Medium ≠ Message

If you read one thing printed on real paper this week, make it this letter (1), followed by this response. (2)

(OK, you don’t actually have to print it on real paper, but know that it is, in fact, available printed on paper in the leading medical education journal. Or you can just point and click. For free.)

The rapid expansion of free, open-access medical edutainment has led us headlong into debate. To sum up the discussion, these two letters to the editor refer to a previously-published article by Mike Mallin, an emergency physician and EM educator in Utah, and colleagues surveying the use by EM residents of asynchronous education resources, which they define as “a student-centered modality of teaching which involves sharing online learning resources and promotes peer-to-peer interactions,” and which includes podcasts, blogs and other online shareable media. (3) Known collectively/colloquially as FOAMed (Free Open-Access Meducation), these resources are now part and parcel of many EM training programs, able to be consumed at one’s own pace, on one’s own time.

Pescatore and colleagues, in their letter to the editor, worry aloud that the messages trumpeted via asynchronous resources are at risk of being interpreted as gospel truth by unsuspecting consumers without critical consideration of their merits. Particularly susceptible to this, they argue, are the most popular of these resources and the most junior of consumers. They cite a discussion about treatment of infant bronchiolitis on an episode of the EM:RAP podcast wherein a popular contributor to that podcast made a treatment recommendation that is not supported by – and may be frankly frowned upon – by national societies in pediatrics (and which, in fact, may have been dangerous). If taken as truth rather than opinion – a real risk when impressionable listeners are swayed by the near-celebrities on popular sites – this may lead to an increase in an arguably unsafe practice.

Mallin and colleagues responded to this letter with the counter-argument that not only did EM:RAP address this concern, they did so in a timelier and more engaging fashion than would have been possible through traditional academic channels (they point out in their rebuttal that the letters to the editor themselves were delayed by a year and a half from the time of the original Mallin article). The podcast in question was followed on in a subsequent episode by a lively debate on the merits of the initial bronchiolitis recommendations, a deeper discussion of physiology, pharmacology and safety. It remains unknown if any infants were harmed in the interim.

I recall listening to the bronchiolitis episode of the EM:RAP podcast while driving and thinking, “that’s sort of a ballsy recommendation, given that it flies in the face of what I know.” I became more than a little bit indignant, in fact. I may have uttered an expletive to no one in particular related to bovine excrement. What I didn’t do, was explore the bases of what I “knew” or what the podcaster “knew.” I didn’t go back to the literature to examine the claims made. I just reacted. I was a critic without thinking critically.

The popularity of asynchronous resources – EM:RAP being the prototypical example, though others have more recently taken its place near the cutting edge – should not be a surprise to any medical educator or trainee with their eyes and ears open, but the debate really comes about when it comes to how best to ensure the reliability of the information presented.

The old school would have you believe that, like the journals and textbooks of (almost) yore, before something’s printed on paper it should be vetted by a jury of its peers. This peer-review process – venerable as it is – is not without its own biases, but it’s been the standard of academic publishing for a century or more.

The up-and-comers will tell you, with equal vigor and conviction, that peer review is stodgy and slow, delaying and prolonging the knowledge translation cycle to the oft-quoted seventeen years, and limiting the dissemination of best practices. Peer review, they say, should come from the crowd-sourced responses to open-access publication of medical practices, procedures, research and opinion; the comments page provides immediate post-publication peer review of the most honest kind.

It’s a collision of new vs. old, but it’s more than that. It’s a debate about how best to share, how best to disseminate opinions and facts and practices, and how to debate these, vet these, and explore these within the academy and beyond.

I’m not here to take a side in the debate. In fact, I can see both sides, and perhaps I’ll take the middle ground, which is to say I think there’s a place for both sides. The danger of FOAM is that personality has the potential to trump substance – who says so risks becoming more important than what they say. Guess what, though? This applies to traditional literature as well.

Because someone says so on EM:RAP does not make it so. But because someone says so in the New England Journal does not make it so, either.

The crucial ingredient is critical consumption. We must be thoughtful about what we consume, and especially thoughtful about how we model this consumption to more junior learners, modeling this critical consumption for others. We must examine our beliefs, and those of others, incorporating into our own practice that which we’ve critically examined and believe to be useful, but we must be willing to part with those beliefs when new information become available. Traditional peer review, with its faults and biases, should be improved. Post-publication peer review – the “comments” section, if you will – should be respected and contributed to. Celebrity should not be equated with reliability. The medium – be it EM:RAP or ALiEM or the New England Journal – should not be the message.



1. Pescatore R, Salzman M, Cassidy-Smith T, Freeze B. The Benefits and Risks of Asynchronous Education. Acad Med. 2015;90(9):1183. doi:10.1097/ACM.0000000000000821.
2. Mallin M, Dawson M. In Reply to Pescatore et al. Acad Med. 2015;90(9):1183-1184. doi:10.1097/ACM.0000000000000832.
3. Mallin M, Schlein S, Doctor S, Stroud S, Dawson M, Fix M. A survey of the current utilization of asynchronous education among emergency medicine residents in the United States. Acad Med. 2014;89(4):598-601. doi:10.1097/ACM.0000000000000170.

6 thoughts on “Medium ≠ Message

  1. Amen, Chris. And this is why learning basic research and manuscript-writing skills are such an important part of residency! Only by understanding where biases come from, can we develop a true ability to critically appraise the literature.

    I will also put in a plug for one of my favorite critical-appraisers-of-the-EM literature, Ryan Radecki — check out his blog at

    • Love Ryan’s site… it has a prominent place of my Feedly. Would love to hear what other sites faculty and residents find useful.

      • Thank you, Chris!! I believe this is precisely why faculty should be engaged with FOAM: educators should know which sources are geared towards basic EM learners, and which sites are more for ‘cutting edge’ discussion.

        There are now many sites dedicated to reviewing the very basics (like EM Basic), and sites such as FOAMCast where residents discuss cutting-edge podcasts and juxtapose them with what “Rosenalli” (Tintinalli/Rosen) say on a a given topic. There are also many peer-reviewed, referenced resources that aim to reduce the ‘knowledge translation window’ without sensationalizing new, unsubstantiated claims. (Love EM Lit of Note, Megan!)

        In our Asynchrony course, what I aspire to do is take FOAM content and put it into context for our learners at different levels. I point out when things are controversial vs. ‘standard of care’. But it shouldn’t be limited to one online course — since the overwhelming majority of EM residents are already using these resources, shouldn’t all of their instructors be aware of what those resources are?

  2. Thanks for finding this and writing your essay, Chris. I think it’s great that we are educators in this time of great change in med Ed. The old methods were NOT good, and we knew it, and they were pretty damn boring. I don’t see how anyone cannot be invigorated by the new ready and rapid exchange of information. We do need to be conscious about the scientific rigor and methods of what appears in our media, but that what educators are for.

  3. I’ve read more primary literature as a result of #FOAMed than before I started using podcasts and blogs to help guide my learning. The best resources build upon an established base to help generate discussion and disseminate knowledge.

    • I agree. We may be at a transitioning point for medium, but most of the blog posts I read have inspired me to read more literature from core journals. In addition, most blogs have a similar layout and feel to opinion articles.

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