Innovations in continuing medical education in the age of Net 2.0 197Innovations in continuing medical education in the age of Net 2.0DR M. JIM YEN, MDProfessor Yen is a Clinical Assistant Professor at LAC+USC Department of Emergency Medicine <strong>and</strong> part-time staffat San Gabriel Valley <strong>and</strong> Lakewood Regional medical centers. His interests include teaching <strong>and</strong> applications oftechnology in education.DR MEL HERBERT, M.B.BS., M.D., B.MED.SCI., F.A.C.E.P., F.A.A.E.MProfessor Herbert is an Associate Professor <strong>and</strong> Director of continuing medical education for LAC+USC Departmentof Emergency Medicine. He is the owner <strong>and</strong> editor of EMRAP, the largest audio series <strong>and</strong> privately run onlineCME course in Emergency Medicine. He is keenly interested in the use of technology to distribute medical education.DR STUART P. SWADRON, M.D., F.A.C.E.P., F.A.A.E.MProfessor Swadron is an Associate Professor <strong>and</strong> Vice-Chair for Education at LAC+USC Department of EmergencyMedicine. His interests include teaching <strong>and</strong> residency <strong>and</strong> medical student education <strong>and</strong> he is co-editor of themonthly audio series EMRAP.Conflict of Interest: Professor Yen is owner <strong>and</strong> editor of EMCoreContent.com, a company that provides onlineEmergency Medicine education. Professor Herbert is owner <strong>and</strong> editor of EMRAP, a company that provides audio<strong>and</strong> online Emergency Medicine education material. Professor Swadron is an associate editor for EMRAP.INTRODUCTIONJust as medicine has evolved with the development of new <strong>and</strong> powerful technologies, so has continuing medicaleducation (CME). Over the past decade, CME has transformed from traditional live conferences <strong>and</strong> seminars intonew electronic formats, which include streaming <strong>and</strong> downloading computer <strong>and</strong> internet-based text, audio, <strong>and</strong>video education materials. While some physicians still prefer traditional CME formats, the Accreditation Council forContinuing Medical Education (ACCME) in the United States revealed in their 2009 annual report that 43% of allphysician participants were using internet-based CME, compared with only 1% in 1998. 1 The proportion of physiciansusing internet-based CME continues to grow with each passing year <strong>and</strong> now exceeds those participating in liveconferences. Internet-based CME is not only here to stay but appears destined to exp<strong>and</strong> <strong>and</strong> change the way wecreate <strong>and</strong> consume medical education.ADVANTAGES TO ELECTRONIC CMECompared to traditional live lectures <strong>and</strong> conferences, electronic CME has multiple advantages. Foremost, it allowsphysicians to plan their education according their own schedule preferences <strong>and</strong> in an environment of their choosing.As laptops, tablets, <strong>and</strong> other mobile devices become lighter <strong>and</strong> more powerful <strong>and</strong> wireless internet connectionsbecome faster <strong>and</strong> more abundant, physicians will be able to consume educational materials wherever they please;materials that previously were only available by travelling for several days to a live course. Physicians will be ableto participate in CME courses via streaming internet video from the comfort of their own home, their favorite café,or even the beach, at any time of the day, night, or year.Another advantage to electronic CME is that as audio <strong>and</strong> video recording becomes easier <strong>and</strong> cheaper toproduce <strong>and</strong> massive amounts of educational material will become available in easily accessible formats. Thiscould be comparable to the YouTube phenomenon in which anyone with a laptop <strong>and</strong> some simple recordingequipment will be able to share their medical educational material. An educator who previously could only teach afew dozen healthcare providers in the settings of a traditional hospital-based conference can now have his or herlecture easily recorded <strong>and</strong> made available for mass education around the world. As computers, mobile devices,<strong>and</strong> high-speed internet technology become ubiquitous, high quality educational material can now be easilydistributed to <strong>and</strong> reviewed at will by thous<strong>and</strong>s of healthcare providers across the world. Physicians previouslyunable to attend live lectures on the other side of the planet will now have access to thous<strong>and</strong>s upon thous<strong>and</strong>sof hours of CME material. This will be particularly useful for healthcare providers in developing countries with limitedaccess to experienced medical educators.
198 <strong>Australasian</strong> <strong>Anaesthesia</strong> <strong>2011</strong>Innovations in continuing medical education in the age of Net 2.0 199LIMITATIONS OF CMEDressing up old CME materials in new technology does not, however, address longst<strong>and</strong>ing criticism that CME ingeneral fails to change physician practice or improve patient-oriented outcomes. 2,3 Nonetheless, studies comparingthe performance of internet-based CME to traditional formats do demonstrate equal effectiveness in impartingknowledge 4 . Indeed, some studies do report that internet-based CME may be more effective at changing physicianbehavior than its traditional equivalent. 5,6Whether it is delivered in traditional or electronic formats, CME in general faces several debilitating limitations.Using new technologies to improve CME requires an underst<strong>and</strong>ing of how practicing physicians learn as well asan appreciation for inherent variation among individual learning styles. No matter how advanced education technologybecomes, it will never obviate the prerequisite for quality content <strong>and</strong> skilled educators. Poorly prepared <strong>and</strong>delivered content will always fail, no matter how sophisticated the technology used to deliver it becomes.Another overarching limitation of CME is its lack of relevance to immediate questions <strong>and</strong> dilemmas thatphysicians face in their daily practice. It has long been assumed that physicians-in-training learn most effectivelyfrom their supervised clinical practice. Practicing physicians, however, rarely have the time or luxury to immediatelyaddress gaps in their medical knowledge as they are discovered in real-time. Diligent physicians will take the firstopportune moment to redress these deficits but still may not have the resources to do so, for example, when aquick internet search is not enough to answer a complex medical question.The production of electronic CME faces challenges similar to those inherent in traditional CME. To be effective,CME content must, at a minimum, be reliable, accurate, current, <strong>and</strong> relevant. If a practitioner identifies a knowledgeor skill deficit during their practice, the ideal CME product will have relevant materials immediately available toaddress <strong>and</strong> remedy this deficit. Furthermore, content must be continually updated to reflect major changes inaccepted practice. It is impossible for a single author or lecturer to produce this breath <strong>and</strong> depth of content. Manysuccessful CME programs recruit <strong>and</strong> utilise a team of physician <strong>and</strong> faculty educators, often in exchange foracademic publication credit, a small stipend or royalty. However, ethical considerations should remain unchanged;whether electronic or traditional, we believe that CME should be free of commercial bias, including any fundingfrom pharmaceutical <strong>and</strong> medical device companies.CHALLENGES TO ELECTRONIC CMETraditional CME offers the advantage of real-time or synchronous learning, but by design it is focused on the teacherrather than the student. The material covered <strong>and</strong> discussed is restricted to what the educator has prepared <strong>and</strong>chosen to present. This may be of limited relevance <strong>and</strong> usefulness to individual physicians as learners. ElectronicCME, on the other h<strong>and</strong>, is able to offer the user a huge selection of topics <strong>and</strong> archived material to choose from,thereby focusing more on the needs of the learner.Nonetheless, electronic CME suffers from delayed or asynchronous interaction in that there is a loss of physical“face-to-face” time between facilitators <strong>and</strong> participants. This limitation has been reported to negatively affect userperceptions of the effectiveness of internet-based CME. 7,8 More importantly, regardless of whether it is synchronousor asynchronous, education is more effective when it features an interactive component that engages the learner. 9Even face-to-face lectures in real-time that do not engage the learner with an interactive component will almostcertainly fail to change physician practice <strong>and</strong> ultimately have little effect on patient outcomes. With advancementsin internet technology, electronic CME can now engage learners with a variety of interactive features includingquizzes, assignments, chat, <strong>and</strong> email. To be truly effective, two-way interaction must occur to make learners activeparticipants in their education.Because it lacks the face-to-face physical interaction of traditional CME, high quality electronic CME shouldoffer multiple formats for online education consumption, including video, audio, text, as well as interactive features.Availability of multiple formats allows electronic CME to effectively disseminate educational information without areal-time physical instructor. Many of these lectures can be recorded digitally at one of the many live CME conferencesheld annually, then enhanced with audio format conversion, text summaries, <strong>and</strong> post-test quizzes. Video <strong>and</strong> audiorecording technology has advanced so that this can be accomplished with a simple setup using a laptop, cameras,microphones, <strong>and</strong> relatively inexpensive software programs.Making large amounts of digital content accessible in a clear <strong>and</strong> intuitive online format presents its ownchallenges. Users must feel confident that the CME product search function returns accurate <strong>and</strong> relevant resultsso that they can use it to immediately answer a clinical question or address a knowledge deficit. At the same time,the content should be presented so that users are constantly exposed to <strong>and</strong> enticed to explore material they havenot reviewed recently. For more novice learners, it is helpful for the CME program to offer a step-by-step curriculumof material with proposed timelines for completion. Meeting these challenges by providing features either througha website or mobile device application requires a large investment in software programming time <strong>and</strong> expertise.Lastly, information or materials that are no longer available or not easily accessible are of limited value. Therefore,any successful CME will need to be enduring, that is available at any time after it is initially accessed.NEW CME TECHNOLOGIESInnovations in communication technology will change the way we search, gather, process, <strong>and</strong> learn new medicalinformation. Since repetition is an important cornerstone of assimilating new information into long term memory,“push” technologies that remind participants of available yet uncompleted educational activities appear to enhanceengagement with CME. 10 These reminders can highlight a knowledge deficit or introduce a novel approach to adifficult problem by engaging participants to think about an interesting clinical scenario or answer a simple question.Electronic mail (email) is the most commonly used format for this purpose. However, newer communicationtechnologies, such as Twitter®, have the advantage of easier accessibility because the recipient can receive shorttext messages or “tweets” automatically without having to log on to a server.Another technology used by webcasts <strong>and</strong> podcasts is Really Simple Syndication (RSS), which allows for theeasy <strong>and</strong> immediate dissemination of text, audio or video updates directly to the end user as soon as the producercreates <strong>and</strong> uploads the file. RSS has transformed media distribution, allowing niche groups to publish updatedcontent directly onto the preferred devices of the target audience (e.g. h<strong>and</strong>held, tablet, laptop or desktop devices).Users can then easily organise, search for, label <strong>and</strong> cross reference these materials on aggregating programs suchas iTunes. 11While repetition is important for memorisation, comprehension is aided by reviewing <strong>and</strong> applying new informationusing a variety of formats. As previously mentioned, individual learners have differing learning styles. While visuallearners may learn best by watching videos, aural learners may benefit more from listening to audio recordings <strong>and</strong>textual learners may learn most effectively by reading written articles. Still others may be kinesthetic learners <strong>and</strong>require opportunities to apply <strong>and</strong> practice new material through testing or simulation. As programming technologycontinues to develop, more <strong>and</strong> more options become available for interactive learning activities that can be cateredto the individual. SpacedEd (Spaced Education, Burlington, MA, USA) is an example of this technology. This on-lineCME program uses “spaced” education to boost long term acquisition <strong>and</strong> retention of information. 12 It takes aquestion bank with multiple choice answers <strong>and</strong> sends learners one or two question per day via push technologywhich can be answered on a mobile device or computer. It then provides real-time feedback of the correct answer.If the user’s response is incorrect it will adapt the sequence of upcoming questions so that items incorrectly answeredwill appear more frequently. Items repeatedly answered correctly will be retired completely. This is only the beginningof the application of artificial intelligence (AI) to CME; the ability of a computer to identify strengths <strong>and</strong> weaknessesof learners <strong>and</strong> incorporate this information into curriculum presentation <strong>and</strong> comprehension assessment.Social networking sites <strong>and</strong> other internet-based tools for online collaboration are being used increasingly forCME. A “wiki” is a collaborative website containing “open” content. This is content that any individual user mayadd to or modify. A “blog” or weblog is a website containing material posted by a single user or group of users.Both have the potential for abuse <strong>and</strong> can potentially cause misinformation to be disseminated. However, the opennature of these formats is also their greatest strength, particularly for wikis that involve broad participation from agroup of appropriately qualified users sharing a common goal. With programming safeguards <strong>and</strong> content monitoring,13, 14the quality <strong>and</strong> clarity of material is rapidly <strong>and</strong> continuously refined <strong>and</strong> improved.THE FUTURE OF CMEEffective healthcare providers can ill afford to invest precious time <strong>and</strong> resources in ineffective CME. Practicingphysicians require continually updated knowledge <strong>and</strong> skills that span nearly every aspect of medicine. Furthermore,the nature of healthcare delivery frequently requires immediate recall <strong>and</strong> access to information at a moment’snotice. We must insist upon the highest quality CME, including content designed by skilled <strong>and</strong> experiencedfacilitators, <strong>and</strong> materials that are enduring, regardless of whether these are offered in traditional or electronicformats or a combination of both. While the evidence is limited, electronic CME is more effective when it utilisesreminder or “push” techniques to introduce material, allows for real-time interaction, provides post-testing toreinforce learning, <strong>and</strong> offers easily accessible, searchable archives for review whenever needed. Table 1 summarizessome of these technologies.Electronic CME has opened up incredible new opportunities for physician learning that only a few years agowould have been impossible. The ultimate CME experience is finally within reach; one that is occurs alongside <strong>and</strong>in harmony with patient care. Nevertheless, while emerging techniques may be measured as efficacious by instrumentstypically used in educational research, we must remember focus as much as possible on patient oriented outcomes.
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