The purpose of the literature review is to conceptually explicate dialogic theory and establish how it helps to explain the emergence and popularity of FOAMed within EM. On a less abstract level this section will also situate FOAMed within the broader OER movement which highlights that it is not an isolated movement but part of broader cultural changes. FOAMed is challenging and subverting conventional dialogic spaces within medical education – especially ideas around curriculum formation and reflective learning – and the broad nature of these changes will also be dealt with here. The literature review will be divided into five sections that align with my research interests and objectives; the first section will define and illustrate key aspects of dialogic theory, specifically via the work of Wegerif and his debt to Bakhtin; the second subsection will attempt to define the emergent but multi-layered OER movement; the third section will situate FOAMed within the OER movement. OERs and FOAMed are linked with a commitment to progressive innovation but this has repercussions for both organisations and learners who need to devise appropriate strategic and operational responses. With these concerns in mind the fourth section will consider the challenges FOAMed is presenting to the ongoing process of curriculum formation and stakeholder involvement in that process, and the final section will analyse the relationship FOAMed has with reflective learning to establish if changes to reflective practice could help overcome FOAMed’s ambivalent attitude towards credentialised learning.
Theories about dialogic education play a significant role in explicating the conceptual underpinnings and continued development of the OER and FOAMed movement. At its heart FOAMed is inherently dialogic as it represents an intermingling of different voices or perspectives – pedagogical, technological, strategic, cultural and increasingly organisational – into dialogues in their own right. Wegerif (2013) is one of the most persuasive writers on dialogic theory and he claims that ‘meaning is never singular’ as it ‘always emerges in the play of different voices in dialogue together’ (p 3). Although writing before the formation of the movement Wegerif helps us to see how FOAMed aligns well with dialogic theory as it contemporizes rather than supersedes traditional educational models and it allows a ‘return to the participatory nature of education’ (Wegerif, 2013, p 101). Logistical and spatial concerns are also important to dialogic education as improving the quality of the spaces in which these exchanges occur, be that via easily accessible sites or discussions mediated via Twitter as is the case with FOAMed, allows exchanges to be sustained and deepened (Wegerif, 2013, p 5). Furthermore a fundamental feature of dialogic education is that it supports peer-to-peer learning which is a notable characteristic of FOAMed (Wegerif 2013).
Mikhail Bakhtin is the principal figure on whom Wegerif predicates his theory of dialogic education. Wegerif argues that the ‘logic of the Internet age returns us to Socrates’ original insight that intelligence lies in dialogues’ (Wegerif, 2013, p 10), which parallels with Bakhtin’s training as a classical scholar influenced by Socrates’ dialogic models. Bakhtin defined dialogue as shared enquiry in which answers give rise to further questions; furthermore in dialogues there is never a final word, which corresponds with the unbounded context of online education (Wegerif, 2013, pp 115, 31). Wegerif also draws our attention to Bakhtin’s notions of the authoritative and persuasive voice; the former is an externally positioned presence related to power and hierarchy, whereas the latter is internal and seeks different challenges and contexts to support its development (Wegerif, 2013, p 9). In the organisational context of the RCEM’s elearning platforms it could be argued that RCEMLearning (the College’s VLE) represents the authoritative, didactic and ‘approved’ voice whereas the RCFN represents the persuasive one, and the tensions and negotiations between the two is the loci in which learning takes place. In other words FOAMed resources such as interview-style podcasts and blogs which actively encourage comments and peer-to-peer interaction are inherently dialogic. FOAMed as a phenomenon is demanding that institutions and individual learners enter into dialogues to determine what constitutes knowledge and legitimate educational resources in rapidly changing contexts.
Central to understanding Bakhtin is his notion of heteroglossia which is the ‘existence of conflicting discourses within any field of linguistic activity’ (Baldick, 2008, p 153). Bakhtin’s conceptualisation helps us see that FOAMed is a dialogic linguistic activity that explores, contests and at times endorses a range of ideological contradictions (Bakhtin 2004a). Bakhtin also contends that the ideological – which can include the educational in FOAMed’s case given that it overtly challenges existing and hegemonic practices – ‘becoming’ of a human being ‘is the process of selectively assimilating the words of others’ from the interplay of hetreroglot languages learners are presented with (Bakhtin, 2004a, p 682). As mentioned above metacognitive activity arises from negotiations between authoritative discourses (represented by institutions and curricula) and internally persuasive discourses which seek out new contexts and voices in order to be challenged and formed (Bakhtin 2004a). Theories of dialogic education help to account for the popularity of FOAMed within EM and the RCEM as resources are characterised by exchanges between authoritative discourse (the curriculum) and the persuasiveness and heterogeneity of FOAMed.
Bakhtin’s notion of the carnivalesque as illustrated through his study of Rabelais also helps to account for an element of FOAMed’s popularity within the EM community. Some aspects of FOAMed evince an anarchic sensibility that parallels with the carnival which ‘marked the suspension of all hierarchical rank, privileges, norms and prohibitions’ (Bakhtin, 2004b, p 686). The carnivalesque facilitated anti-hegemonic discursive or dialogic practices which were otherwise suppressed or elided. The celebration of these marginal voices can also be located in the FOAMed community, especially in the opening ceremony for a recent Social Media and Critical Care (SMACC) conferences which contrasts with the conservatism of many medical conferences and associated processes of knowledge construction:
There is consensus amongst OER practitioners about how to define the movement, although that agreement somewhat disintegrates in debates about its use and application. The term was first adopted at the 2002 UNESCO forum on the impact of open courses (Allen and Seaman 2014). UNESCO’s ‘The Virtual University’ report helpfully outlines the essence of the movement and the challenges it faces. Interestingly the report suggests that OERs are contemporising rather than replacing long-held academic practices, especially those related to collegial sharing of resources and thinking about peer review and quality assurance (Albright 2006). This parallels with FOAMed which updates traditional Socratic methods of teaching in medical educational and readies them for digital environments. The Hewlett Foundation have consistently donated financial aid to organisations looking to initiate OER projects, and they define OERs as:
Teaching, learning, and research resources that reside in the public domain or have been released under an intellectual property license that permits their free use and re-purposing by others. Open educational resources include full courses, course materials, modules, textbooks, streaming video, tests, software and any other tools, materials or techniques used to support access to knowledge (qtd. in Allen and Seaman, 2014, p 3)
FOAMed resources fall under the generic tools or materials alluded to towards the ends of his definition. This illuminates an irony of the OER movement as use and technological innovation tend to outstrip attempts to define it. Another factor that differentiates RCFN from other conventional OER resources is they are not full courses or modules; rather they are atomised learning resources mapped to a curriculum predicated on clinical competencies. The resources look to reinforce or critique established practice.
Crucially FOAMed resources align with broad definitions of OER in their commitment for re-use. A number of studies (Allen et al 2015, Robinson et al 2014, Masterman and Wild 2011) emphasise OERs’ ability to be re-used, re-mixed, redistributed and repurposed by learners. This can entail a leap of faith (strategically for institutions, intellectually for authors and contributors), as resources are disseminated in unbounded and perhaps untrackable contexts. In terms of the resources themselves Weller (2010) usefully differentiates between ‘big’ and ‘little’ OERs. Big OERs are institutionally produced, whereas little OERs are produced individually. Weller sees the former as raising the profile of OERs, whereas the latter can potentially increase participation. The RCFN merges Weller’s categories of OER as the editorial team produces ‘big’ OERs which harness expertise from disparate ‘little’ OERs.
Transparent licensing is vital to the OER concept, and it underpins ethical commitment, reputational benefits and legal protection for institutions committed to OERs (Allen et al 2015, Hilton et al 2013, Weller et al 2015). The most common form of licensing is provided via Creative Commons, and these specify the terms under which resources can be accessed and used (Wiley and Hilton 2009). The RCFN is licensed under a Creative Commons non-commercial attribution license version 3.0, the terms of which directly parallel with the definitions of OER provided here. So whilst the resources may differ (atomised learning resources rather than complete courses or texts) the RCFN evinces a strong commitment to the philosophy and ethos of the OER movement via its licensing arrangements.
Much of the literature about OERs is written by champions of the movement, so a sense of enthusiasm and commitment to the cause is palpable. However a number of studies also deal with its efficacy, principally within high schools and colleges in the United States. Some research details that a move to free digital content increased access rates to resources, boosted learners’ engagement and efficacy and demonstrated improved results (Feldstein et al 2012, Lovett et al 2008, Hilton and Laman 2012). However there is not a universal endorsement of OERs and others are more ambivalent about attributing improvements in results to adoption of OERs (Hilton et al. 2013). Further research in the context of UK medical education is required here as although OERs have proved to be popular in terms of access rates and downloads there is a lack of evidence for how this translates into improved academic performance.
Some OER advocates maintain lofty aims for what the movement can accomplish, believing that it can democratise access and remove barriers to education and knowledge (Allen et al 2015). OERs represent a healthy challenge to established pedagogies and, if implemented well, they can introduce more learner-centred, interactive and self-directed pedagogical models (Conor and Ehlers 2010, cited in Petrides et al 2011, p 3, Sclater 2009, Albright 2006). A well-devised OER programme can have a mutually beneficial outcome for learners and faculty; it encourages individual learners to look for – and indeed perhaps remix or repurpose – resources, and therefore become more self-directed, and it can help teachers gradually introduce more technology into their classrooms, thereby potentially removing financial barriers to accessing resources (Petrides et al 2011, Bliss 2013b). However perhaps the most pedagogically beneficial aspect of OERs is one which fuses traditional theories of learning with realistic promises of what digital education can offer as adotption of OERs enable ‘what was once content to become conversation’ (Moran et al, 2011, p 4). Discussions around OERs and FOAMed can oscillate between extremes but the enhancement of dialogue and critique can have mutual benefits for institutions and individuals; it can help the former to remain progressive and engaged with its stakeholders, whilst it allows the latter to become self-directed and committed to ongoing learning which elides the boundaries between competence and excellence.
Successful implementation of OERs can also transcend longstanding environmental barriers to conducting successful teaching and learning. OERs represent a collection of resources that can be tailored to local contexts, and they can be seamlessly embedded into students’ learning environments (Feldstein et al 2012, Masterman and Wild 2011). The RCFN has attempted to do this by making curriculum mapping mandatory for all submissions; mapping allows learners to select which parts of the curriculum are relevant for them so the production of resources aligns with local clinical and educational contexts. Although branded with RCEM logos the RCFN has attempted to maintain a light touch from an institutional perspective, preferring instead to let the community of learners self-police (Johnstone 2005). This is another pedagogical aspect of OER implementation which the RCFN aligns with.
As OERs are usually embraced by progressive early adopters the tone of the literature occasionally obfuscates strategic and operational issues. Data governance presents a series of challenges as measurable outputs of success and a body of evidence which show tangible positive impacts of OERs – especially around direct correlations between adoption and improvement – are scarce (Allen et al 2015, Hilton and Laman 2012). There are also a number of pedagogical barriers to overcome, most notably the assumption that simply swapping traditional resources for OERs is not effective as it needs to be supported with faculty development programmes (Wiley and Hilton 2012). A complete or partial switch to OERs can also distort the alignment between course content and assessment methods, and faculty have often found that producing OERs is more time consuming – especially in the early stages – than traditional methods (Bliss 2013a).
The abstract notion of OERs as a movement comprised of resources which could potentially democratise education and widen access encounter some considerable strategic issues. OER programmes often rely on individual champions to deliver them when in fact institution-wide change management needs to be involved to ensure sustainable pedagogical and financial models are delivered (Allen et al 2015, Sclater 2009, Albright 2006). Much work needs to be done to legitimise OER programmes as there are question marks around permanency, credibility and quality assurance processes (Anderson 2013). This is a particular concern in the FOAMed community where sceptics question how submissions are approved for publication and subsequently monitored. OERs can also pose a political problem for institutions as some types challenge accepted forms of discourse, which can contradict what is mediated as knowledge in long-established textbooks and print publications (Robinson et al 2014).
In all of this learners’ perceptions of OERs can be overlooked, and it’s vital that processes are in place that prevent this from happening. To date little research has been conducted about student perceptions of OERs and the overall quality of user experience (Hilton et al 2013, Albright 2006). Critics note that content spread is often uneven so learners can never be sure about what they will be able to find (Allen et al 2015). This accusation has been levelled at the FOAMed community as traditionalists maintain that only ‘sexy’ clinical topics are covered, especially relating to airway management and resuscitation (Rezaie 2016). This Twitter exchange was enlightening as it explored the validity of conventional textbook learning compared to the disparate pathways offered by FOAMed. There are also issues around the discoverability of resources, which are offset by negative opinions about quality (Allen and Seaman 2014, Bliss 2013a). OER practitioners must always bear in mind user experience because if quality is inconsistent and irrelevant cognitive activity will be spent on locating rather than engaging with resources, so the objectives of the OER movement will be compromised.
The OER movement is imbued with an admirable philanthropic ethos which is at odds with higher education environments that are becoming increasingly commercialised (Molesworth 2011). Albright (2006) identifies how the laudable ‘ethical push’ of OERs often creates tension with the need to generate revenue and protect an organisation’s intellectual property. Within institutions OERs need to be linked to and embedded within professional development activities to strengthen their credibility (Allen et al 2015). This was a motivation for this research as FOAMed resources need to be acknowledged by CPD systems in order to mature. As the movement evolves coordinated pedagogical and delivery strategies need to be implemented which cross disciplines, and more work needs to be done to establish how educators are modelling OER resources (Allen et al 2015, Bowen et al 2012, Petrides et al 2011). An intriguing experiment to gather evidence in medical education would be to split a cohort for a mock exam and ask one half to revise using conventional resources with the other half using only FOAMed resources. Analysis of the results would enable research into its impact (Weller et al 2015). From an institutional perspective robustly quality assured FOAMed resources could potentially be used to promote public health, which could have organisation-wide benefits (Anderson 2013). An organisational commitment to OERs, which includes a clearly articulated and sustainable strategy, represents ‘the ante necessary to sit at the innovation table’ (Wiley and Hilton, 2009, p 13) which could help maintain reputational and pedagogical advantages and underpin an organisation’s progressive strategy.
FOAMed can be seen as a component of the overarching OER movement. The acronym dates back to the International Federation of Emergency Medicine’s (IFEM) conference in Dublin in 2012; the term was developed to characterise the move away from generically using social media to describe online discussions about contemporary EM education. Mike Cadogan is one of the movement’s most significant early innovators and this video from the IFEM conference outlines FOAMed’s central tenets (Cadogan 2012).
The movement is predicated on open sharing and collaboration, which aligns with the emphasis on remixing and repurposing, highlighted in the OER definition cited earlier (Nicksson and Cadogan 2014). FOAM should not be regarded as a teaching philosophy or strategy but rather a movement that seeks to augment conventional teaching practices (Cadogan 2014). It emphasises self-directed learning and questioning of evidence in democratic online spaces such as Twitter, which improves metacognitive abilities, capacity for self-assessment and enables socially shared exchanges between ‘experts’ and ‘novices’ (Kruger and Dunning 1999, Crook 1994). Learning analytics demonstrate the popularity of FOAMed resources but the extent to which learning organisations should acknowledge or produce FOAMed remains ambiguous.
FOAMed can be situated within dialogic theories of education. Indeed it could be argued that FOAMed actually contemporises rather than replaces or supersedes conventional Socratic approaches to medical education. FOAMed has been likened to a ‘corridor conversation’ or a ‘digital water cooler’ which permits dialogues about learning to take place, communities of practice to be built and serendipitous learning to occur (Scott et al 2014, Nickson and Cadogan 2014, Lin 2012). It is striking how these analogies and metaphors are predicated on images which call to mind dialogues and linguistic activity. The dialogic ethos of FOAMed is reflected in the types of resources it produces (primarily podcasts and blogs) which seek to question established practices and encourage self-directed reflections by FOAMed users. Some of the more popular podcasts are predicated on an interview format so presenters and listeners are conjoined in a dialogic collaborative act of questioning evidence.
EM is a speciality characterised by demanding shift work and pressure from external political narratives and changing demographic and clinical presentations; all of these factors make scheduling conventional teaching time very difficult. FOAMed supersedes environmental and logistical constraints and allows learners to learn how, when and where they want (Cadogan 2014, Nickson and Cadogan 2014). Twitter is also invaluable in helping to overcome environmental constraints as its brevity and unifying hashtags synthesizes content and resources for users, and it enables ‘spontaneous cross talk’ to occur in a highly networked fashion (Scott et al 2014, Nickson and Cadogan 2014, Crook and Light 2002). FOAMed resources and subsequent discussions about them on Twitter mean that ‘participants have access to the resources necessary to learn what they need to learn’ (Wenger, 1998, p.10). The vast majority of FOAMed consumers are highly qualified adult learners and FOAMed helps them continue to learn and challenge existing givens (Rawson 2000).
A number of leading EM educators stress that it is virtually impossible to deliver consistently protected teaching given the challenges departments face on a daily basis. Learning contexts are diverse and unpredictable, which parallels with clinical presentations seen by EM doctors; their working environment demands resourcefulness and holistic understanding so the plurality and breadth of coverage provided by FOAMed supports this (Vartabedian 2014). The essence of many FOAMed learning contexts are ones which promote the Socratic method of scaffolded questioning, critique and discovery (Benitez 2013). The nature of the specialty demands resourcefulness, innovation and sceptical critique, and FOAMed has emerged as a medium to support this. In this respect FOAMed can be seen as contemporizing rather than replacing traditional aspects of medical education, and it also ensures clinicians are well-rounded as there is a more equitable focus on clinical and non-technical skills (Roland and Brazil 2015).
I agree with Nickson (2013) that FOAMed does not need its own curriculum. However one of the motivations underpinning this research was to explore how a learning organisation can be more nimble in recognising if OER resources such as FOAMed could play an integral role in the (re)forming of curricula. It extends the dialogic argument as learners are negotiating and constructing meaning when they engage with FOAMed resources, but the dialogic idea also works on a meta level as FOAMed could potentially enable an institution to innovatively tailor its curriculum so it aligns with the requirements of its stakeholders. In other words curricula which include OERs would help to mainstream and legitimise them (Allen et al 2015, Hilton and Laman 2012). Traditional ‘assembly line’ conceptualisations of education and curricula ‘presuppose students’ sameness’ (Cullen et al, 2012, p 21) and resources which challenge the idea of the curriculum as an ‘organized passage’ should also be embraced (Crook and Light, 2002, p 161).
FOAMed resources can be seen as a meta-commentary on the curriculum in that they critique established competences and practices, so they allow ‘traffic’ between the curriculum and activity beyond and around it (Crook and Light 2002). A relatively straightforward act – albeit one that requires institutional support of OERs – of incorporating them into the curriculum as hyperlinked resources facilitates an ongoing discussion about what a curriculum should look like, it captures genuine learning activities and it integrates OERs into the processes of an institution (Allen and Seaman 2014, Sclater 2009, DiSessa 2000). A curriculum which acknowledges voices and dialogues that may have historically been dismissed would demonstrate a cultural commitment to situating learners at the heart of curriculum development (Smith 2000, Stefani 2008). FOAMed resources present a unique opportunity here, as not only do they represent innovative pedagogies but they also signal a shift to a learner-centred paradigm which is sensitive to changing environmental demands within EDs, and they enable the curriculum to be connected with real-life issues (Cullen, Harris and Hill 2012, Johnson et al 2012). The recognition of FOAMed resources within a curriculum is not a call to overhaul existing practices or artefacts, but rather it’s aimed at demonstrating a sensitivity and commitment to recognising that experiences can and should complement curriculum formation, and that we must look into other dialogic spaces to discover different forms of knowing and ways of talking about learning (DiSessa 2000). On a more pragmatic level those responsible for putting a curriculum together could learn from FOAMed and make the document more multi-modal which would align with user expectations and enable it to be seamlessly integrated into learning activities.
There is a danger here that OER and FOAMed enthusiasts run away with the progressive spirit and discount objections to the movement. A truly ‘wicked problem’ (Clegg et al 2011) is that FOAMed bristles against traditional notions of what constitutes learning and assessment of that learning within medical education (Vartabedian 2014). Whilst it is important for an institution to be sensitive to emerging popular discourses and ways of knowing it’s also important to be aware of the fact that an existing cohort of learners who are extrinsically motivated and syllabus-bound could be alienated (Beaty et al 2005).
The Open University’s 2015 ‘Innovating Pedagogy’ report claims that the ‘engine of learning is a continuous cycle of engagement and reflection’ (Sharples et al, 2015, p 8). As previously discussed the relationship between the RCFN and reflective learning is a paradoxical one; FOAMed encourages self-directed learning but there’s no RCEM-dedicated space to reflect, and the heterogeneity of RCFN consumers means they’ll be reflecting at different professional stages and for different purposes. FOAMed’s relationship with reflective learning is currently ambiguous, yet there is evidence in other disciplines that OER use can lead to increased reflection by educators (Weller et al 2015). A system that enables learners to reflect on learning undertaken via FOAMed could potentially help develop metacognitive skills as resources are often about authentic activities that helps situate learning in context-specific ‘domain[s] of its objective’ (Laurillard, 2002, p 15). Authentic opportunities to reflect could potentially capture the dialogic nature of learning activities and feedback about them, and it enables learners to autonomously construct their own understanding (Nicol & McFarlane-Dick 2006, Alexander and Boud 2001). Moreover delivering an institutionally created reflective space to capture engagement with FOAMed resources would help the movement gain further recognition.
Guidance from the General Medical Council (GMC) stresses the importance of consistent reflective learning to CPD (GMC 2016). Reflective learning seemingly complements FOAMed’s self-directed and meta-cognitive ethos, but this perhaps does not fit with learners’ motivations for using FOAMed resources in the first place. However as demonstrated by the GMC guidance reflective practice is a key component of CPD for all levels of ED physicians. Within the context of medical education reflection is a core component of lifelong learning and it can help capture the complexity and ambiguity inherent in the clinical and ‘emotionally challenging’ aspects of practice (Wald et al 2012).
Consistent reflection represents a mechanism to embed self-directed learning into professional practice. However there is a danger that its value could be undermined if it becomes too inspectorial and associated with a ‘box ticking’ process (Hargreaves 2003). Designing an institutionally approved reflective learning system that does not feel overly institutional is one of the most pressing demands within the specialty’s educational discourse. Moreover developing the functionality to encourage reflective thinking is critical to underpinning the metacognitive potential represented by FOAMed (Roland and Brazil 2015). One of the central motivations underpinning this research is generating data from stakeholders, FOAMed consumers and key EM educators and governance figures to see if developing such a space is desirable and feasible.
This review has presented the pedagogical relevance of dialogic theories of education, the conceptual and contextual backstory to OERs, and how FOAMed resources can be situated within that overarching movement. It has also illustrated the educational features of FOAMed and its technological and environmental fit with EM. It has illustrated the problematic relationship FOAMed has with curricula formation and reflective learning, especially as the movement’s ethos is at odds with the highly credentialised assessment and professional development contexts learners are operating in.