FOAM, a deontological ethos

Michael Jasumback, arch-Devil’s Advocate of FOAM, 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

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of three amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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