I have been doing this for 10 years

I have been doing this for 10 years now.

I am not sure what the future holds. I am not sure what First10EM will look like in another 10 years. I am not sure these words will be published (although if you are reading it, I guess we have our answer). This is an exercise in self reflection. If it is posted publicly, it is either because I think a small number of long time readers might find it interesting, or because I hope to get some feedback on my musings. Either way, please feel free to leave comments below.

In many ways, this project has surpassed my wildest dreams. I am just a community emergency doctor working in suburban Canada. When I started, I had absolutely no ties to academia. I still have no academic support. There was no reason for me to believe that 10 people would want to hear what I had to say, let alone tens of thousands from every part of the world. Beyond anything else, I would like to say thank you.

Thank you to everyone who takes the time to read. Thank you to everyone who has shared First10EM with others, helping it to grow. Thank you for the comments and questions. Thank you for engaging, and encouraging me to continue. I am a better doctor and better person for having undertaken this project, and the project would not exist without an audience. So, thank you.

Reflecting on the audience that First10EM has gained, my first thought is that emergency medicine is incredibly hard. I think it is a reflection of that difficulty that we seem to spend so much of our personal time learning; way more, as far as I can tell, than other professions. We hunger for knowledge. We need support. We need resources to lean on. The last decade has seen a rise and fall in the supply of FOAMed, but it seems clear that the demand will always exist. 

I have been very lucky. I managed to catch the early wave of FOAMed, and got a ton of early support from giants like Anton Helman, Scott Weingart, Rob Orman, and Ken Milne. (Again, thank you so much to everyone who shared my early content despite the distinct lack of polish.) There is nothing special about me. If you are interested in FOAMed and medical education, consider the success of First10EM as evidence of the demand for high quality content. I think that anyone can succeed, if you are willing to put in the effort.

Of course, it is a lot of effort. During the past decade, First10EM and other FOAMed pursuits have eaten far more of my hours than clinical work. Considering that I only get paid for clinical work, FOAMed has some pretty clear costs. I work at least 33% less than I otherwise would, and therefore accept a 33% decrease in pay, in order to pursue this hobby. I have also benefited tremendously, being invited into rooms I never would have been otherwise, and making friends that I hope to keep for a lifetime. I am incredibly grateful for everything I have gained from FOAMed, but reflections on FOAMed must always include the costs. 

When I started, this was an easy hobby to pursue. I am a night owl. My wife is not. If I was not working clinically, I would routinely find myself awake in a quiet house between the hours of 11pm and 3am looking for something to do. Those became my FOAMed hours. For the early years, First10EM was created out of those bonus hours of the day that I otherwise might have spent watching TV. (Although, I am now utterly useless at all pop culture trivia categories, and won’t get any references you make to popular television shows, so I suppose this is a cost as well.)

Over the years, the costs of FOAMed have changed for me. When writing for my own blog, there are no deadlines and no pressures. (I guess that is not entirely true. There are no external pressures, but I definitely feel the push to produce regularly for my audience.) However, as I started to partner with others, deadlines started to accumulate. Work started to spill into daytime hours that I might have spent on other hobbies, or with family and friends. After having a child, the midnight work sessions became impractical, and so now every minute spent on First10EM is a minute taken away from “real life”.

I imagine this is a common pattern across medical education. Quality education takes time, but time is life’s most precious resource. Idealistic young physicians can squeeze hours from their early career to volunteer to teach, but it doesn’t take long to see the costs. Hours have to be claimed from somewhere, whether it is sleep, clinical work, or family time. Some find a balance. Others wake up to the true costs, and the general lack of support for education, and the result is a rapid turnover of young physicians in many education roles. 

So what is the future of First10EM? I can’t imagine First10EM will disappear. Perhaps I skipped too many classes in medical school, but every shift I work raises new questions. My “to do” list of clinical questions that I want to explore already represents at least another decade of work, and it will only grow longer after my shift this afternoon. Emergency medicine is hard, and so I know that I need to constantly learn and improve, or I will fail my patients. So long as I continue to find content that is interesting, and continue to have an audience who is interested, I imagine I will share what I find in one format or another.

First10EM has always had a somewhat split personality. From the outset, I was interested in both resuscitation and evidence based medicine. Originally, the blog was only for resuscitation, and I shared my evidence based medicine “articles of the month” summaries via email. However, I quickly realized that people were happy to get both types of content on the blog. I didn’t need a hyper-focused theme, I just needed to discuss topics that were of interest to the average community emergency doctor (me). 

The name “First10EM” derives from my desire to have a textbook to guide me through the first 10 minutes of resuscitation of an undifferentiated patient. The posts were meant to guide my mental practice sessions, and also be useful as quick reference when on shift. I desperately wanted such a textbook to exist, and it didn’t at the time, so I just started writing it for myself. Since then, others with similar visions have created resources better than I ever could (such as Weingart’s Resuscitation Crisis Manual), and some of my initial motivation was removed. I have never been an expert resuscitationist. I have worked hard to improve, but First10EM has always been written from the perspective of a nervous amateur, combing every possible resource, listening to every possible expert, and trying to distill lessons I could bring into my own practice. I desperately needed this project early in my career. It helped me deal with the incredible anxiety that comes from being left in charge of all the sickest patients in an entire city, while secretly feeling like a complete imposter. It worked. That anxiety has evaporated, and I am proud of the content created. However, resuscitation has never been my true area of expertise or interest.

Over time, the content on First10EM has shifted towards evidence based medicine, which is the area where I feel I can provide the most value. Of course, that content is less exciting, which leads to a smaller audience, which perhaps makes me hesitant to drop resuscitation topics altogether. Am I better off focusing solely on evidence based medicine? Should I separate the projects: leave First10EM as a site dedicated to the first 10 minutes of resuscitation, and start a separate EBM resource from scratch? Do I leave it as it is, mixing topics, recognizing that the blog reflects real emergency medicine: a mixture of exhilarating, confusing, simple, frustrating, and mundane?

What format works best? I have spent a year experimenting with video. There is a new YouTube channel, and short videos have been posted on the many social media platforms that allow it. I have enjoyed the challenge. There are some topics (mostly procedural) that I want to cover that are clearly better suited to video. Video might also be more captivating. It might be my best opportunity to grow the audience, as readership has stagnated after a decade. If I am already spending dozens of hours researching a topic, why not spend a few more creating a video that might reach a wider audience? On the other hand, video takes far more time and effort to produce, and I am very short on free time. 

How important is consistency? Aside from a few vacations here and there, I have posted almost every week for 8 years. There are benefits from consistency. Deadlines, even if artificial, are great motivators. Habits are great for productivity. Google likes consistency and rewards active websites with higher search results. I think the audience also appreciates consistency, and there is some pressure to produce given that I have Patrons contributing monthly to keep the site running. 

However, if I am honest with myself, my current pace is unsustainable. I am publishing the equivalent of 1 or 2 books every year for free. I love what I do, but it is currently just too much. There are not many empty days in my calendar. I want random empty Tuesdays to be set aside to bring my kid to the zoo, not to prepare for a podcast or scroll pubmed until my eyes cross. 

Will the audience stick around if I slow down? Perhaps the content would be better if I focused only on the very long EBM deep dives, but I can’t produce more than a few of those a year. Would they still find an audience if I disappeared for long stretches in between posts? Would First10EM be better (or more sustainable) as a team effort, or is there value in maintaining my personal brand, voice, and viewpoint?

FOAMed is intoxicating because of its reach. Watching a million people a year access your content provides a dopamine hit. The reach is broad, but is it too shallow? I love the occasional back and forth discussion that pops up in the comments, but most of my work is one sided. I am sitting in silence in my office. There is no way to know the impact of my work. People click, but do they read? Do they understand? Does practice change? Faced with too few hours in a day, I chose First10EM over the simulation work I was also doing. I have less time for one-on-one education. Might I have been more impactful if I had made the opposite choice, providing in depth education to a few rather than superficial education to many? Metrics are easy (and sort of fun) to follow, but they aren’t the reason I teach. How do I best invest my time to have a real impact on emergency medicine (and ultimately on the lives of patients)?

Does First10EM have a future without me? Do I care? If I die tomorrow, would the website die with me, or would it remain a useful resource for the years to come? I like to think that some of my content is evergreen, remaining relevant over the years. Certainly, posts are reread and rediscovered with random spikes in readership years after publication. However, neither science nor medical practice are static. I wouldn’t suggest reading 10 year old medical textbooks, so I am forced to wonder: is half of all that I have written already obsolete? Should I delete old material to prevent confusion? Should I work to update old posts? (If so, with what time?) What is the shelf life of most FOAMed content?

I guess it is worth reflecting on finances. All medical education – not just FOAMed – is built on a foundation of volunteerism. As far as I can tell, this has always been the case. The educators at every hospital and every university take time away from well paid clinical work to teach. For the most part, that education is either completely uncompensated, or compensated at way below market rate. We do it because we love it. We do it because it sustains our own careers and helps us learn. Hippocrates espouses the value of education in his oath, and even emphasizes that it should be provided free of charge. I love the idealism, but realistically, the model is broken. It results in way too much turnover. Great educators are lost because they are inadequately compensated. Lacking adequate support, potential great educators are lost before they ever start. Perhaps I am biased by my years outside of academia, but I have watched countless young physicians eagerly embrace education only to retreat when they find a system that requires endless uncompensated and unsupported hours.

This is as true of FOAMed as it is of traditional medical education. From its peak, we have already seen a decline in FOAMed. A few of our biggest creators have found sources of income, or moved away from the free model. Some have grown into large teams, allowing individual contributors to work less. However, many many others have just disappeared, the incredible time commitment of FOAMed presumably not worth the effort compared to the many competing responsibilities of life and medicine. I think this is an incredible loss.

A handful of master educators have managed to transform medical education into a true career. I am not sure the broader medical community understands, but for most educators education is a massive money pit. Conferences might provide a stipend, but it never fully covers the costs of travel, let alone the time away from family, or the countless hours required to create and refine a high quality talk. Perhaps I am just bad at my job, but when I compare the usual conference stipend to the number of hours it takes to research, write, and practice a talk, my pay is far below minimum wage. Conference fees might seem expensive, but I would argue they are actually heavily subsidized by the people doing the teaching. 

FOAMed is free for the user, but actually quite expensive to produce. I am pretty lucky with First10EM. For 8 years, I covered the costs of hosting the website on my own. I now have supporters through Patreon and ads on the website that fully cover the costs of running the website. I am no longer losing money on the website, but I also don’t generate any income. (I think this surprises people outside of FOAMed, when they see the ads and the Patreons links, and assume I have entered the social media influencer space.) It is pretty clear that First10EM will never act as a job replacement. It will never even generate enough income to financially justify setting aside even a few days a month for the project. (Considering I am already working more than full time hours on the project, it is therefore unclear how I would ever be able to expand First10EM, despite my true desires to create more content.)

Thankfully, I have been very happy to have First10EM as a hobby. Running a business is a lot less fun than having a hobby. Perhaps if I was a better businessman, the numbers would not be so pitiful, but it would also transform a work of love into a chore, and I fear that is the recipe for disaster. However, I have to openly acknowledge its current position as a hobby, and I can’t allow this one bizarre hobby to edge out all others. That is why, as I picture the next 10 years with my family flying by, I am certain that First10EM has to change. I am just not sure what direction the next 10 years will take me. 

I have been loath to even consider the possibility, but I suppose a truly valuable reflection will have to include the possibility of blowing it all up. If I am honest, the thought never crossed my mind until I wrote those words. First10EM is a core part of my life; of my career. I can’t imagine it disappearing, but perhaps that is a classic human bias. I am as susceptible to the sunk cost fallacy as anyone else. If I decide that my life would be better without First10EM, does that mean that the endless hours I have toiled for the last decade were all wasted? Am I living in denial?

If First10EM did not exist, and someone was pitching the idea to me, would I jump in? Would it be a “hell yes?” One widely used framework for considering such decisions is “Ikigai”, which asks you to consider your passion (what you love doing), your vocation (what you are good at), your mission (your value to the world), and your profession (what you get paid for). First10EM clearly fails as a profession, but I think (or hope) I succeed in the other 3 categories. I think I am good at medical education, evidence based medicine, and this niche of online content creation. I think online medical education has brought value to the world (although sitting alone at my desk, perhaps this is the part I am least certain of). I may have other priorities, but I love emergency medicine and evidence based medicine, and find great joy in learning and teaching. Three out of four is pretty damn good. Perhaps I should take a more business minded approach, and try to make this a 4/4 Ikigai project, but might that destroy the passion? Even if the anxiety of embarking on a new project might not make this a “helly yeah”, it would at least be an “I am interested”, which is a good sign for the future of First10EM.

One recurrent theme to this reflection appears to be isolation. When I jumped into FOAMed, it was truly a community. Twitter was still a functional space. I could log in and have productive conversations with brilliant physicians from around the world (with just a modicum of trolling). I learned something new every day. That space has disappeared. (I know a lot of people are still on Twitter, but I would argue no one should be supporting a platform owned by Elon Musk. Either way, the Twitter algorithm has long been broken, and can no longer produce a productive medical community.)

I believe that community is essential if First10EM and FOAMed is going to thrive. FOAMed was never about individual voices, despite being founded by some incredible individual voices. What made FOAMed extraordinary was the community. The heart and soul of the FOAMed movement was never EMCrit or Life in the Fastlane or ERCast. FOAMed came alive when those individual voices came together in the ultimate collaboration of SMACC, or in the smaller day to day interactions on a still functioning social media.

Community is essential. Sitting alone at a keyboard, it is impossible for me to get a sense of the value of my work. Without conflicting ideas, it is harder for me to grow and learn. Over the decade, this project has become more siloed. For First10EM to thrive, I believe it needs to reestablish some of the online community feel that arose from early FOAMed, but I honestly don’t know how.

As I read this back, it sounds angsty. If not angsty, perhaps self-indulgent. No, I am not having a midlife crisis. This was just an exercise in reflection; in putting the questions on paper. Too often, we live our lives on autopilot. There is no time for reflection. There is barely time to think. The 10 year anniversary of First10EM provided an excellent excuse to break the momentum – to step off the treadmill – and just take some time to think.

I am done writing, but I am not done reflecting. I am not sure where First10EM goes from here. I have many remaining questions, but there are a few things I am certain of: FOAMed is incredibly valuable and I am incredibly grateful for the last 10 years of my career.