October 1999 Bulletin

Online CME grows; doctors slow to respond

The world wide web is teeming with information, and millions of people are fascinated by the evolving technology, some spending several hours a day fixated on the screen.

Given the fact that physicians as a group-and surgeons in particular-are enamored with technology, you'd think the Internet would be their wonderland, right? Well, maybe not. This time around, doctors just might be behind the curve.

A recent American Medical Association survey of 1,900 randomly selected physicians revealed that only 20 percent used the Internet at all. And that percentage plummeted when it came to using the Internet for continuing medical education.

Online CME courses began popping up in some form more than five years ago.

About 50 sites currently offer online CME courses, according to Medicine on the Net, a monthly magazine. Typically run by hospitals, medical associations, or educational companies, many of these sites have only one or two courses, while others have several dozen.

The cost of online courses tends to be low, occasionally even free, except for minor registration or processing fees. As with traditional courses, though, the price varies according to the sponsor; courses sponsored by pharmaceutical companies tend to be less expensive. Medscape, for example, offers unlimited access to approximately 200 CME credit hours for an annual fee of $50. Another web site, MDConsult, offers more than 300 CME modules for a $19.95 monthly subscription fee and a $16 processing fee for each course.

In addition to relatively low fees, online CME can save physicians hundreds of dollars in travel and accommodation expenses, not to mention the time savings.

In spite of these benefits, doctors have been slow to jump on the "online CME" bandwagon. The reasons for this apparent lack of enthusiasm aren't clear, but one obvious drawback to online CME is the lack of a collegial atmosphere. The interaction between physicians at the courses-often a valuable component of traditional CME courses -is missing when you're sitting home alone at your workstation. Also, despite being spared the travel time, doctors still have to set aside a block of time to devote to the course, and that can be difficult to do.

Still, some fledgling online CME sites are beginning to find their target audience. The "Virtual Lecture Hall" has been in operation since May 1998, and has more than 5,000 registered users-mostly primary care doctors-who have racked up nearly 12,000 Category 1 CME credits in that time. The Virtual Lecture Hall is owned by Medical Directions, a four-year-old Tucson, Ariz. firm that creates Internet-based educational health care programs. Its courses are sponsored by the University of Arizona Medical School, University of Colorado, American Academy of Family Physicians and American Cancer Society, to name a few.

"Our new tag line, 'Best seat in the house for CME-your seat in your house,' pretty much sums up online CME's primary advantage," says John Harris, MD, president of Medical Directions. "You can do this at 6 or 8 at night after the kids have gone to bed. You don't have to take time out of your practice for it, and you learn something."

According to Dr. Harris, when he goes to a medical meeting, he asks how many doctors use the Internet, and virtually 100 percent say, "yes," but they're talking about e-mail. When he narrows it down by asking who uses the Internet for consumer purposes-to buy books off the web, etc.-maybe half will say, "yes." By the time he asks how many have actually gotten CME credit online, only about 3 percent say, "yes."

So why aren't the other 97 percent doing it?

"It's like asking in 1952 'why don't people watch sports on television?' Well, because they're used to going to the local ballpark, and because it's in black and white, and it's hard to see. It's the same situation today. The doctors are used to going to their local hospital for CME, and the courses that are out there on the web, for the most part, are terrible."

The vast majority of online CME, Dr. Harris says, is boring, and just "text on a screen."

"Most of these programs inevitably try to re-purpose their existing material; they use the web as a way to re-present existing didactic lectures," Dr. Harris says. "JAMA just printed another study that said-for the 10,000th time-that didactic lecture programs are very ineffective. So why put them on the computer? This medium demands-just like television did-new ways of presenting ideas that use the medium effectively. It's a lot more than just a cheap post office."

Online CME needs to take an interactive, problem-solving approach that responds to the user's input, Dr. Harris says. Virtual Lecture Hall programs for example, are case-driven. "You work through a real case, but you're not just reading it," he says. "We stop you, and ask you what you want to do next. We require literature searches, and provide links, and real-time feedback. It's truly interactive."

Regrettably, says Dr. Harris, his site has no specialty courses. "I say 'regrettably' because specialties lend themselves nicely to visual images, and the web is a visually rich medium."

Most online CME courses at this time appear to be directed at primary care physicians. Dr. Harris attributes this to financial reasons.

"It's very expensive to produce an online course; it costs us $10,000 to $20,000 to develop a one- to two-hour CME program. I charge $10 a credit, so I need 1,000 users just to pay for it. It's a chicken and egg problem. Specialists won't come to the web until there are good programs for their specialty, but no one wants to create the programs until they know the specialists will come."

The Academy is prepared to accept that challenge, and is readying a "truly interactive" online CME course of its own-"Postoperative ACL Rehabilitation."

"With the changing economics of medicine, physicians have less and less discretionary time," says William Grana, MD, chairman of the online postoperative ACL rehabilitation program and a member of the Academy's Educational Programming Committee. "We believe that an online approach to CME will allow them to continue their education without being away from their practice."

While a variety of online education is available on the Academy web site-Orthopaedic Flashcards, Orthopaedic Short Stories, an osteoporosis slide program, and a wrong site surgery presentation, to name a few-this is just the second online course to offer CME credit. The first course, "Reducing Professional Liability Risks," is free to members, and is worth two CME credits upon completion. Since the professional liability course was introduced in fall of 1997, 145 orthopaedic surgeons have started the program, and 31 have finished it. With this new, more interactive "Postoperative ACL Rehabilitation" course set for a January 1, 2000 kickoff, hopes are high that the new, self-directed format will create much greater interest among orthopaedic surgeons.

Dr. Grana, along with Academy staff, have been working on the course for a year, and it's still in development. The Committee on Educational Programming will review the course in November and the program will be posted in early January. As of now, it's known that the course will have three modules-literature, expert opinions and case studies. The student is able to choose which module to complete first. Each module follows the same format: the problem to be solved is presented, help is offered and the users are "turned loose" to solve the problem on their own. Each module requires that assignments be completed.

The "literature" module requires the user to perform a literature search and requires completion of three assignments. Related links are embedded within the document for the student to refer to when completing assignments. A "lessons learned" screen sums up the module's key messages, but only after the assignments are completed.

The "expert opinions" module presents four prominent surgeons with differing approaches to ACL rehabilitation. Students see a photograph of the surgeon and hear the surgeon summarizing his/her approach. Users then choose which surgeon or surgeons they want to "interview." A list of questions is presented for each surgeon; the student may choose to hear all of the answers or just a few. Two assignments follow. A "Lessons Learned" screen is included, as are related links.

In the "case studies" module, the student reviews five cases. The user is asked to make a diagnosis based on the examinations, and is asked to respond to key issues. Students then are asked to determine how the rehabilitation protocol should be modified to fit the need of the individual. A "lessons learned" screen and related links are included.

Orthopaedic surgeons will be able to register online for "Postoperative ACL Rehabilitation." Registration fees for the course will be $30. Three CME credits will be awarded at course completion. An Orthopaedic Research and Education Foundation grant was obtained to support development of this course.

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