Thursday, March 7, 2013

Drinking from the Firehose - One Sip of FOAM at a Time

The Gist:  Reading/listening/seeing does not equal understanding.  FOAM naturally serves as a conduit for spaced repetition - be open to the wide array of material and filter smartly.  Take advantage of spaced learning, including that offered by Free Open Access Medical education (FOAM), to learn more effectively.

"Medical school is like drinking from a firehose.." We hear this refrain from the beginning of med school but the truth is that this will extend beyond our formal medical training.  As a result, we find our ways to cram what we can in, often one subject at a time.
  • Disclaimer:  I'm no expert, just a professional learner.
FOAM seems like it could help with this but the there's an enormous breadth of content and some view FOAM as disorganized or overwhelming.  I, like many, have joked that emergency medicine folks love FOAM because it appeals to our attention deficit.  In fact, it is somewhat similar to a shift in the emergency department- there's no way I can predict my Twitter, podcast, or blog feed upon opening.  Trainees, educators, and seasoned physicians have expressed the seeming disorganization as a concern regarding FOAM.  However, there is another way of framing this input.

Spaced Repetition - Dr. Chris Nickson of Life in the Fast Lane describes this excellently in Learning by Spaced Repetition and The Magic of Spaced Repetition.  Initially, I merely gleaned over the iTeachEM post as I scrolled through my blog feed to reach the stuff that I thought was actually relevant to me - medicine.  I was wrong.  Learners like me often don't value thinking about how we learn, we just want to learn what we need to know (how do we know what we don't know?).  I have realized, however, that it's actually helpful to understand how I think and learn, regardless of how well I believe I've mastered learning. Simply:
  • Over time, we forget things
  • Reminders, especially well timed one, mitigate this forgetfulness
  • Flashcards can work in this fashion but much medical information doesn't lend itself well to this practice (which can be cumbersome in a field like EM that spans...everything).  
    • Tip: I uploaded flashcards via GoogleDocs to a $1.99 iPhone application that had a "smart learning" feature which was really helpful in the first 2 years of med school for exams (and I could then go back to as I prepped for the USMLE).  There are other similar applications such as 
There's relevant evidence behind this, too:
  • Randomized controlled trial by Kerfoot et al demonstrating effectiveness of spaced repetition in a urology clerkship and another RCT in urology residency programs.  
  • Kerfoot et al have several publications on this intervention, including this one that demonstrated issues with regard to completion of the intervention by students
FOAM naturally produces spaced repetition through a call-and-response-like system, indicating that people are critically thinking about topics (while others of us quickly begin the process of forgetting, ready for an opportune reminder at any time).  Check out this example:
Twitter debate (February)
ALiEM post on PE diagnostics in Pregnancy (March)

What's the key? My thoughts:
  • Don't be afraid to go back and listen to old podcast episodes, listen or re-read bits of FOAM you've already experienced - you can build and reflect upon what you've learned.  
  • Remember that FOAM offers far more than cutting edge medicine - Be open to all topics, even the seemingly mundane ones.  
  • Have a method of filtering FOAM topically for when you want to explore something in depth.
For example:  search FreeEmergencyTalksLife in the Fast LaneEMgoogle, or pose a question on Twitter...Your own syllabus!
    • This can help steer you to literature/texts to read (or supplement/update the ones you have read). 
  • Have a method of saving bits of FOAM.  You can't get through it all.  See a paper tweeted that you should read or an interesting PV card?  Star it in GoogleReader, clip it to Evernote, or save it in Pocket.  It'll be easily searchable when you need it.
  • Shuffle.  Haphazardly download from FreeEmergencyTalks or put your podcast player on shuffle.  This may overcome the desire to listen to the 'latest and greatest' and act as a refresher on things you thought were previously mastered.  This does not mean abandon focused study or curriculum, but more of an encouragement to add on this layer.
  • Relax. FOAM isn't a requirement or a race, it's about learning - a tool.  Given our attention spans, the vast amount of information we have to learn, and the nature of truly understanding/mastering something we will miss things.  Fortunately, we will be reminded of these deficits - by a patient, an attending, or by FOAM
Translation into practice (My wake up call to spaced repetition..but these examples occur daily):
Patient #1 -  A 29 year old male brought into the ED via ambulance for two witnessed seizures, now in his "typical" post-ictal state - not responding to most question but protecting his airway and maintaining posture.  Vital signs were all stable and blood glucose was 88 mg/dL.  His wife provided most of the history, including an apparent "history of seizures," previously on multiple medications.  The patient began having another apparent tonic-clonic seizure.  While 2 mg of lorazepam was being retrieved, the seizure activity abated.
  • This case occurred during my first month in emergency medicine and I felt slick subtly and calmly helping the off-service resident assess and navigate the situation.   
  • With the patient stabilized, we dug through the hospital and clinics' notes and discovered that the patient was, in fact, diagnosed with pseudoseizures.  I felt so..used and wrong. The seizure seemed so real! I made a note to read on these.
I read plenty, but forgot to read on pseudoseizures, as exciting as they sounded, and as many seizing patients that I saw.  Weeks later, I heard Dr. Mattu and company discuss psychogenic non-epileptic seizures (PNES) on the EMCast June 2011 episode.   I had been coerced into "reading up" on something I had dismissed as unimportant or boring.  (Note: EMCast episodes older than 6 months are now, or should soon be free).

The discussion briefly focused on prolactin and I was briefly brought back to my time in the social work field when one of my clients had a letter from her neurologist stating that should she have a particular "episode," the ED should draw a prolactin level within 30 minutes.  Curiosity led me to a quick FOAM search led me to a a discussion on the BroomeDocs blog on prolactin.  

The next week, I saw a patient with PNES in the ED after getting fooled again (which will happen with PNES).  Good job, FOAM, I got the nudge and read.  I began noticing that there were cases of PNES everywhere.

Two months or so passed and, EMRAP (subscription required) reminded me again, of PNES.  That week, I was approached with two cases of suspected PNES.

Ailments are so much more common when we know to look for them and when they're on the forefront of one's mind.  In EM, everything in medicine is on the figurative table.  FOAM has certainly helped me identify gaps in my learning, maintain a broad differential, and refresh my memory. 

Updated March 2014


  1. Great post Lauren. Really interesting that much of pre-specialty training is still focused on delivering a set amount of information without too much attention as to whether transfer of learning is occurring. It is great that you have learned these lessons of self awareness in learning at a very early stage in your career.

  2. This comment has been removed by a blog administrator.

  3. it is great that u have learned these lesson of self awareness in learning at a very early stage in your career.

    san ramon dentist