JOHN M. WIECHA

J. Wiecha

THE development of communication systems via the Internet presents new opportunities for professional education of health care providers, and for promoting rational and evidence-based medical care and medication use. Distance education methods for disseminating new protocols and guidelines from WHO and other organizations to improve the use of medicines may be an important and neglected method of promoting adoption of new standards of care. To be successful, we believe that distance education must include opportunities for communication and discussion about the proposed changes to clinical practices. This type of learning should encourage reflection by the target audience on the complex processes of behavioural and organizational change implicit in the implementation of new guidelines and protocols. Properly designed online professional education programmes provide unique opportunities for these activities.

To date continuing medical education (CME) programmes have not taken advantage of the ability to communicate and collaborate online, however. Collaborative or "peer-to-peer" learning is an important principle, yet online CME programmes are generally completed in a one-to-one relationship between the computer and the learner. This limits opportunities for reflective learning, and does not access the rich potential of interacting with peers. We believe that the Collaborative Online Learning (COL) course developed at Boston University offers these benefits and draws on an awareness that physicians, and other health care professionals, like to learn from each other in a collegial, non-threatening learning environment.

A step-wise approach

We ran a prototype online course designed to improve the skills of general practitioners (GPs) in the care of patients with type 2 diabetes. The course design reflects adult learning principles but, uniquely, applies them to online learning. The course has been taught twice, with the first enrolling 20 GPs from the UK, one based in Bosnia, and one in New Zealand. The second course had four GPs from Singapore, 13 from Indonesia, three from the UK and one from the USA.

The course used BlackBoard(TM) software. Participants logged in twice weekly for seven weeks to study one of seven interactive modules on diabetes from evidence-based sources. The modules were designed with a step-wise approach to learning following the clinical progression of the chronic disease, starting with a module on screening and diagnosis, through lifestyle therapy, use of medications, and, in later weeks, screening for and management of complications of diabetes.

Modules provided for opportunities for learning via links to additional resources. Subsequently, GPs engaged in two online discussion groups, in which learners could participate by posting messages at any time, without requiring the simultaneous presence of learners on the course web site. These discussions were similar to an electronic discussion group rather than a chat room or Instant Messenger. They were at the learner's convenience rather than requiring adherence to a set schedule, so that participants could contribute when it suited them, regardless of the time differences between countries. One discussion group was for reflection on the modules, with an assignment to discuss how the material was being applied clinically. Participants also read and responded to colleagues' postings each week.

In a second discussion group, learners applied concepts from the modules to the collaborative management of a problem-based case of a patient with newly diagnosed diabetes. The patient was presented via an online medical chart and streaming videos. She returned each week of the course to mimic 18 months of care, with the problems and diabetic complications she presented at each week's visit coordinated with the content of the learning modules. Learners used the material from each week's module to develop a management plan for each virtual patient visit, which they posted to the discussion group. They collaborated by reading and responding to the postings with a goal of achieving consensus on the management of the patient. Faculty from Boston University, trained in online teaching, facilitated the discussion groups and provided feedback.

Adapting to participants' needs

Participants' feedback has been was very positive. Many noted how well the course design and timing matched their learning styles and schedule constraints. One powerful feature has been the possibility for course organizers to identify additional educational needs, and quickly add corresponding content online. For example, when participants in the first course indicated a need for more information on the renal complications of diabetes, and how to prevent them, we were able to design and post online a module on this topic within two weeks.

The 22 participants in the first course provided 340 postings, which included evidence of course effectiveness and documentation of application of course objectives and disease management strategies to change actual practice patterns. GPs reported changing screening protocols for diabetes; screening practices for diabetic renal disease; and organizing practice management systems to better track diabetic care. They also reported changing their prescribing of diabetic medications to emphasise medication choice for which there is best evidence for impact on complications of diabetes at lowest cost. Participants were given a written case online before and after the course, and were asked to write a management plan for it Analysis of these documents demonstrated improvement in overall score and in many key areas of diabetes management.

After diagnosing and managing a new diabetic patient during the course, one participant from the UK wrote: "It was fantastic to feel that I am offering an up-to-date evidence-based approach in something that I am deskilled in." There was similar feedback from the second course, and participants noted additional positive aspects of this method of professional development. In particular, the peer-to-peer learning from interaction with other participants was frequently mentioned as a major strength.

A Singapore GP commented that the course "crosses international borders and allows participation of people I would have never met from other countries." A GP from Indonesia commented on strengths: "The modules are concise and straight-forward. There are many experienced participants in the discussion forum. It is free of charge..." Because the two participants from the UK were thoroughly schooled in the evidence-basis for ambulatory diabetes care, they could generate useful debate and counterpoints on some of the clinical practice guidelines promoted by medical associations in the UK, USA and Singapore.

Suggestions for improvement included requests for hard copies of materials, to reduce the need for downloading and printing material, which is prohibitively slow on the unreliable Internet connections in some countries. The need for more discussion of the psychosocial issues of the case patient, rather than emphasising the medical management, was mentioned. Several participants requested the course run longer than six weeks to give more time to learn new material. Most participants indicated they would enroll in future online courses using this collaborative method, on additional topics - the most requested of which were treatment and prevention of cardiac diseases.

Summary

Our experience to date suggests that this teaching method provides exciting and rewarding opportunities for educating health professionals. New guidelines or protocols are particularly appropriate as the basis for an online course of this type. This model of providing professional development can be truly global, as health care providers confront many of the same problems caring for patients with chronic diseases whether they are in Asia or South America.

The COL approach is particularly suited for health care providers with Internet access and who might not otherwise be able to participate in conventional professional educational activities. In addition, the electronic connections established between participants can be used subsequent to the course for additional periodic update, monitoring of implementation of new practice guidelines, and research and evaluation.

For health care professionals with slow Internet connections, an e-mail-only version of this method is also possible, relying on moderated e-mail list-serve interactions and a CD-ROM of the resource materials.

These methods should be applicable to the many activities at WHO and elsewhere in which clinical guidelines and/or new research findings relevant to clinicians are a component. Currently, we are creating an online course with WHO's Department of Reproductive Health and Research to teach physicians, and other providers of antenatal care, how to implement the Department's new model of antenatal care. Other international collaborations include a project with the University of the West Indies to use the COL method to train primary health care providers in the Caribbean in the management of patients with HIV/AIDS, including the efficient and effective use of newly available medications.

For more information contact: Dr John Wiecha, Director, Distance Education for Health, Boston University School of Medicine, 715 Albany Street, A305, Boston, MA 02118, USA. E-mail: John.Wiecha@bmc.org, web site: www.bu.edu/familymed/distance.htm

Further reading

• Chumley-Jones H, Dobbie A, Alford CL. Web-based learning: sound educational method or hype? A review of the evaluation literature. Academic Medicine, 2002 Oct;77(10 Suppl):S86 - 93.

• Cauffman JG, Forsyth RA, Clark VA, Foster JP, Martin KJ, Lapsys FX, Davis DA.

• Randomized controlled trials of continuing medical education: what makes them most effective? Journal of Contin Educ Health Prof. 2002 Fall;22(4):214 - 21. Review. Erratum in: J Contin Educ Health Prof. 2003 Spring;23(2):67.

• Lalonde J. How physicians learn. Cost and Quality, 2000. 6(3): 29 - 31.

• Collison G, Elbaum B, Haavind S, Tinker R. Facilitating online learning: effective strategies for moderators. Madison, Wisconsin: Atwood Publishing; 2001.