About Michael Gisondi, MD

Associate Professor and Vice Chair of Education
Department of Emergency Medicine
Stanford University
Editor, ALiEM EM Match Advice series

The Fall of FOAM

Fork in Road Disappearance of FOAM blog podcast

The landscape of emergency medicine and critical care (EM/CC) blogs and podcasts has changed dramatically over the past 20 years. The number of free, open-access EM/CC blogs and podcasts has plummeted. As reported by Lin and colleagues in JMIR Education (2022), these sites decreased in number from 183 in 2014 to just 109 this year– a drop of 40.1% [1].

via GIPHY

This comes after a period of rapid growth of these educational resources in the late 2000’s [2], with expectations that new sites would continue to come online. It is unclear when the combined number of EM/CC blogs and podcasts peaked, or how recently it declined.

Why do we care in these declining numbers?

The FOAM (free open-access medical education) movement has become an important component of EM curricula at many training programs. Online learning resources such as medical blogs and podcasts have all but replaced traditional textbooks, and research suggests that some trainees use these products as their primary study materials [3]. Therefore, the observed decrease in FOAM sites is alarming, as training programs and trainees have come to rely on their availability.

Featured paper

In our JMIR Medical Education paper, Lin et al. sought to identify active EM/CC blogs and podcasts during a 2-week period in May 2022. The authors found a total of 50 blogs, 25 podcasts, and 34 blogs + podcasts (n=109). The age of these FOAM sites ranged from 1-18 years and most were physician-led. Just over half had leadership teams of 5 or more individuals. Support was identified for approximately 75% of the sites and included advertisements, institutional sponsorship, or the sale of goods and services (though site access remained free).

The Christensen Theory of Disruptive Innovation may explain the recent decline in EM/CC blogs and podcasts. Using this lens, FOAM sites are considered ‘disruptors’ in medical education that quickly gained market share previously dominated by ‘incumbents’ such as medical textbooks, journals, and in-person conferences. Rather than cede their influence, incumbent organizations co-opted the disruptive innovation itself, in this case leveraging their assets to create their own online learning resources, blogs, and podcasts. As these incumbent offerings grew, there was less need for new, independent FOAM sites. Concurrently, FOAM sites continue to generate little-to-no revenue and academic value for the creators, making it difficult for the disruptors to challenge the market dominance of incumbents or to create its own unique, sustainable market space. We theorize that older sites likely succumbed to these financial and academic opportunity costs as well as high user expectations for design and functionality.

What is the future of FOAM?

Though EM/CC blogs and podcasts changed the landscape of medical education in fundamental ways, they will likely not endure as independent entities without new business models for sustainability. A recent study suggests that the costs of FOAM might be offset by advertising or other revenues [4]. Based on our observations of current practices on existing FOAM sites, this might include at least incorporating any/all of the following:

  1. Inserting advertisements
  2. Creating products for sale such as books, courses, swag, or consulting services
  3. Developing partnerships
  4. Soliciting for donations

In the meantime, we posit one of 3 potential futures of new and existing blogs and podcasts: hybridization, disappearance, and new-market independence.

future of foam christensen

  1. Hybridization strategy: Incumbents partner with or create their own blogs/podcasts. This loss of independence, which was part of the initial appeal of FOAM grassroots efforts, is traded for more stability and infrastructure. Already 44% of EM blogs are officially affiliated with a sponsoring institution.
  2. Continued disappearance of sites: Progressively fewer independent, free blogs/podcasts because of site demise, merging of sites, or conversion to paid subscription model
  3. Independent sustainability: Growth of independent, free blogs/podcasts as its own new-market endeavor, separate from the incumbent market space, only achievable with better return on investments (academically and financially) for bloggers/podcasters. Once FOAM efforts are no longer a major opportunity cost, educators may even be able to pivot their careers towards this primarily, rather than as a side project.

It remains to be seen whether FOAM can withstand market and academic pressures or whether it is destined to be assimilated by better-resourced incumbent organizations.

What is the future of ALiEM?

We hope to stick around and hope the rest of the FOAM community will evolve with us.

Comments?

Join the interesting discussion on Twitter. We are thrilled to bring this conversation to the forefront.

https://twitter.com/M_Lin/status/1582021848958500864?s=20&t=nBcJtrRvgML2QMRNnZkwwA

References

  1. Lin M, Phipps M, Yilmaz Y, Nash CJ, Gisondi MA, Chan TM. A Fork in the Road: Mapping the Paths of Emergency Medicine and Critical Care Blogs and Podcasts. JMIR Medical Education. 2022 (preprint available: https://doi.org/10.2196/39946)
  2. Cadogan M, Thoma B, Chan TM, Lin M. Free Open Access Meducation (FOAM): The rise of emergency medicine and critical care blogs and podcasts (2002-2013). Emerg Med J. 2014;31(e1):e76-e77. doi:10.1136/emermed-2013-203502
  3. Branzetti J, Commissaris C, Croteau C, et al. The Best Laid Plans? A Qualitative Investigation of How Resident Physicians Plan Their Learning [published online ahead of print, 2022 May 24]. Acad Med. 2022; doi:10.1097/ACM.0000000000004751
  4. Lee M, Hamilton D, Chan TM. Cost of free open-access medical education (FOAM): An economic analysis of the top 20 FOAM sites. AEM Educ Train. 2022;6(5):e10795. Published 2022 Sep 9. doi:10.1002/aet2.10795

How I Educate Series: Michael Gisondi, MD

This week’s How I Educate post features Dr. Michael Gisondi, the  Vice Chair of Education at Stanford University. Dr. Gisondi spends approximately 80% of his shifts with learners which include emergency medicine residents, off-service residents, medical students, and physician assistant students. He describes his practice environment as a busy, high-acuity, university-based, suburban hospital with an annual ED census of 85,000. One-third of the patients speak a language other than English and one-third are without health insurance. Below he shares with us his approach to teaching learners on shift. 

Name 3 words that describe a teaching shift with you.

Direct observation & autonomy

What delivery methods do use when teaching on shift?

Hypothetical questioning

What learning theory best describes your approach to teaching?

Relational autonomy

What is one thing (if nothing else) that you hope to instill in those you teach?

Patients deserve comprehensive evaluations. That doesn’t mean sending every test on every patient, but it does mean considering broad differentials and testing when appropriate.

How do you balance your flow with on-shift teaching? Does this come at the expense of your documentation?

Every interaction is teaching, though perhaps it isn’t signposted as such. For instance, how much time I spend with one patient relative to another speaks volumes to those who are paying attention.

What is your method for reviewing learners’ notes and how do you provide feedback on documentation?

I read them all, and I point out errors of omission or misstatements that need correction.

Do you feel departmental flow and metrics adversely affect teaching? What is your approach to excelling at both?

Absolutely not. Being efficient is one of the most important learning outcomes during emergency medicine training. Metrics are measures of these learning outcomes and are not at odds with training in any way. Residents must learn how to excel as attendings and operational metrics are part of their future.

It can be difficult to sit back and let senior learners struggle what is your approach to not taking over prematurely?

I’ve learned to give a long leash to the senior residents. I stalk the board constantly and read all the notes, both from physicians and nursing. I sneak in to examine patients when the residents aren’t looking. I know what’s happening on my team and can gauge how much autonomy to give my residents.

Do you start a teaching shift with certain objectives or develop them as a shift unfolds?

I let the shift play itself out.

Do you typically see patients before or after they are presented to you?

I try to see as many patients with residents as possible. There are so few direct observation opportunities in training that I try to create them as much as possible. It helps me give better feedback to residents and it improves efficiency.

How do you boost morale amongst learners on shift?

Everyone gets a meal break. I try to help chart or disposition patients when busy. I liken myself to a good second-year resident.

How do you provide learners feedback?

Again, I’m giving feedback constantly, whether it is signposted or not. Simply agreeing with a plan is feedback. I find that I don’t have much to say on end-of-shift feedback forms because I’ve been teaching and giving feedback throughout the shift.

What tips would you give a resident or student to excel on their shift?

Stop for 3 minutes after every patient and write the H&P in the chart. It will save so much time later in your shift. Similarly, complete your entire note before calling report. It saves you and the admitting team a lot of time on the phone.

Are there any resources you use regularly with learners to educate during a shift?

Equianalgesic opioid dosing charts.

What are your three favorite topics to teach during a shift?

Running a code, motivational interviewing, and how to remove an ingrown toenail

What techniques do you employ when teaching on shift?

Relational autonomy, direct observation, The Feedback Formula.

What is your favorite book or article on teaching?

Fostering the Development of Master Adaptive Learners: A Conceptual Model to Guide Skill Acquisition in Medical Education

Who are three other educators you’d like to answer these questions?

Holly Caretta-Weyer, Abra Fant, Sara Krzyzaniak

 

How I Educate Series logo

Read other How I Educate posts for more tips on how to approach on-shift teaching.

 

By |2022-07-29T09:06:43-07:00Aug 3, 2022|How I Educate, Medical Education|

EM Match Advice 37: EM Program Directors Reflect on the 2022 Match

EM Match Advice 10 year table residency match

In this 37th episode of EM Match Advice, we discuss the results of the 2021-22 EM Residency Match with lots of shocking numbers and surprises to review. The table above lists the trends and data since 2014, extracted from the National Resident Matching Program (NRMP) site [1]. Could this have been foreseen? What does this mean for the 2022-23 EM Match season? In this podcast, Dr. Mike Gisondi and Dr. Michelle Lin host the following esteemed panel of 3 program directors to review this juicy table and discuss the future:

  • Dr. Abra Fant (Northwestern University)
  • Dr. Sara Krzyzaniak (Stanford University)
  • Dr. Bonnie Kaplan (Denver Health)

More Numbers from ERAS/AAMC by Program

emergency medicine EM Match Advice ERAS table

EM Match Advice Podcast

 

Read and Listen to the Other EM Match Advice Episodes

Blog posts: https://www.aliem.com/em-match-advice-series/

 

References and Additional Reading

  1. National Residency Match Program: Data and Reports
  2. Pelletier-Bui AE, Schnapp BH, Smith LG, et al. Making Our Preference Known: Preference Signaling in the Emergency Medicine Residency Application. West J Emerg Med. 2021;23(1):72-75. Published 2021 Dec 17. doi:10.5811/westjem.2021.10.53996. PMID 35060866
  3. Preference/Program Signaling (PS) in Emergency Medicine. CORD website, 2022.
By |2022-05-28T09:30:51-07:00May 11, 2022|EM Match Advice, Podcasts|

EM Match Advice 36: It’s Time to Make Your Rank List

Now that interview season for residency match has concluded, our residency director panel tackles the hot topic of making your rank list, which includes “love letters” to programs and second look visits. In this podcast, Dr. Mike Gisondi and Dr. Michelle Lin host an esteemed panel of 3 program directors, Dr. Emily Fisher (University of Oklahoma), Dr. William Paolo (SUNY Upstate), and Dr. Michael Van Meter (University of Texas Health Science Center at Houston) to discuss these issues. Good luck to everyone in the match this year!

EM Match Advice Podcast

Read and Listen to the Other EM Match Advice Episodes

Blog posts: https://www.aliem.com/em-match-advice-series/

By |2022-04-26T16:24:10-07:00Feb 9, 2022|EM Match Advice, Podcasts|

EM Match Advice: Where did all the jobs go, and did the applicants follow?

In this episode of EM Match Advice, our panel takes on the tough issues of 2021. Specifically we discuss the American College of Emergency Physicians (ACEP) Workforce Study [1] that projects fewer jobs for emergency physicians and the hot-off-the-press ERAS data showing a drop in the number of EM residency applicants, compared to 2 years ago. Did one cause the other? In this podcast, Dr. Mike Gisondi and Dr. Michelle Lin host an esteemed panel of 3 program directors, Dr. Cassandra Bradby (East Carolina University), Dr. Adam Kellogg (Baystate Health), and Dr. Craig Krausz (Saint Louis University).

The Numbers

  • The ACEP Workforce Study projects a whopping 7,845 excess of emergency physicians in 2030 who could be left without jobs. And our very smart medical students have been eyeing those numbers carefully.
  • While EM is still an attractive specialty for many medical students, some enter this year’s residency application season with a trepidation that hasn’t been seen before. And a good deal of  students clearly chose a specialty other than EM, with approximately 200 fewer applicants projected this cycle, compared to 2 years ago. Most of that drop came from students at LCME-accredited medical schools. [Silver lining: These numbers may make for a buyer’s market that greatly favors the students in the upcoming Match.]
  • Below is a summary of the ERAS data, pulled from their downloadable Excel data. Note that these data were collected on October 3 of each year and only summarize data from EM-only residencies (not EM/IM or EM/FM).
Characteristic2016-172017-182018-192019-202020-21*2021-22
Number of EM residency applicants3,2203,3303,3383,601x3,408
Average number of submitted applications in EM49.153.3557.8659.75x61.23
Average of applications received per EM program883.3866.6850.82874.58x772.82
AAMC’s ERAS data for 2016-2022 for the specialty of Emergency Medicine, collected on October 3 of each year
(* Because of the pandemic, the 2020-21 season’s timeline was shifted later by about 1 month, resulting in non-comparable data.)

EM Match Advice Podcast

Additional Resources

Read and Listen to the other EM Match Advice Episodes

Blog posts: https://www.aliem.com/em-match-advice-series/

References

  1. Marco CA, Courtney DM, Ling LJ, et al. The Emergency Medicine Physician Workforce: Projections for 2030 [published online ahead of print, 2021 Aug 2]. Ann Emerg Med. 2021; doi: 10.1016/j.annemergmed.2021.05.029. Epub ahead of print. PMID: 34353653.
By |2021-10-27T09:50:17-07:00Oct 30, 2021|EM Match Advice, Podcasts|

Stanford’s INFODEMIC Conference on COVID-19 Misinformation: Open-access podcasts

In July 2021, Dr. Vivek Murthy became the first U.S. Surgeon General to declare health misinformation a public health crisis. Specifically, COVID-19 vaccine misinformation and disinformation on social media greatly affects vaccination rates in certain populations. Rapid increases in reliable health information about COVID-19 can be overshadowed by the spread of even greater amounts of misinformation, leading to an ‘infodemic.’

The World Health Organization defines an infodemic as:

“… too much information including false or misleading information in digital and physical environments during a disease outbreak. It causes confusion and risk-taking behaviours that can harm health. It also leads to mistrust in health authorities and undermines the public health response. An infodemic can intensify or lengthen outbreaks when people are unsure about what they need to do to protect their health and the health of people around them.”

INFODEMIC Conference on Social Media and COVID-19 Misinformation

On August 26, 2021, Stanford University’s Department of Emergency Medicine and Ethics, Society, and Technology Hub co-sponsored a unique conference to address this issue, “INFODEMIC: A Stanford Conference on Social Media and COVID-19 Misinformation.” Speakers presented virtually from around the world including experts in social media, health policy, ethics, and medicine. The conference focused on the causes of COVID-19 misinformation and mitigation strategies. Vaccine Confidence, Vaccine Hesitancy, and Vaccine Equity were among the main topics of the meeting. INFODEMIC also featured representatives from Facebook, Google, and Twitter, as well as physician influencers, to discuss the role of social media companies to address misinformation online.

Below are recordings of each of the INFODEMIC conference presentations, presented as podcasts. Video recordings of these presentations are also available to view online. The conference agenda and featured speakers are listed on the Stanford INFODEMIC website.

Podcasts

By |2021-10-06T19:40:30-07:00Oct 8, 2021|Academic, COVID19|

EM Match Advice: Program Directors Reflect on the 2021 Residency Match

How competitive is EM emergency medicine match EM Match Advice

Dr. Mike Gisondi and Dr. Michelle Lin return for their annual review of the most recent Match in emergency medicine (EM) in latest episode of EM Match Advice. They were joined by a panel of 3 outstanding program directors, Dr. Jacob Ufberg (Temple), Dr. Amita Sudhir (University of Virgina), and Dr. William Caputo (Staten Island Medical Center). Was the EM Match more competitive this year? That’s a complicated question and you need to listen to the podcast discussion for the nuanced answer.

The Slide: The Nitty Gritty Annual Numbers of the EM Match

“The Slide” above is a summary of EM Match statistics taken from the annual National Residency Matching Program (NRMP) Data and Results publication over the last 10 years. Trends suggest that EM is becoming less competitive year over year; however, 2021 saw the greatest number of unmatched medical students who were EM bound. What are the most competitive specialties and how does EM compare? Generally, we use the % fill rate with LCME students to determine the competitiveness of a specialty. That is the % of entry-level positions filled by allopathic senior medical students from the US, Puerto Rico, and Canada. Who’s on top this year? Four combined programs that each have very few PGY-1 positions in the match all filled with 100% LCME students: EM-anesthesiology, medicine-anesthesiology, pediatrics-anesthesiology, and pediatrics-PMR. Here’s how a few of the other specialties fared:

  • Thoracic surgery 93.5%
  • Plastic surgery 89.3%
  • Vascular surgery 82.3%
  • Orthopedic surgery 80.5%
  • Obstetrics-gynecology 66.7%
  • Surgery 65.6%
  • Emergency medicine 62.1%
  • Pediatrics 60.3%
  • Radiology 58.2%
  • Internal medicine 39%

Podcast: Program Directors Reflecting on the 2021 EM Residency Match

Read and Listen to the other EM Match Advice Episodes

Blog posts: https://www.aliem.com/em-match-advice-series/

By |2021-07-19T19:27:46-07:00Jul 21, 2021|EM Match Advice, Podcasts|
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