The flipped classroom might just be the future of medicine


Since the days of Sir William Osler, medical education has been done in much the same way by everyone everywhere. Doctors and academics slave away for hours and hours preparing lectures for students and trainees, all the while being locked away in their own isolated little silos. An anthropologist from Mars (to borrow an image from Temple Grandin made famous by Oliver Sacks) would find this remarkable.  Could it really be true that so many dedicated, brilliant people with the same objectives could be doing exactly the same thing at the same time without sharing their resources? That they could be missing out on the interactions that fuel innovation? That they could put so much work put into teaching sessions that so few actually attend?

The Martian would think to herself, why don’t these educators find a way to share resources? Why don’t they make video and audio recordings so that learners can review them when it suits their hectic schedules and learn asynchronously? Why don’t they make notes and links to references available online too? Perhaps students could even do all the didactic stuff before the teaching session even begins, then learn actively through discussion and simulation in a flipped classroom? The Martian would also spare a thought for those who do not ever have face-to-face access to expert educators. Such people include medical learners in remote regions and throughout the developing world. Why not give them access to free learning resources that can help them teach others, and help them to improve the health of their patients? The Martian would wonder, “isn’t that what medicine is all about?”

Fortunately, you don’t have to be a Martian to see that the traditional approach to medical education doesn’t make much sense. Fortunately, the times are always a changin’.

I first started medical blogging as a clinical toxicology registrar for two reasons.Firstly, to help with my own learning and, secondly, to make the teachings of the masters I had the privilege of learning from available to all.  My blog had small beginnings but was inspired by that of a senior colleague, emergency physician Mike Cadogan. One day, five or so years ago, Mike and I were sat in his office in Perth, Western Australia, when we realized that we needed to join forces on a fledgling medical education adventure in social media.Mike said “this stuff is going to take the world by storm.” I laughed, not sure if he was serious, half-believing, half incredulous., in its current form, was born.

Let us fast forward to the present. now receives over 20,000 page views daily and has a global reach and reputation as a high quality source of free online medical education (with a twist of Antipodean humor  for those interested in the emergency medicine and critical care specialties. More importantly, we are not alone. There are now over 130 emergency medicine and critical care blogs and podcasts around the world. Yet this is just a small part of the open, collaborative educational activity that now occurs online, whether that be through Twitter, or videos shared on YouTube and Vimeo, or (yes it’s true) even Facebook.

Despite this, doctors, as a species, are laggards. We tend to be conservative, and like to have all the squeaks and squeals oiled out of anything before we dare use it. Mike and I (among many others) have been proselytising the potential of social media for medical education for some years, but when most doctors hear the words “social media” their minds slam shut. Social media is kryptonite to our medical super-colleagues; it conjures up images of peripubescent teens tweeting on the playground and rating viral kitten videos on YouTube.  Yet, thankfully, more and more doctors are starting to pull their heads out of the sand.

Now let us rewind to June of last year. The 2012 International Conference of Emergency Medicine was being held in Dublin, Ireland. Mike was due to give yet another talk on how social media was the next big thing in medicine. Whilst sharing a Guinness or two with friends new and old, an idea was found at the bottom of a pint. Doctors need a new name for social media. Actually, we need something that transcends social media, because that is only a part of what we, and our like-minded friends from around the world, are trying to do. The name for this is FOAM.

FOAM is ‘free open-access meducation’. On Twitter, where the #FOAM hashtag can lead one into less educational realms, we call it #FOAMed. For me FOAM is simply medical education available to anyone, anytime, anywhere at no cost. Since Dublin, this banal little acronym has become something of a worldwide mini-movement.  A community has developed around an effervescent collection of constantly evolving, interactive open access medical education resources shared on the web with one objective — to make the world a better place. FOAM is independent of platform or media — it includes blogs, podcasts, tweets, Google hangouts, online videos, text documents, photographs, Facebook groups, and a whole lot more.

FOAM is not just for emergency medicine and critical care doctors. Other specialists have joined in, as well as our medical student, nursing and pre-hospital colleagues. A key feature of the movement is that the hierarchy is flat. There are no leaders; everyone is a leader. A nurse can teach a doctor, a medical student can teach an attending.  When it comes to FOAM, quality cannot be stopped from bubbling to the top.

Yet FOAM, like anything innovative, has its critics. Perhaps the burden is upon us to show that FOAMphilia is not simply a case of ‘gizmo idolatry’ run rampant. In the absence of hard numbers, we can offer the testimonies of many zealous FOAM users who are happy to recount the myriad times they have learnt something that changed their practice, got them out of a sticky situation, or that helped them to teach others and save lives. FOAM supplements the explicit knowledge found in journal articles with the tacit knowledge that is learnt on the job. Like parachutes, not everything needs a randomized trial to prove that it works. Yet I will concede we have work to do if we are to provide an objective measure of the impact of FOAM. This is a challenge for the future.

A constant criticism of FOAM is that it lacks peer review. This criticism is akin to proponents of fascism decrying the rise of democracy. Traditional peer review is a fatally flawed process, as expound by former editor of the BMJ Richard Smith in the Journal of the Royal Society of Medicine, and is not something we should necessarily look up to. We should be seeking a better way of ensuring quality. Indeed, prominent podcaster and emergency medicine critical care expert, Scott Weingart of recently stated on Twitter that the ‘post-publication peer review’ he receives on his podcasts exceeds the rigor of that received by his traditional scientific publications.

In my experience, if you put a foot wrong in the FOAMosphere you find out about it fast. As for traditional textbooks, these out of date goliaths are largely devoid of any peer review, are renowned for errors, and tend to impede rather than accelerate knowledge translation from the primary literature. FOAM, on the other hand, is unrivaled in its ability to be updated, its capacity for expediting knowledge translation, and for allowing conversations between minds – both great and not-yet-great – to take place where all can see and hear. The take home message is that whoever you are, whatever your read, see or hear — whether from a journal, a textbook or FOAM — you have to think critically, be skeptical, and speak up if something is not right.

The future of FOAM is yet to be written. By getting involved we can predict the future by making it happen. In the immediate future of emergency medicine and critical care FOAM there are two exciting developments I would like to mention.

The first is another brainchild of Mike Cadogan, namely GMEP, the Global Medical Education Project. This promises to be a unifying platform that will allow everyone to engage in FOAM in a way that is free and easy. Through GMEP, medical educators and learners alike can share, reuse and modify questions, video, podcasts, blogs and more and have it all hosted for free. It is early days yet, but GMEP is already something that everyone in medicine needs to know about. Have a look for yourself.

Finally, emergency medicine and critical care FOAM truly comes of age on March 11th 2013 when the SMACC (Social Media and Critical Care) conference begins in Australia. This conference, led by Sydney Intensivists Roger Harris and Oliver Flower, is dedicated to FOAM and is social media enabled. It will feature some of the biggest names in critical care research (many of whom are social media laggards, but are willing to have their minds opened!) and online education. More importantly it will give people, both users and creators of FOAM, from across the world a chance to finally meet in person. All the talks and presentations will be recorded and distributed for free for anyone to access.

There will be competitive medical scenario simulations called ‘SimWars’, a similar bedside sonography challenge (called ‘SonoWars’ of course!) as well Q&A sessions and post-talk discussions that will not only involve those physically present, but also those virtually present through social media such as Twitter. In one sense however, the conference has already begun. A global competition is being run to see who can create the best 400 second long medical education talk — these ‘PK SMACC-talks’ speak for themselves.

In conclusion, FOAM, together with asynchronous learning and the concept of the flipped classroom might just be the future of medicine. We — all of us in the health sphere who want to help others —have a chance to make it happen.

Chris Nickson is a physician in Australia who blogs at Life in the Fast Lane.


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