Mark H. Gelula, PhD

Continuing Medical Education (CME) is dominated by a single type of activity: the lecture. No matter how it is clothed, more than 95% of all physician-oriented continuing education is organized as what may be called "show and tell." From the one-hour, hospital-based weekly "update" to the five-day, forty (plus)-hour board certification-oriented "review course", the lecture remains like a seawall, resolute against tides of change. In an informal survey, I recently queried about ten physicians friends, and asked them how they best liked to learn in their CME opportunities. Their response -- lecture. This is interesting, because we know that the lecture is the least effective form of instruction for physicians (or anyone, for that matter). In fact, when I further questioned my physician friends all but one agreed that he or she actually found lectures less stimulating than case-oriented activities. Further, all ten admitted that it was extremely rare that they would use any ideas offered in the lecture-based traditional CME offering.

Interestingly, this very traditional model continues to be predominant in the "virtual world" of world wide web (www) CME offerings. In investigating the Web we found a variety of online opportunities for physicians, but we were unable to identify any that offer group-oriented, case-based interactive learning activities. We found none that offer this process synchronously.

Prior to the consideration of an online course, we developed the Specialty Needs for the Primary Care Physician continuing education program. It was based on our beliefs that physicians will use what they learn when they are actively engaged in their learning. Such outcomes are central to CME. If physicians are not informed in a way that leads them to change their practice habits, why offer CME courses? Why require CME?

The Specialty Needs program is intended to provide information to physicians in a way that allows participants to achieve clarity with respect to specific patient management processes. These outcomes are more likely achieved because the participating physicians actively reflect on their current case management processes while engaging in active dialogue with colleagues who are describing their practice procedures. Against this concerted effort rest the interventions and ideas of the course instructor, a specialist with specific experience in the disease process described by the cases.

Courses in the Specialty Needs program are comprised of modules about specific patient problem areas. Each contains background readings, very brief focused lectures, group problem-solving sessions based on two-to-three cases that are aimed at patient management strategies, and a final discussion session. Sessions last no more than three hours.

Already, physicians who have participated in this innovative case-based, small group discussion process have indicated that they enjoy, learn, and use the information obtained in the programs. When physicians actively participate they are led to compare the case at hand with patients and situations from their own practices. Further, when participants discuss the case in a structured manner with seven or eight other physicians the learning becomes intensified as each physician reveals and recognizes personal assumptions, practice biases, and experiences with similar cases, necessary laboratory tests, treatments and management strategies.

We have adapted the Specialty Needs of the Primary Care Physician program to an online, computer-based delivery system. These courses will combine self-instruction with collaborative learning. Unlike an in-person class, an online course provides significant flexibility for participants. Activities that can be conducted individually can be done at the most convenient time and place for the physician--at home, at the office, during the days, evenings, or weekends. Access to relevant readings, slides and other materials, dialogue with other participants, review of case material and questions to the instructor are available at the click of a "mouse." It is important, given the collaborative nature of the Specialty Needs Program, that these courses have some time constraints, and some scheduled synchronous activities. Each participant will be assigned a "group" time, during which he/she will be available for online chats and problem solving sessions. These sessions will provide students with the opportunity to work together to jointly solve and manage the cases. It is likely that what would be a three hour program if offered at a hospital will be provided to physicians over a two-week period.

Three programs will be initially offered, with a total of eight in the planning stages. Each course has five modules; ultimately at least forty educational modules will be available to physicians through CME Online©. Gastrointestinal Diseases, Women's Health, and Endocrinology are scheduled to begin in early Summer 1999. Gastrointestinal Diseases will be the first course with its five mini-modules addressing (1) gastroesophageal reflux disease (GERD) ; (2) helicobacter pylori and ulcer disease; (3) diseases of the pancreas; (4) the hepatitides, and (5) diseases of the bowel.

Little more than computer-aided instruction, the typical CME online course remains a traditional, passive method of instruction. In contrast, CME Online© is an innovative program. It requires attention to the variety of learning styles, cognitive styles, practice patterns, and time schedules which make up the physician-learner. Its pedagogical basis lies in the experience of adult education. Opportunity for reflection on practice is central to adult learning; it is founded on the learner's own experiences. Still further, it assumes the intrinsic social needs of the individual, whereby discussion opens the learner to new ideas and reinforces new ways of approaching old problems. Employing online teaching methods supports these assumptions and goes further by allowing greater time for physician reflection both on practice and in practice. Finally, using a collaborative, case-based approach provides a social and intellectual structure to assist the learner and support a growing cognitive map that is based on that person's own practice experience. There is no question in our minds that through the active learning process of the Specialty Needs of the Primary Care Physician CME Online© program, physicians will be actively involved, challenged, and engaged in ways that lead to observable practice changes.