Hacking Medical Education with FOAM

Dr Christopher Peter Nickson


Dr Christopher Peter Nickson
Intensivist, The Alfred Hospital, Melbourne, Australia
Adjunct Lecturer, School of Public Health and Preventative Medicine, Monash University, Melbourne, Australia
Monash University SPHPM - Alfred ICU Education Practitioner Fellow

Chris is an Intensivist at The Alfred Hospital in Melbourne and is the Monash University SPHPM-Alfred ICU Education Practitioner Fellow. He is also an emergency physician and has completed further training in clinical toxicology and clinical epidemiology. He coordinates The Alfred ICU education and simulation program, and teaches on many other Alfred ICU courses. He is co-creator of free open-access medical education (FOAM) projects such as Lifeinthefastlane.com and the SMACC conference, and is @precordialthump on Twitter™.


 

“There’s no charge for awesomeness…”

­— Kung Fu Panda

Hacking medical education!?

‘Hacking Medical Education with FOAM’… ‘What?’ I hear you whisper under your breath. A title like that deserves an explanation, I agree.

To many of us, hacking means “gaining unauthorised access to data in a system or a computer” [1]. This works for me because I have often found that access to knowledge, and how to make the most of it, is not always transparent in medicine. However, the definition of ‘hacking’ that I like the best is, “to modify or write… in a skillful or clever way” [1]. I think FOAM or Free Open-Access Med(ical Ed)ucation helps do these things [2,3].

I should also clarify what I mean by medical education. I don’t mean medical school… Or at least not just medical school, which is somewhat arbitrarily bound by examinations and assessments. Indeed, I have to agree with Sir William Osler who claimed that “Perfect happiness for student and teacher will come with the abolition of examinations, which are stumbling blocks and rocks of offense in the pathway of the true student” [4]. Yet, even the great Osler, the man who brought bedside teaching to North America, knew that ‘assessment drives learning’: “I do not know of any stimulus so healthy as knowledge on the part of the student that he will receive an examination at the end of his course. It gives sharpness to his dissecting knife, heat to his Bunsen burner, a well worn appearance to his stethoscope, and a particular neatness to his bandaging” [4]. However, what I am really writing about is how FOAM can be used to achieve lifelong learning in medicine, learning that begins in medical school but, hopefully, continues forever after.

FOAM

FOAM is a dynamic collection of free educational resources available online and largely shared via social media [2,3]. These resources include blogs, podcasts, videos, tweets, graphics, animations, and more. However, FOAM is more than just resources; it is an interactive community of like-minded individuals bound by a common ethos. The FOAM ethos holds high quality educational resources that can and should be available, free of charge, to anyone who helps people with health problems.

There are now at least 316 blogs and podcasts creating these resources worldwide in my specialties of emergency medicine and critical care alone [5]. It has also culminated in the Social Medical and Critical Care Conference (SMACC) [6], which provides a physical meeting place for this community and releases all talks as FOAM. The next SMACC will be held in Berlin, Germany in June 2017.

Importantly, these resources are available to anyone, anytime, anywhere. This makes them ideally suited for ‘just in time’ learning at the point of care. They help provide interpretations of the published literature by practicing clinicians as well as approaches to problems when there is no good evidence informing the topic. They also provide an additional means of tacit knowledge sharing, the ‘on the job’ ‘know how’ that can never be found in textbooks or journals [7]. Furthermore, FOAM is another way in which we can socially construct knowledge and learn from, and with, our peers [8].

Arghh, information overload!

Given this explosion of resources, many people worry about information overload – but that is a myth – the real problem is ‘filter failure’ [9]. If you determine your knowledge needs, and connect with other people you trust – via TwitterTM, for instance, the high quality, relevant resources will ‘bubble up’ through your network of filters making it likely that you will find what you need. Try searching for the #FOAMed hashtag (not #FOAM!) to see what is out there [10]. Alternatively, if connecting with people is not your thing, you can use the GoogleFOAM search engine [11] or read ‘The LITFL Review’, a weekly FOAM summary on lifeinthefastlane.com [12]. Some people argue that they don’t have time to use social media for medical education. Others would respond that, if used correctly, you don’t have time not to [13].

Is there a curriculum?

The bare facts of life as a learner in medicine are that you have to earn your stripes – usually through passing exams… and many exams await the medical trainee. FOAM can help students master the medical school curriculum and pass the inevitable exams. Indeed, there are now resources such as FOAMmedstudent.com specifically designed for medical students [14]. However, FOAM itself has no defined curriculum, and it does not need one [15]. To do our best for our patients we must all create our own ‘internal curriculum’. This is the path of learning we each must journey along to become the doctor we want to be, practicing the type of medicine we want, and looking after the particular patients that we will actually encounter. Textbooks and prescribed curricula are not sufficient – we must learn from our patients, our colleagues, the published literature, and FOAM.

Goodbye, bedside mentor?

As a learner it is easy to get caught up in the engaging nature of FOAM resources, the fancy graphics, and the funky podcast intro music. However, FOAM is just an adjunct to learning and nothing ever replaces the bedside mentor. One of my own former teachers was Auckland-based pathologist, Professor Tim Koelmeyer, who would constantly remind us that the patient is “our first, last, and only teacher” [16]. What he meant was that real learning takes place at the bedside, where it is facilitated by experienced clinicians who help students make sense of what patients are trying to teach them. Similarly, these experienced clinicians are vital for helping the inexperienced make sense of FOAM resources. In particular, junior trainees must always be supervised and should never institute what they have learned from FOAM without discussion with their seniors first. This is important because medical knowledge (regardless of the source) can be taken out of context and does not apply to all settings or may require a specific skill set to be safely used. In turn, learners can help their teachers by suggesting that engaging FOAM resources be used in a ‘flipped classroom’ model [17]. Learners can watch, read, or listen at home and then come prepared for meaningful discussions and active learning sessions in the workplace facilitated by an expert. In this way, FOAM does not replace the bedside mentor, but helps learning happen.

Caveat emptor!

Critical thinking skills, for some reason, are often not explicitly taught in schools or universities [18]. However, I firmly believe that critical thinking is the hallmark of the expert clinician. Critical thinking and decision making skills are what link evidence from the literature, to clinician expertise, the patient’s individual circumstances and the setting in which it occurs [18]. Importantly, if we want to thrive in medicine – and have our patients thrive too – we need to learn from multiple sources of information and we have to critically evaluate them all rather than blindly applying them. Which raises the question, how do we know if a source of information is reliable?

I have developed a brief list of questions that I use to assess the quality of FOAM resources before using them, though they can be applied to almost any source of information.

  1. Is the author identifiable?
    (If a FOAM resource is anonymous, sound the alarms!)
  2. What are the author’s qualifications?
    (This does not mean a student’s blog should be ignored, it just helps put it in context. At the other extreme, beware of ‘Arguments from Authority’ that lack any other basis.)
  3. Are there conflicts of interest?
    (Beware of financial conflicts in particular, including Big Pharma’s influence on the published medical research.)
  4. Does what I know check out?
    (I’m reassured to an extent if the author has written about topics that I do know about and did a good job, however, an expert in one sphere is not necessarily an expert in another!)
  5. Is it logical?
    (Does the author commit logical fallacies?)
  6. Is it referenced?
    (Claims should be referenced appropriately so they can be verified.)
  7. Is it supported by trusted recommendations?
    (Do other people I trust rate the resource highly?)
  8. How does the author respond to criticism?
    (No one is right all the time – and if we truly base our knowledge on science, then nearly everything we know will be falsified or revised in the future. I am reassured by authors that respond to constructive feedback openly and are willing to make improvements as part of a post-publication peer review process.)

Critical thinking is perhaps the most useful medical education hack in your armoury. It is a pre-requisite for using FOAM, or any other source of information, effectively. Unfortunately, for various reasons, even most published medical literature is false [19,20]. FOAM can be a mixed bag. Caveat emptor!

Learn using learning science

Now is an exciting time to be a learner because scientists are actually figuring out how people learn effectively [21,22]. Although much of this work from the cognitive science and educational psychology literature has yet to be validated in the world of medical education, we are silly if we ignore it. Fortunately, FOAM can neatly integrate with many of the principles of the new science of learning.

First, cognitive scientists tell us that we are actually quite good at putting things into our memories, then the challenge comes when we try to recall them at the right time and in the right form. To get good at memory retrieval, we have to practice retrieving. This can be done by testing oneself, using the so-called ‘test effect’ [21,22]. Retrieval practice is even more effective when it takes place in similar contexts to that which we are training for, such as the examination hall or the patient’s bedside. FOAM resources such as the case-based ‘show-hide’ answer blog posts on Lifeinthefastlane.com, BroomeDocs.com, and INTENSIVEblog.com are well suited for such practice [23-25]. Retrieval practice is even more effective when we combine the test effect with spaced repetition. We make stronger, more retrievable memories if we exercise our recall when we are just on the verge of forgetting. Spaced repetition software are available that have built in algorithms that allow us to do this with virtual flashcards [26]. Fortunately, FOAM resources, which are free to reuse and modify with appropriate attribution, can easily be cut-and-pasted into flashcards or linked from them for this purpose.

FOAM also lends itself to ‘interleaving’, another effective learning strategy [21,22]. An analogy is, the batsman who will see greater improvements during practice if they do not know what type of delivery is coming next. This is because they will get better at discriminating between different types of deliveries and thus perform better under real world conditions. Similarly, we can better prepare ourselves by mixing up problem types and topics when preparing for an exam and/or when preparing to work in the real world of medicine. Progress may seem slower, but the long-term benefits are likely to be greater.

Becoming a FOAM creator is also an effective way of boosting your own learning, and was a major motivation for my own involvement as a trainee. Education scientists tell us that we need to engage in reflection by taking the time to review experience so that we can learn from it [21,22]. The creation of a blog is an excellent tool for reflection, but we must ensure that anything we write is fictionalised and never based on a particular patient unless valid consent is obtained. Patient safety and confidentiality must never be compromised, whether inadvertent or otherwise.

Calibration is the last principle of effective learning that I will mention. Without calibration we can easily become self-deluded learners. Calibration involves the learners aligning their own judgements of their state of knowledge or learning with objective feedback [21,22]. This is another reason why testing yourself on questions is so effective for learning. Being subjected to post-publication peer review through the creation of FOAM resources is also a powerful learning experience. Few things sharpen your understanding or thicken your skin better than open dialogue with intelligent people about something you have just created.

Last words

There you have it, my tips for ‘hacking medical education’ using FOAM with the support of insights from the evolving science of learning and an emphasis on the importance of critical thinking skills. Ultimately, we must always remember that FOAM is simply an adjunct to learning that aims to help, rather than to replace, our bedside mentors. Furthermore, these ‘hacks’ are not shortcuts. There is no easy way in learning, indeed Osler said that, ‘work’ was the ‘Master Word’ in medicine [4]. True learning is always hard work, but this hard work is worth it, as through it we can improve patient outcomes, relieve suffering, and save lives.

“It is up to us to save the world!”
— from Peter Safar’s Laws for the Navigation of Life [27].

Author disclosures

I have no financial conflicts of interest to declare.

I am heavily involved in the creation of FOAM resources and the FOAM community described in this article. I am co-creator of the following FOAM resources mentioned in this article: Lifeinthefastlane.com, SMACC and INTENSIVE.

References

[1] The definition of hacking [Internet]. Dictionary.com. 2016 [cited 13 March 2016]. Available from: http://www.dictionary.com/browse/hacking

[2] Nickson CP, Cadogan MD. FOAM / FOAMed – Free Open Access Medical Education [Internet]. Lifeinthefastlane.com. 2012 [cited 14 March 2016]. Available from: http://lifcom/foam/

[3] Nickson CP, Cadogan MD. Free Open Access Medical education (FOAM) for the emergency physician. Emerg Med Australas. 2014;26(1):76-83.

[4] Osler W, Silverman M, Murray T, Bryan C. The quotable Osler. Philadelphia: American College of Physicians; 2002.

[5] Cadogan MD. Emergency medicine and critical care blogs EMCC [Internet]. Lifeinthefastlane.com. 2016 [cited 14 March 2016]. Available from: http://lifeinthefastlane.com/resources/emergency-medicine-blogs/

[6] SMACC [Internet]. SMACC. 2016 [cited 14 March 2016]. Available from: http://www.smacc.net.au

[7] Peach P. Technology, tacit knowledge and collective competence [Internet]. SMACC. 2014 [cited 14 March 2016]. Available from: http://www.smacc.net.au/2014/10/technology-tacit-knowledge-and-collective-competence/

[8] Cabrera D, Roland D. FOAM and the Rhizome: An interconnected, non-hierarchical approach to MedEd [Internet]. ICE Blog. 2015 [cited 14 March 2016]. Available from: http://icenetblog.royalcollege.ca/2015/01/27/foam-and-the-rhizome-an-interconnected-non-hierarchical-approach-to-meded/

[9] Nickson CP. Information overload in the age of Free Open-Access Meducation (FOAM) [Internet]. Lifeinthefastlane.com. 2009 [cited 14 March 2016]. Available from: http://lifeinthefastlane.com/information-overload/

[10] News about #foamed on Twitter [Internet]. Twitter.com. 2016 [cited 14 March 2016]. Available from: https://twitter.com/search?q=%23foamed

[11] GoogleFOAM [Internet]. GoogleFOAM. 2016 [cited 14 March 2016]. Available from: http://googlefoam.com/

[12] LITFL review [Internet]. Lifeinthefastlane.com. 2016 [cited 14 March 2016]. Available from: http://lifeinthefastcom/litfl/litfl-review/

[13] Smith R. Meet and learn from Dr Twitter [Internet]. Blogs.bmj.com. 2016 [cited 14 March 2016]. Available from: http://blogs.bmj.com/bmj/2012/10/30/richard-smith-meet-and-learn-from-dr-twitter/

[14] com [Internet]. 2016 [cited 14 March 2016]. Available from: http://FOAMmedstudent.com

[15] Nickson CP. We don’t need no FOAM curriculum [Internet]. Lifeinthefastlane.com. 2013 [cited 14 March 2016]. Available from: http://lifeinthefastlane.com/we-dont-need-no-foam-curriculum/

[16] Nickson CP. The Breakfast Club | LITFL: Life in the fast lane medical blog [Internet]. Lifeinthefastlane.com. 2009 [cited 14 March 2016]. Available from: http://lifeinthefastlane.com/the-breakfast-club/

[17] Prober C, Heath C. Lecture Halls without Lectures — A Proposal for Medical Education. N Engl J Med. 2012;366(18):1657-1659.

[18] Jenicek M, Croskerry P, Hitchcock D. Evidence and its uses in health care and research: The role of critical thinking. Med Sci Monit. 2011;17(1):RA12-RA17.

[19] Ioannidis J. Why most published research findings are false. PLoS Med. 2005;2(8):e124.

[20] Young N, Ioannidis J, Al-Ubaydli O. Why current publication practices may distort science. PLoS Med. 2008;5(10):e201.

[21] Dunlosky J, Rawson K, Marsh E, Nathan M, Willingham D. Improving students’ learning with effective learning techniques: promising directions from cognitive and educational psychology. Sci. Public Interest. 2013;14(1):4-58.

[22] Brown P, Roediger H, McDaniel M. Make it stick. Harvard University Press/Belknap; 2014.

[23] Clinical Cases in Emergency Medicine and Critical Care [Internet]. Lifeinthefastlane.com. 2016 [cited 14 March 2016]. Available from: http://lifeinthefastlane.com/education/clinical-cases/

[24] Parker C. Clinical Cases – Broome Docs [Internet]. Broome Docs. 2016 [cited 14 March 2016]. Available from: http://broomedocs.com/category/clinical-cases/

[25] Labs and Lytes[Internet]. INTENSIVE. 2016 [cited 14 March 2016]. Available from: http://intensiveblog.com/labs-lytes/

[26] Nickson CP. Learning by Spaced [Internet]. Lifeinthefastlane.com. 2011 [cited 14 March 2016]. Available from: http://lifeinthefastlane.com/learning-by-spaced-repetition/

[27] Nickson CP. Peter Safar’s laws for navigation of life [Internet]. Lifeinthefastlane.com. 2009 [cited 14 March 2016]. Available from: http://lifeinthefastlane.com/laws-for-the-navigation-of-life/