Access to knowledge through the Internet has spawned a world of online learning, stimulating a new passion for lifelong learning in academia, professional environments, the workplace, and at home. This article takes a fresh look at the wide spectrum of opportunities for online medical education for physicians. We first explore a continuum of “e-learning” models and then look at the range of platforms used to support these systems. We will also look forward to the options likely to change e-learning in the near future and improve physician performance and patient outcomes.
Knowledge is of two kinds. We know a subject ourselves, or we know where we can find information on it. —Samuel Johnson (1709–1784)
Statistics on the growth of the Internet and its revolutionary impact on how the world accesses information, without the barriers of location or time, are captivating but largely superfluous. With more than 1 billion users, the opportunities for finding new knowledge need only be described as both vast and inexhaustible. Samuel Johnson, circa 1755, and his publication, A Dictionary of the English Language , could not have possibly found in a lifetime what the average user can find in a day on the Internet .
Access to knowledge has spawned a world of online learning. What is not to love about on-demand access to expert knowledge, fed by a nearly constant infusion of new or updated information and enhanced through multimedia, interactive tools, or virtual discussions? Report after report document the ways in which the World Wide Web is stimulating a new passion for lifelong learning in academia, professional environments, the workplace, and at home . Not only has the number of students studying online increased at a higher rate than the rate of growth in higher education overall, access to online education is a strategic imperative for organizations ranging from Fortune 500 companies to developing nations.
Whether one faults the user or the usability, a decade ago it was not uncommon for physicians to be characterized as Internet technophobes . Gradually, over the past 5 years, surveys have demonstrated that nearly all physicians have access to the Internet and know how to use it to obtain medical information. The most recent release of an annual survey conducted by Manhattan Research, entitled Taking the Pulse: U.S. Physicians and Emerging Information Technologies , found that 99% of doctors are now using the Internet on a daily basis . These researchers consider that the tipping point and suggest that physicians are prepared to make major shifts in using the Internet to impact health care.
The path to effective online continuing medical education has been a steady but slow one. In their study on Web-based instruction, Casebeer and colleagues reported 209 continuing medical education sites in 2001, a doubling of sites from just a year before. Yet, despite offering 18,263 hours of continuing medical education credit, 28% of these sites contained only text; only 17% were interactive and 7% were guideline-based. And although the availability and quality of sites may have increased since then (at press time, sites such as CMEList.com were tracking 300 online CME sites, offering about 16,000 activities and more than 26,000 hours of AMA Category I CME credits), concerns persist about inconsistent use of content that is evidence-based and methods grounded in adult learning theories.
Rather than spending time characterizing online medical education sites as suboptimal tools for improving physician performance or patient outcomes, the intention of this article is to take a fresh look at the wide spectrum of opportunities for online medical education for physicians. We first explore a continuum of “e-learning” models and then look at the range of platforms used to support these systems. We also try to look forward to the options likely to change e-learning in the near future.
A continuum of e-learning models
Fig. 1 illustrates a continuum of e-learning models in use today. The basis for the continuum is interactivity of the content as well as the learner. This is in keeping with what is often referred to as the “new science of learning” . The premise is that as learners become more directly involved with the learning content and materials, they make active choices about the path they need to take and the “building blocks” of their studies. By controlling their learning, they monitor their mastery of skills and transfer learning into practice. Additionally, interactive content typically requires that such knowledge seeking does not occur passively, but instead through more compelling, interactive formats that offer a virtual extension of a teacher-centric model of learning .
Internet access to digitized content
At the most basic level, physicians spend a great deal of time researching and learning from digitized content on the Internet, just like the rest of its 1 billion users. In the 10 years since Senators Tom Harkin and Arlen Specter announced free Web-based access to MEDLINE through PubMed and Internet Grateful Med in June 1997, complete with a demonstration by Vice President Al Gore, there now exists a nearly complete digital archive of the volumes of medical knowledge found in more than 5000 biomedical journals . Other commercial aggregators, such as Ovid ( www.ovid.com ), offer premium access to a growing list of journals, books, and 200 databases . Through sophisticated and unsophisticated search engines, physicians and their patients are offered access to the equivalent of a 24/7 virtual library of medical education resources, well beyond traditional peer-reviewed journals, found on academic, government, nonprofit, and commercial Web sites.
One example of a typical online textbook is ACS Surgery: Principles and Practice . First published in 1989 as a loose-leaf reference, the entire contents of this textbook are available in an online format . Access to this content is on a pay-per-chapter basis or through an annual or monthly subscription; for a modest surcharge, users have access to tests through which they can obtain up to 60 CME credits. Although it is described as “practical, fast, and richly illustrated,” this online textbook is simply a digitized version of the same text-rich product that normally resides on office or library shelves.
Another example of digital content sometimes erroneously called an online course is the CME available from the commercial Web site CMEWeb . Whereas some courses are described as containing multimedia features, a typical course on CMEWeb requires the learner to read several different articles and complete a post-test for claiming CME credit.
As a tool for continuing medical education, access to digitized content on the Internet is an important but limited offering. While specialized search engines are powerful tools for addressing specific clinical questions, their current formats are not straightforward enough to be undertaken during the clinical encounter. The burden remains on the learners to critically assess the validity of the content, extract meaning, and teach themselves when and how to apply what they have learned. CME tests measure if they have gotten it right. Box 1 summarizes the advantages and limitations of online content for physicians.
Model: Internet access to digitized content
Description: Access to medical education resources via the Internet
Advantages
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24/7, transportable accessibility to a virtual library
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Convenience of digitized versions of online textbooks and other reference materials
Limitations
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Clinician must leave the clinical encounter to seek information
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Still requires the learner to extract meaning and teach themselves when and how to apply it
Examples
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MEDLINE and PubMed
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ACS Surgery: Principles and Practice
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CMEWeb
Shared library of multimedia and video-based learning objects
One step up from digitized text is a much more fun side of e-learning. Thanks to significant increases in bandwidth and digital storage, today most Internet users can watch and interact with objects online in ways they never imagined. Whether it is live streaming lectures or a central online shared library for slides and digital images, the Internet is a natural source for stimulating different cognitive processes to enhance learning. These objects are largely used to create more sophisticated interactive learning courses rather than as stand-alone learning interventions. Yet there is educational opportunity to be found in searching and browsing a shared library of multimedia and video-based training.
One hot topic in medical education is the creation of shared digital resource collections, such as media libraries and learning object repositories. A noteworthy example is the Health Education Assets Library (HEAL) . HEAL is a digital library providing free access to a centralized national repository of high-quality digital teaching resources in the health sciences. Resources are submitted by individual authors and peer reviewed before publication in HEAL. HEAL has also partnered with other digital libraries to include their content as affiliate collections that can be searched and browsed through HEAL.
In a similar way, medical schools in Canada are collaborating to develop and share noncommercial digital media files through The Common Currency Project . This project aims to bring together one-time, limited funding projects, such as the DalMedix media library, McGill’s Health Library, and the Alberta and British Columbia-based BELLE project, to build up these media collection mechanisms “beyond the pilot stage” of test content.
The AAO-HNSF has begun to develop and use an image library for various initiatives, including the National Resident Online Study Guide (NROSG) . As shown in Fig. 2 , images are accessible through a custom-built image viewer tool, allowing users to search for cataloged images using metadata and text searches, read and store slide notes and annotations, and zoom in and out on the images and image sectors.
If a picture is worth a thousand words, then videos at 60i (interlaced; frames per second) should be worth 60,000 words per second. High-resolution digital images stored at 200 × 200 and viewed with pan and zoom tools on today’s monitors offer a universe of words and information to explore. Opportunities are no longer limited by technical issues of capturing, storing, and sharing digital media learning objects online. Instead, institutions and communities are tackling logistical, financial, and copyright issues of maintaining a high-quality, comprehensive, and consistent collection into which contributors are comfortable exchanging widespread distribution for the hope of future enhancements to medical education and for commercial sale. Box 2 summarizes advantages and limitations of multimedia and video-based learning.
Model: Shared library of multimedia and video-based learning objects
Description: Central online shared library for digital images and videos for direct learning or reuse in other learning programs
Advantages
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Multiple media sources stimulate different cognitive processes to enhance the learning
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24/7, transportable accessibility
Limitations
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Clinician must leave the clinical encounter to seek learning
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Still requires the learner to extract meaning and teach themselves when and how to apply it
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Challenged by intellectual property and copyright issues
Examples
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Health Education Assets Library (HEAL)
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The Common Currency Project
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AAO-HNSF Image Library
Point-of-care e-learning
As an educational tool, point-of-care systems provide real-time learning in a manner designed to be informative and not intrusive in the clinical pathway. The key is in the quality of the content and the usability of the interface. Today’s point-of-care offerings tend to use real-time automated tools that are integrated into existing clinical information systems to provide contemporaneous education for the physician. The educational product is essentially highly customized knowledge linking a clinical diagnosis with the appropriate guidelines, order rules, or point-of-care recommendations.
According to Manhattan Research, approximately 25% of physicians are accessing the Internet during patient consultations; typically, these physicians are in group practices with an electronic health record system and spend more than 10 hours online per week .
One example currently released in beta version is the American College of Physicians’ (ACP’s) Best Dx/Best Rx . Best Dx/Best Rx captures the patient care recommendations from ACP Medicine and offers them in a format for use on a computer or a handheld wireless device. The clinician browses condition modules to access “bullet-style lists of key clinical features, differential diagnosis and best tests, best therapeutic regimens and recommended references for further research.”
Another example are the InfoPOEMs (Patient-Oriented Evidence that Matters) from InfoRetriever, which are designed to bring clinicians daily evidence-based learning . For subscribers, one or two POEMs are delivered via email everyday, each structured to provide a 5-minute, high-level yet evidence-based answer to a specific clinical question. For example, one POEM might ask “Is modafinil safe and effective for night-shift sleep disorder?” In addition to offering a bottom-line answer with an evidence-level rating (“Modafinil provides modest benefit for patients suffering from disordered sleep due to shift work. This must be balanced against the very high cost of this drug. [Level of Evidence = 1b]”), the POEM provides a link to the source article and a structured, 300- to 400-word synopsis of the article. Because all of these daily POEMS are readily available on the vast InfoRetriever Web site, seeking highly focused clinical answers can occur at the point-of-care.
As mobile devices and electronic health record (EHR) usage increases, this format for education will overcome the current content limitations. Several current CME offerings associated with point-of-care systems offer 0.5 credits by tracking the physician’s activity—what content or activity was accessed, the status of progress within the activity, and the resulting actions as they pertain to the clinical encounter. It is not yet clear just how much depth of knowledge can be provided during an encounter. Box 3 summarizes the advantages and limitations of point-of-care e-learning.
Model: Point-of-care e-learning
Description: Contemporaneous education from real-time automated tools integrated into existing clinical information systems, linking diagnosis-specific information to knowledge resources such as guidelines, order rules, and point-of-care recommendations
Advantages
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Clinician gains learning during the clinical encounter in a manner that is informative and not intrusive in the clinical pathway
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Increasingly offered through personal digital assistants and other mobile devices
Limitations
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Systems are limited by content
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Limited depth of knowledge can be provided during an encounter
Examples
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Best Dx/Best Rx: Point of Care Recommendations from ACP Medicine
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InfoPOEMs and InfoRetriever
Online courses
When most people hear the term “e-learning,” an online course is typically what they think about. In fact, a recent survey of nonprofit organizations found that of the 54% of respondents with active e-learning programs, 71% used on-demand, self-paced e-learning as a component of their program, followed by custom-built courses based on their organization’s content (52%) and blended classroom-based e-learning (46%) .
For purposes of our discussion, we define an online course as any variety of learning formats specifically designed for online delivery and learning. A course can vary greatly in content format and delivery method. One characteristic, though, that sets online courses apart from digitized content is the application of a teacher-centric model. That is to say, long before the course “goes live online,” an instructional designer and a subject matter expert will have spent hours designing a course that will aid the learner to extract meaning from the materials to be presented.
There are three basic content structure models for online courses: presentation, interaction, or collaboration . In a presentation model course, information is presented one-way to the learner via text, graphics and sound and is akin to a demonstration, simulation, story or movie. People who watch TV to learn will be most comfortable with this medium. The interactive model goes beyond a one-way presentation and requires users to interact directly with the program. This may be as simple as clicking buttons to navigate through the course content or more involved such as answering test questions, running simulated experiments, or connecting objects and concepts. A more collaborative approach would be to encourage the social aspect of learning through online communities to share discourse or collaborate on projects.
Online courses also fall into one of three delivery models: synchronous, asynchronous, or blended . Synchronous courses hinge on real-time, ritualistic communication methods (eg, Web-based video conferences) to bring together multiple participants from various geographical locations in a real-time, virtual classroom. Asynchronous delivery follows the “anytime, anywhere” approach that lets the learner set their own pace. Blending a hybrid of the two models will encourage the social side of learning, reduce the burden of costly technology and live instruction, and maintain the adult learner’s demand for self-paced study, repetition, and a personalized learning plan.
Commercial start-ups such as Medscape were the first to market online courses to physicians. Medscape, part of the WebMD Health Professional Network, started with the goal of helping physicians and health care professionals “stay current on medical and scientific research and findings, patient care and the latest treatments.” They provide online CME in a variety of what they consider to be interactive formats, including News CME/CE, Clinical Cases, Clinical Reviews, Conference Coverage, and Slide/Lecture Presentations. Of these, only the clinical cases go beyond having the learner read an article online and achieve a minimum score on a “post-test” to earn AMA Category I credit.
In 2007, the American Academy of Otolaryngology—Head and Neck Surgery Foundation launched its new Web-based learning system, AcademyU, to provide a one-stop Web site and transform the way education is delivered to otolaryngologists. Using convenient and efficient new technologies, AcademyU will provide “anytime, anywhere” access to practical, vital, and relevant medical education authored by otolaryngologists for otolaryngologists.
In addition to providing access to knowledge documents and policy statements, two unique types of online courses will be available in AcademyU in its first generation. A series of 15-minute video courses have been built from the most popular instruction courses and miniseminars present at the prior year’s Annual Meeting. In a different learning opportunity, contents from the Academy’s successful self-instructional package (SIPac) series are being repurposed into an entirely new interactive learning format. In both cases, Academy members have the unique opportunity to receive the latest instruction from experts in the field while obtaining CME credit from their own desktop. Box 4 summarizes some of the advantages and limitations of online courses.
