Back to Front PageVOLUME 6, NUMBER 4

Point and Click CME: The Future of Continuing Medical Education

By Barbara A. Gabriel

In Seattle, a physician sits at his desktop computer and listens to a presentation on emerging treatments for rheumatoid arthritis delivered by a specialist at the Johns Hopkins University School of Medicine. He follows along with illustrative slides, e-mails a question and receives an answer from the instructor, and then takes an online test based on the material he has just learned. A few days later, he receives a certificate in the mail granting him continuing medical education credit.

For a growing number of physicians throughout the country, this is the future of CME. Gone are the days when physicians' only option for earning CME credit was to travel to conferences and workshops. Now, medical schools are increasingly putting lectures, slides, and interactive material on the Internet, creating "virtual classrooms" that offer CME credits to physicians any place, any time.

"This can be a wonderful way for physicians in remote areas who may have trouble getting to conferences to learn about the latest developments in their field," says Rhonda Dix, Internet outreach specialist in the Office of Continuing Medical Education at the University of Wisconsin Medical School.

The University of Wisconsin jumped-started its Internet CME program after alumni voiced interest in earning credits online. The school surveyed physicians in eight Midwestern states to determine topical interests and offered its first online course, "The Diagnosis and Management of Dyslipidemias," in April. It was followed by three more courses in June, and Dix and her team continue to develop new online offerings.

Noting that the concept of online CME is foreign to many physicians, Dix says she is striving to make the courses both interactive enough to hold their interest and user-friendly enough to be easily accessible. "Our goal is to make the courses as sophisticated as possible without exceeding the technological knowledge of our physicians," she says. Current online courses offered by the University of Wisconsin allow physicians to read material and ask the course director questions. Future courses will allow physicians to interact with one another and listen to audio recordings of lectures.

Dix points to several advantages of online CME, including the automatic feedback that accompanies online testing. "Within seconds, you get feedback on which questions were answered correctly and which were not," she says. "You can then go back to the course and review the necessary sections." Currently, access to the University of Wisconsin's online CME courses is free to anyone who logs on. Physicians who wish to earn CME credit are charged on a per-credit basis.

Transcending Distance with 'Webucation'

Thomas Norris, M.D., associate dean at the University of Washington School of Medicine and chair of its CME Advisory Committee, agrees that there are numerous advantages to online learning. He explains that the University of Washington aims to provide continuing medical education opportunities to physicians in the states of Washington, Alaska, Montana, Idaho, and Wyoming, a landmass characterized by a sparse physician population. "In some of those areas, it's difficult to travel to CME courses," Dr. Norris says. "The Internet is giving us another method of delivering our CME material."

Dr. Norris also notes that, especially in rural areas, the costliest part of earning required CME credits for physicians is leaving their practice. "Even if they don't have to travel," says Dr. Norris, "being away from their patients and what they do for a living is usually their largest expense. Taking CME courses from their office or home, without interrupting their normal activity level, is much cheaper and more efficient."

Online CME also gives physicians a wider scope of courses to choose from. "To some extent, because of cost and convenience, doctors are restricted to CME events in the area around them, and may not always be able to find topics they are particularly interested in or teachers they would like to learn from," Dr. Norris says. "By going online, issues of proximity and selection are eliminated."

The University of Washington has been offering CME courses online for the past two years and makes a number of courses available at no charge to anyone who wants to learn on an informal basis. For an annual subscription fee, physicians can take as many of the university's online offerings as they want for credit.

Dr. Norris explains that the University of Washington has used two approaches to developing online courses. The first involves converting campus lectures into text-based documents illustrated by slides and diagrams. The second involves crafting courses offered on campus into online courses, an approach Dr. Norris says has met with much enthusiasm from physicians. The university's online courses do not yet offer sophisticated interactivity such as streaming audio and discussion groups, but he says that the university is quickly moving in that direction.

A Hefty Price Tag

The Johns Hopkins University School of Medicine offers two online programs for CME credit, both of which use streaming audio and illustrative slides. The first, the Internal Medicine Board Review, is taken from the university's existing internal medicine board review course and includes more than 70 lectures covering core subjects, such as substance abuse, preventive care, and psychiatric disease. For a fee, individuals may listen to the lectures, follow along with slides, and then take tests for CME credit.

The second program, Saturday Medicine Rounds and Conjoint Clinic, broadcasts live case study presentations delivered by Johns Hopkins faculty each week. Individuals logging on could listen to the presentation, e-mail questions to the presenters, and follow along with slides. The program was discontinued last October but will start again next year with the backing of new funds. For a fee, physicians may access any of the archived presentations and then take a test on the material for CME credit.

David P. Heaphy, Ph.D., associate dean and director of Continuing Medical Education at the Johns Hopkins University School of Medicine, says that although the Saturday Rounds program was very popular, it became cost prohibitive. "That level of interactivity is difficult to sustain economically," Dr. Heaphy says. "You need to have sponsorship."

Turning a CME Profit

Stanford University, for one, knows all about the economic investment that a successful Web venture entails. The school has invested $3 million to develop an Internet spin-off company called e-SKOLAR Inc., an endeavor that the university says has the potential to transform the way continuing medical education is delivered and learned.

This online CME course from the University of Washington uses illustrative diagrams to examine common knee disorders.

Launched in May of this year, e-SKOLAR's flagship product, Stanford SKOLAR, M.D., grew out of the Stanford Health Information Network for Education (SHINE), a medical search engine that performs rapid searches across multiple medical sources, including peer-reviewed journals, textbooks, drug databases, and clinical guidelines. SKOLAR, M.D. enables physicians to enter unstructured queries into a vast database of information resources to come up with disease information ranging from basic symptoms to complex drug dosage schedules.

SKOLAR, M.D. is meant to supplement clinical decision-making at the point of care. The product also aims to introduce the concept of "physician-initiated, in-context CME" by allowing physicians to earn CME credit as they learn while using the system. "SKOLAR does something simple and obvious," says Paul Lippe, CEO of e-SKOLAR. "It recognizes that people learn most in the course of doing. By creating an information system that can be used at the time of diagnosis and treatment, we integrate learning and doing. SKOLAR, M.D. recognizes that learning has occurred and awards CME credit." Physicians earn credit either based on the amount of time they spend researching within the system or after taking a test following a specific search.

Although Stanford will hold a sizable stake in the new company, SKOLAR, M.D. will operate independently from the university. For a $240 annual subscription fee, physicians or medical groups can access the Internet-based product. Cost for CME credits will range from $25 to $50.

Stanford also provides more mainstream online CME offerings. For example, Stanford's Department of Radiology offers a range of courses that feature multimedia lecture presentations delivered by university specialists. Several free courses are available for informal learning, while others may be purchased for CME credit.

Why Leave Home?

With so many universities joining the world of online education, why would physicians take on the expense of traveling to conferences and seminars to earn their CME credits? For one thing, not everyone is comfortable in front of a computer. "I think that will change as younger physicians come along," says Wisconsin's Dix. "Our survey indicated that most of the physicians interested in online CME were in the 30-to-40 age range." But, she adds, "a lot just depends on individual preference and learning style."

Dr. Norris agrees. "There will always be a place for face-to-face learning," he says. "Working with a peer group on a problem or personally hearing a terrific lecture from a great teacher will always remain viable learning modalities. Online learning may replace some of what we have, but I don't think it will completely take the place of traditional CME."

Stanford SKOLAR, M.D. awards CME credits as doctors perform searches and research specific conditions online.

Dr. Heaphy points out that technology still has a long way to go before it can replicate the classroom experience. "Real-time, large-screen presentations broadcast over small bandwidths are slow to transmit and provide poor video quality," says Dr. Heaphy. "Self-study on the Internet does have its possibilities, but the interactive part of it can't be done that easily." Dr. Norris echoes that sentiment. "Transmitting a lot of images or a highly complex, interactive graphic can take a long time over a small modem, especially in smaller communities where broad-band Web access may be hard to find."

But Internet technology is changing every day. Given the speed at which ever-improving technologies are reaching us over the Internet, is it feasible that one day online learning will completely replace traditional classroom-based CME?

"Who knows?" asks Dr. Heaphy. "I remember when the VCR came along, and people said the movie industry would be put out of business. Well, the movies are still around. I suspect the classroom also will always have its place."

Information University of Wisconsin; University of Washington; Johns Hopkins University, and Stanford University

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