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Editorial |
1 From the Department of Radiology, Division of Neuroradiology/ENT, Thomas Jefferson University Hospital, Suite 1080B Main Building, 132 S Tenth St, Philadelphia, PA 19107-5244. Received and accepted November 20, 2006. The author has no financial relationships to disclose. Address correspondence to the author (e-mail: adam.flanders{at}jefferson.edu).
Blog, Wiki, RSS, Podcast, Moodle, CMS, LMS, Internet 2, Web 2—the public is regularly barraged with an increasing number of Web acronyms as new Internet technologies are being developed. The Web as we know it is barely over a decade old, and although the services that leverage the public Internet have become an essential part of the public consciousness (eg, via e-mail, Web browsing, file sharing), advocates and pundits alike will likely agree that we are nowhere near to seeing the maturation of these services and their assimilation into our daily activities.
The infrastructure of the Internet is designed to promote knowledge sharing. It is no surprise then that some of the earliest uses of the document hyperlinking technology of the World Wide Web were in the area of education. Almost from the inception of the first Web browsers in the early 1990s, educators embraced these tools as a lightweight solution for dissemination of almost unlimited amounts of educational material to anyone with a personal computer, a Web browser, and a connection to the Internet. The multimedia capabilities of Web browsers were of particular interest to radiology educators who could now display digital versions of clinical images with textual information. Rather than being restricted to conventional textbooks, which present material in a fixed format, educators could use the World Wide Web and experiment with presenting similar material in different formats, ranging from structured reference or learning modules to digital teaching files and case presentations. Although the technology available to deliver and display content has expanded in scope (eg, multimedia, streaming video and sound), speed (ie, broadband connections), and availability, it remains debatable what the best vehicle is for delivery of educational material.
This issue of RadioGraphics presents two articles that provide different perspectives on radiology online learning. In the first article, Rowell et al (1) examine the utilization patterns and preferences for electronic learning (e-learning) through a survey of 92 practicing radiologists. Although there is substantial bias in the survey sample, the underlying message is that the majority of radiologists surveyed preferred traditional means to obtain information about advancements in our profession. However, virtually all of the survey respondents acknowledged some use of the Internet for what they consider "radiology education," with the majority (84%) claiming that their Internet usage for this purpose had increased in the past 3 years. Despite the extensive online availability of many radiology journals, only 9% of the survey participants admitted to reading journals exclusively online, with 67% of the participants preferring hard copy exclusively to online versions. Most of the radiologists in the survey (72%) believed that online material was just as reliable or more reliable than printed materials on similar subjects. Interestingly, whereas almost one-half of the participants (45%) admitted that they have used online continuing medical education (CME) materials, 70% also stated that they preferred to obtain CME through traditional venues such as meetings and courses.
Although utilization of online educational resources is on the rise, the results of the survey suggest that radiologists still express some ambivalence about using online resources exclusively.
Although the percentages reported by Rowell et al (1) should not be interpreted at face value, these survey results do confirm the trend toward increased Web utilization to obtain medical reference and decision-support information. The ubiquitous Web-enabled desktop computer is no longer relegated to the back office and is now within arm’s reach of most radiologists. The familiar and popular search engines such as Google (or even Google Scholar) have made it all too effortless to access scientific literature and reference materials. Moreover, online access to radiologists’ leading publications such as Radiology, RadioGraphics, and the American Journal of Roentgenology is easier than ever. The majority of participants in the Rowell et al survey (1) routinely used the Radiological Society of North America’s portal to access online radiology information and the Google search engine (www.Google.com). The most significant drawback to use of a general portal such as Google.com is that the material returned to the user is often not presented in an organized or usable form. The user is still forced to examine multiple links and wade through the content attached to these links before finding the item of interest.
Also in this issue of RadioGraphics, Sparacia et al (2) discuss the advantages of a learning management system (LMS) as an online delivery vehicle of educational content. The authors analyze the utilization patterns of two such systems: One LMS site is focused on neuroradiology (Neuro-RAD), and the other LMS hosts general pediatric topics and curricula http://www.PediatricEducation.org. An LMS differs from a standard Web site in several important ways. The LMS concept was spawned by the need for educators to post content easily in an organized and structured (ie, modular) fashion for students. An LMS also provides a mechanism to monitor student usage of the materials, provides a means for online testing and evaluation, and facilitates communication between the educator and the student through discussion groups or collaboration. Depending on the site design, access to certain features can be restricted to registered users only. Registered users can gain access to utilization statistics, and they can receive periodic updates of new content and track test performance on learning modules. Although an LMS can be used as a repository for reference material, its greatest strength lies in its ability to create a virtual classroom environment. (For more information about e-learning and creating an interactive Web-based course, see the article by Hoa et al (3).)
To study the utilization of the material on these two systems, Sparacia et al (2) analyzed the Web server logs along with supplemental information obtained from a voluntary online survey. Cursory analysis of Web server log files provides only a limited perspective about the value of a Web site, as it does not provide information about how the visitor uses the content (ie, simply browsing or actually reading it). It is interesting that the typical visitor to the NeuroRAD site (which contains primarily lecture-based learning modules) displayed—and not necessarily read— nine pages per visit on average, with an average elapsed time per visit of only 5.5 minutes. PediatricEducation .org contains primarily case presentations, and the typical visitor displayed only two pages per visit on average, with a total average visit time of 1.5 minutes. The elapsed time per visit should be interpreted in the context of the type of material being displayed on a page (ie, text, images, multi-media), since the time required to actually digest a page’s content is directly related to the type of content on that page. Although visits to the Neuro-RAD and PediatricEducation.org sites in 2005 were 9,959 and 91,000, respectively, only 152 users actually registered on the NeuroRAD site, and even fewer (n = 83) actually completed online courses and tests. These data suggest that while usage of the sites appears high, the number of regular users (ie, registrants and repeat visitors) is actually quite low.
To gain a better understanding of how a Web site’s content is being used, more detailed metrics need to be collected that incorporate factors such as time elapsed per page relative to the content of the page (eg, text, media, mixed media) and the actual path that a user traverses when entering the site. This information could be compared with benchmark page display intervals to determine whether a visitor is absorbing the material or simply browsing past it.
A common theme in both of these articles is that radiologists are interested in Web delivery of educational materials but are somewhat reluctant to embrace online resources as the sole solution for decision support, reference materials, and CME. Use of technology for technology’s sake is not always the solution if it does not offer more robust results than do conventional methods. One example of this is the relatively stagnant development of educational tools for handheld devices (eg, personal digital assistants, smart phones) in the face of exponential growth in sales of these devices (4).
What then are the barriers to adoption of online radiology CME and decision-support solutions? Is the quality of online radiology educational material an issue? Are there regulatory measures to oversee the quality and accuracy of online content? Do users "trust" online content to the same extent that they do the printed page? The reliability measure from the survey conducted by Rowell et al (1) suggests that most users of Web-enabled educational content believe that the online material is as reliable as printed materials. Although most of the content within print versions of scientific publications (or online versions of the journal) has been adjudicated in the peer review process, many other public sites are subject to "variable" review processes. For obvious reasons, authors and readers therefore place a higher "value" on online material that has undergone peer review. Because not all online educational content undergoes the same level of scrutiny as used for content in printed journals, the quality and accuracy of the material can vary considerably. Therefore, while the amount of effort involved in creating an online version of an educational article is equivalent to that for a printed article, an online-only contribution may be unfairly devalued, a factor that may discourage authorship of such material. Although no process currently exists to enforce quality control on publicly available online content, methods could be developed to certify independent educational sites that meet specific educational standards of governing bodies such as the RSNA or the society could even provide links to certified sites through the RSNA portal.
There is certainly no disagreement that online educational materials are more convenient, versatile, and accessible than conventional printed materials, and that physicians prefer the individualized self-directed approach to learning that Web-based CME programs provide. There is little evidence, however, that online delivery of content is more effective as an adjunct to learning than traditional CME activities (5). Furthermore, there is little evidence to support that traditional methods of CME are effective in promoting learning, and, in its current form, traditional CME has not been shown to have a measurable impact on the quality of care (6,7). The real challenge to educators is to provide a more successful and efficient method of learning that also provides a measurable impact on physician performance improvement.
Medical educators have become increasingly aware that learning is most effective when new concepts or relationships are directly applied in a clinical environment (8). Learning at the point of care or in the context of a clinical problem is often referred to as situated learning (9). A novel situated learning model, referred to as just-in-time learning (JITL), for radiologists is discussed in a recent article by Kahn et al (10). JITL proposes delivery of brief (5–10-minute) micro-CME learning modules directly to the radiologist’s PACS workstation. The modules are context specific; that is, the topic delivered to the desktop would be selected based on the clinical context of imaging examinations under clinical review (eg, a review of extraaxial brain tumors would be delivered while the radiologist was interpreting MR images of a brain with a meningioma). The radiologists surveyed by Kahn et al (10) in this study showed a preference for modules of short duration (5–15 minutes), content consisting of a mixture of text and images, highlighted bullet points, and quizzes with immediate feedback. Several vendors have successfully built subscription-based, decision-support tools around this concept.
There is substantial interest in the radiology community to leverage the technologies that we use everyday to improve the process of lifetime learning. With existing and developing technologies, there may come a time in which your PACS workstation will silently monitor and analyze the context of your clinical work, and, through a series of interfaces with a subscribed CME portal, the PACS will deliver context-specific learning modules to you on your workstation at a time of your choosing. Based on your user preferences, you could elect to take a 5-minute break to complete the module or defer to complete it over lunch. The central CME portal, in turn, would subsequently credit your CME account and automatically update your learning plan based on participation, user preferences, and availability of new content. Sometime in the near future, lifetime learning will become so inexorably linked to radiology clinical work flow that we may not even notice it!
Footnotes
See also the articles by Rowell et al (pp 563–571) and Sparacia et al (pp 573–581) in this issue.
References
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