Dr. Scott Weingart of EMCrit on burnout, FOAM, beef jerky, and why emergency medicine is broken

Dr. Scott Weingart is one of the founders of the free, open-access medical education movement. Last year, he spoke with Figure 1 co-founder Dr. Joshua Landy about FOAM, emergency medicine, critical care, the future of academic publishing, and on-call snacking. Dr. Landy presented Dr. Weingart with a series of questions asked by the Figure 1 community as well as some of his own. What follows are the highlights of their conversation as well as the complete edited transcript of their conversation.

Heroes of FOAM (No. 1 in a continuing series) Name: Dr. Scott Weingart Specialty: Resuscitation & Emergency Department Critical Care Motto: Attempting to Bring Upstairs Care, Downstairs One Podcast at a Time Why FOAM? “FOAM allows you to discuss clinical experience in areas where evidence doesn’t exist or in areas where evidence may send you to a path of confusion.” Where to find him: On the EMCrit site, on the EMCrit Twitter, but as audio is his preferred format, on the EMCrit podcast. (With more than 19M downloads, you’ll be in good company.) Favorite on-call snack: “I have some strong feelings about this. Beef jerky or some kind of high protein thing because I don’t think you should be eating anything enjoyable and high carb on shift because your stress hormones will just turn into fat.” Favorite intubation technique: “I don’t have a favourite, it depends on the individual patient, but if you forced me to have one it would be the one I created, the delayed sequence intubation.” Favorite ventilator: “I am a strong strong fan of the Evita by Drager, the highest of the line that’s available at any given moment. That’s a bias because I am an airway pressure release ventilation fan, and I think the Dragers have the best valves in the industry.” Favorite attending as a learner: During my fellowship the head of the Shock Trauma centre in Maryland, who I think delivers the best trauma care in the world, Thomas Scalea. He is my hero, my mentor, the person that I hope I can have some portion of his greatness at some point in my career.

On FOAM and academic publishing

Dr. Joshua Landy Let’s dive in. First of all, I wanted to tell you that the healthcare professionals on Figure 1 — and me in particular — are fans of yours. I use a lot of your materials when I teach critical care.

The first question is from a paramedic who writes:

“My question has to do with how you see FOAMed becoming incorporated into the traditional medical community who rely solely on literature/studies. Do you think they are on the verge of integration, or perhaps polarizing medical education to two schools of thought, or do you see a little of both in the coming decade? Please be specific”

Dr. Scott Weingart I think it’s a great question. The first thing I’d say is that we need traditional medical publishing no matter what, that is the sine qua non for all, but the question references FOAM. For anyone in the audience who has no idea what that is, it’s an acronym for Free Open Access Medical Education meaning stuff on the web you get for free or behind a password wall but you don’t have to pay for and with the desire to educate people in medicine, that’s FOAM.

Most of FOAM is built on traditional medical publishing, so it’s never going to be a replacement for it, but the two do work beautifully and synergistically together as long as people are not too busy defending their silos.

You need research, and research should never be published on FOAM. That would be crazy to have an original research topic published on a blog or podcast, because there is no peer review, there is no vetting and it doesn’t make a lot of sense. So publish in the traditional journals, but then to actually try and translate to the bedside, to make this usable, to have dissemination, the obvious channel is free open access medical education.

The authors and researchers and scientists that are savvy to this are engaging with these new outlets are calling me up and saying “Hey, I just published this study, it’s right up the alley of EMCrit, can you do a show on it or have me on for an interview?” I say hell yes, because that’s what we do best. It’s taking that work and getting it out there.

The standard dissemination cycle takes like ten years and we can do it in ten minutes. And then what I think my bent is, is trying to figure out is how to take the research and actually make it usable on a clinical ship or on a doc in the trenches of the ICU or an ED.

Dr. Landy I want to follow up with something that you said which was that it was crazy to publish primary research on a blog because it’s not peer reviewed. Do you think that there is a possibility that there could be a new platform type out there, in the future or potentially out there now, that can expedite peer review and make things available much faster than the current legacy systems of publication?

Dr. Weingart Yes, but I don’t call that a blog. This is all semantics at some point, but first of all I don’t think any journals 10 years from now will be publishing a print version for any reason, except to put in libraries, and those libraries should really come to their senses and stop stocking those and they will disappear, too. A bunch of really high level journals are going to online publications only and they look very much like a blog, but my distinction between a blog and a journal is that a journal does have pre-publication peer-review. That may change, but for now that’s part of my definition. They have an editorial board instead of one person making decisions, and they have the aegis to not put stuff that’s pure opinion unless clearly delineated as such. This is, in my mind, the structural difference between a blog and a journal, even if that journal is online and is using the same Wordpress theme as a blog is.

Dr. Landy I was going to say there a little blow-up on Twitter recently about a study that was just published in The Lancet on the topic of hypertension. It had 24 authors and 21 patients in the study. I feel like this, in itself, represents the fact that we really should be doing a better job.

Dr. Weingart Yeah, and SMACC had some wonderful panels where they pitted the former editor of the BMJ, who is very forward-thinking, to the editor-in-chief of The New England Journal, who also had some beautiful points to make but may be a little bit more into the conservative, older style of journal publication. I would highly recommend that anyone interested in this topic check out that panel.

Dr. Landy One of the things that hits me between the eyes on this topic is the writing style. If you go back and read journals from the 1950s and 60s, their descriptions and their recommendations in writing is just so beautiful, elegant and descriptive. We have seen that writing style sink into a very technical, automated, formatted collection of text which can be very harsh to digest. To get this information in the hands of practitioners, writing in a style like yours seems to be the way to go, and on that point, a vascular surgery resident asks on Figure 1:

“Do you think that it’s better to disseminate information through academic channels or through FOAMed social media, etc.? If you could only choose success in one domain, which one would you select?”

Dr. Weingart Such a good question and I’m going to link it up to the comment that you just made because I think it was particularly incisive. In the old journals from 50 years ago, you were allowed to publish articles on “here was my clinical experience for the last 10 aortic dissections I took care of”, and there’s value to that. It’s not a randomized control trial, but if it’s speaking on a topic of tacit knowledge or of just “here is my clinical practice, I’m regarded as a good clinician, maybe you want to hear what I have to say”– there’s huge value to that. That’s kind of disappeared in traditional journals. There’s no outlet for that, and the new world of social media and FOAM has filled in the gaps to allow you to discuss clinical experience in areas where evidence doesn’t exist or in areas where evidence may send you to a path of confusion. So if I had to choose between traditional publishing and FOAM, then it’s pretty clear for me, I am a FOAM publisher. That’s the stuff I care about. I care about talking evidence, and if there’s no evidence out there then taking the best physiology and applications of clinical experience and trying to make sense of what to do on an actual patient encounter.

On keeping up with FOAM

Dr. Landy That leads us to owensowens817’s questions, who writes:

“Dr. Weingart - thank you for being open to questions on Figure1! You are certainly a subject matter expert and an influence to many in EMS. Do you have any advice regarding how many articles/journals/podcasts we should be reviewing daily to keep fresh? With FOAM, one could spend hours reviewing the latest and greatest”

Dr. Weingart I did a talk on this and it’s up on the podcast site. It’s called the path to insanity and by the title you should basically get an idea of what I don’t recommend doing, which is what I do: I try to read every single research study that is even tangentially related to my field of practice, critical care. I just to listen to any podcast out there, and any blog post that I try to read. That is not sustainable unless you want to eliminate everything else in your life except for friends, family and work, which is pretty much what I have done.

I don’t recommend that as a path, but there’s an economic principle called the Pareto Principle. It’s the 80⁄20 rule which applies to most things in life: To get 80% of the benefit it only takes 20% of the effort. It’s that last 10-20% that requires the other 80% of the effort, so you can get almost all of the way there by doing a much more streamlined approach. I cut the 60 journals I read to 12 journals a month. Which, when you think about it, means if you are reading one journal every three days, you are of course not reading a journal cover to cover.

I get a table of contents in my email,and I’ll browse through, see what’s of interest, check