The rebel, the professor, and the entrepreneur: Qualitative study to explore creator stories of FOAM

Abstract Introduction The free open access medical education (#FOAMed, or FOAM) movement creates educational content intended to inform medical education and clinical practice and is distributed in an unrestricted fashion (e.g., open access website). The who, what, and in particular the how of FOAM has raised important questions about the sustainability of the movement. Methods We recruited a diverse research team that included educational researchers, FOAM contributors, a business academician, and medical trainees to design and conduct a qualitative study exploring the work of FOAM creators. We analyzed the transcripts of interviews with 11 participants from top FOAM websites in emergency medicine and critical care. The team met frequently to iteratively identify and discuss emergent themes (major and minor) until saturation of concepts was achieved. Results Creators of FOAM could be categorized using three archetypes: the rebel, the professor, and the entrepreneur. The rebel was categorized as distinctly rejecting “traditional academic structures” yet was compelled to deliver educational content via alternative routes. The professor retained a traditional academic role, instead creating FOAM to supplement academic activities (teaching courses, disseminating scholarship, promotion). Entrepreneurs focused on creating a sustainable entity in an effort to supplement their income and reduce clinical obligations. Conclusion While all FOAM creators appear unified in their passion to create, promote, and distribute educational material with unfettered access to educators, their motivations for creating content could be differentiated. Given the grassroots nature of FOAM, creators share concerns related to financing, time commitments, and threats to sustainability of these businesses. The longevity of FOAM and what business models are best suited to support them are uncertain. Further exploration of the implications could investigate the best ways to engage with and support the different FOAM creator archetypes and develop models of sustainability.


INTRODUC TI ON
Free open access medical education, herein called FOAM, is a phenomenon ostensibly defined as "… a globally accessible crowdsourced educational adjunct providing inline (contextual) and offline (asynchronous) content to augment traditional educational principles." 1 At its core, FOAM is educational content that is made freely accessible via various technologies including podcasting, blogs, and social media and widely understood as being available "to anyone, anytime, anywhere." With origins that predate the emergence of these disruptive technologies, the movement of FOAM is playing an increasingly important role in education of medical specialties. 2,3 Scholarly work has been conducted investigating the impact and quality of these online, open access, resources and suggests that they are commonly used by learners to keep up with current literature and learn core content. 1,2,4 Despite our increasing reliance on FOAM resources and growing scholarship on its use and application, little is known about the FOAM motivations, particular goals, and experiences of individuals who functioned as creators of the resources. Addressing this gap is vital to sustaining an essential source of information. For those within academia, a better understanding of what motivates FOAM creators may provide transferable insights and wisdom that can be applied more broadly to other scholarly pursuits. [5][6][7][8] For those who seek to become FOAM creators, it may serve as a blueprint to success in FOAM and barriers to expect along the way. For consumers, the origin stories, motivations, and insights could influence how they engage with content (e.g., critical appraisal, financial support). FOAM sites, like all organizations, are often a reflection of those who create them; understanding the people who lie at the heart of the FOAM movement may provide critical insights into the origins of FOAM and a peek into future directions of this phenomenon. We conducted a qualitative, interview-based study of individuals who were identified as creators of FOAM to gain a rich understanding of their motivations and perspectives that have shaped their experiences and work.

Research paradigm
In this qualitative research study grounded in the constructivist research paradigm, the aim was to analyze the motivations of FOAM creators through in-depth interviews. We acknowledged that knowledge and reality are constructed through participants' experiences and social interactions. We interviewed the leaders of FOAM websites to identify underlying themes and phenomena guiding their entry and continuation into FOAM. Our inductive, interpretive description methodology thematically explored the motivations and experiences of our participants. 9

Participants
The site administrators of the top 25 emergency medicine and critical care FOAM websites as indicated by the Social Media Index were identified as eligible participants. [10][11][12] They were contacted via email or their website and invited to participate in a semistructured interview regarding their role as creators. Participants were informed a priori that the purpose of the study was to determine the value of their sites as well as the inputs required to produce these sites.

Ethics approval and reporting standards
Ethics approval was sought through the Hamilton Integrated Research Ethics Board (approval HIREB-11529). Participants consented to being recorded. Our results are reported in compliance with the Standards for Reporting Qualitative Research checklist. 13

Data collection
Participants engaged in a single, virtual interview session with one of four members of the research team (PP, MZ, BD, TMC). All interviewers were trained by the senior author. Semistructured interview prompts were constructed into the interview guide (Appendix S1).
Interview prompts were pilot tested with three exemplar participants. Participants did not review transcripts following their synthesis but did agree to respond via email if clarification was required. All interviews were conducted and recorded using Zoom (Zoom Video Communications, Inc.). Audio files were transcribed by a trained medical transcriptionist. Transcripts were anonymized and identifying details were redacted. Transcripts were verified or corrected if required by the analysis team.

Data analysis
Five authors (MZ, PP, TH, BD, YY) conducted the analysis. The remaining authors reviewed and checked the source data against the analysis via an internal auditing process.
The qualitative data were analyzed by the researchers using thematic analysis to determine the routes of entry for, resources available to, and barriers faced by FOAM creators. The authors coded two interviews line by line to develop an initial list of codes and to develop an inductive coding framework. This framework was then used to code the next transcript. This continued until all of the transcripts were coded. Coding discrepancies were resolved by discussion until consensus was reached. The research team met multiple times over 6 months to analyze the codes and framework. New codes emerging during coding were added to the list upon consultation with the research team. The lists of codes were regrouped into larger categories as connections emerged from the data. Versions of the coding tree were kept in Google Docs. Themes were constructed by analyzing, combining, and comparing codes and the relationships between them.
Analysis was undertaken concurrently with data collection to check for thematic saturation. This systematic approach to the analysis established an audit trail from the transcripts of raw data through to the final interpretation. Quotations, linked to respective interview sources, were presented illustrated major and minor themes.

Images
Images for each archetype were generated by NightCafe Studio AI Art Generator with iterative prompts (e.g., "doctor with computer and headset Mark Brooks and Dan Mumford, comic book art, perfect, smooth").

RE SULTS
Eleven of the top 25 Social Media Index site administrators, aged 35-63 years, agreed to participate in our study. Eight (73%) were male. Interviews lasted between 14 and 48 min, yielding 125 pages of transcripts. All participants were physicians. Interviewers recused themselves if there was a pre-existing relationship with a study participant and were replaced with a different trained interviewer.
Our analysis identified three themes: origins, motivating factors, and resources to overcome barriers. Though origins overlapped a great deal, an analysis of motivating factors and responses to obstacles resulted in an organizational framework around three spontaneous FOAM archetypes (Figure 1-3). Major themes are summarized in Table 1 and further elucidated below.

Origin stories
While almost 90% of emergency medicine residents regularly consume FOAM resources, a small minority of them will become contributors. 4 This led us to evaluate the origin stories of FOAM creators. What led them to write their first blogpost or record their first podcast? The FOAM mindset seemed to focus on problem solving, opportunities for collaboration, and interest in education.
Participants repeatedly identified an interest in applying new tools to solve problems, especially highlighting the free distribution of educational content: I felt that it was an opportunity to take the social media platforms which are free and open and available and ameliorate them in a way that was able to be used for medical education purposes when currently it wasn't. It was being used, which it currently is as well for cat gifs and various other things.

(Participant 6)
Participants were motivated to collaborate with others and, in particular, leverage the ability to reach an expanded number of individuals in medicine. One participant highlighted this in the following quote: And I just saw it as an awesome opportunity to actually use the platform … to get to know colleagues from around the world and to share medical information. Um, and so it just started to grow naturally. I never had a plan to make it grow. I probably could be a lot better. I am not very good at making you know there is … search engine optimization and advertising. I don't do any of that kind of stuff. So, it just kind of naturally, though quite nice actually.

(Participant 4)
Sometimes these online conversations on microblogging platforms prompted users to work together to create longer form blogs and podcasts: We just thought, I just thought that this space for a [name redacted] blog and I just put out a tweet does anyone want to start a [name redacted] blog. And three people replied. I hadn't met them before. And, um, that was it. And we just got together. And now we are still working on it eight years later. And they are my closest friends. So, I was lucky.

(Participant 5)
The rebel: ex-or antiacademic Initial innovators in FOAM were educators who had left mainstream, traditional systems of academic medicine, but wanted to engage in forms of education delivery and collaboration with colleagues. These creators were motivated to challenge the concept that an academic physician necessarily works at a university hospital and aligns with a particular faculty. As "ex-academics" they expressed dissatisfaction with formal academia, already having transitioned out of formal, professorial roles. Despite this, they identified as educators with a desire to continue to teach and disseminate education that would improve patient care:

Themes Summary
Origins Most participants identified a common story of wanting to use new tools to solve problems, collaborate, and educate.

Motivations
This theme varied between the archetypes. Whereas rebels were motivated to continue education outside of a traditional academic institution, professors utilized FOAM to advance a traditional academic career. Entrepreneurs frequently sought to reduce clinical demands through monetization of FOAM.

Resources to overcome barriers
This theme varied between archetypes. Whereas rebels improvised to overcome barriers, professors transferred principles and resources from academia to their FOAM projects, including peer review. They also viewed FOAM as a tool to overcome barriers found in traditional course teaching (e.g., customized learning materials).
Entrepeneurs focus on diversified revenue as a primary goal.    was not yet perceived as a traditional publication pathway (e.g., limited peer review of content placed direct to social media) was a concern that they grappled with 16

The pro: Entrepreneur
A third archetype creator was categorized as the "entrepreneur." Characteristic of this creator was the motivation to create content as a sustainable business, a commodity, which could be produced and sold, outside of traditional medical education infrastructure.
Whereas other creator archetypes initially appeared to take on FOAM without much attention to the resources required to produce it, entrepreneurs prominently identified the need to generate revenue streams to support their FOAM organization as a central discourse of their interviews. One participant (Participant 10) stated: "I really hope it keeps going because that will help motivate us to create more free content because we assume that the free content drive is to the paid content." Many creators, clinician entrepreneurs, were motivated to create growing which we did, that we would need to plan that involved some financial planning as well.

(Participant 5)
While advertisements were ubiquitous for funding websites and video-based content, participants described the sobering realities associated with such revenue streams: I do not get ad revenue from YouTube because you have to have so many I think it's so many hours or so many followers before you get to that. I am trying to build up to that. But I haven't gotten to that yet.

(Participant 2)
Some participants attempted to overcome financial barriers by utilizing a subscription model or by organizing paid conferences and research associated with their FOAM: [We] actually started as a subscription model. And then we, that was just before FOAM sort of started taking off … We saw the advantages of FOAM, but we needed to get some sort of funding. So, we went FOAM, we went free and instead of a subscription model we have funding from a research and education institute.

DISCUSS ION
This study categorized a purposive sample of FOAM content creators into three major themes and three distinct archetypes: rebels, professors, and entrepreneurs. This categorization allowed the de-  One interesting theme in the interviews is the natural way many of the participants entered FOAM. It was often organic and experimental, driven by a need to communicate beyond their current role or a way of returning to a past role. Early founders of FOAM initially disseminated work on personal websites and received little scholarly credit. 2 Exploring the medium or teaching in a new way was frequently the initial motivation for starting to produce FOAM content. Because there were not necessarily any preexisting models of success, they were laying out a path as they followed it.
Regardless of whether they began their journey as a solo producer or part of a group, successful FOAM creators identify with a network of colleagues online allowing for growth and expansion.
Some of these were "early enthusiasts" or formal members of the FOAM community of practice. 2 The most successful creators were then able to share the burden of content creation with a group of people or ask family and friends to help out. Some of these relationships became formal in terms of research projects or hosting conferences. This evolution is seen in other industries, where a shared interest leads to networking, specialty knowledge, and the development of a formal business model. 19 Many creators of FOAM found that success led to growth, which led to increased costs. This increased demands for time away from traditional work and from family. As the endeavor became more expensive, they frequently sought ways to monetize content to mitigate the growing burden. However, paid subscriptions and paid ads did not lead to full financial independence. While the median value of a top site can be over $23,000, this represents a fraction of the associated server, labor, and organizational costs. 20 These factors may have contributed to a contraction in the number of FOAM sites and an increased reliance on paid models. 8 The creators that we interviewed were similar in that many were willing to devote their own time and money to enhance medical education. This finding aligns with research suggesting that wealthier people are more likely to spend leisure time on active behaviors (e.g., exercising and volunteering) rather than passive behaviors (e.g., watching television). 21 Physicians are often in a privileged position to engage in such endeavors, but they are not monolithic, and those with less resources may not be able to contribute funds and time to such an endeavor. 22 For instance, women with young children have experienced a drop in academic productivity throughout the pandemic. 23 This is also seen outside of academia where women leaders are leaving their companies at the high rates. 24 This may also illuminate the global disparity between FOAM creation in high-income countries versus low-income countries. 25 Though we identified three types of FOAM creators, they all de-

LI M ITATI O N S
Our study is limited by a number of factors. Our enrollment strategy focused on top-rated and currently active sites; less successful creators of smaller and defunct sites could have different stories.
The lead investigators had expertise in FOAM, which may have introduced preformed interpretations. To mitigate bias from prior expertise, interviews were led and transcribed by different people and anonymized prior to analysis. To avoid potential bias resulting from the overrepresentation of minority viewpoints and expertise, we ensured analysis and reporting was performed by members of the group with disparate backgrounds and experience in FOAM. in design, data, and interpretation; drafting and revising for intellectual content; and final approval and will stand by the work. Bhargavi

CON CLUS IONS
Dhanireddy was involved in design, data, and interpretation.

ACK N OWLED G M ENTS
Elizabeth Clow is a trained medical transcriptionist who transcribed interviews.

CO N FLI C T O F I NTER E S T S TATEM ENT
The authors declare no conflicts of interest.