In Discussion, the rapid growth of online CME sites and courses is reviewed; the growing gap between large sites and small sites is discussed; the slow growth in the numbers of users is presented; ideas are suggested to explain the discrepancy between the number of visitors to online CME sites and the number of credits awarded; and a brief discussion of the use of educational theory in online CME.

Rapid Growth of Online CME

The number of online CME sites is growing rapidly as is the number of offerings at the larger sites. The number of sites found grew from about 18 in late 1997 to 96 in mid-February 1999. Since then about 10 new sites have appeared. Instruction is becoming more sophisticated, with better use of graphics, slides, animation, audio and video. The number of credit hours available has grown to over 3000.

The Growing Gap Between Large Sites and Small Sites

The three largest sites (HealthStream, Medscape and ArcMesa) account for 40-45% of the available hours. The twenty-nine smallest sites account for only 2% of the number of the available credit hours. Since the data presented in Results was gathered and analyzed (early February 2000), the larger sites have been growing even larger. Medscape now (April 9, 2000) lists 453 hours of free and paid CME; ArcMesa now (April 9, 2000) offers 200 hours. HealthStream has recently acquired or formed co-marketing agreements with Silver Platter, Cleveland Clinic, and CMEWeb. A visit to the HealthStream site on April 9, 2000 reveals that HealthStream plans "to have more than 2500 hours of continuing education available on the site by the end of 2000." 

As the customer base of the larger sites enlarges, their instruction has become more attractive to look at and listen to. Many of the smaller sites have let their content stagnate and have done little to attract or retain customers. A significant customer base is required to at least break even on the costs of creating and maintaining an online CME site.

Slower Growth in Numbers of Users

The number of users is somewhat more difficult to quantify. Although a few of the larger, more-efficiently run sites believe that physician usage is growing, the sparseness of responses and the lack of precision of some of the responses make it difficult to estimate growth.  The ACCME reports for 1997 and 1998 indicate that about 0.3% of CME credits were earned online in 1997 and about 1.0% of CME credits were earned online in 1998. Erickson (2000) pointed out a possible small decrease in the percentage of CME credits earned online and the apparent absence of interest in online CME by women physicians. 

The Discrepancy Between Numbers of Visitors and Numbers of Credits Awarded

The growth in the number of credits awarded is not nearly as great as the growth in the number of courses and credits available. Many sites experience a large number of "hits" or page views in contrast to a very small number of CME credits awarded.

There is a series of "gates" affecting the journey from visiting a site to receiving CME credit. A large number of physicians visit sites, take a look around, and if they find nothing of interest or have difficulty navigating the site, they leave. If they stay, the next step at most sites is to register. Registration frightens away some portion of physicians who do not wish to give any information about themselves, especially medical license numbers, social security numbers or credit card information.

If the physician decides to register, or if the site allows further viewing without registering, there are some additional gates to pass. These gates depend on whether the courses are free, "pay-as-you-go," or by annual subscription fee.

If the instruction is free, a smaller number of physicians look at individual courses and then leave. A smaller number start to view one or more courses, decide that it does not meet their needs and leave without completing the course. An even smaller number complete the course and leave without completing the post-instruction quiz or questionnaire. And the smallest number complete all of the preceding steps and apply for the CME certificate.

If the instruction is "pay-as-you-go," the path through the gates is the same as above, except that at the last gate, a physician must submit his or her credit card information online. The fear of revealing this information further reduces the number of physicians receiving credit.

If the site charges a fixed fee for all the credits a physician can earn in a given period (usually one year), the physician has another choice. Should he or she pay in advance for instruction he may not use? Or pay in advance for instruction he may not even look at without paying? Most fixed fee sites allow viewing of a "demo" course to help with this decision, but surprisingly, some do not. 

A further complication is that each site has its own registration and payment procedures that must be mastered in order to participate. An active user of online CME sites can end up with several dozen user names and passwords.

The Use of Educational Theories in Constructing Online CME

A number of theories of distance education, web-based instruction and physician continuing education are discussed in the Review of Literature. However, in examining the instructions found at the sites, there is very little evidence suggesting that the creators of these instructions had these theories in mind while they were constructing their programs. This comment applies especially to those sites which are primarily text-based, text-and-graphics-based, guideline-based, and most of the slide-audio and slide-video presentations. Much of the motivation for creating the Online CME programs appears to stem from the pleasure of experimenting with the new medium and from the hope of disseminating CME to a very large audience.

An educational module intended to teach physicians to recognize, evaluate and refer victims of domestic violence was constructed, but not completed or tested for effectiveness (Sklar, 1999). This module was intended to conform to certain instructional principles: the goals of the instruction are clearly stated; the learning objectives are measurable; cases are presented; the instruction waits for feedback before proceeding; the physician is given an opportunity to practice the skills presented; the program gives feedback on the quality of the user’s performance of those skills, and then allows the user to practice again. 

Although each site was examined to find an expressed or implied educational theory, only one site was found in which the creators clearly were working from theoretical principles. This site is EPIC, (Expert Preceptor Interactive Curriculum) a site that intends to aid physician-preceptors to teach medical students. EPIC’s introductory page has these sections:

Describe collaborative clinical education and the characteristics associated with collaborative clinical teaching.

Develop a plan for orienting the student to the preceptorship site.

Describe how to assess a student's learning needs and level of professional development.

Describe the steps involved in negotiating goals and expectations with students.

      Develop a plan for patient scheduling to accommodate the student in the practice.

The director of Alcohol Problems: Psychosocial Issues, in an answer to a direct question about educational theory, said “I am not sure how to answer your question re: educational theory. It is adult education, and assumes that (the students) already have basic knowledge and experience in the management of alcohol problems.”

At least one site, CME-WebCredits, has an instructional theorist on its team. Although one could speculate that those sites providing interactive instruction subscribe to newer “learner-centered” or at least “patient-centered” theories, none of these sites stated an expressed educational theory.