FOAM & SMACC craic – from outside the citadel

I’ve been thinking about FOAM since SMACC2013 (Social Media and Critical Care)…thinking a lot and talking to some friends.

I’ve cleared my desk literally and figuratively for a while and intend to read a lot and spend sometime away from computers and in the fresh air. But for good or ill I’m going to share some of my ruminations about FOAM post-SMACC and where it stands:

I thought SMACC was an amazing conference, and I had a fantastic time. I was inspired and challenged by many, especially some icons of the Critical Care world – Cliff Reid, Scott Weingart and Joe Lex. Meeting them, and others, as if I had known them for years, was a surreal experience. I also got a real buzz from speaking among such eminent company and not self-destructing, despite my extreme anxiety about it (or perhaps because of my anxiety – since as Myburg and Weingart say, adrenaline is “God’s own nectar”).

But among all of this enthusiasm, euphoria and exaltation, I have become aware that not everyone felt like I did about SMACC2013. Some people I have the utmost respect for, including several colleagues who I consider to be mentors in my professional life, had what they describe as a “mixed” experience. Rather than trumpet my own overwhelmingly positive experience, I thought it would a be useful exercise to explore the experience of others. So this will be an opinion piece discussing the discomfort of some with how the “Brave New World” of FOAM and #FOAMed is playing out. I think it is important to air and address these views in order to ensure that the “product” we deliver as FOAM is as good as it can be.

FOAM as espoused by SMACC is unfolding with some of the features of a new religion:

  • It has a “big idea” at the core.
  • It sets out to reject dogma and challenge the status quo.
  • It is somewhat anti-establishment.
  • It has evangelists. It has an inner circle of disciples, it has zealots and it has converts.
  • Thus, it faces the same problems as a religion, and could fall into similar traps, and could eventually leave itself open to some of the same criticisms as religions are.

There are several traps FOAM could fall into, I believe:

  • It could lose itself in enthusiasm, evangelism and quasi-religious fervour.
  • It risks the criticism that there is a “cult of celebrity” developing (I don’t think this is true, but it is how some see things from the outside).
  • It preaches openness and yet some see it as a clique. It can appear somewhat smug to the “uninitiated”
  • It risks portraying itself as the “one true path.”
  • SMACC spent a lot of time discussing ideas about how we can ensure that FOAM self-polices content and quality, but little time addressing the fact that there is risk that it develops into a “club” which some may not feel they can join.
  • Although a version of “peer review” is important, I think this perception of a clique is a bigger threat to FOAM.

The big ideas of SMACC2013 apart from furthering FOAM as an educational movement were: challenging dogma and destroying silos – particularly those separating pre-hospital medicine, ED and ICU. But we MUST be careful that we do not replace these silos with another silo, the FOAM silo. We must not just challenge the dogma that exists and then fall into the trap of creating a replacement dogma (The central message of a certain prophet/son of god/historical figure was love, equality, rejection of dogma and openness – but his followers somehow contrived to develop a new boys club and a new dogma as exclusive and prescriptive as what preceded it).

FOAM, and conferences like SMACC, risk alienating further the slightly more open and curious skeptics precisely BECAUSE they don’t feel part of the evolving club despite taking the courageous step of attending to dip their toes in the water. For those of us who, as Scott Weingart says, “jump in and drink from the stream” it seems self evident that you get out what you put in, but not everyone feels able to commit to that degree, and we risk losing the swinging voter unless we accept and address the perception that FOAM can appear like an exclusive inner circle to the outsider. This may seem crazy to us and is light-years from the intentions and principles of FOAM, but it is definitely how some perceive us. We think we are making it easy because it worked for us, but we need to be rigorous about how open the FOAM movement is.  So what can we do?

FOAM must remain truly open and inclusive.

FOAM must listen to and embrace the uncertain and dissenting voices.

Pretty simple, and yet I suspect it will be very difficult.

Specialist Emergency Physician from Ireland currently based in Tasmania, Australia


  1. It is very important to state that the idea of cult of celebrity is I think a PERCEPTION of those on the “outer” rather than the reality. All the individuals who have been thus accused are in fact humble approachable and altruistic folk for whom I have the utmost respect. The cult of celebrity accusation definitely stems from some mistrust of motives. I do not share that mistrust, but I still feel we need to address the perception.

  2. Hey Mike – thanks for reading and for the comment. I completely agree with your view on this, but it is important to address the fact that these things are being said and try and see why, so that we can stay true to the principles and not fall into the traps!

  3. I guess I mean that it’s not so important what we think, but “we” need to be aware of what “they” think even if the ethos of FOAM is such that there shouldn’t be or isn’t a “them and us.” Unfortunately, a “them” will define themselves no matter what we do.

  4. Very interesting! Similar thing happened with EMS 2.0 two or three years ago. Many were turned off and had the perception that a select few were declaring themselves the founders and writing manifestos. A precautionary tale for any social media movement. I look at it like rugby. The set piece collapses but then there’s a second phase of play. FOAM will have its ebb and flow but can come back stronger.

    • Gotta love a rugby metaphor! We need to flood the breakdown, secure possession and go through the phases…

  5. Hey Domhnall,

    Love the post. Disappointed that I couldn’t witness the CRAIC at SMACC in person. It sounds like it lived up to all expectations and then some. I think, in analysing the conference, you are employing the mentality of someone like Roy Keane or other successful sportsmen/women – i.e. instead of just patting oneself on the back for a great success, looking at how we can improve for next time.

    I am wondering if the organisers (or should I say we, as this conference encouraged everyone, even those not physically present, to participate) managed to flip the classroom at SMACC2013? It did seem like all the leading lights giving the talks at the front and others listening, similar to other more “traditional” conferences (again I was not there so please correct me). But maybe that is not a bad thing. These “leading lights” are leading lights for a reason, and if I hear that speakers like Weingart, Myburgh or Cadogan are at a conference it will make me want to go and attend their tracks while I’m there. Or at the very least follow it on the twittersphere.

    I don’t think the word “celebrity” that some critics have used is fair as celebrities in today’s culture are perceived as vain, superficial folk generally not to be taken seriously. This is obviously the antithesis to the people who Mike eloquently referred to on the Jellybean interview as the “thought leaders” on FOAM. Given that FOAM has evolved so quickly, perhaps others will float to the surface over the next 12 months and will be the stars of SMACC2014.

    Or maybe we need to “dream it all up again” as Bono said on the last night of the Joshua tree tour. Think I’m rambling now. Regards


  6. Excellent points. As much as I love FOAM, it is often in danger of turning into a “circle jerk”.

    I would suggest that if we want to avoid the evangelical feel (or even if we just want to be taken seriously as a speciality), we should ban geting the audience to chant “We are Crictical Care’. Imagine walking into a room and everyone is chanting “We are cardiology! We are cardiology!” You would piss yourself laughing at them. Entheusiasm is great but lets just dial it back a little.

  7. Thank you for a great post, and some insightful suggestions. Guess we’ll have to scrap the 70 metre high effigies we had planned for next year…
    If anyone has feedback that they do not feel comfortable sharing in the public domain, please
    – email us [email protected],
    – DM us @smacc2013, or
    – respond to the feedback survey which will be e-mailed to SMACC attendees in the next few days.
    Get back to us soon, as we’re already planning for next year.
    If you could keep it specific to SMACC (not FOAM) that would be very helpful.



  8. In my personal opinion, free, high-quality medical education will exist on the internet, and be shared via social media, with or without what we call FOAM (or FOAMed). It was happening before FOAM and it will happen after FOAM. But, the #FOAMed hashtag on Twitter is a really neat way to share medical education. For example, Stephen Smith, M.D. is an amazing educator (I don’t think it’s a stretch to call him a guru but such titles would mean absolutely nothing to him) who knows almost nothing about social media. I tweet blog posts from his archives with the #FOAMed hashtag (and encourage him to do the same via his Facebook page) because his content is top notch, deserves to be widely read, and I hope that people who follow #FOAMed are being nourished by it. In the last analysis, content is king. I mean, who wouldn’t want to learn how to distinguish LAD occlusion from early repol? 🙂

  9. i attended SMACC2013 as very much an ‘outsider’ and think the organisers did a great job of INCLUSION.

    i identify as an outsider as i didn’t fit the same demographics of many of the attendees.
    im an RN not a doctor. i work a country ED that’s too small to have many staff or much in the way of fancy equipment but too big to need the services of external agencies such as air retrieval. i don’t blog, but i do follow. i am a toe dipper in the world of FOAM, i’m too busy being human (and not dedicated enough!) to be a dive in and drink it FOAMer.

    my outsider’s perspective of SMACC and FOAM is that they are inclusive, multidisciplinary, respectful of the different skill sets and environments and appreciative of all levels of involvement.
    there may be some self promotion and congratulation, but I’m not sure it’s misplaced. great ideas don’t just happen, they need to be propelled forward by enthusiastic and passionate people.

    SMACC for me was sometimes a steep learning curve, but one where i felt equally valuable as a participant as anyone else there.
    thank you organisers for a conference where i felt welcome, safe to participate and learn and most of all inspired

    • That’s fantastic to hear! Your perspective is invaluable and it is great that you felt that SMACC and FOAM are accessible. That is what all the humble altruistic people (Mike Cadogan’s “SHARKS” – smart happy altruistic rational knowledges sharers, if I correctly recall) who happen to also be amazing practitioners and wonderful speakers would hope for FOAM, and no doubt the SMACC organisers would hope for too (although I can’t pretend to speak for them!). Great stuff!

  10. Great comments Andy – I really appreciate the fact that you have taken the time to reflect and come up with some solutions to the problems with FOAMed that Domhnall has eloquently articulated.

    Being further on the “outer” than you on the “periphery”, my perception of the “FOAM founders” and contributors is one of awe for those who can put themselves out there. With the global nature of SoMe (social media, with it’s own language and abbreviations!) I have a great fear and reservation about moving from toe dipping to immersion, much of which stems from having been on the receiving end of particularly vitriolic and misogynistic comments about 6 months ago (in another forum, not related to FOAMed). If I feel this way, I am certain that many others do also.

    I also think that there is a very loud male voice in the FOAMed world – not that this is a bad thing, it’s just “a thing”. Perhaps more female voices will help moderate (?dial it back, as Toby says) the phenomenon? We need the perspective of (more) women too… but we also need to be kind to each other, as was mentioned at SMACC at one point.

    As a passionate educator, I love what FOAMed can offer in addition to more traditional (and other developing) learning methods. But I do think that by following some of Andy’s suggestions will help make this medium more palatable to those not so willing to embrace the FOAM.

    • Great comment Kate – so when are you going to start contributing as an author on underneathEM.com?

      And Andy, I am not sure you are really on the periphery. You are not so much Pluto, but more a Mars, Saturn or Jupiter…

  11. I thoroughly enjoyed SMACC. On some occasions I didn’t always agree with all the speakers and other times it gave me pause to think about my practise. Being both anti-authorian and anti-celebrity, I tend to prefer to look at the evidence rather than the personality.

    The internet era has brought a wonderful ease of communication and its own specific challenges as was discussed in the FOAMed plenary. I think we are still working out how to master the art of ‘netiquette’ or the appropriate and responsible use of this media. The informal and abbreviated (i.e. Twitter) approach is much more prone to misinterpretation in both tone (‘cult-of-personality’) and content.

    Things that I see in FOAMed that annoy me:

    – quoting a raft of selectively identified studies to justify a viewpoint rather than careful dissection of the papers involved
    – simply collating data from the results and conclusions from a heterogenous group of studies rather than properly analysing the populations and methods looking for reasons for discrepancies or applicability in different sub-groups
    – putting forth a over-simplified viewpoint with no context of the geographical locale, resource-capability expertise of the clinician, severity of illness of the patient or the cause of the condition. In other words considering that ‘your mileage may vary’

  12. And considering for every critical intervention, there is always risk for harm that needs to be evaluated and quantified.

  13. I’m not sure the perspectives being offered are all that surprising. When EM really got going as a specialty, it started producing its own journals. Those initial journals contained articles that largely reeked of self justification of the specialty. This is entirely understandable as a novel group wrestle with their purpose and immediate future. And the more people that are involved in that discussion, the more heterogenous the opinions and the longer it takes for everything to settle into a rythmn.

    Which it eventually will, assuming that its raison d’etre is valid.

    EM ultimately sorted itself out and now produces a wealth of high quality, influential literature. They are not alone.

    I have benefited from FOAMed (that is the term that has been applied, so that’s what I’ll use) and I hope I have in turn contributed (but I’m not offended if no one has read a single thing I’ve written). And that’s one of the major differences between a movement like FOAMed and a cult or a clique. FOAMed is open to all comers, whether you are a producer or a consumer; and either or both are acceptable. And anyone can leave whenever and as often as they want to. Anyone how feels they have been left out of an exclusive club, just hasn’t asked yet. I haven’t written a multitude of journal articles and I certainly don’t feel excluded from that cohort; and if I did, I probably just need to write more articles and do it to an acceptable standard (How that standard is judged might be debated, but it would be hard to say that FOAMed is alone in deficiencies in this area).

    If you start something that seeks to offer an alternative, even if there is no intent to replace what is already available, there will inevitably be those who are wary of it and may look for agendas and sub-texts. That’s life. If we believe in what we do, then no amount of destructive criticism should deter us. Constructive criticism should be attended to. We will be established or crumble based upon what we do and how we conduct ourselves. What we are doing is not new, it’s just in a new environment and it will take some time to settle in and for the biases to diminish, though they may never fully disappear.

    • Good points, sir! There is indeed a fine line between promotion and the perception of that as self-promotion. I reiterate, I am merely giving air to views that we need to consider, I am not necessarily agreeing with them, although I really value the alternate perspective offered in order to moderate the FOAM movement and ensure it really does remain open!

  14. thanks Domhnall. this article and the comments by folks here …I find very helpful.

    If you enjoyed SMACC2013, thats good enough for me 😉
    if you learnt something, even better
    If you left , inspired and wanting to contribute and help educate, perfect!

    The Twitter medium I agree we can do better as it does tend to be more socialisation than education. It also did not help that the Twitter hashtag for SMACC2013 got spammed with sex robots!
    We dont expect everyone to embrace Twitter, facebook, G+ etc, but they are there and free and all sorts of medical education is occurring vis them. The international urology journal club via Twitter is one great example of a CLIQUE of surgeons getting involved with FOAMEd! And thats not entirely fair to call them a CLIQUE as the club is open to anyone to join and participate..it just depends if you are interested in urology research and practice!

    Which is why FOAMEd is not a cult or quasi religious movement..even if we start the meeting with a chant of We are critical care ;-)!! ok that could have been done another way..but so what…do you all agree with what is taught to you on EMST/ATLS course that you pay $$$$$ for?

    FOAMEd you take it or leave it. as much or as little as you want.

    Is there a small group of enthusiasts at its core..yes but so what? People wonder why SMACC2013 program was of such good quality? It was because of the use of FOAMEd networks by a small group of enthusiasts!

    Oh and I agree about the male dominance of it all..we are working on that and certainly Vic Brazil’s lectures at SMACC 2013 prove that we try to promote a meritocracy rather than who has got the biggest…blog or podcast 🙂

    fantastic feedback folks..keep it coming!
    and thanks big guy for writing your articles..love em!

    • Thank you for adding you thoughts Minh! I agree that the extent to which one uses FOAM is up to the individual. My concern is that some (perhaps more circumspect and skeptical) folks may be put off and feel alienated by the manner of expression of the enthusiasm that the rest of us feel for FOAM. The non-US English speaking world (read Australia, UK, Ireland etc) does have a tendency to baulk a little at, and potentially feel alienated by, over-exuberant expressions of enthusiasm, however genuine the sentiment underlying them is! There is likely to be great value in keeping them on board, that’s all!

  15. Aside from not fitting into ‘cliques’ or being fearful of technology there are also reasons people may be circumspect about participating:

    1) Are their any ‘rules’ of publication – is it a place for mere opinion or editorial? Are topics just focussed on the esoteric or controversial? is there any place for a quality literature review and commentary or robust on-line journal club? Is it acceptable just to provide a good summary of the conventional and accepted points of clinical practise for those who require an introduction to the subject?

    2) Will the expanding growth of blogs just create more ‘noise’ that needs to be filtered within the medical literature? Will be overwhelmed by the sheer number of voices and opinions? Can we really test the reliability, experience (and importantly, outcomes) of the on-line clinicians who voice them? Will it lead us down many blind alleys, false hopes or half-truths? Will our own participation just add to the noise?

    3) Perhaps social media belongs to a certain ‘type’ or personality who also perpetuate, encourage and reinforce a certain ‘way’ about thinking, teaching or practising medicine? Is there a potential for creating bias in the sphere of medical knowledge? Maybe there will be a large proportion of ‘lurkers’ who prefer to use a wider range of materials to draw their own conclusion?

  16. Just stumbled across this post – very useful, thanks Domnhall. Good discussion too, espec Andy Buck.

    What struck me about SMACC2013 (and like Angie, as a country doctor I felt a little excluded)… was that for non-users of social media and FOAM, it was impenetrable how to access

    As one ED physician sat next to me said, when a twitter poll was request from audience “why dont we just do a show of hands?”

    Can I suggest that next year there is

    – more opportunity for breakout sessions, whether it be Michelles poetry class, Tims drunken rants on rural EM/PHEC, or whatever

    – or better still, ‘how to do its’ in blogging, twitter usage, feedly or whatever ie how to access FOAM and make it useful for the sceptic?

    Its difficult re inclusive/exclusiveness. Although it was great to meet Weingart, Lex in person…to be honest I wish Id met Domnhall and Angie above…as well as Minh, Andy Buck, Casey, Cliff etc…or spent time with non-FOAMites to help facilitate their inclusion

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