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Among all the other changes in the Health Service there has been a revolution in the way that continuing medical education is provided. There is a much greater awareness of the principles of adult education and more willingness to apply these in medicine and to experiment with new ideas. One of the fundamental principles of adult education is that individuals have preferred methods of learning and therefore it is important to provide a variety of means to keep up to date. The interactive problem based CD-ROM format is now an established part of this repertoire and it is very pleasing to see that the British Society of Gastroenterology has sponsored such a CD with a promise of more in the future.
There are two features to consider with the CD-ROM format: the quality of the interface and the educational content. A high quality interface between the learner and the program enables the learner to focus on the task in hand and not spend time and energy making the program work. A high quality educational content enables rapid learning of relevant material that will help the learner to deliver better quality care. How does this CD perform against these criteria?
Without reading the instructions it was not difficult to load the program and get started with the first clinical problem. My DVD loaded the CD in less time (about 90 seconds) than the maximum possible (15 minutes). The CD is arranged around 12 clinical cases. There are lists of symptoms, other relevant historical data, physical signs, investigations, and possible treatments or management strategies. The learner has to choose from these lists a limited number of items in three stages: history and physical; investigations; and management. After the first stage he has to propose three possible diagnoses and after the second a final diagnosis. Points are scored according to how discriminating the choice of items is. A highly relevant enquiry scores the most points while a ridiculous suggestion can lead (sometimes) to a negative score. Further points are awarded for the most appropriate differential and final diagnoses.
The final part of the programme involves multiple choice questions (MCQs) relating to the case for which more points can be accrued or lost. The final score is expressed as a percentage and for more than 70% a CME certificate is awarded. Apparently this certificate is valid for official CME credits in Europe and Australia as well as in the UK. Although the CD seems expensive at £135, it provides a relatively cheap way to accrue CME credits (£11.25 each). Certainly this is much cheaper than attending a British Society of Gastroenterology conference, just not so much fun!
With the first few clinical problems attempted I struggled to reach a score of 50% and was ready to throw my computer in the pond. However, before I decided to hand in my notice and change specialties, I read the instructions and learned that the cases had been chosen to tax even the most experienced gastroenterologists. Learners (even old crusty ones like me) are only expected to achieve 70% after they have been through a case two or three times. There is a learning curve associated with using the CD and, with further experience, my mark reached 63%. I have a few more cases to go and I am determined to score 70% first time on at least one occasion.
The CD contains a remarkable amount of helpful information. There are help screens available that explain the significance of items in the lists such as the indications for and performance of tests. There is a gastroenterology textbook available that can be accessed at anytime with easy searching facility. Finally, it is possible to obtain help while answering or reviewing MCQ responses. Thus a huge amount of information relevant to the program or the problem is readily at hand, minimising the need to go searching for information elsewhere. This process is time efficient but, more importantly, it forces the learner to link the information he or she is reading to an active real world problem. This increases the relevance of the information and therefore the chance of remembering it.
The cases chosen (at least the ones I have done) are rare and would not normally come high on a list of differential diagnoses. This bias of rare disease has the effect of not giving enough credit for proposals of more common diagnoses which, because they are more common, are more likely to have been correct. On one particularly frustrating occasion I had, after the first stage, the correct diagnosis in the differential of three but the computer only awarded me half the marks available. I was told that my differential diagnosis “included some of the most likely diagnoses” rather than “your differential diagnosis seems likely”. Initially, I interpreted this to mean that I had not included the correct diagnosis. However, after 10 minutes of frantically searching through the list of potential diagnoses, I stuck to my guns and was rewarded with full marks for the final diagnosis. If the intention was to induce arousal to facilitate learning through anger then the editors deserve full marks and a special certificate. In fact, choosing appropriate diagnoses from the list supplied was unnecessarily difficult and a very frustrating aspect of the interface.
An even more annoying feature of the interface was the quality of the endoscopic and histological images that accompanied the investigation section or second stage. Making some diagnoses seemed to depend on interpretation of these images and all the ones I found were of insufficient quality to make any sense of at all. The endoscopic and histological reports are available with the images but accessing these incurs a penalty the size of which is not revealed before a decision is made.
In summary, this is a good first attempt at producing an increasingly popular educational product. There are some frustrating aspects of the interface, particularly the differential diagnosis list and the quality of the diagnostic images. However, with minimal effort it was possible to get going with one of the cases. From an educational viewpoint the CD is short on early reward and encouragement. Learners perform best if they are encouraged and told they are doing well right from the start. Some, particularly those who are not required to write a review, may give up on it too soon. Having said this, the CD is based on sound adult learning principles. The subject is relevant to the learner (albeit largely small print stuff). The learning is self directed and problem based and there is a great deal of background information that means the learner can usually find the answer to a question without leaving the programme. Finally, there is an iterative quality for those who can be bothered to return to the case to achieve the higher mark required for a certificate. If they do, no one can say that their CME point was not well earned.