EMCrit Wee – Tacit Knowledge and Medical Podcasting


I received a distressed email from a fan who was dismayed that other residents in her program were bashing medical podcasting; this is my response.

What is Tacit Knowledge?

Slide Show on Tacit Knowledge and Wicked Problems

Social Media as a Transmission Tool for Tacit Knowledge

Next horizon is to answer the question of how to solve Wicked Problems and can social media and FOAM help?

What do you think?

You finished the 'cast,
Now get CME credit

Not a subcriber yet? Why the heck not?
By subscribing, you can...

  • Get CME hours
  • Support the show
  • Write it off on your taxes or get reimbursed by your department

Sign Up Today!


Subscribe Now

If you enjoyed this post, you will almost certainly enjoy our others. Subscribe to our email list to keep informed on all of the ED Critical Care goodness.

This Post was by , MD, published 3 years ago. We never spam; we hate spammers! Spammers probably work for the Joint Commission.


  1. says

    Thanks for addressing such a sensitive and complex topic. I am very interested in this topic and I am researching this topic in the world of education via MOOCs (Massive Online Open Courses). I came across Dave Cormier’s website, one of the first people to coin the term MOOC in Canada during a course with other people very involved in education. He has further explored this online community and address the subject of how people learn in these types of environments. His conclusion is that when people come together in a network environment the conversation looks more like a rhizome. He calls this rhizomatic learning, where people with different backgrounds but with a common goal, are having a discussion about a topic with the goal of greater understanding but not necessarily final conclusion.

    The use of online community for learning still pretty new and there’s much to be explored. I think FOAM offers a great opportunity to start this discussion. The important thing is to keep the discussion going and try to measure its impact on the learner so we can use it to its full potential. I totally agree that the goal is not take anybody’s word for it, but to appreciate the discussion, explore the literature, and reach your own conclusions.

    I’m not yet set that rhizomatic learning is what’s happening in the FOAMEd discussion, so I can be dissuaded otherwise.

    Trying to write rhizomatic learning in 300 words by Dave Cormier:
    Rhizomatic Learning: Embracing Uncertainty – YouTube Video by Dave Cormier explaining rhizomatic learning:

  2. says

    I think your comparison of a medical podcast to a grand rounds talk is a good one… “Grand rounds aren’t peer-reviewed”. It’s not meant to replace one’s judicious search and critique of available literature. It’s a tool in one’s toolbox for knowledge transmission. The great thing about podcasts and FOAMed in general (from what I’m learning and experiencing) is that the WAY in which one learns is enhanced by innovative methods. We all learn in different ways; we all are impacted by knowledge in different ways…some by reading, some listening, some by creating (writing a blog post, making a PK SMACC talk), some by hands-on experiential tactics.

    Your passion for this topic (and frustration? ) is evident in your voice. I commend you for taking the time to “respond” to the critics. Well presented, especially with the Panahi links and the slideshare. They’ve really got me thinking.

    Take care,
    and a sincere thank you for all you share,

    PS- Never even heard of “tacit knowledge.” Beauty of FOAMed!

    • says

      Thanks for those kind words. No frustration. I am so lucky to have my listeners, who obviate any questions of peer review or external validation. It would be much more difficult to be just starting to enter the FOAM world and have to wrestle with issues of legitimacy of form.

      • says

        I can relate to what you’re saying, “wrestling with issues of legitimacy of form.” When I first stuck my toes in the FOAMed waters a few months ago, I was jolted a little bit by thoughts of peer review, trustworthiness…am I consuming content that is valid and evidence-based? But after wading through the waters and now beginning to swim, I realize FOAMed is not meant to replace scientific inquiry.
        FOAMed provides resources to learn about current research, enhance knowledge, inspire investigation, spark conversations and debate. Your post here is a prime example.

  3. Todd says

    It’s disheartening to hear that EM residents, so early in their career, are already discounting internet/podcasting/blogs as a form of learning.

    I completely agree with all the points you made in your podcast. I think those that dismiss podcasts as a tool for transfer of tacit knowledge are missing the point. This isn’t and never was meant to represent primary literature. This isn’t the format to present the results of RCTs. It’s absolutely a straw man argument to criticize podcasting for not being “peer reviewed”.

    I’m glad you made the analogy of a podcast being comparable to grand rounds. How come the residents don’t complain about their typical weekly lectures? How evidence based and peer reviewed is that recycled abdominal pain powerpoint given by the same faculty every year? When you’re on a shift and you’re attending teaches you not to give lido with epi for the digital block, who is peer reviewing that teaching moment?

    To be honest, I feel sorry for those residents who turn their nose at this form of learning, as they’ll certainly be left in the dust. With technology, there is absolutely no reason for information to flow glacially. You demonstrated this perfectly in a past EM:RAP episode, where you and an anesthesiologist were able to have a back and forth about a paper you published. This in contrast to the traditional approach of: submit paper –> months later published –> rebuttal submitted –> months later published. That can happen in the blink of an eye on the internet, and there’s not reason for it not to.

  4. Kath Woolfield says

    One of the reasons I listen to podcasts and read EM blogs is that exact point you made: transmission of tacit knowledge. Textbooks can provide me wth background knowledge but I am often left unsure how to actually apply that knowledge in clinical practice.
    It’s like an extension of bedside teaching. Except with FOAM now I have access to expert clinician teachers from all over the world. And there’s an additional bonus, I don’t have to sit at my desk with a textbook open!

    From an avid listener and emergency medicine registrar (resident) in Australia. Looking forward to seeing you at SMACC

  5. Minh Le Cong says

    Kath, agree! There are literally hundreds looking forward to seeing Scott at SMACC! No pressure, boss!

    For those who follow EMcrit podcast and blog closely, you will know that occasionally Scott and I disagree on certain points. we discuss and debate and offer points of reference and opinion. This is peer review. It happens quicker and more openly than traditional methods of academic discourse.

    Scott is being modest by comparing his podcasts to grand rounds. It is so much more than grand rounds. Where else would you get references and weblinks to video, audio learning resources? Most grand rounds you would be lucky to get a printed handout.

    I know for a fact that at least 4 lives from around the globe have been saved as a result of teachings from the Emcrit blog. Scott is far too modest to mention them.

    One of the hardest things to do as an educator is to engage the learner. Without it there is really no learning. Podcasting is another method to be added to the educational repertoire to seek better engagement. Its not the be all or end all.

    So I agree that there should be a blending of traditional academic methods with novel newer ones like podcasting. To be authentic and respected , medical podcasters and bloggers in my view need to have a foot in both worlds. We should be seeking to communicate teachings via traditional methods whilst at the very same time, translating this to newer ones like podcasting.

    Scott does this. I try to. Many within the community understand the discipline and responsibility. You search for our names as authors in peer review journals and you will find us, often writing on the same topics as we podcast on.

    but that is academia

    when it gets down to it, Kath and Todd are right. The patient in front of you wants you to be a thinking compassionate doctor/nurse/paramedic/RT, not a parrot, robot or lawyer.

    • DocXology says

      I think that Scott’s blog highlights important concepts or issues that are helpful for relatively experienced and insightful clinicians but I am also wary of junior registrars misapplying information from EmCrit and doing something dangerous or causing harm.

      The technological and computer age brings itself its own challenges of information overload.

      More important than just disseminating information, there is now a pressing need to teach novice clinicians how to filter, process, analyse, integrate and apply information. Hopefully as the readership of social media sites expands, the rigour and robustness of debate improves and provides useful examples for other doctors to follow.

    • DocXology says

      I think that Scott’s blog highlights important concepts or issues that are helpful for relatively experienced and insightful clinicians but I am also wary of junior registrars misapplying information from EmCrit and doing something dangerous or causing harm.

      The technological and computer age brings itself its own challenges of information overload.
      More important than just disseminating information, there is now a pressing need to teach novice clinicians how to filter, process, analyse, integrate and apply information. Hopefully as the readership of social media sites expands, the rigour and robustness of debate improves and provides useful examples for other doctors to follow.

  6. says

    Hi Scott, I really appreciated this podcast and think that it was done at a relevant and important moment. We have all seen Twitter explode with back and forths over what is peer review and what makes good medical content.

    But I think the key to the email that you received is very nature of how the podcasts are being used by this residency. It sounds like they have pretty much stated that everything you state is fact, just like rosens. They have replaced an hour of their conference with your podcasts, which is great. But unless they use the reference literature, discuss the literature, create lively discussion, they are really really missing out on the point of the podcast. That can lead to the residents feeling the way that they are.

    Another point – education is changing, lectures are going out the door, textbooks are being used as door jams… technology is here and here to stay. We all need to embrace and learn how to utilize the new resources, or we can going to fall by the way side.

    Life is always evolving, and in this case, so it adult medical education.

    Thanks for the great podcast!

    • says

      I would love it if they assigned the podcasts and then spent an hour as a group discussing and debating the points made with support of the referenced literature and any additional literature they could find. This is the concept of the “flipped” classroom.

  7. Minh Le Cong says

    actually thats a good point that Nikita raises. I dont ever intend nor am sure does Scott that our podcasts are used to replace traditional lectures or tutorials. I only ever see them as supplementary material not core. I would never want my podcast to breed laziness or lack of academic discipline into the profession. It would be a stretch of intent if anyone regards listening to a 30 minute or less podcast to be covering all aspects of that topic. I intend them to stimulate discussion, inspire personal learning and help with practical application of knowledge.
    If say I was ever to want to go back to school to learn how to fly a space rocket, I would not be relying upon listening to Neil armstrongs podcast to get me there! Traditional teachings still have a vital role. There are no shortcuts.

    • says

      Exactly, Seth addressed this point in his blog
      “Not that you shouldn’t read or listen to this stuff, but recognize that the topics covered are generally things that are sexy: interesting, controversial, or very practical or technical tips & tricks. But those are all different than a core curriculum.”

      My understanding is that podcasts like emcrit, ercast, smartem, pharm are intended for more complex discussions where there is plenty of uncertainty. At the same time embasic podcast, which is not a discussion, deals with core concepts. There is a distinction.

      Seth Trueger (@MDAware): Residents: Please Read

  8. Oli Hawksley says

    It does sounds like someone at that residency is being a tad lazy if its a case of instead of booking a speaker here’s a podcast.
    Getting to teaching and having trainees together is such a logistical problem in shift based specialities that the time together can’t be wasted on didactics.
    Asynchronous content with group discussions (the flipped classroom mentioned above) is I believe the way forward.
    Online lecture, group discussion then maybe simulation rather than sit in a room being talked at by someone who mumbles their way through the latest guideline with a look of boredom on their face.
    My expectations of my teachers has massively increased since getting into FOAMed maybe some ‘academics’ are feeling threatened by the ‘competition’

    • says

      Most programs outside of large academic centers do not have the budget to birng in Grand Rounds speakers more than a few times a year. Even big power house places like my residency that have the budget have instituted an async component.

  9. Tony says

    There are many attendings that seem to be opposed to their residents listening to podcasts because the residents don’t research the topic and use the podcasts as a shortcut to really understanding the content.

    There was a nice piece in ACEP News recently http://www.acepnews.com/views/commentaries/single-article/podcasts-take-1-podcasts-are-great-but/a61c84dd2f9e3a3e05ac78fc3a14ee71.html that nicely articulates why podcasts are so great for residents. The spontaneity in learning keeps a level of excitement to read topics that might be on the fridge of the core competency reading lists plus podcast allow everyone to hear great “grand rounds” no matter where they train.

    • Jeremy Faust @jeremyfaust says

      I imagine that the number if journal articles that residents read actually goes UP once they start listening to podcasts regularly.
      It’s easier to engage in the literture if you think about the issues being covered in the podcasts. Once you’ve heard about an article in a podcast, you’re probably more likely to seek it out, or even just read it when you later happen to see it, or to debate it in academic settings. I don’t think most people hear podcasts and then stop thinking. I think, rather, that it inspires further interest and gives people a sense of what issues matter to a bunch of very smart people who are well into their careers.

      • Tony says

        Jeremy, I like to think you are right which is why I always talk about audio casts with my residents to show them how to integrate multiple ways of learning into residency training

  10. Kirsty Challen (@KirstyChallen) says

    Peer reviewed data is the science of medicine.
    Tacit knowledge (whether podcast or grand round) is the art.
    We need both.

    I could say more but it’s been covered above!

  11. Pelle Staffan says

    Scott, thank you for this excellent wee!

    I´m a resident EM doc that often has to defend my practice. I´m pioneering in Emergency medicine in a small University hospital in Sweden. I see a big difference in evidence based practice and what is accepted as “this is how we do things here since the past decade” You managed to address our main challenge in a very nice way!

    I try to do the best I can for my patients but sometimes my practice is questioned especially when it comes to resuscitation because I tend to be more goal focused and aggressive than before and use ultrasound. Some claim that “if pts need that you should send them to ICU” The truth is that most of the time they won’t accept the pts that are multi sick, old or if they still have a systolic BP that are not crashed yet. They go to a medical ward with the recommendation to call ICU if pts get worse and for that reason i feel that i must resus these pts (e.g sepsis) aggressively first 30-60 min in the Emergency room, I can´t hold them longer. There is a strong focus on shortening pts time at the emergency department. At the wards pts will only recieve the amounts of fluids and meds that you order on the papers you send with the pts. Often there are only nurses that see pts at the wards outside office hour. I think most pts get under resuscitated and never receives proper boluses and a few gets fluids that they don’t benefit from at the wards. No one get pressors or inotropes outside ICU. Evidence based territorial and conventional thinking?

    We managed get our first specialist only a couple of years ago (side specialty), and now we have more than 30 more in pipeline as EM residents. We struggle with a lot of dogmas from the old days and our specialists are in a way trained into these and other clinics tend to defend their territory. It is not easy to chose between the conventional way and what you think is best for the pts sometimes.

    Out of 40 of us I think its less than a handful that use social media as a tool for developing our practice. I can clearly see that this make our small number a bit more progressive. I will link this wee and the slideshow to the rest of my colleagues.

    Thank you Scott, I think you are making a difference for us.

    • says

      Thank you for that comment. You and your colleagues are breaking new ground, which is incredibly hard. But your efforts will save more lives in the long term than many of us.

  12. Eric says

    It seems some people have a difficult time understanding their own education. Some of what we learn is hard science, some of what we learn is theoretical. A large part of what we learn and why we do residency is experience based art of medicine. This is how we learn to be a doctor. The huge benefit of shows like yours is that we can access the art of medicine, the experiential, the art and vast knowledge of many more great doctors. Those denigrate this are blind to how much this shapes their own education. We all do things the way we were trained. But you add training. I DSI’ed a 16 mo RSV pt 2 days ago because we couldn’t pre oxygenate her otherwise. It worked brilliantly. And Lord knows I apneic oxygenate all my tubes now.

  13. James Gruber says

    I must admit, I was a bit angered that some folks were bashing EM podcasts. I work in rural ER’s and up until you started EmCrit I felt like I was stagnant in my knowledge of EM. I don’t have access to all the journals, grand rounds, or interactions with academic EM docs. Since you started your pod casts I feel as though I am back in residency–constantly learning. Learning not only the basics of EM critical care but also the most advanced EM practiced by some of the brightest folks in EM. Since your pod cast started, I now listen to multiple other podcast in EM. These podcasts have renewed my enthusiasm in EM and allowed me to deliver the kind of care that my patients deserve. Now when I transfer pt’s to tertiary hospitals I feel confident that I am at the forefront of EM. I know longer feel isolated and stagnant. Thank you for all that you have done for EM! Don’t let the “Bashers” bring you down or stop what you are doing for EM!

    • says

      James, Thanks for those kind words; makes it all worthwhile. The questioners don’t bother me at all. We need to explore the pluses and minuses of this new educational format.

  14. Minh Le Cong says

    Right on James!
    I heard one of the coolest things a couple of months ago.

    I teach on a national emergency care course for rural and remote providers ( docs, nurses, paramedics, indigenous workers)

    One of our instructors on a recent course got asked about apnoeic oxygenation via nasal cannula. The delegate had read about on a blog. My colleague was not too sure about it so I got asked to comment. I had all these great FOAMEd references, videos, talks, presentations to refer our faculty too.

    When new concepts that help save lives can reach the most remote practitioner in OUtBack Australia, before any journal, course, conference, that IS no humbug sir!

  15. says

    Ditto Minh

    I’m a rural doc and attend annual upskilling conference in anaesthesia in the big city. It’s a sort of pilgrimage supposed to ensure I am current

    Couple of other FOAMites there, who stuck out like a dogs nuts when asked Qs about NODESAT, DSI, TXA etc. – blank looks from the (mostly anaesthetics) Faculty

    FOAM has made me read more, improve my practice and benefit my patients – sure, I will read peer-reviewed articles – but the exchange of ideas is so much more enriching and swift than turgid Grand Rounds, annual conferences or even traditional teaching ‘thats the way we’ve always done it’

    I pity the doctors who are not using FOAM – more so those who discount it on basis of ‘not peer reviewed’

    It will change. It is changing.

  16. Anand Senthi says

    This podcast was a great response to the bashers of this new forum of learning. You delivered a well executed SMACC-down!

    Without wanting to repeat everything that has been said above, let me just say I agree wholeheartedly with their comments. You are doing a fine job and this new forum of communal e-learning will improves the lives of patients around the world. I personally have found it very enriching.
    I would just like to add one additional point about the relationship between the literature and these podcasts. Through the robust debate and e-peer review that is occurring, there are just as many questions created as there are answered and this will without doubt create the fertile ground and passion required to inspire new research to answer these questions. In years to come we will see papers published answering questions raised via the FOAM podcasting network, if we haven’t already.

    Keep up the top effort Scott. Look forward to meeting at SMACC!

  17. says

    One of the better ways I’ve found for low-tech transmission of “tacit” knowledge to new clinicians is scenario training. Higher fidelity is better, of course, but old-school verbal scenarios can also work, particularly when it comes to the cognitive components (the decisions) rather than the psychomotor skills.

    What I’ve found particularly helpful is eschewing traditional scenarios — ritualized, “textbook” cases that are clearly designed to teach a specific point, and in which that point can often be guessed — in favor of more “realistic” scenarios. These focus on the realistic environment the student works within, the real everyday challenges and logistics, and especially, go down to the details… I’ll demand that they address the smallest steps, and deliver no prompts unless they’re really floundering. Rather than telling them “the patient is an 80-year-old male presenting with bilateral rales and pleuritic chest pain,” I’ll say, “there’s an old man breathing fast. now what?” They must provide their own structure, just like in real life. Often it becomes clear that while they’ve learned the “big” steps in their training, they lack the small connecting steps you learn by experience, such as how to phrase a question, whether to do A or B first, and of course always, “now what?” But with enough of these drills, you can both identify those gaps and help correct them.

  18. Josh Farkas says

    Great comments, all.

    I would add that just because something is “peer reviewed” doesn’t mean that it’s correct. The literature is packed with peer reviewed articles which are incorrect or misleading. Peer review provides some quality control, but it doesn’t guarantee anything.

    Ultimately we are responsible for maintaining a healthy skepticism toward information from all sources (whether it’s the New England Journal, EMCrit, or something taught by an attending on teaching rounds). Caveat emptor.


  19. Cassandra says

    While I am late to the game, I wanted to add a couple of things.

    I am currently an EMT-B, who is returning to Paramedic School in January. While taking classes and during my long commute to work, I frequently listen to a couple of medical podcasts (one being EMCrit, the other two are produced by a doctor, the other a paramedic/RN).

    I have found not only do I value the information provided given by others who have more experience than I do, I find the few podcasts have made me a very good critical thinker.

    Generally while listening to the pod casts, I can understand where the presenter is coming from, but while pondering them later in the day, I find myself questioning on how certain things relate or how they can be applied into my field.

    I have found that based on listening to pod casts, I have been able to pick up on things that I may have missed in class or given further explanation on things the class only touched on. It has also made me a little more credible in the field when talking with instructors, doctors or paramedics to be able to have a good solid base of knowledge that I gained from class, reading, discussions and listening to podcasts.

    I wouldn’t base my whole career on them, but it’s kind of cool when I hear a new procedure or technique being used or debated, to be able to have some baseline information, and be able to understand it enough to be able to weigh the pros and cons.

    So don’t worry about those who rag on the podcasts, either they are listening to the wrong ones, or don’t understand they are great as supplemental education, or both.

  20. says

    Really late this this! (but demonstrated the power of the Social Media in keeping things like this alive)

    I am really interested in the evaluation dynamic of this. Personally I think we really do need to think of FOAM as a differently paradigm when it comes to evaluation http://rolobotrambles.com/2013/06/24/the-foamed-universe-normal-laws-of-evaluation-dont-work-here/#comments

    However on a different tack I remain astounded that no-one in their right mind would read on solitary journal article and then fundamentally change their practice without further discussion/referencing. Yes it appears if you create #FOAMed type material that is exactly what people might do….! This argument hangs no fire with me anymore and educational leaders are doing themselves a great disservice, and I think being implicitly derogatory to health care professionals who are very able to make reasoned choices, when they cite this concern about podcasts etc.

    All the best


  21. says

    This is what I think should be used as the disclaimer in every FOAMed site:

    ‘Best’ evidence and ‘best’ practice?

    At one stage or another, a medical student or clinician will explore broader sources of information to enhance their medical knowledge.

    These include:

    – Sub-specialised textbooks
    – Journals
    – Review articles
    – Meta-analyses (Cochrane review)
    – Non conventional online sites (e.g. FOAMed)

    Some of the information can be invaluable in elaborating or refining current understanding.

    However, despite what conclusions are made or drawn from this material, the novice needs to be wary of indiscriminately applying this in the clinical setting within the vain belief they are invoking ‘best practise’

    The main issue is context.

    As defined by one of the originators of the EBM concept, Dr. David Sackett

    “Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients”

    For any given conclusion or recommendation, it must be appreciated that the usefulness or benefit of a test or treatment is conducted within a studied population of patients.

    It is entirely possible that the external validity of the study may be completely altered by a different population of patients – such as the one in front of you.

    To further add to the complexity is that the studied population may have been over-represented by certain sub-groups which distort the findings and give the impression that the results could be generalised to all other members.

    Another way to paraphrase this would be:

    – The Fallacy of composition – ‘What is true of the studied group, is equally true for everyone else’
    – The Fallacy of division – ‘What is true of the studied group, is equally true for each individual in that studied group’

    Here are some possible factors.

    – The studied population were:
    – Sicker (more likely to have disease? higher likelihood of tests being positive? more co-morbidities? failed conventional therapies? different risk:benefit to treatment? more likely to suffer complications from treatment? died/withdrew before study ended?)
    – Healthier (vice versa)
    – More compliant (higher success of treatment?)
    – Less compliant (vice versa)
    – Treated in a system with special expertise (higher chance of successful intervention?)
    – Treated in a system with general expertise (vice versa)
    – Had greater access to health resources and followup (closer monitoring? greater chance of having issues and complications addressed?)
    – Had Less access to health resources and followup (vice versa)

    The enrolment / selection process can significantly alter these factors:
    – Well established health networks vs Limited health networks
    – Developed vs Developing world
    – Metropolitan vs Peripheral centre
    – Specialist patient vs Primary care patient
    – Hospital patient vs ambulatory/community patient
    – High SE class vs Low SE class

    So whenever you are tempted to implement a new idea you need to consider:

    – The composition of the studied population and the context of your patient
    – Are there alternative factors that may have lead to the observed results (a good knowledge of the social determinants of disease, aetiology, pathophysiology, pathology and therapeutics helps)
    – If this is applicable or not in your patient
    – Most importantly, does your patient want it?

    Lastly this ignores systematic bias introduced into the study from selection and randomisation.

    Therefore it is important to first identify any significant differences in the baseline characteristics (confounders) between comparison groups such that all of the observed differences can be attributed to these rather than the intervention itself.

    These can completely invalidate any results that may have been concluded from the study.

    So remember:

    ‘Best evidence’ is not best for all so that ‘best practise’ leads to ‘inappropriate practise’


Speak Your Mind (Along with your name, job, and affiliation)