Net le@rning

After the rigors of medical school, most physicians could be forgiven for never wanting to see a lecture hall again. With nearly a decade of hardened cramming behind them, many doctors feel they've earned a break from studying. Unfortunately for those in need of an educational vacation, there are three letters standing in the way: CME (continuing medical education). And as of 2006, whether you're a physician, pharmacist or nurse practising in the UAE or Saudi Arabia, CME is non-negotiable if you want to hang on to your licence.

Many regional physicians, however, face a blip on the path of lifelong learning. While on paper, compulsory CME ticks all the right boxes, the dearth of local conferences mean physicians can struggle to clock up their requisite hours. Certainly for those in less glamorous specialties, searching out relevant educational events means long-haul travel, time out of the practice and a hefty conference fee. All reasons why, when it comes to picking up CME credits, swelling numbers of physicians are following the learning curve out of the classroom and on to the web page.

e-learning

As an offshoot of the dot-com bubble, online CME has been around for more than a decade. Cheap, quick and unrestricted by location, e-learning has always attracted interest, but, since 2002, CME sites have seen physician participation triple. Steve Zatz, executive vice president of CME website Medscape, links this growth to the convenience factor for time-short doctors. "You can find the courses that match your practice, the sort of patients you see and the information you need," Zatz explains. "Then you can take that course whenever works for you. If it's 5am or it's during practice hours, and you have the time to do it, you can."

Medscape is one of the biggest online CME contenders, with more than two million courses completed for credit in 2006. Now 11 years old, the ACCME-accredited site has gathered a steady following over the years, winning over physicians through medical news, specialty-specific newsletters and email alerts. Medscape is organised as over 30 separate sites, Zatz reveals, so your home page and the content that you see is tailored to your medical training and interest.

"We try to make the site as convenient and interesting to physicians as we can, to support their information needs," he adds.

Niche content is the trump card of e-learning, as the variety of speakers and material is unmatched by conferences or journals. For physicians, says Zatz, this range means they can source information they feel they need to know, based on their practice experience, rather than learning what someone else thinks they should. "You don't have to sit through a lecture and suddenly realise some way into it that it's not at the right level for you or not the information you were looking for," he explains.

But for less web-savvy physicians, the sheer breadth of CME available online can be daunting. It can be hard to know where to start. To pick courses that will really make an impact on your practice, Zatz advises taking the time to identify the holes in your knowledge, rather than seeing courses as a quick way to notch up credits. "Steer away from subjects you already know because you're comfortable with that information," he says.

To encourage self-assessment, Medscape has begun posting quizzes as part of its CME courses, and then recommending content based on user answers. "Rather than saying to the physician, ‘Ok, just figure out the one you need', we can say; ‘Based on your responses to this assessment, you would benefit from the following courses,'" Zatz explains.

In the absence of online aids, experts recommend you select courses that complement the questions you face in your daily work. One study found that almost half of all queries prompted by patient interactions in primary care go unanswered. If you don't know the answers to the questions your patients ask, it's probably a good indicator that it's time to brush up on your knowledge.

Results driven

A real perk of online learning, reveals Alexander Nason, senior manager of telehealth for Johns Hopkins Medicine International (JHI), is that it can improve the way you process and retain information. "Adults learn best in a ‘blending' approach," he says, "In addition to reading content or sitting in a lecture, online education is one of many tools that can improve the way you learn."

JHI has been quick to latch on to the concept of ‘anytime, anywhere' learning. Its GlobalAccess series features a range of lectures, held via video conferencing, designed to allow physicians from around the world to access up-to-date information from JHI staff. Several Middle Eastern hospitals, including Al Noor Hospital, Abu Dhabi, Tawam Hospital, Al Ain and the American Hospital, Dubai, have participated in the programme.

Nason, who heads up the series, is now in the process of developing a digital library, which will capture live lectures and allow users to access courses at any time. "There's a real range of possibilities with this medium," he explains. "Physicians could log in and watch a lecture and then, a week later, we could go back and hold an hour's Q+A session with the lecturing physician.

"With more time for physicians to formulate questions, there is an opportunity for improved learning."

"With conferences," Zatz agrees, "If you're not ready to receive that information when the lecture starts, there isn't a great match between your receptivity and the information being delivered.

"The web lets users experience educational courses whenever it's an ideal time for them."

And, report CME analysts, it's an approach that works. Casebeer et al found that physicians who rely on online CME make evidence-based diagnostic and therapeutic decisions 59% more frequently than physicians who do not. A later study showed the difference held true for physicians who completed CME activities, but did not seek credit. A study carried out by CME site The Virtual Lecture Hall (VLH) concurs. The website enrolled NHS general practitioners in a programme designed to improve their ability to diagnose and manage pigmented skin lesions. After viewing the online programme, doctors reported feeling more confident in their abilities to manage pigmented skin lesions. This improvement in confidence was endorsed by a significant jump in knowledge; physicians scored, on average, 59.9% on the test before viewing and 86.3% after viewing.

"Physicians who go through CME activities online really pick up a substantial amount of knowledge that impacts their practices," Zatz says. "That's another reason there's been a high level of interest in online CME - it just works.

"If the goal of CME is to improve patient care and get physicians to adhere more closely to evidence-based medicine, online is a great medium to do that in."

Virtual vices

That's not to say that online learning doesn't have its own drawbacks. One boon of conference attendance is that it takes you out of the practice, and away from knocks on the door, phone calls or pages. Although online CME is theoretically more convenient, it can be tough to carve out uninterrupted time during practice or family hours to focus on an Internet course.

Another aspect of e-learning that can raise a red flag is the issue of funding. According to Dr Bernard Sklar, founder of website www.cmelist.com, 70% of CME sites in 2005 were free and a brief hunt round most will reveal why. Many display an array of adverts pushing pharmaceutical products or medical devices, leading to fears of commercially biased content. According to Zatz, however, users have nothing to worry about. "We're an ACCME-accredited provider and it's very important that, no matter what the source of funding, the material be independent and objective," he stresses. "Two-thirds of all CME activities on the site don't have any external commercial support, and we spend a lot of time ensuring our content meets the standards for independence."

For physicians prepared to pay out for their CME, subscribing to sites that are ad-free is one way of avoiding conflicts of interest. Another, preferable, option, according to Dr Abdulrazak Abyad, is for the government to partially shoulder the funding of CME to keep material independent. Abyad is a team leader in Abu Dhabi Health Authority's CME department. He is fronting an ambitious project to create the emirate's first Government-owned digital library, for health professionals in the public sector. Due to go live within a month, the site has been created in association with the National Library of Medicine at Al Ain University, and features links to online journals, books and educational sites.

"Doctors will effectively have access to a library on their screen," he explains. "This is a big benefit to those with limited access to conferences. At the moment, we have no online resources, so this is a real starting point for us."

This approach also tackles the sticking point of accrediting online sources. As the UAE does not have a standardised body for CME, the issue of what activities count towards your annual target can be confusing. Currently, says Abyad, most online activities are designated Category B accreditation by the Health Authority; meaning they count towards overall CME hours, but aren't recognised as formal learning activities.

"All requirements cannot and should not be fulfilled online. We can't control the content or participation enough," he explains. "Tracing authenticity is a problem, but with our own website, we may be able to offer Category A accreditation as we can monitor the content."

Funding aside, for older doctors new to the online revolution, the logistics of accessing and completing courses can also be off-putting, Sklar notes.

"Registration frightens away some physicians who do not wish to give any information about themselves, especially medical license numbers or credit card information."

Sites have also been criticised for over-hyping and under-delivering on content. Despite being billed as the future of CME, physicians report that few sites utilise the interactive potential of online education, making for a disappointing user experience. And a high number of websites simply reproduce monographs or slide presentations, Nason notes.

"A large number of physicians visit sites and if they find nothing of interest, or have difficulty navigating the site, they leave," Sklar agrees. But with a demanding new generation of physicians more accustomed to carrying a PDA (personal digital assistant) than a stethoscope, CME users can expect to see websites raising their game.

Generation next

"All our students are technology-savvy," states Mike Vertigans, director of Weill Cornell Medical College in Qatar (WCMCQ), "and this will stand them in good stead once they graduate. Medicine is a lifelong calling, not a job, and that requires a commitment to learning."

With an e-library linked to Cornell New York, wireless access throughout the University, and handheld PDAs for each student, WCMCQ is churning out a class of online learners. "The University is all Apple Mac wireless, and fully equipped with G5s," Vertigan explains. "Students and faculty have PDAs and information pods are available throughout the building, so students can sit down and log on without returning to a classroom."

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