PRO/CON: Why #FOAMed is Essential to EM Education

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joe-lexThe editor of this publication asked me to address the question, “Is FOAM an essential tool for medical education?” My first response was, “Are you kidding me? Of COURSE it’s an essential tool, and especially for emergency and critical care practitioners.” We of notoriously short attention spans who endure the blessings and curses of shift work are exactly the people for whom FOAM is essential.

The editor of this publication asked me to address the question, “Is FOAM an essential tool for medical education?” My first response was, “Are you kidding me? Of COURSE it’s an essential tool, and especially for emergency and critical care practitioners.” We of notoriously short attention spans who endure the blessings and curses of shift work are exactly the people for whom FOAM is essential.


More than 100 years ago, Sir William Osler recognized the limitations of pedagogical teaching: “We have outrun an educational system framed in simpler days and for simpler conditions. The pressure comes hard enough upon the teacher but far harder upon the taught, who suffer in a hundred different ways.”(1) Yet many of our instructors are still mired in this inefficient but comfortable means of instruction. While it is difficult to move from pedagogy (teaching the child) to andragogy (teaching the adult), FOAM practitioners have already gone to the next step, heutagogy: learning how to learn, a non-linear process involving true learner self-direction. While andragogy focuses on structured education, heutagogy considers all learning contexts, formal, informal, and usually self-directed. Lombardi describes heutagogy as “…the highest order learning where problems are solved using heuristic problem solving, meta-cognitive knowledge, creativity, and originality.”(2) FOAM is a perfect example. Harden said in 2002, “technology may be queen but pedagogy is king.”(3) Twelve years later, this may no longer be the case.

I am jealous of students now, learning in an age of seemingly endless resources. I clearly remember the era of pre-xerographic stencil mimeographs for handouts and bulky recording devices and playback mechanisms. When I was in medical school, there were but four computers in our library and data was saved on 1MB floppy discs. Our class notes consisted of transcriptions by careful listeners who put their combined notes together to come up with an approximation of what the instructor had taught. There was no Internet. There was no PowerPoint or Keynote. There were no battery-driven pocket audio recorders. And there were no smart phones on which to keep data at our fingertips.

But now the depth and breadth of the curriculum for emergency medicine is available at no charge on-line – everything from free textbooks (see to procedural videos (see Dr. Larry Mellick’s channel on YouTube).


“If you want to know how we practiced medicine five years ago, read a textbook.”(4)

As we all know, this is essentially true, but I will also assure you that, at some point during your training, you must read a textbook from cover to cover. You cannot expand on knowledge without having the basic building blocks. FOAM by its very nature tends to cover the “sexy” topics, like airway management or resuscitation, but in itself is an incomplete curriculum. But it would be naïve to think that a standard textbook covers the complete curriculum either. The two tools can be used together to complete your knowledge base. My personal bias is that FOAM cannot substitute for a textbook in training programs; it may supplement what is in the books, but almost certainly cannot replace it. I believe that FOAM is a far more useful and powerful tool for the practicing emergency physician, seeking convenient ways to supplement knowledge and stay current with, if not ahead of, the medical literature.

“If you want to know how we practiced medicine two years ago, read a journal article.”

FOAM is not seeking to unseat medical journals. While it is not peer-reviewed in the traditional sense, FOAM is subject to immediate crowd-sourced review and criticism. Almost all FOAM advocates who post blogs encourage readers to comment, and a healthy discussion can occur in real time concerning the information presented, with self-correction occurring within minutes or hours, rather than weeks or months. FOAM is not research: it is a useful way of “disseminating, discussing, dissecting and deliberating over the products of that research.”(5)


“If you want to know how we practice medicine now, go to a good medical conference.”

Or, if you cannot afford that, listen to talks recorded at that conference. My website, started with the help of my Temple University residents a few years ago, contains more than 2300 mp3s of talks for free streaming or download, recorded not at medical meetings around the world. In fact, it was while I was recording the International Congress of Emergency Medicine 2012 conference in Dublin, Ireland (ICEM2012), that I had a long discussion with The Father of FOAM, Mike Cadogan, the morning after he came up with the general concepts over a pint of Guinness. Many organizations have not jumped on the FOAM bandwagon yet and still attempt to sell their talks to non-attendees, with mixed success. I predict they will eventually join the FOAM fold.

“If you want to know how we will practice medicine in the future, listen to the conversations in the hallway … and use FOAM.”

Blogs, podcasts, Google hangouts, text documents, photographs, web-based applications, etc., are the lifeblood of FOAM. There are more than 240 bloggers and podcasters putting out material on almost a daily basis. And Twitter is a world in itself, with conversations sprouting over controversial topics within minutes and continuing for days. A landmark article is discussed on the same day as publication. A new technique is disseminated around the world within hours. A good example is the recent series of tweets concerning bougie-guided thoracostomy tube placement. Links to free articles, videos, and blogs appear at a dizzying rate if you follow the right Tweeters.

Because of my long-burning passion for free medical education, I have been dubbed “The Godfather of FOAM.” Despite being a semi-Luddite (I own neither television set nor cell phone and have no desire to obtain either), I am an active member of the FOAM community, vigorously engaged in debate and discussion with practitioners around the world on listservs (EMED-L and CCM-L) and on Twitter, where I have more than 2800 followers.

When I hear fellow educators decades younger than me make the excuse that “I’m not of the Twitter generation,” I point out that I started receiving Social Security payments in 2013 when I turned 66. The future of emergency medical education is in the hands of people like Haney Mallemat (@CriticalCareNow), Anand Swaminathan (@EMSwami), Scott Weingart (@EMcrit), Michelle Lin (@M_Lin) and Rob Rogers (@EM_Educator), among dozens of others. They too are passionate about FOAM and will be on the front lines for the next 20 or 30 years.

The change to FOAM will not take place overnight, but it will take place. As Max Planck wisely noted, “A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it.”(6)


  1. Delivered at the Opening of the Winter Session at St. George’s Hospital Medical School on Oct. 1st, 1913, BY SIR WILLIAM OSLER, BART., M.D., F.R.S., REGIUS PROFESSOR OF MEDICINE IN THE UNIVERSITY OF OXFORD.  Pdf of transcript of entire talk is available for download from
  2. Lombardi, S.M. (2011). Lombardi, “Internet Activities for a Preschool Technology Education Program Guided by Caregivers.”  Available on-line at
  3. Harden R M. Myths and e-learning. Med Teach 2002. 24(5)469–472.
  4. Lex JR.  International EM Education Efforts & E-Learning, recorded August 2012 in New York City.  Listen or download from
  5. Nickson CP, Cadogan MD.  Free Open Access Medical education (FOAM) for the emergency physician.  Emerg Med Australas. 2014 Feb;26(1):76-83.  Available for download from
  6. Wissenschaftliche Selbstbiographie. Mit einem Bildnis und der von Max von Laue gehaltenen Traueransprache. Johann Ambrosius Barth Verlag (Leipzig 1948), p. 22, as translated in Scientific Autobiography and Other Papers, trans. F. Gaynor (New York, 1949), pp. 33–34 (as cited in T. S. Kuhn, The Structure of Scientific Revolutions).

Joe Lex, MD, has been called the “Godfather of FOAM” in part because of his establishment of


What is  FOAM?

In 2012, Mike Cadogan conceived of FOAM – Free Open Access Meducation – over a pint of Guinness in Dublin. Cadogan, one of the emergency physician technophiles behind the Australian “Life in the Fast Lane” blog, had observed first-hand the meteoric rise in the use of social media, blogs and podcasts in emergency medicine education. (His own blog currently catalogs 279 such online resources.) Cadogan also noted that in the broader universe of medical education, these resources were getting lumped together as “social media” which, to Cadogan’s mind, gave them short shrift. A new term was in order, out of which was birthed a community, even an educational movement.

These days it’s hard to find a credible emergency physician Twitter account that doesn’t give at least a passing reference to FOAM. In fact, many mention the hashtag #FOAM right in their Twitter description. Why? Because this term has galvanized a community of online educators who believe in the free – and rapid – dissemination of medical information.

As the name suggests, FOAM resources are free and predominantly social media based, including podcasts, tweets, blogs, video, photographs, web-based applications, Facebook groups and Google hangouts. Accessibility is key: by being web-based these resources are available to any and all providers, from Malaysia to Madagascar to Minnesota.

The content of FOAM is as varied as the bloggers and tweeters who create it, but its strength appears to be encouraging open debate of hot topics and keeping readers up to date with rapidly emerging trends. Students have embraced the community as a low-barrier way to enter the medical conversation. Universities have seen FOAM resources as a convenient – and cost-effective – way to augment traditional learning and “flip the classroom.”

Defining a digital movement that is based on the principle of open access is a bit like trying to nail jello to a wall, but the proof of the pudding is in the tasting. There is no doubt that FOAM is changing the way emergency physicians learn and is spurring on a new level of global dialogue.

-Mark Brady, PA-C



Read the counter argument – No!

by Nicholas Genes, MD, PhD HERE


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