FOAM Helps to Bridge the Knowledge Translation Gap

Published on April 18, 2016
Letter to the Editor re: Pundit-Based Medicine [EPI Issue #18, page 34]

AUTHORS—Damian Roland, BMedSci, BMBS, MRCPCH, PhD (United Kingdom); Dr. Seth Trueger, MD, MPH (USA); Dr. Brent Thoma, MD, MA, FRCPC (Canada); Dr. Teresa Chan (Canada)

In his recent commentary “Pundit-Based Medicine,”(1) (EPI, Fall 2015) Peter Cameron reminds the EM community to be skeptical of dogma in all forms, whether in print or online:

"The evidence-based medicine movement from 20 years ago promoted evidence above eminence. It seems that now our colleagues bypass reading the real evidence and go straight to the latest false prophet—usually in 140 characters."

As professionals who practice evidence-based care and also use social media, we question Dr. Cameron’s assertions. We enjoy debate: it is a cornerstone of both the evidence-based movement and FOAM (Free Open Access Medical Education). Evidence-based debate among clinicians and researchers bridge theory and practice. On social media, practitioners are able to interact with leading clinician-scientists such as Jeffrey Kline (@KlineLab), Ian Stiell (@EMODaddy), and Rick Body (@richardbody). Moreover, the ever-mourned knowledge translation gap between researchers and clinicians is closing, at least partially due to “chatter online;” sharing research online significantly increases the reach of research.(2)

Health professionals have long used formal and informal communications for knowledge transfer. We propose that there is nothing unique about social media, other than that it accelerates communication.(3) Every critique of social media can be applied to traditional knowledge exchange; countless physicians have modified practice because of a hastily-read journal publication, at the recommendation of a lecturer, or after a chat with a colleague over coffee.

We agree that we need to be critical. Leading participants of the FOAM community have long registered concerns about poorly constructed and insufficiently evidenced online material, sparking debate and proposing strategies to improve the use (and production) of evidence.(4–6) Many leading scholarly blogs are developing, and journal-style pre-publication peer review strategies (such as ALiEM.com[7]) and CanadiEM.org (formerly known as BoringEM.org) has created a “coached peer review process,”(8,9) which was selected as a Top 5 What Works innovation at the 2015 International Conference in Residency Education.(10) The ALiEM AIR certification and scoring system similarly holds online resources to a high standard.(11–13) In truth, there has been more literature published in the last two years on the quality appraisal of FOAM(14–17) (ironically, none of this peer-reviewed work was cited by Dr. Cameron in his article) than there has been in centuries of widespread use of textbooks, lectures, and other secondary sources.

Dr. Cameron asks: “How useful is all this information? If we had neglected the last 10 years of these ‘scientific advances,’ would we have lost any salvageable patients?”

This nihilistic perspective suggests that decades of new evidence have yielded no benefit to patients. While the support for many innovative management strategies often wanes in light of subsequent evidence, let’s not throw out the baby with the bathwater. Many innovative practices have withstood scrutiny.

Social media provides an excellent vehicle for knowledge translation. We are not aware of any notable cases of “authoritative” websites ignoring accepted evidence or misleading readers into inappropriate practice. At the edges, individuals may have attempted techniques or procedures still in a grey area clinically, but learning tacit knowledge from peers is nothing new. Evidence-based medicine has its limits; the contextualization and adaptation of evidence, guidelines, and rules are paramount. Many blogs focus on linking EBM commentary between clinicians and researchers; many have experimented with virtual journal clubs, which may be instrumental in engaging clinicians in new literature, and the development of critical analysis skills.(18–21)

Dr. Cameron asks “whether any of the constant flow of information is useful? Would it matter if many of the advances were delayed by a few years until adequate assessment of cost and impact were undertaken?”

Fads come and go, and as new evidence rolls out, sometimes the retrospectoscope suggests that delaying adoption “a few years” would have been wise. However, like all good journal articles, FOAM websites frequently cite the need for further study. We too bemoan the paucity of adequate cost and impact assessments. But when they are completed, the necessity for speed in disseminating results is all the more profound.

Past studies have found that the duration of the KT gap is an astonishing 17 years.(22) We must do better. The last decade and a half has seen sepsis management change remarkably. While the pendulum has swung back, would anyone consider 1999-era care acceptable? More specifically, did EGDT spread because of online discussion, or because of “definitive statements from appropriately qualified expert groups”? When PROMISE, ARISE, and ProCESS were released, the FOAM community helped digest and disseminate the results,(23–27) reining in EGDT much faster than the speed of print. Papers discussing these three important works are only just now being put online, nearly a year after the first online analyses.(28)

We thank Dr. Cameron for raising his concerns; we all must read critically. Whether online or in print, we must hold our colleagues accountable and support our arguments with evidence. Dr. Cameron criticizes those who would quickly change practice due to social media, but fails to provide any evidence to back his claims. Educated skepticism should always be applied, even to our work. We urge all health professionals to continue the quest for truth. It is through these debates that we can better serve our patients.

Dr. Peter Cameron Responds:

I thank the correspondents for their well-constructed arguments regarding my observations on the impact of social media on clinical decision making. The basis for my editorial comments was purely anecdotal, because of frustration borne of talking to trainees quoting the latest online blog (often abbreviated to a few words) rather than reading the context around the subject. The immediacy of social media gives credence to opinions (from often eminent people) that should always be framed by the caution of collective experience.

REFERENCES

  1. Cameron P. Pundit-Based Medicine. Emergency Physicians International.

  2. Hoang JK, et al. Using Social Media to Share Your Radiology Research: How Effective Is a Blog Post? J Am Coll Radiol. 2015;12(7):760-765.

  3. Roland D, et al. Top 10 ways to reconcile social media and “traditional” education in emergency care. Emerg Med J. 2015;32(10):819-822. doi:10.1136/emermed-2015-205024.

  4. May N. When FOAM Doesn’t Wash. St. Emlyn’s website. http://stemlynsblog.org/when-foam-doesnt-wash/; http://www.aliem.com/medic-series-the-case-of-the-foam-faux-pas/. Published 2013. Accessed January 16, 2016.

  5. Purdy E, et al. MEdIC Series | The Case of the FOAM Faux Pas. Academic Life in Emergency Medicine. http://www.aliem.com/medic-series-the-case-of-the-foam-faux-pas/. Published 2015. Accessed January 16, 2016.

  6. Chan T, et al. MEdIC Series | The Case the FOAM Faux Pas – Expert Review and Curated Commentary. Academic Life in Emergency Medicine. www.aliem.com/MEdIC-Series-The-Case-the-FOAM-Faux-Pas-Expert-Review-and-Curated-Commentary. Published 2015. Accessed January 16, 2016.

  7. Thoma B, et al. Implementing peer review at an emergency medicine blog: bridging the gap between educators and clinical experts. CJEM. 2015;17(2):188-191.

  8. Chan T. Battle Hymn of the Tiger Editor: Introducing the Coached peer review for FOAM. CanadiEM.org (formerly BoringEM.org).

  9. Sidalak D, et al. Coached Peer Review: Developing the Next Generation of Authors and Reviewers. Acad Med J Assoc Am Med Coll. 2016;In Press.

  10. Introducing the Top 5 What Works Abstracts. ICRE Blog. http://icreblog.royalcollege.ca/2015/07/21/introducing-the-top-5-what-works-abstracts/. Published 2015. Accessed January 16, 2016.

  11. ALiEM Approved Instructional Resources (AIR Series). ALiEM.com. http://www.aliem.com/aliem-approved-instructional-resources-air-series/. Accessed January 11, 2016.

  12. Grock A, et al. ALiEM AIR Series Grading Tool. Academic Life in Emergency Medicine.

  13. Lin M, et al. Approved Instructional Resources (AIR) Series: A national initiative to identify quality emergency medicine blog and podcast content for resident education. J Grad Med Educ. 2016;8(2):In press.

  14. Paterson QS, et al. Quality Indicators for Medical Education Blog Posts and Podcasts: A Qualitative Analysis and Focus Group. In: Association of American Medical Colleges Medical Education Meeting. Chicago; 2014.

  15. Paterson QS, et al. The quality checklists for health professions blogs and podcasts. 2015:1-7.

  16. Lin M, et al. Quality indicators for blogs and podcasts used in medical education: modified Delphi consensus recommendations by an international cohort of health professions educators. Postgrad Med J. 2015;91(1080):546-550.

  17. Thoma B, et al. Emergency Medicine and Critical Care Blogs and Podcasts: Establishing an International Consensus on Quality. Ann Emerg Med. 2015.

  18. Chan TM, et al. Ten Steps for Setting Up an Online Journal Club. J Contin Educ Health Prof. 2015;35(2):148-154.

  19. Thangasamy IA, et al. International Urology Journal Club via Twitter: 12-Month Experience. Eur Urol. 2014;66(1):112-117.

  20. Oliphant R, et al. Early experience of a virtual journal club. Clin Teach. 2015:389-393.

  21. Lin M, et al. Creating a Virtual Journal Club: A Community of Practice Using Multiple Social Media Strategies. J Grad Med Educ. 2015;7(3):481-482.

  22. Morris ZS, et al. The answer is 17 years, what is the question: understanding time lags in translational research. Jrsm. 2011;104(12):510-520.

  23. Milne WK, et al. ARISE Up, ARISE Up (EGDT vs. Usual Care for Sepsis). The Skeptics Guide to Emergency Medicine. http://thesgem.com/2014/10/sgem92-arise-up-arise-up-egdt-vs-usual-care-for-sepsis/. Published 2014. Accessed January 16, 2016.

  24. Body R. The ProMISe Study: EGDT RIP? St. Emlyn’s website. http://stemlynsblog.org/the-promise-study-egdt-rip/; http://blogs.nejm.org/now/index.php/the-final-nail-in-early-goal-directed-therapys-coffin/2015/03/24/. Published 2015. Accessed January 16, 2016.

  25. Allen-Dicker J. The Final Nail in Early Goal Directed Therapy’s Coffin? Now @ NEJM. http://blogs.nejm.org/now/index.php/the-final-nail-in-early-goal-directed-therapys-coffin/2015/03/24/. Published 2015. Accessed January 16, 2016.

  26. Boka K. NephMadness 2015: ProCESS ARISE ProMISe and the promise of Early Goal Directed Therapy. AJKD blog. http://ajkdblog.org/2015/03/18/nephmadness-2015-process-arise-promise-and-the-promise-of-early-goal-directed-therapy/. Published 2015. Accessed January 16, 2016.

  27. Mathieu S. Trial of Early, Goal-Directed Resuscitation for Septic Shock. The Bottom Line. http://www.wessexics.com/TheBottomLine/Review/index.php?id=3665078336903245716. Published 2015. Accessed January 16, 2016.

  28. Sharif S, Owen JJ, Upadhye S. The End of Early-Goal Directed Therapy? Am J Emerg Med. 2015:8-10. doi:10.1016/j.ajem.2015.10.039.

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