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Do EPs Put Too Much Stock in FOAM?

Frumkin, Kenneth PhD, MD

doi: 10.1097/01.EEM.0000578656.56250.2f

New media have taken education in emergency medicine by storm. Free open access medical education (FOAM) is a major source of online educational resources with almost 900 million #FOAMed tweets in 2014. (ECG Medical Training. April 22, 2015;

It's only natural: Digital media are free, quick to read and publish, often entertaining, increasingly difficult to ignore, and arrive conveniently in one's inbox. Commenting, amending, correcting, and retracting are easier and evolving. (F1000Research. 2017;6:1960; Opinion pieces are easy to publish. Even traditional publications are signing on, increasingly using social media to engage their audiences. (J Am Coll Radiol. 2018;15[1 Pt B]:173;; CJEM. 2015;17[2]:184; SAEM. Tweet chats, Altmetric scores, and online journal clubs provide views and post-publication feedback. (Ann Emerg Med. 2017;69[4]:469.) Major developments in sepsis management were facilitated, chronicled, and disseminated this way. (Chest. 2017;151[6]:1229; Acute Med. 2013;12[2]:83;; Chest. May 2, 2014;; PulmCCM. May 2, 2018;

But I often wonder, who are these people producing so much of our specialty's content, and why should we listen to them? Blogs and podcasts are typically one doctor's opinion. Why should we value their impressions more than those of other peers? Less than 20 percent of top EM and critical care online resources list their academic affiliations. (AEM Educ Train. 2018;2[3]:204.) Should online broadcasting of the unfiltered and unedited views of persuasive bloggers or entertaining podcasters trump dry science or delegitimize alternatives? EM derives so much from the research and best practices of other specialties. How should we validly assess information from unreviewed sources?

The signal-to-noise ratio is further attenuated by blogs citing other blogs as references. All 21 suggested resources on an important (airway) topic in a piece for EM educators were from FOAM. (emDocs. July 17, 2018; Often multiple online resources discuss the same journal article. Dilution is not always the solution to pollution. Retweets, clicks, and likes are neither peer review nor a quality measure. Chan, et al., noted that “research translated too quickly may cause harm if its findings are incorrect; there is little editorial oversight of online material; and eminent online individuals may develop an outsized influence on clinical practice.” (CJEM. 2018;20[1]:3.) Measures for critically appraising online content have only recently been developed. (Ann Emerg Med. 2016;68[6]:729; West J Emerg Med. 2016;17[5]:574;

As with modern politics, physicians can cherry-pick sources to validate the answers they seek. Twitter cheerleaders offer unsupported praise for new “advances.” (Medscape. Sept. 19, 2018; Once disseminated, correcting health misinformation requires more than a comment; a source is needed to confirm the correction. (Information, Communication & Society. 2017;21[10]:1337.)

Unlike traditional media, no one is following the money. Only 1.3 percent of physicians disclosed financial ties when tweeting about specific drugs for which they had a conflict. (Lancet Haematol. 2017;4[9]:e408.) Sponsored media are subject to influence. Shane Parrish, a podcaster with more than 155,000 Twitter followers, tweeted, “While sponsors have no editorial influence, there is a ton of editorial pressure to do things that I don't want to do.” (Tweet since deleted.), which proclaims itself to be “social media's leading physician voice” with 157,000-plus subscribers and a website that says it has three million monthly page views replete with advertising, solicits “to keynote your next event.”

How will reliance on online resources hold up in court? When every patient, juror, and attorney can research his own medical questions and anyone can publish, how will expert testimony and standard of care be defined?

As an educator, I have taken both sides of the issue, often coming down on residents who cite blogs and podcasts instead of peer-reviewed journals. GME has embraced asynchronous learning largely without the evidence base or rigor we apply to other instructional advances. Methods for assessing the educational quality and impact of new media are still in their infancy. (J Am Coll Radiol. 2018;15[1 Pt B]:173;; CJEM. 2015;17[2]:184; Ann Emerg Med. 2016;68[6]:729; West J Emerg Med. 2016;17[5]:574;; Ann Emerg Med. 2014;64[4]:396; Ann Emerg Med. 2018;72[6]:696.)

Is the information provided by online resources adequate? An example was a 560-word take on a 6,800-word JAMA review of infective endocarditis (2018;320[1]:72): “This thing is 12 pages long with 117 references. Let's make it bite-sized, shall we?” (JournalFeed. July 28, 2018; In relying on 30-second bites of pureed education, how will our residents differ from the millennials in the waiting room googling their symptoms?

Do we adequately prepare our students to evaluate traditional literature critically, let alone the unregulated information on the internet? Do we let them teach us, abdicating our role to the most articulate spoonfeeders with the coolest infographics? Chan, et al., recognize the need for a new type of scholar, moderating the changing landscape of knowledge translation by appraising research as lay reviewers critique restaurants, working with researchers to disseminate their findings effectively, and engaging with clinicians to ensure bedside applicability. (CJEM. 2018;20[1]:3.)

Students will (correctly) argue that these concerns are generational. (Ann Emerg Med. 2014;64[4]:396; Ann Emerg Med. 2015;65[5]:573; But debate is no less healthy because it starts with old folks. Ask an experienced primary school teacher about cycles in the evolution of the three Rs. As your teachers age into being your patients, optimizing GME is selfishly in our own best interest.

All information intended for use in patient care should be subjected to a defensible form of peer review. Success comes from the optimal alignment of messenger, message, and recipient. These will vary with the parties and purposes in the communication equation.

We all need a strategy for triaging the tsunami of medical information. (Medscape. Sept. 25, 2018; I believe in traditional means of validation and new means of dissemination. I choose peer-reviewed literature for clinical decision-making and research, but I am increasingly finding that literature via social media and other nontraditional means. I eagerly await the application of artificial intelligence to scour the web for trustworthy evidence reflecting my needs and interests.

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Dr. Frumkincurrently serves as volunteer faculty in the emergency medicine residency at Naval Medical Center in Portsmouth, VA. The views expressed in this article are his, and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government.

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