“Will this be a no-cookie world, like my house?” Murray Kopelow, MD, executive director, Accreditation Council for CME, asked attendees during a session at the Alliance for CME's annual meeting, held in January in San Francisco.

Kopelow wasn't talking diet. With his trademark wry humor, he was ruminating about the impact of the Web on the CME world.

From a plenary session speaker who described a not-so-distant future where computers sense user's emotions to Kopelow, presenters and attendees debated the philosophical and practical challenges arising from new technologies.

e-Bill of Rights?

At the American Medical Association Conference on CME Provider/Industry Collaboration in September, Kopelow led a lively discussion about how to ensure that e-learners see disclosure statements — since there is more than one entry point in online CME. The discussion continued at the Alliance conference, during a session on the Standards for Commercial Support. Kopelow suggested including a drop-down tab that would appear all through an activity, which physicians could click to see disclosure information.

Another issue of concern is the separation of promotion from education, particularly links to commercial supporters' Web sites. One attendee credits the commercial supporters at the beginning of the online CME activity, but doesn't allow links to commercial sites.

At the IRS site, said Kopelow, a window pops up, alerting visitors that they are leaving a government site and that the IRS takes no responsibility for anything on other sites. “It's a clear and useful tactic,” he said.

Privacy is another major challenge in Internet CME. “I envision commercial supporters using participant demographics for marketing purposes,” said one attendee.

“That is an alarming question,” responded Kopelow. “I haven't been asked that before.” While the issue of patient privacy has been addressed by various Internet health care coalitions, “You raise a new issue — and an agenda item for the task force,” Kopelow told the attendee. (The ACCME has set up a task force to explore the development of guidelines for e-CME, chaired by Linda Casebeer, PhD, associate director, University of Alabama School of Medicine in Birmingham.)

“Who has control over the learner's opportunity to say ‘no’?” Kopelow asked. “There isn't a learner's bill of rights.”

One solution would be to post privacy policies on online CME sites. “Every medical education Web site has a privacy policy that clearly states how information will be used,” said one attendee. “Web CME sites could include a box where you click your consent or non-consent to follow-up by commercial supporters, as is done in evaluations of live activities.”

Fifteen Minutes of Credit

The American Medical Association is also integrating the realities of online CME into its guidelines. “With the realization that [education] on the Internet is in smaller modules, we are making [credit rules] more flexible,” announced Greg Paulos, associate director, division of continuing physician professional development, during an AMA Town Meeting. Physicians can now claim credit in 15-minute increments.

The AMA's Council on Medical Education is also conducting a pilot program about Internet CME, Paulos said, to develop rules for awarding category 1 credit for self-directed Internet CME activities. The first participant is Stanford University's e-SKOLAR program.

Assigning credit hours for online CME activities is problematic, said one attendee. A physician can fill out an evaluation and immediately get a certificate — but there's no way to know how much time the physician actually spent doing the activity.

Providers should use the rules for enduring materials, answered Dennis K. Wentz, MD, director, division of continuing physician professional development, AMA. “Figure out an average time that the physician should spend,” he said. Physicians' credit reporting for online CME is based on the honor system, as with other types of activities. If a physician claims more hours than he or she actually spent on an activity, that is not the provider's responsibility. “We are not asking you to be CME police,” Paulos said.

Get the Genie Back in the Bottle

But those arguments presuppose physicians are logging on to Web CME. Suppose you produce a great online education program but nobody comes? It's no secret that many physicians are frustrated with technology. Or, as Jann Balmer, PhD, director, CME Office, University of Virginia in Charlottes-ville, put it: “Some [physicians] are techno-wizards and others have their secretary print out their e-mails.”

Therefore, CME providers need to help physicians access information literacy skills, said Barbara Barnes, MD, associate dean, CME, University of Pittsburgh. During a session entitled “CME Congress 2000,” Barnes and other speakers recapped the April congress for Alliance attendees.

“The explosion of medical knowledge is a blessing and a curse,” Barnes continued. “You have to be careful what you wish for. We need to get the genie back in the bottle. We have a different role as CME professionals.”

Barnes, who summarized a session given at the CME Congress by Philip C. Candy, vice president, University of Ballarat in Australia, said CME providers need to help physicians access information-literacy skills. “We need to empower physicians to tell the difference between relevant and irrelevant information.” This is an opportunity for CME providers to partner with their colleagues in other parts of the medical education continuum, she said. Since younger physicians tend to be more computer literate, the tradition of older physicians teaching younger ones can be turned around. “Residents and students can serve as faculty and mentors,” Barnes said.

“[On the Internet] who has control over the learner's opportunity to say ‘no’?” There isn't a learner's bill of rights.”
— Murray Kopelow, MD

In the mini-plenary about Web CME, Jann Balmer, moderator, said that she has incorporated computer education into live courses. Teaming up with her medical librarian, she has set up “collateral learning areas” — computer demos in the lobby where attendees can get computer skills training for no additional cost.

What About Interaction?

Of course, even tech-savvy physicians will take advantage of online CME only if the educational content is relevant. During the mini-plenary on Web CME mentioned above, panelists visited several sites, analyzing their strong and weak points.

After looking at a site which simply posted journal articles, attendee John Parboosingh, MD, director, professional development, The Royal College of Physicians and Surgeons of Canada, in Ottawa, asked, “Can a physician interact with peers? Is there the opportunity to ask questions of the teacher? To share in discussions — as there would be in a real-time program? This is a major challenge.”

Most sites provide no opportunity for interaction with peers or faculty, acknowledged panelist Bernard M. Sklar, MD, consultant, online CME. However, he said that the AMA had launched two new online diabetes activities that include an exciting feature: When a physician answers a question, a bar graph pops up, showing how colleagues have answered that question. Sklar said, “It's pseudo-collegiality.” (Visit www.ama-assn.org/cmeselec/courses.htm and check out the first two diabetes cases. Head straight to “Continue” at the bottom of the page. Start the case and go though a few pages. After you give your response to a question, click on “User Response Statistics.” It's similar to the Ask the Audience feature on “Who Wants to Be a Millionaire?” Sklar says. Another Web site with a peer comparison feature is www.ast macasestudies.org/home/default.cfm.)

Panelist Harry Gallis, MD, vice president, regional education, Carolinas Healthcare System in Charlotte, said he is currently taking an e-course that encourages interaction. The class is divided into groups of four to five people, who meet in chat rooms, discuss an issue, develop a consensus statement, and uplink it to the instructor. “It's very effective,” he said.

Computers That Say “I'm Sorry”

At last year's conference, plenary speakers emphasized that physicians need to learn how to treat their patients with warmth and compassion. This year, plenary speaker Rosalind Picard talked about how computers need to treat physicians with more understanding.

“There are more flavors of emotion than there are of ice cream,” she said. Picard, who works with the MIT Media Laboratory in Cambridge, Mass., painted a fascinating picture of a future where computers can sense and respond to the user's emotions.

Whether a physician snoozes during an online CME activity, or almost kicks the computer out of frustration when the program won't load properly — the computer remains maddeningly oblivious. But wouldn't it be great, said Picard, if computers could recognize the user's state of mind and adjust accordingly by using some of the same techniques people do when dealing effectively with someone who is upset? Imagine a computer that apologies for frustrating you. Or, when things go awry, instead of telling you that you have performed an illegal operation — not exactly a supportive response — the computer could pop up with the message, ‘That must feel lousy,’ and explain what went wrong. If users get help from a computer, they will stick with it longer, Picard said.

Though she made frequent references to the film 2001: A Space Odyssey, Picard said what she was describing was not science fiction. Right now, computers are being taught to recognize the emotional signals we express through our skin and body language, Picard said. Skin conductivity and other devices can detect when our jaws are clenched, and when we lean forward in excitement or furrow our brows in confusion.

“Some [physicians] are techno-wizards and others have their secretary print out their e-mails”.
— Jann Balmer, Phd

Sensors are not enabling computers to read our minds, Picard emphasized. Rather, they read the outward changes in our bodies. Picard predicts that in 35 years or less, emotion-recognition technology will be at the same development stage as voice-recognition technology is today.

Body language sensors also have the potential to improve videoconferences and live meetings by providing instant feedback to speakers. Attendees can wear devices that glow when they are engaged, and fade if they are falling asleep in their chairs.

At the end, Picard linked the skills computers need with the ones physicians need — echoing last year's plenary themes. She cited a study conducted by a major insurer that looked at which doctors were sued for malpractice. Controlling for the severity of the medical errors, the study showed that biggest factor determining whether doctors would or would not be sued was their sensitivity and rapport with their patients.

“So much new technology is cute and neat — and drives people crazy when they try to use it,” she said. In effect, the computers talk without listening — just what patients accuse physicians of doing. “If it won't work in human-to-human interaction,” Picard said, “it won't work in human/computer interaction.”

Web CME Strategies

MM June will focus on the Internet and CME, including these items:

  • CME Tech Innovators: A feature story highlighting exciting and creative online CME programs

  • Web maps: Information specialist Anne Taylor-Vaisey helps you navigate the Internet to find the information you really need.

  • For Adult Learners Only: Columnist Hank Slotnick, PhD, PhD, will devote his June column to incorporating adult learning techniques into online education activities.

  • Eye on e-CME: Beginning with MM July/August, this section will include news, resources, and reviews of online CME and CE.