Waves of FOAM: Does the discussion of quality and impact suggest #FOAMed’s maturation?

In Commentary, Counterpoint, Featured by Teresa Chan6 Comments

The founders of the Free Open Access Meducation (FOAM; #FOAMed) have described the phenomena as a movement. Historically, social movements have come in multiple waves. Feminism, for instance, is thought by many scholars to have at least 3 waves (some would argue 4), each with its own characteristics and stance on how to achieve its ends. If FOAM is a movement, it is likely to have similar waves of FOAMites with variable perspectives on how they interpret the role of FOAM in their lives and careers.

The recent post by Dr. Simon Carley at St. Emlyn’s and summarized a debate held at smaccUS regarding the Social Media Index and the role of an impact factor for FOAM. It raised some interesting points and was followed by this rebuttal by Dr. Brent Thoma on ALiEM.com. Taking a step back, rather than debating the merits of the SMi, I believe that it is far more interesting to examine these pieces as differences of opinion between different waves of FOAMites. Within these waves we can see that a progression of thought may be occurring that are representative of the tensions that naturally occur between these waves.

My impression of the four waves is outlined below in an infographic and in-line text.

Waves of FOAM 

(Download the infographic here)


First Wave: The Founders

This wave comprises of the group of people who decided to adopt new disruptive technologies in an attempt to reach and teach other clinicians. These innovators were the people who created FOAM before the term FOAM was even coined! This foundational group includes people like Mike Cadogan, Nick Genes, Michelle Lin, Simon Carley, Chris Nickson, and Scott Weingart who had the foresight to begin creating websites and podcasts to host freely accessible online educational resources (OERs), thereby providing a disruptive and innovative alternative to pay-for continuing medical education (CME).

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Second Wave: The Enthusiasts

The second wave of FOAM comprises many early adopters who saw the great work of the founders and sought to add their contributions. Enthusiasts include individuals like Salim Rezaie, Lauren Westafer, Jeremy Faust… and many more! They fully ascribe to the central values and tenets of FOAM set forth by the founding wave. Much like any community of practice, these “enthusiasts” often began as peripheral members (i.e. social media novices). Via peripheral participation (e.g.. starting a new FOAM site) and engagement with the central FOAM community, they learned and developed their craft. Most were heavily influenced and mentored by the first wave of founders.

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Third Wave: The Structuralists

The third wave of FOAM consists of those who both see the value of FOAM and the merits of incorporating formal structures that align FOAM to traditional measures. This wave includes FOAM educator-scholars who have begun conducting research about FOAM and disseminating their findings in peer-reviewed publications. These “structuralists” are interested in fueling the critique and critical appraisal as well as evaluating quality impact.

This wave has an interesting mixed citizenship. It includes FOAM new-comers, who provide a lateral-thinking, academic, perspective (e.g. Jonathan Sherbino, myself), as well as some first- and second-wavers. Many from this third wave may actually be FOAMites who started to do FOAM with a pioneering spirit, and later began creating structures that foster and reward those for their service within the world of FOAM (e.g. Michelle Lin, Brent Thoma). The converts from these waves have dealt with the behind-the-scenes issues of disenchantment of burnt-out volunteers and the critique of their resources. They have begun legitimizing FOAM by creating documents that define the scholarly merits of open educational resources (OER), such as the following from the 2014 International Conference on Residency Education’s Social Media Summit.

  • Hillman T, Sherbino J. Social media in medical education: a new pedagogical paradigm? Postgrad Med J. 2015 Oct;91(1080):544-5. PMID: 26338982. [Open access PDF]
  • Lin M, Thoma B, Trueger NS, Ankel F, Sherbino J, Chan T. 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 Oct;91(1080):546-50. PMID: 26275428. [Open access PDF]
  • Sherbino J, Arora VM, Van Melle E, Rogers R, Frank JR, Holmboe ES. Criteria for social media-based scholarship in health professions education. Postgrad Med J. 2015 Oct;91(1080):551-5. PMID: 26275426. [Open access PDF]
  • Flynn L, Jalali A, Moreau KA. Learning theory and its application to the use of social media in medical education. Postgrad Med J. 2015 Oct;91(1080):556-60. PMID: 26275427. [Open access PDF]
  • Pereira I, Cunningham AM, Moreau K, Sherbino J, Jalali A. Thou shalt not tweet unprofessionally: an appreciative inquiry into the professional use of social media. Postgrad Med J. 2015 Oct;91(1080):561-4. PMID: 26294333. [Open access PDF]

This focus on structure and sustainability is the key facet that denotes a third-waver. It is characterized by discussions around sustainability and funding. For examples, check out this blog post series on the International Clinician Educator (ICE) blog written by Anthony Llewellyn and I, the Teaching Course’s commitment to fuelling FOAM.

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Fourth Wave: The Participants

The work done by the structuralists is paving the way for a more participatory wave of FOAM. As opposed to the enthusiasts who got involved with FOAM earlier on and could be more directly mentored by the founders, this “participant” wave builds upon the structuralist’s effort to provide guidance and structure learned through experience and scientific inquiry. The technological barriers that existed for first and second wave FOAMites have been lessened by those in the third wave who created open access how-to guides. The legitimizing actions of some of the third wavers may also have created a window for ‘legitimized’ participation by creating perceived value in the participants’ local contexts.

Additionally, fourth wavers may find that the structural changes created by certain FOAM outlets have allowed them to more easily become a participant. Creations such as open and transparent submissions processes (e.g. ALiEM and CanadiEM), peer review processes (by experts or by coaches), FOAM-related fellowships (e.g. ALiEM’s social media fellowships), online communities (like the ALiEM Chief Resident, Fellowship, and Faculty Incubators) are forms of sustaining innovations. In an effort to make the FOAM movement acceptable and adoptable in this largest group of FOAMites, discussions of critical appraisal have emerged from social media outlets which urge the community to consider quality more seriously.



While the discussion of the Social Media Index within our community may be seen as a scholarly debate among colleagues, I propose that it can also be examined as a clash in perceptions around the role and culture of FOAM. While I agree that many participants are interested in contributing to FOAM for the purposes of bettering the world, FOAMites who identify with each wave may perceive the benefits of FOAM differently.

Earlier waves believe that volunteerism is to be expected, as they themselves have been selfless volunteers to whom our online community is deeply indebted. Their blood, sweat, tears, and money have been the foundation upon which the whole FOAM community is based upon.

Later waves may perceive that their online educational efforts are valuable works that are on par with other more traditional forms of educational scholarship. Acknowledgement of their work via formal organizations (e.g. university promotion committees) may be as important as the altruistic component of FOAM. Increasingly, FOAM is seen as a respectable form of educational scholarship that is worthy of consideration and acknowledgment via traditional spheres. After all, if a lecture at a one day local CME course where you might speak to 100 people is worthy of your curriculum vitae, shouldn’t a podcast on that same topic with a reach of 10,000 be considered a scholarly contribution as well?

In September of 2015, the ALiEM team featured an online discussion on the idea of using FOAM in one’s file for promotion processes (MEdIC case & discussion; summary digest). This discussion was expanded by Rob Rogers, Anand Swaminathan, and Damian Roland on the Teaching Course Podcast in January 2016. It may be that senior educators who have already made their mark via other more traditional routes have little desire to pursue such processes. However, because of the work that these FOAM founders have done, they have lent credibility to this new form of educational scholarship, and opened a new virtual door in education for others.

Some blogs & podcasts, like the Life in the Fast Lane (LIFTL) team, ALiEM team, and our own CanadiEM (formerly BoringEM) team, have sought to link with peer-reviewed publications. LIFTL team members have published about FOAM in the Emergency Medicine Australasia (EMA) journal. ALiEM team members published educational innovations and fostered relationships with both Annals of Emergency Medicine and the Journal of Graduate Medical Education to assist with knowledge translation. The CanadiEM team has linked up with a national association (the Canadian Association of Emergency Physicians) to repost some of their working group materials and supported the Canadian Journal of Emergency Medicine social media team. The Skeptics Guide to Emergency Medicine (The SGEM) have linked up with the Academic Emergency Medicine Journal and Canadian Journal of Emergency Medicine to translate their papers in the SGEM-Hot-Off-the-Press series.

The merging of a disruptive movement with more traditional outlets might be a cause for contention. However, we all believe in the basic tenet that the FOAM movement is to ensure that we continuously develop freely accessible OERs for healthcare providers so that they may improve patient care.

Moving Forward

Given the evolution of FOAM, is it really so bad that some parties attempt to quantify its impact in order to research and advance this field further? Shouldn’t junior faculty members who spend hundreds of hours on FOAM projects able to receive academic credit for their work? We believe that researching FOAM is a natural and important step in its development. Mirroring scientific inquiry methods, the first goal in this research was to develop a way to define a population of FOAM websites to include in our studies. This was one of the driving forces for creating the Social Media Index. Is it a perfect metric? No, but it’s the best that we have thus far and we will be happy to adopt a newer metric if one is developed.

This synthesis summarizes the perspectives of our research teams from ALiEM, CanadiEM, and MedEdLIFE (notably the METRIQ study, which is currently recruiting collaborators to participate in our studies of quality). In the meantime, let’s continue the discussion while respecting that there may not be a ‘right answer and that everyone is entitled to their opinions about the measurement of the quality and impact of the FOAM movement.


Teresa Chan

Senior Editor at CanadiEM
Emergency Physician. Medical Educator. #FOAMed Supporter, Producer and Researcher. Chief Strategy Officer of CanadiEM. Associate Professor, Division of Emergency Medicine, Department of Medicine, McMaster University.