Translating knowledge about emerging science in clinically relevant fields is important. However, continuing medical education (CME) is costly and challenging to provide; the academic medicine community needs effective, novel methods to reach busy clinicians, trainees, and rural practitioners.1,2 Online education is attractive because it is efficient, convenient, and as effective as in-person or print training in improving learners’ knowledge, confidence, and skills.3–10
Our previous research comparing different strategies of delivering an online continuing education course suggested that all four strategies (offering courses via e-mail versus through a Web site and offering course content in small amounts over time versus presenting all course content at once) significantly improved clinicians’ knowledge, confidence, and communication practices during an average of six months of follow-up compared with more traditional CME strategies.11,12 Although we had a large enrollment (>1,000 participants), we wondered whether different marketing strategies would influence enrollment in future online courses. Because outcomes were similar for all delivery strategies, we decided that for future courses, we would offer courses only online (not by e-mail) and would allow clinicians to complete courses at their own pace rather than in a prescribed amount of time (as long as participants completed the course work within the time frame of the CME accreditation; i.e., two years from initial posting).
Presumably, busy clinicians want to spend time gaining skills that actually affect their practice (behavior); thus, marketing geared toward behavior change might be attractive. On the other hand, for unfamiliar topics, clinicians may be more comfortable with introductory, knowledge-oriented courses than with those that demand a higher skill set (such as talking with patients). Therefore, we compared the enrollment for two different titles—one knowledge-oriented and one behavior-oriented—for each of seven online classes on the topic of herbs and dietary supplements (HDS).
Through the Northwest North Carolina Area Health Education Center (NW NC AHEC) Internet site (http://northwestahec.wfubmc.edu), we offered 14 online classes about HDS between October 1, 2005, and September 30, 2007. Clinicians of any health profession, including dentists, dieticians, nurses, nurse practitioners, pharmacists, physicians, physician assistants, as well as trainees, could enroll.
The 14 classes included seven topics, marketed under two different titles. The seven topics included two general topics, Introduction to HDS and Safety of HDS, and five specialty topics, HDS for women, HDS for children, HDS for the elderly, HDS for depression, and HDS for gastrointestinal (GI) problems. The two titles were “Introduction to topic” (knowledge-focused) and “Talking with patients about topic” (behavior-focused). The main content presented under the two titles was otherwise identical.
We primarily marketed the classes by posting their availability on the NW NC AHEC Internet site along with other online courses. Practicing clinicians in North Carolina are very familiar with this site. In addition, one of us (K.K.) sent approximately 400 personal e-mails to colleagues, pediatric residents, and medical students at Wake Forest University (WFU) School of Medicine (SOM), to steering committee members of the Consortium of Academic Health Centers for Integrative Medicine, and to subscribers of a listserv for the provisional Section for Complementary, Holistic and Integrative Medicine of the American Academy of Pediatrics. These e-mails included general information about the classes (such as fees and topics) but not extensive information about class objectives or content. Those who responded to the e-mail accessed the Web site directly, so we do not know the response rates to these e-mails.
The online listing of the classes was not in order by title or topic. For example, the first class listed was “Talking with your female patients about herbs and dietary supplements”; the second was “Herbs and supplements for today’s woman”; the third was “From infant to teen: An introduction to pediatric herbs and dietary supplements”; the fourth was “From infant to teen: Talking with your pediatric patients’ parents about herbs and dietary supplements”; and the fifth was “Talking with your patients about safety issues with herbs and dietary supplements.” The class titled “An introduction to the basics of herbs and dietary supplements” was listed 10th among the 14 classes.
The Web page listed the four overall course goals and objectives for all 14 classes: (1) to demonstrate improved knowledge of the clinical indications and potential risks of the most commonly used HDS, (2) to report increased confidence in discussing HDS with patients and colleagues, (3) to report more consistent communication about HDS with patients, families, and other health care professionals, and (4) to improve self-reported documentation on the medical record. By clicking on each class title, participants could access the objectives for that class, which used the same basic objectives, but referred to the specific topic, such as HDS for children or HDS for women.
The NC NW AHEC marketed the course by posting it on its Web site, which is geared primarily toward practicing clinicians in the 17 counties of northwestern North Carolina. Because our earlier study showed higher completion rates for enrollees who were required to pay fees,12 NC NW AHEC charged an overall course registration fee ($35 for out-of-state clinicians, $20 for out-of-state students, $25 for in-state clinicians, and $15 for in-state students). We waived all fees for trainees at our institution. Fees were identical for all classes regardless of their title or topic.
We allowed clinicians and students to enroll in as many classes as they wished in any order without additional charges. Enrollees could complete all classes at their own pace, as long as they completed all their work by course closure on September 30, 2007. Initial registration information included gender and profession, but this information was not linked to individual class enrollment. We provided continuing education credit to those who achieved 70% or higher on the posttest for each class.
We used chi-square methods to compare categorical variables. We used the SPSS 16.0 (SPSS Inc., Chicago, Illinois) statistical software. The WFU SOM institutional review board deemed our study “exempt” as an educational research project.
Of the 195 clinicians who enrolled, most (125; 64%) were women, and most (111; 57%) were from North Carolina. Enrollees included a variety of clinicians: 65 physicians or physician assistants (33%), 38 nurses and nurse practitioners (19%), 18 pharmacists (9%), 16 dietitians (8%), and 26 students/trainees (13%). Other health professionals included five licensed counselors, five radiology assistants or technicians, one hospital chaplain, and other professionals in allied and public health (such as librarians, administrators, and athletic trainers).
The 195 clinicians who registered enrolled in a total of 1,487 total classes, which is 7.6 classes per enrollee (Table 1). Overall, 866 participants enrolled in the seven knowledge-titled classes and 621 enrollees in the seven behavior-titled classes (P = .018). The average enrollment was significantly higher for the two general (introduction and safety) classes than for the five specialty (women, children, the elderly, depression, and GI) classes, with 266 and 191 students enrolled, respectively (P < .01) (Table 1).
Scores were similar for confidence and communication practices for both knowledge-oriented and behavior-oriented titles for all seven classes (Table 2).
In this study, knowledge-oriented marketing (via course title) led to significantly higher enrollment than behavior (talking with parents)-oriented marketing. Furthermore, compared with specialty topics, general introductory topics garnered significantly higher enrollment. These findings support the social marketing theory that clinicians are more likely to enroll in introductory, knowledge-oriented classes for topics with which they are unfamiliar. Medical training has historically been based on fact-driven objectives that direct content; however, in today’s medical environment, efficiency has become more of a priority for learners who demand that developers of medical education techniques create ways to present new information in ways that appeal to their desire for both efficiency and achieving targeted goals easily. Marketing to today’s physicians with goal-driven titles—those that appeal to the need to increase one’s medical knowledge base in a novel, but important, area—is a strategy consistent with this theory.10 For unfamiliar topics, clinicians want basic knowledge before considering applying that knowledge to new behaviors such as talking with patients or recording information in the medical record.13 On the other hand, for material that is already quite familiar, marketing might be directed toward practical benefits such as improved scores on recertification exams (board exam courses), improved quality of care, or improved reimbursement (coding classes).14–16
This study has several strengths as well as some limitations. First, a wide variety of clinicians enrolled, which strengthens generalizability. Second, the fact that enrollment was significantly higher for both knowledge (versus behavior) and general (versus specialty) topics makes the findings more robust and further confirms social learning theory. A third strength is that our study reports experiences in a real-world setting, which means that the results are not hampered by the self-selection encountered in research settings. Finally, the wide variety of clinicians from across North Carolina and elsewhere who enrolled in the course is also a strength.
However, it is possible that marketing nationally (rather than focusing on a portion of North Carolina) would result in different outcomes. Another limitation is the lack of data at the individual class level about enrollee gender, age, or specialty; future studies would benefit from both obtaining demographic data for each course and collecting data on the order in which participants enroll and complete multiple courses. Also, as noted above, clinician–enrollees in review-type classes on more familiar topics may respond differently than clinicians enrolled in classes on novel topics. Future marketing research focused on CME should test this hypothesis.
Further, the classes in our study were all electives, and we cannot speculate on the implications of marketing differences for required courses, for which marketing may be a moot point. Another limitation is the lack of pre- and postcourse comparisons of knowledge, attitudes, and behavior; however, this study focused on enrollment differences rather than instructional outcomes. (Future research focusing on instructional outcomes should include both pre and post data as well as control groups.)
Titles oriented toward general topics and introductory knowledge are significantly more effective than titles geared toward specialty topics and applied knowledge (behavior) for online classes on an unfamiliar topic such as HDS. Additional research is warranted to elucidate the most effective marketing strategies to improve enrollment in online courses on more familiar topics. Given the enormous national expense involved in professional health education and the need to transmit knowledge in rapidly expanding fields, such research is urgently needed.
The authors thank Jessica Gobble, Chris Jones, and Dr. Michael Lischke at North Carolina Northwest Area Health Education Center for their invaluable assistance.
1 Whitcomb ME. CME reform: An imperative for improving the quality of medical care. Acad Med. 2002;77:943–944.
2 Glazebrook RM, Harrison SL. Obstacles and solutions to maintenance of advanced procedural skills for rural and remote medical practitioners in Australia. Rural Remote Health. 2006;6:502.
3 Bennett NL, Casebeer LL, Kristofco RE, Strasser SM. Physicians’ Internet information-seeking behaviors. J Contin Educ Health Prof. 2004;24:31–38.
4 Cook A, Salle JL, Reid J, et al. Prospective evaluation of remote, interactive videoconferencing to enhance urology resident education: The genitourinary teleteaching initiative. J Urol. 2005;174:1958–1960.
5 Davis D, O’Brien MA, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A. Impact of formal continuing medical education: Do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? JAMA. 1999;282:867–874.
6 Fordis M, King JE, Ballantyne CM, et al. Comparison of the instructional efficacy of Internet-based CME with live interactive CME workshops: A randomized controlled trial. JAMA. 2005;294:1043–1051.
7 Maki RH, Maki WS, Patterson M, Whittaker PD. Evaluation of a Web-based introductory psychology course: I. Learning and satisfaction in on-line versus lecture courses. Behav Res Methods Instrum Comput. 2000;32:230–239.
8 Rees CE, Sheard CE, McPherson AC. A qualitative study to explore undergraduate medical students’ attitudes towards communication skills learning. Med Teach. 2002;24:289–293.
9 Wutoh R, Boren SA, Balas EA. eLearning: A review of Internet-based continuing medical education. J Contin Educ Health Prof. 2004;24:20–30.
10 Cauffman JG, Forsyth RA, Clark VA, et al. Randomized controlled trials of continuing medical education: What makes them most effective? J Contin Educ Health Prof. 2002;22:214–221.
11 Beal T, Kemper KJ, Gardiner P, Woods C. Long-term impact of four different strategies for delivering an on-line curriculum about herbs and dietary supplements. BMC Med Educ. 2006;6:39.
12 Kemper KJ, Gardiner P, Gobble J, Mitra A, Woods C. Randomized controlled trial comparing four strategies for delivering e-curriculum to health care professionals [ISRCTN88148532]. BMC Med Educ. 2006;6:2.
13 Nugent J, Ruperto N, Grainger J, et al. The British version of the Childhood Health Assessment Questionnaire (CHAQ) and the Child Health Questionnaire (CHQ). Clin Exp Rheumatol. 2001;19(4 suppl 23):S163–S167.
14 Casebeer LL, Strasser SM, Spettell CM, et al. Designing tailored Web-based instruction to improve practicing physicians’ preventive practices. J Med Internet Res. 2003;5:e20.
15 Sinkov VA, Andres BM, Wheeless CR, Frassica FJ. Internet-based learning. Clin Orthop Relat Res. April 2004:99–106.
16 Pearson J, Mensing C, Anderson R. Medicare reimbursement and diabetes self-management training: National survey results. Diabetes Educ. 2004;30:914, 916, 918 passim.