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SadFaceWhat if a resident-physician attempted a technique she read on a blog or listened to on a podcast, but the procedure didn’t go as planned and the patient was harmed? Is Free Open Access Meducation (FOAM) to blame for medical errors? What about the blog site? If the site has a disclaimer (like most medical databases), is it enough to limit liability?

These are challenging questions, but ones that deserve discussion, especially in light of the recent post on St. Emlyn’s blog about a theoretical scenario just like this.

The Power of N=1

The FOAM era of learning and knowledge dissemination has arrived, taking particular hold in the fields of emergency medicine and critical care. Tips and pearls are shared fast and furiously through various social media outlets, including blogs and podcasts. In fact, FOAM has become a leading source of N=1 innovations. Whereas we might previously have only locally shared our method of turning a paper clip into a make-shift eyelid retractor, we can now post a video of it on YouTube to be shared with the world. Most of them have at least some basis in the literature, but not all. It is in these tips and pearls that we can sometimes be lured in by an interesting or novel approach. Sometimes these experiences lead to new ideas to manage complex, critically ill patients such as the DSI technique, and sometimes it can merely be a ‘nifty’ way to approach a frequently encountered problem, such as the adenosine flush trick for SVT.

The trouble with ‘case report’ blog posts or podcasts is that the N=1 study may not be sufficient to allow for full testing and vetting of novel experiences. The alternative perspective may also be valid; in some cases N=1 may be the best study possible. If you have an awful experience with a method, you’re likely never to use it again; if you succeed, you’ll want to tell the world. As a reviewer for several peer-reviewed journals, I dread reviewing the case report submission. Seemingly vital information is often excluded, presenting an enormous challenge when deciding its publication fate. In the case presented by St. Emlyn’s, what was the physician’s level of training? Had they tried this method previously? What was the thought process behind why they elected this particular patient for this method? What is their Interventional Radiology department like? Are they responsive to calls? So many variables exist in any given patient case.

There are some things that will likely never be studied through double-blind, randomized, controlled trials. Sometimes, the best we will ever have is a novel, one-off, MacGuyver approach that is needed for a specific and infrequent occurrence. This is the role of case-report sort of scholarship. This exists both in FOAM form… but also in print newsletters (e.g. ACEP News’ Tricks of the Trade series) and peer-reviewed journals (e.g. ‘Tips from the Trenches‘ in CJEM).

The Medium or the Message?

Have you ever met a resident who ‘understood’ the central tenets of fluid resuscitation in sepsis, but then slightly misapplied the Early Goal Directed Therapy formula? In that situation, do you blame the textbook from which he learned said formula? Would you blame a website that synthesized that information? What about an app? Would you blame the preceptor that misspoke and said “8” instead of “4” when explaining a calculation? Or, worse yet, the information was stated correctly, but misheard or misinterpreted by the end user.

How is this unfortunate medical error case different from situations where someone misapplies non-EBM skills from textbooks like Roberts and Hedges, or even Rosen’s or Tintinalli? If one reads about ultrasound and then misses free fluid on a FAST exam (having not received proper training), do we really know the root cause of the problem? In the end, does it really matter where he acquired the semantic information?

Marshall McLuhan once wrote – “The medium is the message”.  Dr. Teresa Chan (@TChanMD) has recently wrote about what that means to us in the medical profession on BoringEM’s blog. In brief, the medium can greatly affect the ‘message-received’ from those who view/hear/read that message (‘consumers’). And herein lies the great conundrum – when respected and well-qualified medical professionals write on an educational blog, does the blog itself then become a trusted entity that is immediately useful to ‘consumers’?

For a non-medical example, what would happen if you found a recipe on Pinterest by a renowned chef and it comes out tasting terrible? Is that the fault of the recipe or the lack of skill and interpretation of the chef? Few would jump to say it’s the fault of Pinterest for allowing you to find the recipe.

Not Playing the Blame Game

Interestingly, FOAM content is seemingly more at risk for blame compared to more traditional resources. Our opinion is that FOAM itself is not to blame. Nor is any specific website or resource. Misapplication of information applies to all forms of knowledge – and sometimes, regardless of the information we read, we will make mistakes. Canadian emergency physician Dr. Brian Goldman has reflected on this process in his TED talk ‘Doctors Make Mistakes – Can We Talk About That?‘.

Pointing fingers to the textbook, the lecture, or the physician who taught us that knowledge is not really all that constructive. Regardless of how venerated a source is, the application of a technique to patient care is just that… It’s patient care. And as a practitioner, you’re going to try your best to do ‘right’ by your patient. Sometimes you will be armed to the hilt with the best, most up-to-date evidence. And sometimes you will not. Sometimes you have to make do with what you know and act upon it.

When this does not go right, the knee-jerk reflex is to start looking for someone to blame. And for some, FOAM may be a convenient scapegoat. But, people have also made mistakes based on the most robust of guidelines and evidence. This is not a ‘unique’ feature of FOAM. The size, reach, and immediacy of the access, however, can be why it is so tempting to blame ‘the internet’ or ‘FOAM’. But then, textbooks can be ‘out-of-date’ and systematic reviews can be ‘updated and revised’.  ‘Truth,’ at least in medicine, is a moving target, and we will always be at its mercy.

The Role of a Site Disclaimer 

Up-To-Date (Wolters Kluwer), one of the most widely used clinical resources, has the following disclaimer:

USE OF PROFESSIONAL JUDGMENT: The editors and authors of the Licensed Materials have conscientiously and carefully tried to create the identified diagnosis measures, treatment alternatives and drug dosages in the Licensed Materials that conform to the standards of professional practice that prevailed at the time of publication. However, standards and practices in medicine change as new data become available and the individual medical professional should consult a variety of sources. For this reason, only the most current release of the Licensed Materials should be consulted when information is sought. New updates of the Licensed Materials are issued periodically; do not rely on older versions. In addition, when prescribing medications, the user is advised to check the product information sheet accompanying each drug to verify conditions of use and identify any changes in dosage schedule or contraindications, particularly if the agent to be administered is new, infrequently used or has a narrow therapeutic range.

The Licensed Materials describe basic principles of diagnosis and therapy. The information provided in the Licensed Materials is no substitute for individual patient assessment based upon the healthcare provider’s examination of each patient and consideration of laboratory data and other factors unique to the patient. The Licensed Materials should be used as a tool to help the user reach diagnostic and treatment decisions, bearing in mind that individual and unique circumstances may lead the user to reach decisions not presented in the Licensed Materials. The opinions expressed in the Licensed Materials are those of its authors and editors and may or may not represent the official position of any medical societies cooperating with, endorsing or recommending the Licensed Materials.

A bit extensive? Maybe. But, are the producers of FOAM not trying to accomplish a similar goal of distributing timely and accurate information with the intent of improving patient care? FOAM-producing blog sites probably should have a similar disclaimer.

The Future Is Now

While peer review of FOAM resources may not occur in the traditional sense, strides are being made to do just that. Post-publication peer review comes fast and furious by way of comments on the blog (+/- revisions), direct emails to the author, and discussion on Twitter, Facebook, and Google+. This is the virtual equivalent to the rabid debates we have at EM conferences throughout North America. If a trusted colleague presents a technique to you at change-of-shift, this is unvetted N=1 success as well.

But just as you might let a colleague know that you had trouble with her technique, so too must we contribute to that collective wisdom about shared concepts and techniques. The power of FOAM is just that: Your materials can be released to and reviewed by ‘the masses’. As is true for all medical knowledge, with time and feedback, we can continue to improve.

See 5 Rules to Guide Your Learning Approach in Social Media.

Bryan Hayes, PharmD

Bryan Hayes, PharmD

ALiEM Associate Editor
Clinical Assistant Professor, University of Maryland (UM)
Clinical Pharmacy Specialist, EM and Toxicology
Teresa Chan, MD
ALiEM Associate Editor
Emergency Physician, Hamilton
Assistant Professor, McMaster University
Ontario, Canada + Teresa Chan
Michelle Lin, MD
ALiEM Editor-in-Chief
Editorial Board Member, Annals of Emergency Medicine
UCSF Academy Endowed Chair for EM Education
UCSF Associate Professor of Emergency Medicine
San Francisco General Hospital
Michelle Lin, MD