The Rise of FOAM in Emergency Medicine and Critical Care

The Rise of FOAM

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 health care related hashtags there were almost 900 million Twitter impressions containing the #FOAMed hashtag in calendar year 2014.


In June of 2015 the SMACC Conference (Social Media and Critical Care) is coming to Chicago and the “tribes” of Critical Care from prehospital, emergency, intensive care, and anesthesia will converge from around the world to share their passion for emergency medicine, resuscitation, and critical care.

But not everyone is happy.

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

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

Some counter that peer review is highly political, 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 when he explained why the real action in economics is happening in the blogosphere and not in peer reviewed journals:

“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 that 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.

There’s no doubt that 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 “Emergency Medicine and Critical Care Blogs and Podcasts: Establishing an International Consensus on Quality,” which has just been published in Annals Emergency Medicine.5

The researches 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 is not the end of the conversation but only a beginning. It is 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.

  1. Cadogan, Mike, et al. “Free Open Access Meducation (FOAM): the rise of emergency medicine and critical care blogs and podcasts (2002–2013).” Emergency Medicine Journal (2014): emermed-2013.
  1. Nickson, Christopher P., and Michael D. Cadogan. “Free Open Access Medical education (FOAM) for the emergency physician.” Emergency Medicine Australasia 26.1 (2014): 76-83.
  1. Thoma, Brent, et al. “Implementing peer review at an emergency medicine blog: bridging the gap between educators and clinical experts.” CJEM 16 (2014): 1-4.
  1. Purdy, Eve, et al. “The use of free online educational resources by Canadian emergency medicine residents and program directors.” CJEM 17.02 (2015): 101-106.
  1. Thoma, Brent, et al. “Emergency Medicine and Critical Care Blogs and Podcasts: Establishing an International Consensus on Quality.” Annals of Emergency Medicine (2015). Published Online: March 31, 2015.


About author

Tom Bouthillet
Tom Bouthillet - 25 posts

Tom Bouthillet (@tbouthillet) is Editor-in-Chief of (@ECGTraining) and Fire Captain/Paramedic in South Carolina where he is the Emergency Cardiac Care Program Manager and the STEMI and CARES Site Coordinator of his fire department.

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