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Information Seeking in the Digital Age—WhyClosing Knowledge Gaps Is Not Educationand Why the Difference Matters

JOHN M. HARRIS, JR., MD, MBA

In March 2005 the American Medical Association beganallowing physicians to claim Physicians Recognition AwardCategory 1 creditTM for participating in self-directed on-linesearches, categorized as Internet point-of-care ~PoC! learn-ing. In 2006 there were 79 151 physician participants in PoCactivities. This number increased to 103 155 in 2007 and127 571 in 2008.1 On-line companies are rushing to developthis new continuing medical education ~CME! format byoffering Web sites where physicians can quickly earn “ef-fortless” CME credit, “. . . for the online research you arealready doing.” 2,3

PoC learning is supported by recent CME literature thatdiscusses information seeking by physicians. These reportssuggest that closing knowledge gaps is the purpose of CMEand that the process of searching for information via theInternet is an important and evolving CME modality.4–5 Thisreasoning is finding ready acceptance. But is this really apath medical educators should encourage? Will it lead tobetter doctors or will it water down serious efforts to im-prove CME and further marginalize medical educators?

Step outside of CME for a moment and consider the sit-uation where an airplane pilot contacts air traffic control forweather information and uses the information he or she col-lects to adjust the flight plan. The pilot detects an informa-tion gap, gathers knowledge to address the gap, changescourse heading, and improves results. Does this process makea better pilot? Should the pilot be issued a certificate veri-fying that an educational event occurred? Of course not.Pilots check the weather and adapt flight plans because theyare already well-trained. In pilot school they are taught how

to fly a plane and how to seek information to improve re-sults. These are previously acquired piloting skills; theweather reports are simply new facts.

PoC learning exposes several fundamental questions. Whatis the real purpose of education? Is it about improving out-comes, closing knowledge gaps, or improving individualskills? Which of these concepts should drive our definitionof CME?

PoC learning seems to have resulted from a gradual ac-ceptance within the CME establishment that the purpose ofCME is to improve health outcomes and that information-distribution activities associated with better health outcomesare better CME.6 It is a short step from here to conflatingfact acquisition with CME because fact acquisition reallycan improve health outcomes. However, we should not con-fuse the actions doctors take with the skills they have. Wein-garten performed a prospective clinical trial of informationsharing in the coronary care unit with the use of an alternate-month design. He found that giving physicians informationon their patients’ cardiovascular risk, along with relevantclinical guidelines, improved physician decision making, butonly during the months the information was available.7 Thisdemonstrates that information acquisition can improve phy-sician performance, but that the effects may be due to thepresence of the information, not to durable improvements inphysician skills.

Progressive educators, such as John Dewey, spent theircareers teaching that the true purpose of education was skillacquisition, not fact acquisition.8 Eventually, better skillsshould lead to better outcomes, but so can several other ac-tivities that individuals and organizations might take. Areall of these activities CME? Not if the purpose and raisond’être of CME is skill improvement. If a physician does notremember a drug dose or side effect and looks it up on theInternet, thereby achieving a better outcome than he wouldby guessing, this does not make the physician a better doc-tor. In this case, information seeking is the result of previouseducation, which taught and encouraged him to seek out thatwhich he did not know or could not recall. Although thedefinition of a “good” ~or better! doctor is elusive, most

Disclosures: The author reports none.

Dr. Harris: President, Medical Directions, Inc.

Correspondence: John M. Harris, Medical Directions, Inc., 6101 East GrantRd., Tucson, AZ 85712; e-mail: sharris@md-inc.com.

© 2009 The Alliance for Continuing Medical Education, the Society forAcademic Continuing Medical Education, and the Council on CME,Association for Hospital Medical Education. • Published online in WileyInterScience ~www.interscience.wiley.com!. DOI: 10.10020chp.20047

JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS, 29(4):276–277, 2009

agree that the definition relates more to skills and characterthan factual recall.9

By allowing self-directed information seeking to be con-sidered CME, the education community may be giving upon traditional CME. Commenting on the many shortcom-ings of existing CME, experts have noted that perhaps it isindeed time to abandon the medical education0professionaldevelopment model and come up with new ways to improvecare.10

If traditional CME goes away, the “skills” problem willstill exist. Professional skills will get rusty, new skills willbecome relevant, and no one will be very good at assessinghim- or herself.11 Whatever other approaches are taken toimproving care, the remedy for this unpleasant future willstill be education, not self-directed on-line searches. Effec-tive education requires incremental, tailored programs thatimprove knowledge and skills, most often led by experi-enced teachers. Skill improvement necessitates the use ofwell-designed educationally relevant experiences. Lastly, itrequires external assessment. No amount of self-reflectioncan substitute for this.12

A 2009 report from the US Department of Education notedample evidence that on-line education is often more effec-tive than live education, quite possibly because students spendmore time on task. It also noted that on-line education blendedwith live education may be more effective still.13 This doesnot justify Internet information-seeking as CME. Instead itshould provide encouragement to develop more rigorous on-line CME programs, ones that physicians will use and onesthat will improve skills. For this to happen we not only need

a better understanding of what works and what does not, weneed clarity in the purposes of CME. This may require somegentle reminders from educators that knowledge acquisitionis part of education, but not all of it.

References

1. Data from ACCME Annual Reports. http:00www.accme.org. AccessedJuly 20, 2009.

2. Earn “Effortless CME0CE”. http:00www.uptodate.com0home0clinicians0cme.html. Accessed August 10, 2009.

3. Imagine earning AMA PRA Category 1 Credit™ or AAFP Prescribedcredit for the online research you’re already doing. http:00www.eeds.com0index.asp. Accessed August 10, 2009.

4. Schoen MJ, Tipton EF, Houston TK, et al. Characteristics that predictphysician participation in a Web-based CME activity: the MI Plus study.J Contin Educ Health Prof. 2009;29~4!:246–253.

5. Bennett NL, Casebeer LL, Kristofco RE, Strasser SM. Physicians’ In-ternet information-seeking behaviors. J Contin Educ Health Prof.2004;24~1!:31–38.

6. Bennett NL, Casebeer LL, Zheng S, Kristofco R. Information-seekingbehaviors and reflective practice. J Contin Educ Health Prof.2006;26~2!:120–127.

7. Davis D, O’Brien MA, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A. Impact of formal continuing medical education: do confer-ences, workshops, rounds, and other traditional continuing educationactivities change physician behavior or health care outcomes? JAMA.1999;282~9!:867–874.

8. Weingarten SR, Riedinger MS, Conner L, Lee TH, Hoffman I, JohnsonB, Ellrodt AG. Practice guidelines and reminders to reduce duration ofhospital stay for patients with chest pain. An interventional trial. AnnIntern Med. 1994;120~4!:257–263.

9. Dewey J. Experience and Education. New York, NY: Touchstone; 1997.10. Hurwitz B. What’s a good doctor, and how can you make one? By

marrying the applied scientist to the medical humanist. Br Med J.2002;325~7366!:667–668.

11. Davis D, Evans M, Jadad A, et al. The case for knowledge translation:shortening the journey from evidence to effect. Br Med J. 2003;327~7405!:33–35.

12. Davis DA, Mazmanian PE, Fordis M, Van Harrison R, Thorpe KE,Perrier L. Accuracy of physician self-assessment compared with ob-served measures of competence: a systematic review. JAMA. 2006;296~9!:1094–1102.

13. Eva KW, Regehr G. “I’ll never play professional football” and otherfallacies of self-assessment. J Contin Educ Health Prof. 2008;28~1!:14–19.

14. US Department of Education, Office of Planning, Evaluation,and Policy Development. Evaluation of Evidence-Based Practicesin Online Learning: A Meta-Analysis and Review of Online Learn-ing Studies. Washington, DC, 2009. http:00www.ed.gov0rschstat0eval0tech0evidence-based-practices0finalreport.pdf. Accessed July 21,2009.

Lessons for Practice

• Information seeking may improve patientoutcomes, but neither information seekingnor outcome improvement means that ed-ucation has occurred.

• The real goal for CME must be assessingand improving physician skills, not closingknowledge gaps.

Information Seeking in the Digital Age

JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS—29(4), 2009 277DOI: 10.1002/chp