Breaking the Mold: CME Moves Beyond Text

Continuing Medical Education (CME) has now been available online in quantities sufficcient to make the Internet the primary or only CME source for some physicians—for more than 10 years. What was an oddity, and then a paradigm shift, has become the status quo. With the growing pains of the online CME experience mostly fi nished, we have arrived at a historical vantage point from which this now-mature phenomenon can be accurately assessed. From this perspective, what is most remarkable about online CME is the fact that, when it comes to the actual nature of the educational materials on offer, nothing has really changed.

Oh, the method of delivery has changed. Th e use of the Internet as a tool to distribute CME activities has made the process of obtaining continuing education much more effi cient and convenient for the physician, and has allowed activities to be supplemented by any number of audiovisual goodies (cf, every issue of MDNG, including this one). But the essential pedagogical strategy employed by most online CME activities is no diff erent from what was used in the days when print journal articles and expensive conferences were the only sources of CME credit. Specifi cally, most CME continues to employ a didactic model, in which an expert provides information, to be passively studied by the participant.

This is most obvious in the case of text-based activities: read this article on congestive heart failure, and then answer a few questions to determine whether or not you’ve internalized the appropriate information. But webcasts and live lectures are essentially didactic, as well. Even those activities that introduce some element of interactivity generally still conform to this basic expert teacher—student model. Th ere is certainly nothing inherently wrong with a didactic approach, which has dominated education since Plato. However, there are indications that other educational philosophies may generate better results among physician learners. In a September 1, 1999 article published in the Journal of the American Medical Association, Davis, et al. reported that traditional, didactic sessions “do not appear to be eff ective in changing physician performance.” Davis and colleagues went on to observe that CME activities that provide the opportunity to practice skills—that encourage “learning by doing,” as it were—have greater potential impact on patient outcomes.

Of course, in 1999, with connective technology still in its relative infancy, the power to create truly immersive CME was limited. Not so today. Th e technical facility now exists to create an entirely new kind of activity, and physician comfort with the Internet and related technology is now at a level to make such an activity practical and likely to be used. So, let’s take a look at the CME transformation that will seem as unremarkable in 2018 as online CME seems to us today.

CME in Real Life

One simple innovation that seems likely to become more common in years to come is the provision of CME credit for educational tasks carried out in the course of everyday practice. Most physicians are learning every day, on the fl y, as they research symptoms, conditions, and treatments. Because this information is obtained in the context of actually using it, it’s more likely to be both memorable to the physician and specifically applicable to his or her practice than a general CME article or webcast. Now that the technological means to document this sort of learning is readily available, attaching CME credit to educational experiences of this kind is only a short step. Writing in The Permanente Journal, Carol Havens, MD, and colleagues envision the following potential scenario:

A physician using a computer to review her schedule sees that she will soon see a patient for skin rash and hyperlipidemia. She clicks on an option labeled “diagnosis” and is taken to a diagnostic algorithm... [and] the latest guideline for treating hyperlipidemia... As she records the diagnosis of hyperlipidemia, the computer automatically shows a list of medications. The physician clicks on her fi rst choice and is taken to the pharmacy site, which describes dosages, interactions, contraindications, and formulary status for the drug selected.

The physician’s computer logs the time and locations for all her Internet searches and provides her with a summary that she then sends electronically to her local CME office for credit. Again, the hypothetical physician described here by Havens and colleagues is more likely to retain the new information she sees during the process, because it is contextually tied to a specific, real-life situation.

Another alternative is to tie CME credit directly to specific, measurable eff orts at performance improvement. In 2004, the American Medical Association modified its standards, allowing vendors to off er such performance-based CME programs. Although adoption of this approach has been sluggish to date, some interesting programs have been developed. The United States Centers for Medicare and Medicaid Services (CMS) sponsored a pilot program, involving approximately 4,000 physicians nationwide. Participants were offered the opportunity to implement any of three quality improvement programs (diabetes management, breast cancer screening, or immunization) and to track their success using standardized measures of outcome. A physician who implemented all three programs was eligible to receive up to 30 hours of CME credit in a single year. The pilot was generally considered successful; 95% of participants considered the overall experience to be positive, and more than 80% found the educational material to be at least somewhat helpful.

CME Consultant Steve Passin notes that academic medical centers are now authorized to sponsor similar programs for affi liated physicians. These programs divide quality improvement into three stages worth up to five credits each:

• Self-assessment - based on specifi c measures of performance
• Intervention - with an eye toward improving those specifi c measures of performance Re-evaluation - with summary of practice, process, or outcome changes

Beyond Real Life

Of course, in-practice, CME has its limits. Some skills are obviously best mastered before a fl esh-and-blood patient is introduced into the system. Meanwhile, valuable clinical and communication skills are diffi cult to practice in a fashion amenable to feedback in a real-life environment. For many years, standardized patients (SPs)—actors trained to simulate a real patient to help refi ne communications skills—and static mannequins have allowed providers to practice on subjects that will not suff er from any missteps along the way. However, the utility of both of these models is limited; SPs are expensive to train (and require consistent training) and obviously cannot be treated, whereas mannequins off er only a rough facsimile of a real patient encounter.

Contemporary technology has made possible increasingly useful and immersive educational simulations of real patient encounters. The e-journal Med-Ed-Online describes the human patient simulator (HPS), a computerized, fullbody mannequin with simulated vital signs and other functions. The HPS is capable of responding realistically and in real-time to any number of conditions, stimuli, or treatment interventions. A wireless microphone implanted in the head of the HPS allows an unseen operator to carry on a conversation with the provider, answer questions, and respond verbally to treatments, further increasing verisimilitude.

To date, the HPS described above has been programmed to function under three scenarios, all related to bioterrorism response preparation:

1. exposure to mustard gas;
2. exposure to a nerve agent; and
3. exposure to a nerve agent in the context of an abdominal wound and subsequent shock.

A study was conducted comparing physician training using this HPS system with a comparable (non-simulated, PowerPoint-based) program delivered via CD-ROM. Investigators found that the two educational approaches were comparable in terms of the two lowest levels of cognition: knowledge (remembering), or the strict ability to remember facts; and comprehension (understanding), the ability to translate information from one form to another. However, providers educated using HPS showed a signifi cant advantage in terms of higher-level cognition (applying, analyzing, synthesizing, and assessing the value of the information learned) compared with providers educated using the CD-ROM program. The authors concluded that this simulated learning environment—which they term “situated cognition”—is superior to a strictly didactic approach in terms of outcome.

The HPS evaluated in the paper described above was limited in scope. However, there is no reason to expect that the technology utilized to teach bioterrorism response could not easily be applied to any type of continuing education. Given that encouragement of situated cognition is likely to be more interesting to physicians than didactic programs, and appears to be more eff ective at accomplishing its goals and improving outcomes, eventual incorporation of increasingly immersive simulation into CME in every area is likely.

A Whole New World (No, literally, a whole new world)

The software that may underlie the next great revolution in CME was developed by a small, San Francisco-based company called Linden Labs. In 2003, Linden released an online computer game called Second Life, which quickly became popular enough to register 13 million accounts worldwide. At first blush, Second Life appears to be very similar to the wildly popular game The Sims; users—“residents” in Second Life parlance—create a graphic representation of themselves called an “avatar.” They then pilot this avatar through a highly realistic simulated world.

But whereas Th e Sims is most certainly a game—with limited tasks that may be accomplished, no dialogue, and minimal interaction with other players—Second Life takes the concept a step further. Residents inhabit a world together with the virtual representations of millions of other users worldwide. They can play games, start virtual businesses, buy and sell goods and services, create and distribute creative properties, and generally live out... well, a second life. Users are able to create special worlds within the larger world, called “islands,” for a specifi c purpose. All residents are expected to conform to certain standards of behavior; administrators may punish transgressors by placing them temporarily in an inescapable island called “Th e Cornfi eld,” which is precisely what it sounds like it is.

By now, we’re guessing you see where we’re going with this, and we can all but see your eyebrows lifting skeptically. But hold on. A number of colleges and universities maintain presences in Second Life and allow students to attend virtual lectures within the network as a form of distance learning. Six libraries have created virtual representations of themselves within Second Life, along with four museums, including San Francisco’s well-known Exploratorium. Is it really so unlikely that medical education could follow suit?

In December 2007, Student BMJ described a newly developed MSc course in clinical management, now offered at the UK’s Coventry University. Sessions in this course are conducted through Second Life; students create avatars and manage an entirely simulated healthcare facility. Similarly, at the University of London, courses are under development that would allow medical students to practice interacting with patients within the world of Second Life and gather in a virtual hall to hear lectures from experts based anywhere in the world.

Stateside, Idaho State University is using Second Life to allow providers to practice disaster response in a simulated environment; players could also practice working in teams and using simulated equipment. Second Life “engages people in a way that traditional methods don’t,” programmer Dr. Ramesh Ramloll said. “Also, using Second Life costs dramatically less than designing your own virtual reality environment from scratch, and building environments in Second Life is a collaborative exercise with people who are experts in whatever fi eld you want to learn about.” Widespread incorporation of elaborate simulations based on Second Life (or other entirely virtual worlds) into everyday CME is not likely to happen in the near future. However, providers and consumers of CME are both eager to identify ways to increase the eff ectiveness of continuing education programs. Activities that increase immersion and allow users to obtain knowledge in the context of using it in everyday practice appear likely to achieve this goal. In this way, the CME of the years to come will move beyond text, and in some respects, beyond teaching as well.

Frank Ferrara is a freelance healthcare journalist and a former MDNG editor.