We come from all the divisions, ranks, and classes of society…to teach and to be taught in our turn. While we mingle together in these pursuits we shall learn to know each other more intimately; we shall remove many of the prejudices which ignorance or partial acquaintance with each other had fostered…In the parties and sects into which we are divided, we sometimes learn to love our brother at the expense of him whom we do not in many respects regard as a brother…We may return to our homes and firesides with kindlier feelings toward one another, because we have learned to know one another better.   –Thomas Greene¹

The putative benefits of free open-access med(ical ed)ucation (FOAM) including decreased time for knowledge translation to the bedside, enhanced post-publication analysis, and increased portability of medical knowledge.^2,3 There may also be other less tangible but no less important benefits from connecting an international group of energetic, articulate, and charitable educators, clinicians researchers and administrators. Beyond its educational remit, FOAM could be a a powerful form of ‘social capital’ that helps create a community of like minded individuals. These communities can, in turn, make us feel not just more informed, but also more resilient as we attempt to care for patients and for each other.

Social Capital

The first formal discussion of social capital as a distinct concept came from the world of education reform. Lyda Judson Hanifan was a staunch advocate of developing education systems in very rural communities.⁴   Having completed his undergraduate degree at the University of Chicago and a Master of Arts degree from Harvard, he returned to rural West Virginia in 1910. He advocated for reform and development of education in rural areas, writing extensively on the subject over the years. At the core of his education philosophy was that the interaction of community members was vital to improving education:

If [an individual] comes into contact with his neighbor, and they with other neighbors, there will be an accumulation of social capital, which may immediately satisfy his social needs and which may bear a social potentiality sufficient to the substantial improvement of living conditions in the whole community.⁵

The focus on social capital waxed and waned in popularity throughout most of the twentieth century, but eventually made it to prime time on the academic stage in the 1980s. Appropriately returning to its native realm of education, prominent sociologist James Coleman once again discussed the importance of interaction of individuals in social networks as paramount to education, in particular, and the very fabric of our society, in general.^6,7

The concept of social capital has been reinvented a number of times in the last century. While subtle changes have appeared as it has been applied in different contexts, the tenor of the concept has maintained intact: social networks and the normative behaviors that arise from them, such as reciprocity, trustworthiness, and good will, have tremendous value. Thus, social capital is, at its very core, the powerful resources contained in the human relationships, both casual and more formal, that exist in a society. There is now robust evidence base that indicates the virtually undeniable importance of social capital in everything from the arts to business.⁸

In the 2001 bestseller, Bowling Alone, author Robert Putnam outlines the science of social networks.⁹ Although Putnam explicitly examines the topic within the context of the dynamic cultural landscape in the United States, his observations appear to be widely applicable: “Social capital turns out to have forceful, even quantifiable effects on many different aspects of our lives. What is at stake is not merely warm, cuddly feelings or frissons of community pride.”⁹

The Scope of Social Networks

What is, perhaps, most impressive is the vast scope of social networks that are able to influence the health, happiness, prosperity, and stability of a society: “The forms of our social capital – the ways in which we connect with friends and neighbors and strangers – are varied.”⁸ For many years, sociologists focused on more formal networks and interactions such as political parties, religious groups, athletic organizations, or philanthropic clubs. However, we now understand that even informal social networks can have surprising results on patterns of thought and behavior. Simple, unstructured interactions such as talking to an acquaintance at a local bar, chatting briefly with a neighbor, or a spontaneous barbeque with friends may build social capital. As Robert Putnam describes, “Like pennies dropped in a cookie jar, each of these encounters is a tiny investment in social capital.”⁹

Even the most casual interactions among strangers can fundamentally change behaviors. Bibb Latané and John Darley were psychologists that explored the curious “bystander effect” in the 1970s.¹⁰ In their landmark book The Unresponsive Bystander: Why Doesn’t He Help?, the authors explain the results of numerous social experiments in which they examine the effect of a crowd of bystanders on a single individual’s action. As it turns out, time and time again they noticed that when a large group is present an individual is less likely to act to help someone in an emergency. They suggested that, “the responsibility for intervention is diffused among the bystanders and focuses on no single one. In these circumstances, each person may feel less responsibility to help the victim.”¹¹

Certain interventions seem to mitigate the bystander effect. When a stranger is announced to have a “seizure” in a room full of students, the percentage of people that respond to provide aid to the stranger decreases as the number of bystander students increases. However, this effect was significantly mitigated if the stranger spoke briefly in the hallway with student subjects in the experiment. So, even a brief conversation with a complete stranger seems to blunt the diffusion of responsibility and perhaps generates some sense of social reciprocity or duty to act.

The Benefits of Social Capital

Social Capital does more than just breed good will and encourage people to help one another. There are quantifiable effects on important aspects of society. One effect that social capital exhibits, which is of particular importance to the FOAM world, is education. When you quantify measures of social capital into what authors have referred to as a “Social Capital Index”, correlations with other metrics can be evaluated.¹² In the United States; for example, higher levels of social capital correlate with better primary and secondary school performance as well as lower dropout rates. This is true even when controlling for poverty, race, and level of education attained by adults. Oddly enough, when examined, it was higher levels of informal social capital that had the greatest effect.

As it turns out, academic performance is better in schools where family members of students have multistranded relationships. For example, when parents of school children interact at fitness classes, adult social events, religious gatherings, and other events outside the context of their children’s education, they form strong social networks. These networks are bound together even more tightly when the parents’ goals and priorities align around their children’s education and development. When the great sociologist James Coleman explored these situations, he found that the result of this increased social capital was the increased provision of social resources and maintenance of academic standards of performance.^13,14 Coleman made a point that one should never underestimate the “importance of the embeddedness of young persons in the enclaves of adults most proximate to them.”¹⁵

These effects seem to exist outside the context of primary and secondary education. When adult students are involved more deeply in community activities, interact outside of class, participate in athletic teams or otherwise build strong relationships, their performance in higher education is better.   The rate of withdrawal from school decreases, their academic scores increase, and their general “personal development” seems to improve as well.^16,17

Social capital also makes us feel happier and better able to cope with challenges. Mood and supportive social networks are tightly linked. Most people who have close friends, loving family members, and intimate significant others are happier.^18,19 Most people report that social interaction is the most important ingredient in their recipe for happiness, ahead of notoriety, work satisfaction, or money.^20,21 Large population studies world-wide indicate that the depth of a person’s social connections are the best predictor of happiness.^22,23

Beyond producing general happiness, social capital may inoculate against clinical depression. Social connections seem to counteract the effects of low mood.²⁴ Interacting with our friends, sharing our problems, or even taking our mind off things by discussing other life events seems to decrease stress and ward off untoward physiological effects.^25,26 Moreover, in the setting of major depression, social ties seem to ameliorate symptoms and speed recovery.²⁷

In addition to mood disturbances and disorders, there are other important health effects of accumulating social capital.²⁸ Well-designed, multinational, longitudinal studies indicate that low social connectivity and isolation result in a two to five times increased likelihood of all-cause mortality compared to matched individuals with strong social networks.^29,30,31 While no definitive answer has been offered to why this is, several interesting hypotheses have emerged. Lisa Berkman, Professor of Public Policy, Epidemiology, and Population Health at Harvard,  suggests that lack of social connectively induces a “chronically stressful condition” and has distinct physiologic sequelae, such as increased atherosclerosis.³²

Observational studies seem to support this hypothesis. People in communities with geographic proximity and similar rates of risk factors for coronary artery disease (diet, central obesity, smoking and similar ancestral background) have demonstrated dramatic differences in rates of mortality from heart disease. After extensive analysis, the authors concluded that the primary difference between communities were metrics of social capital (high participation in sports clubs, church organizations, and a mutual aid society to name a few).^33,34,35 In short, the community with substantially lower mortality had significantly higher indices of social capital. Other studies have suggested lower overall mortality in individuals that experience social interactions as simple as phone calls from friends and relatives, going to parties, or attending church.^36,37,38 Still others have implicated social connectivity in helping to prevent the common cold.³⁹

FOAM, Social Media, and Social Capital

FOAM networks, as Chris Nickson (@precordialthump) and Mike Cadogan (@sandnsurf) suggest, are strong communities of learning that use a wide variety of platforms and media to provide medical education. Bound by a common “ethos of open sharing and collaboration” the community provides current, constantly evolving content that supplements traditional learning modalities and peer reviewed journals. Interestingly enough, the authors recount that it was a social interaction in a Dublin pub where the term “FOAM” was coined. Thus, it was born in the context of building social capital.²

The FOAM world engages in meaningful interactions, through various social media and online platforms, that generate social capital.  Anytime one signs onto Twitter™ and “likes”, “shares”, or responds to a tweet, they are engaging with someone in a small, but not insignificant way. A post on a blog or comment on a podcast can start an international conversation among colleagues. These are very similar to the casual social interaction that other authors have discussed. Like many of the informal acts that build social capital between neighbors in proximity, these interactions generate social capital among medical colleagues across great distances.

Stronger interactions occur through the development of FOAM’s powerful learning networks. In their post, FOAM and the Rhizome: An Interconnected, Non-Hierarchical Approach to MedEd, Daniel Cabrera (@cabreraERDR) and Damian Roland (@Damian_Roland) discuss the effectiveness of models of learning that are fluid, continually evolving, interconnected, and non-hierarchical.   They explore the theory of FOAM using the analogy of the rhizome (the branching root structure of plants). Extension of their theoretical framework suggests that, as individuals in the learning community are empowered to create material, negotiate content, and collaborate, community members socialize.   This tangled web of more formalized, academic interaction also facilitates the development of social capital.⁴⁰

More recently, Roland and Cabrera, along with colleague Jesse Spurr (@Inject-Orange), suggested that through FOAM we build communities of practice (CoPs).   These communities develop around nuclei of professional medical education and endeavor to develop said concept.   A distinguishing characteristic of a CoP is that it also works to “foster development of individual members.” The CoP is investing in its constituents. The interactions within the CoP, by design, build social capital as well as a body of medical knowledge.⁴¹

There are fundamental differences between social networks that exist in person and those that exist through electronic media.²⁶ Most studies regarding the power of social capital have examined interactions face-to-face. Even though in-person interactions seem to be more powerful for a number of reasons (eye contact, body language, touch),^42,43,44 there are still effects with digital social connectivity. There is evidence that online communication, such as FOAM, can still build social connections and social capital.^45,46,47,48

Not all interaction in the FOAM community is online. While the majority of it takes advantage of social media, online, and digital platforms, FOAM has not entirely forsaken face-to-face interaction. There are a number of formal events that bring members of the FOAM community together live and in person. Perhaps the best example of this is the Social Media and Critical Care (SMACC) conference. At SMACC there is nearly continuous social interaction between doctors, nurses, paramedics, students, and a host of other health professions from every corner of the globe. SMACC is the Fort Knox of social capital in the FOAM community. So, while the majority of the FOAM community’s interaction is done online, it still reaps the benefits of more traditional, in-person interaction.

The interesting aspect of FOAM’s role in building social capital is the specific type of capital that it builds: bridging social capital.^49,50,51,52 This is an important aspect of learning and development in online or network communities.⁵³ Bridging social capital is what some sociologists have referred to as “outward looking” and “inclusive”.⁹ This form of networking tends to pull people in across a wide variety of social, economic, and cultural backgrounds. Furthermore, this form of social capital is best at linking information from disparate sources and information diffusion. It is this form of social capital which is most potent when it comes to fueling the fires of change and driving innovation. So, from a sociological standpoint, it should not be surprising that the FOAM community is attracting some progressive, forward thinking individuals and starting to drive change in medical education. ⁵⁴

The Dark Side of Social Capital   

It is important to recognize that social capital is not unilaterally beneficial. Like many things, it can be unhealthy or even destructive. When groups of people come together, insulate themselves, and unite around a commonality it can be powerful, but also dangerous; for example, gangs and other forms of organized crime. Individuals of less-than-altruistic political ideology can coalesce to form very powerful parties with malevolent intent. In these cases there is plenty of social capital (often referred to as “bonding social capital”^9,48 ), but it does not necessarily benefit society.

FOAM is not immune from the pitfalls of social capital. The community needs to be careful to avoid sectarian practices that deviate from the ultimate goal of spreading information and improving patient care. Tribalism, in-fighting, and acting with intentions that are anything less than honorable are all risks. There is a thin line between collegial joking and statements that could be interpreted as divisive and insulting. Comments or dialogue that ostracizes any group inside (or, for that matter, outside) of the FOAM community must be avoided. Critiques should build community members up, not cut them down. Debates should include divergent opinions, not shut them out. Conversations should bridge socio-cultural differences, not isolate them.

Conclusion

The development of the global FOAM community offers dissemination of translation of best practice while building social capital within a community. This has benefits beyond clinical practice. It can make us healthier and happier as well as bridging innumerable differences, so that we can unite in pursuit of a common goal. It is a wonderful and, yet, unexplored concept in our community. This article focused on the benefits of FOAM at the community level. It approached the issue from sociological and epidemiological standpoints. Part 2 will delve into the neuroscience and psychology of how this FOAM benefits us on an individual level. How does FOAM change the way we think, the way we approach problems, and can it make us more resilient?

Acknowledgements

Special thanks to Peter Brindley (@docpgb), Vic Brazil (@SocracticEM), and Chris Nickson (@precoridalthump) for their time, kind feedback, and editorial assistance with this post.

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Mike Lauria

Regular Contributor at EMCrit.org

Emergency Medicine Resident
University of New Mexico Health Sciences Center
Former US Air Force Pararescue and Critical Care/Flight Paramedic

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