not only removal of key patient details (eg, names, ages, and birth dates) but also more subtle identifiers such as unique conditions, events, locations, and time lines. When participating in FOAM, emergency physicians should follow the guidelines established in ACEP’s forthcoming policy on use of social media.

(click for larger image) Table 1: Pros and Cons of Characteristics of FOAM

Conflicts of Interest

The disclosure of FOAM authors’ conflicts of interest should follow the same standards recognized by traditional peer-reviewed journals, namely that all professional and financial conflicts be fully disclosed to readers.⁶ In FOAM, this expectation should apply not only to content authors but also commentators. A high-traffic website, social media page, or Twitter feed has significant potential value for advertising revenue. A complete ban on industry sponsorship or ad placement is not a tenable solution, as there can be substantial costs in the creation of high-quality FOAM content. Disclosing these conflicts is crucial. Transparent and reduced-bias funding sources for FOAM, such as grants, may mitigate but not reduce the risk posed by conflicts of interest.

Similar to the publication bias of journals, there may be selection bias for content that will be of interest to and shared by users. This constant pressure for innovative and engaging posts, particularly in concert with the limitations in peer review, may create content that misrepresents standard practices by emphasizing new techniques and studies. Furthermore, the lack of verification of the identity and credentials of commenters clouds the reliability of information and opens the door to covert industry infiltration, astroturfing, and other malicious intents. Social media platforms common to FOAM, as well as social media users in general, have proven to be extremely vulnerable to manipulation and dissemination of false information. There is an ethical imperative for the FOAM community to establish firm safeguards, aggressively self-regulate, and promote the skepticism that is the bedrock of scientific advancement.

There is an ethical imperative for the FOAM community to establish firm safeguards, aggressively self-regulate, and promote the skepticism that is the bedrock of scientific advancement.

Peer Review

Attempts have been made to implement formal peer review in FOAM. The blog Academic Life in Emergency Medicine (ALiEM) introduced an “expert peer review” process for providing feedback, edits, and commentary on published articles while still not delaying their release. Furthermore, there are emerging structured mechanisms to evaluate nontraditional educational sources (eg, ALiEM AIR Series and AIR Score, Medical Education Translational Resources: Impact and Quality [METRIQ], and Social Media Index).^7–10

The open-access nature of commenting on FOAM resources does allow for a uniquely real-time appraisal. This interactive process gathers the insights of multiple practice backgrounds and experiences and is a form of ground-truthing that is not similarly available in print media. On the contrary, for FOAM in general and for comments in particular, users may be left to assess the authenticity of a statement by either the reputation of the author or the perceived accuracy of a post in a manner that is vulnerable to bias and error.

Eminence Versus Evidence

One criticism of FOAM is that it threatens a return to the time of “eminence-based” medicine rather than the evidence-based medicine that underpins modern practice. The validity of this criticism is undermined by the fact that eminent voices continue to have an amplified role in traditional educational venues. The presence of individuals with unique access to platforms and followings that allow dissemination of information is not exclusive to online communities and can be found in academic and scientific circles as well.^11,12 FOAM could be considered, in part, a reaction to the crowded space of traditional medical education and may be an attempt to democratize the process of information generation and dissemination.

Although the gold standard for medical learning remains the personal review of primary source materials, the time in which practitioners could read all of the literature relevant to their practice has long passed. Reliance on trusted sources to summarize and sort the wheat from the chaff is no longer optional. However, like any educational tool, participation in FOAM without a curricular road map can neglect and even create substantial and dangerous knowledge gaps.

There is no equivalent to PubMed for FOAM. Reliance on search engines like Google is not adequate because how search results are generated is opaque, not optimized for this purpose, and easily vulnerable to technical manipulation. A counter to this concern about locating quality information is that FOAM is about community and participation. The idea that all emergency physicians will be active participants in a worldwide community of practice is noble and exciting but improbable, and it makes the “casual” user of FOAM unlikely to reap all of its benefits and more vulnerable to its risks. This problem will only grow as more FOAM content is created.

Knowledge Translation Time

FOAM has the ability to decrease the time from knowledge discovery to knowledge integration into clinical practice, though this process continues to be less regulated than traditional methods.¹ The traditional methods of inquiry and assimilation of research findings into medical practice can take decades, with an estimated lag from time of inception to clinical practice of as much as 17 to 23 years.¹³ Traditional medical journals are incorporating FOAM techniques through partnering strategies. The Annals of Emergency Medicine and ALiEM.com have collaborated on online journal clubs; one such encounter had 1,401 readers and 313,229 Twitter audience impressions.¹⁴ Also, FOAM is by definition free, and eliminating the cost barrier gives it another advantage.

However, the increased speed of knowledge translation raises the question, How fast is too fast? Significant changes in clinical practice could occur before further study can verify and confirm exciting new findings.¹⁵ Future important directions for FOAM are to establish the real-time ability to publish and discuss not only new ideas but also the structure necessary to evaluate them in standardized trials with subsequent peer review.

Distinguishing FOAM from Crowdsourcing

Crowdsourcing is the solicitation of real-time clinical input from others over an electronic platform. Distinguishing crowdsourcing from FOAM can be difficult because crowdsourcing isn’t FOAM, but it may occur in the same space as FOAM activities. For example, a Twitter discussion about the best agent for blood pressure control in aortic dissection is likely FOAM, whereas tweeting, “Help!!! What should I do for my patient with an aortic dissection?” is crowdsourcing. The social media platform SERMO advertises crowdsourcing as a benefit of its network.

Crowdsourcing is a seductively appealing modern combination of informal, or “curbside,” consultation and telemedicine. There is the potential benefit to provide practitioners easy access to colleagues or specialists. However, crowdsourcing lacks the robustness of telemedical consultation in terms of the amount of information shared, accountability of the consulting provider, and a mechanism to document it in the medical record. In addition, while curbside consultation (informally requesting patient management information or advice from a medical colleague) is a common practice, it has been criticized due to its greater risk of inaccurate recommendations compared to traditional consultation.^16,17 Online crowdsourcing through FOAM platforms increases these risks because the identity and credentials of those providing advice cannot be independently verified. Crowdsourcing through FOAM resources shares the appeal of FOAM itself to harness “the wisdom of crowds.” However, without established processes to vet those providing input and a validated structure to balance differing views, crowdsourcing places patients at unacceptable risk.

Conclusion

Over the last two decades, the Internet has transformed how we access information and how we learn and practice medicine. The FOAM movement has created collaborative communities capable of ultra-rapid dissemination of information and remote interaction between learners and educators. These pioneering advancements must be coupled with new responsibilities for both educators and learners. The flood of available information must be consciously processed and methodically vetted by those learning through FOAM to maintain the peer-review process and promote evidence over eminence. In addition to this responsibility, FOAM contributors also must keep patient confidentiality paramount and disclose commercial interests or involvement. FOAM will likely continue to grow and expand over time, and attention and research are needed to focus on how FOAM can best integrate with, augment, or supplant more traditional existing resources. Emergency physicians are forerunners in medical education and should continue this leadership role to ensure FOAM evolves responsibly.

Dr. Allen is in the department of emergency medicine at Billings Clinic in Billings, Montana.

Dr. Chandrasekaran is at Boone County Emergency Medicine in Indianapolis.

Dr. Goett is in the department of emergency medicine at Rutgers New Jersey Medical School in Newark.

Dr. Kluesner is at UnityPoint Health in Des Moines, Iowa.

Dr. Vearrier is in the department of emergency medicine at Drexel University College of Medicine in Philadelphia.

The authors are members of the ACEP ethics committee.

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