FOAM risks and benefits

The recent podcast on altered level of consciousness with Dr Rob Hislop illustrates some of the benefits and risks of Free Open Access Medical Education (FOAM). His opinion is that our current management of delirium on the ward is often inadequate and that we should consider earlier use of IV agents to appropriately sedate patients. This contrasts with the more traditional management discussed in the podcast on delirium with geriatrician, Dr Scott Murray.

FOAM has provided an important platform for challenging conventional wisdom and dogma. For example, the online discussion on the role of cricoid pressure in rapid sequence intubation has led many clinicians to review the associated literature and change their practice. However, if new concepts are posted without being challenged then there is a risk that the information will be accepted without appropriate critical appraisal. Junior doctors may be a group at particular risk of accepting practices based on the seniority or reputation of the doctor giving the advice.

The issue of peer review

FOAM has been criticised for the lack of a formal peer review process. However, it has also been argued that the comment section provides immediate post-publication peer review.  The website has the capacity for comments to be posted but there have been only a few received so far.

There are likely to be a number of reasons for this. The website is in its infancy and we do not have the number of viewers compared to the popular FOAM websites and it has been noted that the more popular resources are subject to greater scrutiny and discussion than those with fewer subscribers. The rule of 90-9-1(90% of users are lurkers – read, observe, but don’t contribute; 9% contribute from time to time; 1% of users participate and account for most contributions) suggests that you need a large number of participants to ensure that you have contributors. What number of viewers to a FOAM website is needed to ensure appropriate peer review?

onthewards is a FOAM resource aimed at junior doctors

Our website is aimed at junior doctors whilst most of our speakers are senior clinicians. The power dynamic between junior doctors and senior doctors is significant and may act as a barrier to junior doctors commenting or disagreeing with the opinion of a consultant.

Currently, there is an internal review process within the website prior to the podcasts, summaries and blogs going online. However, it is more difficult with podcasts than written posts. If there is an idea or concept in the discussion that is controversial, is it reasonable to edit the podcast? Does a website such as ours need external reviewers?

The problem that I now face is; do I only post information that is safe and by the book; or do I allow ideas that are challenging or controversial? Or am I underestimating the critical thinking of junior doctors?