Doctor, Teach Thyself

Will doctors warm to the idea of taking continuing medical education courses online? And will CME dot-coms survive?



It's late on a Tuesday night and more than 240 physicians and nurses are listening to Dr. Joseph Calabrese discuss bipolar disorder, an often-overlooked form of mental illness that affects more than 2 million people in the United States.



As slides illustrating his points flash before the audience, Calabrese, a psychiatry professor at Case Western Reserve University in Cleveland and world-renowned expert on the topic, elaborates on the affliction's symptoms and treatments.



What makes this presentation unlike most is that Calabrese has no idea whether the people in the audience are confused or, for that matter, if they're even paying attention. That's because Calabrese is lecturing from his office near campus and participants are sitting in front of their computer screens in such faraway places as Taiwan, Israel and The Netherlands.



Webcasts such as this one , produced by HealthStream, a Nashville online education company, and funded in part by GlaxoSmithKline, a pharmaceutical company that makes a drug used for treating bipolar disorder , represent what many believe will be the future of continuing medical education (CME), the training that doctors often must take to maintain their licensure. Enthusiasts predict that more than half of all CME activities will one day be delivered over the Internet; skeptics see the percentage topping out at around 15 percent.



For now, however, online CME is in its gangly adolescence, embodying the hopes of physicians and entrepreneurs who feed it cash and inspiration. Bernard Sklar, a Berkeley, Calif., physician, began monitoring the proliferation of , and the hype associated with , online CME as a graduate student in medical informatics and has watched the number of Web sites offering CME grow from 13 in April 1997 to more than 160 in January 2001. (For a comprehensive list of online CME providers, visit www.netcantina.com/b...).



And in its annual report, the Accreditation Council for Continuing Medical Education (ACCME), the organization that accredits CME providers, found a 110 percent increase in the number of physicians who registered for online courses , from 37,879 in 1998 to 79,536 in 1999.



Despite the volume of enrollees, the 1999 total accounted for only 2 percent of the CME delivered that year. "Physicians have been relatively slow in adopting online CME. They're not accustomed to going to a computer to seek out information. That is changing and will change appreciably," says Bruce Bellande, executive director of the Alliance for Continuing Medical Education in Birmingham, Ala., an international association of CME providers.



Even though the percentage of physicians who currently take CME online is small, the market's potential hasn't gone unnoticed. According to the ACCME, continuing medical education in the United States has become big business. Expenditures topped $1.1 billion in 1999 , up from $650 million three years earlier.



There are several reasons for the growth in spending. For one, more physicians need to take continuing education courses. Thirty-seven states require physicians to complete a certain number of CME hours each year to renew their licenses; in 1990, only 23 had such mandates. And a recent study by Medical Meetings, a professional publication, found 66 percent of physicians needed to participate in such activities to maintain privileges and credentials with hospitals and managed care organizations.



That's not all that's driving demand, however. "The underlying pressure on CME is the rate at which medical knowledge is changing," says R. Van Harrison, director of CME for the University of Michigan Medical School in Ann Arbor. "Physicians? knowledge becomes obsolete faster than ever before."



Consider, for example, the number of new drugs that have come onto the market since the passage of the Prescription Drug User Fee Act in 1992 and the FDA Modernization Act in 1997, both of which speeded up the Food and Drug Administration's once-sluggish approval process. According to the Boston-based Tufts Center for the Study of Drug Development, the FDA approved 108 new drugs between 1996 and 1998 , the largest three-year total since 1962.



Wanting to get the word out about their new products, drug companies began investing heavily in formal education, paying for about half the CME that took place in the United States in 1999. In a survey of medical school CME directors last year, the Society for Academic Continuing Medical Education found virtually all medical schools accept financial support from commercial companies, usually in the form of "unrestricted educational grants."



On top of that, drug companies often sponsor their own educational seminars. "There's hardly a meeting you can go to where you don't see a pharmaceutical company's name prominently displayed," says Sklar.



About the same time as pharmaceutical companies began infusing money into CME, farsighted entrepreneurs and educators began thinking about ways to use the Internet to bring courses to time-strapped physicians. Universities started experimenting with developing CME for the Web, as did commercial providers that had made a business out of selling print, audio and video self-study materials.



And a growing number of Internet companies, fueled by investor capital, began courting well-known physicians and prestigious institutions who have developed CME. The idea was to put their classroom courses online in order to lure physicians , and advertising dollars from companies wanting to sell to them. "I went for a year where my phone rang every two weeks with would-be entrepreneurs wanting to provide a golden opportunity to put our medical school's CME activities on the Web," says Harrison.



CME directors and physicians began signing on with Internet companies that promised technology, marketing expertise and often hefty honoraria in exchange for content and use of the university's good name.



HealthStream, one of the largest publicly traded Web-based health education companies, is helping Cleveland Clinic and Vanderbilt University in Nashville, Tenn., develop and sell their content online. Cyberounds, a private New York City online CME venture, contracts with individual physicians as course authors. And Medscape, a for-profit company in Hillsboro, Ore., has been working with specialty medical societies, such as the American College of Cardiology, and 24 medical schools to put CME programs on its Web site.



Harrison, who is skeptical about many of the current approaches to online CME, admits even his school is working with three such organizations on projects, including a multimedia program on headaches. "We need to have some experience with this medium," he says, adding that he's willing to experiment with it, particularly when someone else is paying the bills.



Still, the question remains: Will physicians want to take CME over the Internet, as the CEOs of these dot-com companies hope? While there are those who argue each side, all agree that several things will have to happen before online CME grows into the size 13 shoes some investors are banking on.



For one thing, physicians will have to become more Web wise , a phenomenon that's finally starting to happen. When it looked at physicians? use of the Internet, the American Medical Association (AMA) found the number of physicians who went online nearly doubled from 20 percent in 1997 to 37 percent in 1999.



Second, the technology that drives online education will have to improve, as those who attempted to listen to Calabrese's talk discovered. After putting up with minutes of buffering audio, participants with less than a 56K connection heard only intermittent non sequiturs. "When everyone gets the one-gig computer at home and gets Internet access over cable, we'll be singing. But right now, a doctor isn't going to fool around with a program that has marginal quality because the screen is tiny and the sound is bad," says David Heaphy, associate dean and director of CME at Johns Hopkins University School of Medicine in Baltimore.



Sklar discovered other reasons why online CME has been slow to gain acceptance: a lack of awareness of where to find courses on the Net, difficulty navigating Web sites, trouble downloading and installing plug-ins, concern about giving out license and credit card information online, and a preponderance of dull programs. Of the Web sites he monitors, more than half offer courses that are text-only or that use text and graphics; 44 percent have offerings that use a combination of slides and audio or video; 18 percent offer courses with interactive components; and just six percent give learners the opportunity to ask questions of the expert.



Sklar says CME developers will have to pay closer attention to educational theory if they want their courses to catch on. They'll also have to serve up CME in "chunks," small bits of learning that a doctor can complete during rare moments of down time.



Having taken more than 100 hours of online CME himself, Sklar believes the industry will soon see more case-based offerings similar to the University of Virginia's mypatient.com. In this simulation, a group of virtual patients appear in an onscreen waiting room. Students select a patient, gather information about the person and his or her health problem, perform a physical exam, order tests, make a diagnosis, recommend treatment and learn from their mistakes. "From an educational viewpoint, people would consider these superior," he says.



But for CME to truly change physicians? behavior, Sklar explains, it will have to be integrated into their daily practice. And systems will have to be developed that provide information on the spot when a physician is making a mistake or needs additional instruction. That's starting to happen.



Last May, Stanford University in Palo Alto, Calif., spun off its own for-profit Web-based educational venture called Skolar that sells access to an interactive knowledge acquisition system called Stanford Skolar, M.D. Doctors type in a question and the system searches medical textbooks, journal articles, drug databases, practice guidelines and other sources for information on the topic.



In a nod to the influence of the Internet and the promise this type of instant, self-directed education holds, the AMA, which awards CME credit, has established a pilot project through which doctors can earn category 1 credit , the kind recognized for licensure , by using Stanford Skolar, M.D.



Skolar will be the test case for possibly establishing new AMA rules for interactive online CME, says Dr. Dennis Wentz, director of continuing professional development for the association. "Our long-term goal is not simply to allow physicians to get CME credit for using the Net, but to establish a system of continuous learning and development and improve the quality of patient care," he says.



But developing good interactive CME courses isn't cheap, as John's Hopkins? Heaphy discovered. In 1999, Heaphy worked with an upstart Internet company to launch two online CME programs. One was an internal medicine board review that used streaming audio and slides to deliver more than 70 lectures on topics such as preventive medicine and substance abuse. Participants paid $795 to take the course and exams for CME credit. The other was a series of live online case studies presented on Saturday mornings. Physicians logged on, listened to the lecture and emailed questions to the speaker.



After spending $70,000 to produce the board review, Heaphy collected only $10,000 in fees before the Internet company he was working with collapsed. And while the Saturday morning sessions proved popular with physicians all over the world, Heaphy wasn't able to get people to pay to listen to the archived programs. "There's a lot of free stuff on the Net," he says. "And if there's a lot of free stuff out there, you won't get people to pay for anything."



Heaphy discontinued the programs later that year, but hopes to revive them. "My business model next time is to find someone else to pay for it," he says.



Other online CME providers are also continuing to search for ways to make their efforts pay off. These days, HealthStream is downplaying its attempts to profit from CME for physicians. Instead, the company is concentrating on providing safety and regulatory training to hospitals and selling its online learning technology to pharmaceutical companies and device makers. "We're still interested in physician education and consider ourselves a leader, but it's not our primary focus," says CEO Robert Frist, Jr.



Skolar is charging a $240 annual subscription fee and forming partnerships with medical centers, health care companies and tech firms such as Agilent, which plans to incorporate the Stanford Skolar, M.D., database into its Web-enabled medical devices. Cyberounds is relying on user fees and educational grants to pay for CME content. And Medscape, which gave up on making money from subscriptions, is relying on advertising revenue to support its offerings.



Josh Fisher, health care research analyst with WR Hambrecht and Co. in San Francisco, expects that CME for physicians will become a commodity on the Internet. "A lot of companies will offer it as part of their strategy. As a stand-alone business, offering just CME is going to be tough," he says.



Sklar is already starting to witness the dashed hopes of some CME dot-coms. During a recent interview, he expressed his frustration over not being able to call up the site for MedLecture.com. "I just get a screen asking for my password. I have no password and there's no information about contacting anyone associated with the site," he says. He expects to see more sites disappear or be abandoned, but doesn't believe it spells the beginning of the end for CME on the Web.



Rather, what's happening to the online CME providers may foreshadow what's to come for the e-learning industry as a whole. Sklar predicts that the market will be dominated by a few big players and a number of small sites dedicated to promoting a point of view or discussing a rare disease rather than making money. "It's not tenable," he says, "to have 160-some online CME sites and have 160 good ones."



-Kim Kiser (kkiser@onlinelearningmag.com) is managing editor of Online Learning Magazine.



COPYRIGHT Bill Communications Inc. 2001. All rights reserved.