Authors: Nikki Abela, Chris Walsh / Codes: SLO7, SLO9 / Published: 16/10/2017


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As two producers of FOAMed, we would forgive you for expecting us to tell you about what a wonderful place the internet is. Indeed, without it, we may not be here talking/writing to you.

But the truth is the online world has a dark side, and it is our job to make you aware of that too.

Let’s start with a story, one that can easily be found online (and in the book So You’ve Been Publicly Shamed by Jon Ronson): that of Justine Sacco- a 30 year old and the senior director of corporate communications.

In 2013, Justine was on the way to South Africa from New York to meet her family. Before she got onto the plane to Cape Town, she tweeted to her 170 followers:

During her 11-hour flight, the tweet was picked up by more popular people on Twitter and gathered momentum online. While Justine slept, she lost her job and got off the plane to find that she was the number one topic on Twitter, and someone had even followed the hashtag #HasJustineLandedYet to go Cape Town Airport and take a photo of her to post online. Her life was changed in the time of a long-haul flight.

Sacco, a South African herself, later explained that she never intended this to be racist comment, rather she wanted to mock American ignorance of South Africa. She said her intention was to “mimic and mock what an actual racist, ignorant person would say.”

We would like to think that one in a million chance is not going to happen to us. But as Fin McNicol reminds us in his blog, regardless of how careful or competent you are, one of your patients or their family will be unhappy with their care, and they may turn to social media to express that.

Moreover, you, as their caregiver, may become the focus of their concern.

Think about the family photos you’ve posted online, the disgruntled Facebook or Twitter post about something which caught your interest, or worse, a photo a friend may have uploaded of you on a not-so-sober night out.

Worried about what they might find? Then you really need to check (and double check) your security settings. Be especially cautious when the app updates, as security settings may be lost – although the big social media sites are getting better at protecting your privacy and Facebook even allows you to view your profile/feed as another person to get an idea about how public your data is.

Personally, however, as an ex-journalist (Nikki), regardless of security settings, whenever I post something online, I always question “what if” the media/my mum/a patient/my boss saw this. Facebook and Twitter are of course different social media beasts, and even their users tweak what they post accordingly.

But the truth is that once it is online, it can live on forever. From my experience in a newsroom, I can say that once a person is in the spotlight, the first thing a journalist will do is try to acquire an image/social media post to go with their story – and if they do not have access to your account – they will find someone who will.

Surprised? You shouldn’t be – the truth is in the name – social media sites are in actual fact just the most visited news sites in the world, and if you soul search, you may notice that you use them in this way too.

The aim behind social media channels is not only to put people in touch with each other, as as Professor Gerard Hastings told the North West Alcohol Conference in 2015 (and Fin McNicol reminded us in his blog):

However, if we had to look at “media” as “bad” and “private” as “good”, that would be a very narrow minded way of looking at news producers and social media.

Indeed, journalists’ raw ambition to reveal the truth is something I have always admired and is a trait we can learn from as doctors.

Being open and honest is a quality to be admired, and working with the media will enable you to lobby for patients, their interests, and that of the organisation you work for.

Think of the anti-vaxxers campaign for example – if we didn’t work with the media – then they would only have a limited view of the skewed data provided to them. Without quotes from “experts” and medical interpretations of the papers referenced, they wouldn’t be able to present a strong pro-vaccination story.

It’s the same online – while you should be prudent about what you post, you can also embrace the openness to make it work in your favour.

What you post online should be viewed as your “digital footprint”: defined as your personal/professional/organisation’s information that can be found online as a result of your activity there. If you think of social media like this, then it will change your mind frame to be safer every time you post something.

The GMC also reminds us of our online obligations in their guidance.

“Disclosing identifiable information about patients without consent on blogs, medical forums or social networking sites would constitute a breach of General Medical Council (GMC) standards and could give rise to legal complaints from patients.”

Moreover, they advise against entering “into informal relationships” with patients on social media because of the increased likelihood of inappropriate boundary transgressions, particularly where previously there existed only a professional relationship between a doctor and patient.

In spite of the very real pitfalls associated with social media our presence on it – be that individually or institutionally – we must also keep in mind that it can also be a force for good, especially as the way knowledge is made, talked about and shared is fundamentally changing. As a speciality EM has a legacy of innovation and resourcefulness, and the increasing significance of social media within it is another manifestation of these traditions.

RCEMLearning attempts to harness social media (and we’re not alone in this of course) to promote a lot of our elearning, and to underpin our online presence. They’ll be a bias towards Twitter here as that’s where a lot of our activity is mediated. Part of the reason we do this from an educational and pedagogical perspective is because FOAMed and social media fulfils a fundamental need for storytelling and social interaction as ‘there is far more to human cognition than what goes on in the brain: we are social, interacting creatures’ (Norman, 1993, p 117). It’s no coincidence that some of the most persuasive metaphors to explain the importance of social media within EM – one thinks of its likening to a ‘corridor conversation’ and a ‘digital water cooler’ (Nickson and Cadogan 2014, Lin 2012). – are infused with a conversational ethos that encourages critique.

Moreover in clinical and educational environments characterised by scarcity (of time, resources, people, ‘cognitive bandwith’ and perhaps places and times to physically meet) it helps overcome these constraints. So social media helps fulfil some cognitive requirements, and it can help overcome some logistical ones too.

A lot of recent academic and educational literature is devoted to how scholarship is changing as it becomes increasingly digitised. Although ‘scholarship’ can sound quite intimidating it’s really just a synonym for a whole bundle of educational activities which Twitter helps support. The multiplicity of functions include the following:

  • Announcing publications
  • Sharing ideas
  • Disseminating resources
  • Building networks (professional, educational and even social).
  • Keeping up to date
  • Engaging in peer review, and helping to change and challenge what is constituted by peer review.

This is a pretty big list, and it is simultaneously exhilarating and a bit scary. But taking part in these activities makes us more active agents in the whole process of knowledge creation and dissemination, embodied in the concept of Network[ed] Participatory Scholarship (Veletsianos and Kimmons 2012, quoted in Stewart 2017 p. 66). The terminology might seem quite technical but the premise is simple;  it doesn’t matter if you’re consistently Tweeting, occasionally liking, sharing, (re) using resources or taking things into offline contexts, it’s all part of a network that’s conversational, collaborative and innovative. It also helps to bring a lot of traditional, closed-in practices into a public place, which is enormously beneficial:

This brief quote from Daniels is significant because Twitter can use a network or community to help shape and create knowledge, but it can also help individuals reflect on what they need to do to become better. This emphasis on reflective practice is becoming an increasingly significant part of educational and CPD paradigms.

(A very cool consumer of some recent FOAMed, according to Chris).

Not all that is FOAMed is gold, however, and there’s a fundamental irony or tension with a lot of the educational activities promoted via social media as they appear to promote and privilege openness and participation, but only if you’re part of a particular group.

This reinforces rather than flattens hierarchies,  and it can feel coercive rather than collaborative. It’s not for everyone, especially within such a broad church as EM, and there’s a real danger of becoming quite dogmatic about it.

Moreover, FOAMed and knowledge disseminated via social media requires it’s own critical appraisal. Now I (Chris) have to admit that I think this part of the argument is somewhat over-determined, but that doesn’t mean it shouldn’t be addressed. Shifting the medium through which you consume resources shouldn’t mean that you dispense with your critical faculties.

We like stories, and learning can be made easier when its wrapped around or inside of a narrative. We also (generally speaking) like to talk about stories, recommend them, critique and pick holes in them, share them and re-visit them; all of these ‘scholarly’ and educational activities are facilitated by Twitter. It can be quite dogmatic when it claims to be otherwise, and context can be hard to interpret at times in 140 (sometimes even 280) characters.

But the bottom line is that it can help re-evaluate existing knowledge and help inform things we’re just beginning to know about, both of which are at the heart of a commitment to innovation and improving which EM should be rightfully proud of.


  1. Daniels, J., and Thistlewaite, P. (2016). Being a Scholar in the Digital Age. (Bristol: Policy Press).
  2. Lin, M. (2012). Twitter: The digital watercooler. Retrieved: 10 April 2016.
  3. Nickson, C. P., and Cadogan, M.D. (2014). Free Open Access Medical Education (FOAM) for the emergency physician. Emergency Medicine Australasia(26): pp. 76–83
  4. Norman, D.A. (1993). The human mind. In Things that make us smart: defending human attributes in the age of the machine. (Reading, Mass., Addison-Wesley Pub): p. 115-38
  5. Veletsianos and Kimmons 2012, quoted in Lupton., D, Mewburn, I., and Thmson, P. The Digital Academic: Critical Perspectives on Digital Technologies in Higher Education. p. 66.  (Abingdon: Routledge).