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(Chest. 1999;115:1429-1436.)
© 1999 American College of Chest Physicians

Realizing the Promise*

Delivering Pulmonary Continuing Medical Education Over the Internet

Michael W. Peterson, MD, FCCP; Jeffery R. Galvin, MD; Charles Dayton, BS, RPh and Michael P. D'Alessandro, MD

* From the Departments of Internal Medicine (Drs. Peterson and Galvin), Pharmaceutical Care (Mr. Dayton), and Radiology (Drs. Galvin and D'Alessandro), College of Medicine, University of Iowa, Iowa City, IA.

Correspondence to: Michael W. Peterson, MD, FCCP, C33H GH, University of Iowa, Iowa City, IA 52242


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Study objectives: Continuing medical education (CME) is meant to bridge the gap between new scientific observations and clinical practice. However, traditional CME has not been effective at altering the behaviors of physicians. One reason for this failure of traditional CME programs may be their inflexibility. In traditional CME, the clinician does not choose the topic, the pace of the program, or the place of learning, and the CME material cannot be easily delivered to the point of care where the clinician needs the information. Computers and computer networks have the potential to accomplish these goals. CME has begun to appear on the Internet; however, there have been few evaluations of its usefulness, acceptance, and effectiveness. Over the last 18 months, we have developed three on-line pulmonary CME programs, and we have delivered them on the Virtual Hospital, the University of Iowa's digital health sciences library on the Internet. We report our initial experience with this CME material.

Design: We measured the frequency with which the Internet-delivered CME is accessed by monitoring page accessions and by using a log file analysis program (Analog 1.2.3; University of Cambridge Statistical Laboratory; Cambridge, UK). In addition, we collected all completed CME examinations and evaluation forms submitted by registered users.

Measurements and results: We have found that the frequency with which the Internet-delivered CME is accessed has continued to increase with time (2.3-fold increase over 18 months), that evaluations of technical and content issues are strongly favorable, and that some clinicians have been willing to pay to receive CME through the medium of the Internet.

Conclusions: We feel that with adequate peer review and quality control, physicians will use the Internet-delivered CME. However, several obstacles to wide use remain. These obstacles include issues regarding training in using the Internet for physicians, reluctance of physicians to participate in on-line commerce, and the current unavailability of CME to be delivered in small-grained quantities to the point of care. As these issues are addressed, we feel that on-line CME will represent an increasingly important CME medium for clinicians.

Key Words: computer • continuing education • internet


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Today, United States physicians routinely involve themselves in continuing medical education (CME); however, CME has a unique and interesting history. The history of CME can be traced to the city of Venice in 1300 where specialty certification for initial medical licensure was required in order to maintain a minimum standard of professional competence. Licensed practitioners also attended a yearly refresher course in anatomy consisting of lectures and dissections in order to renew their licenses.1 Unfortunately, the trade in counterfeit certificates of licensure was brisk, and the system was abandoned in 1800.

The Association of American Medical Colleges first suggested mandatory CME in a 1932 study of medical education. However, mandatory CME was not formally proposed until the 1940s. Political battles soon erupted between general practitioners and specialists over who should have admitting privileges to hospitals. As a result, in 1947, the American Academy of General Practice first required 150 h of CME every 3 years as a condition for membership.2 In the early 1960's, The American Medical Association (AMA) and the Association of American Medical Colleges stated that a "knowledge gap" existed between the findings being generated by research funded by the National Institutes of Health and its application by practitioners. With part of its intention to bridge this gap, the AMA established the Physician's Recognition Award in 1969 to be awarded to physicians who completed 150 h of CME over 3 years. The legislative focus then switched to the states, with New Mexico being the first state to pass a bill authorizing its Board of Medical Examiners to require CME for license renewal in 1971.2 Today, 31 states require CME performance each year for medical license renewal.

Required CME was proposed, in part, to improve physicians' applications of new scientific discoveries to clinical care. Traditional CME was based on a dogmatic approach in which an instructor defines the curriculum and transmits the information to the student in a didactic manner using textbooks, journals, meetings, symposia, audiotapes, and videotapes. There is little proof, however, that traditional CME is effective when used alone. In fact, studies over the past 20 years have consistently demonstrated that educational interventions fail when physicians passively receive information on a one-time basis.3 4 Consistent with these findings, studies have also shown that practice guidelines, when taught without patient contact, are also ineffective.5 However, when traditional didactic CME is integrated into a clinical setting, the results are encouraging.6 7 Feedback and reminders are also more effective when traditional didactic materials are incorporated into a multifaceted program.3 4 8 In summary, our findings, which are consistent with the adult learning theory, demonstrate that there is a direct relationship between the "students'" level of active involvement in the educational intervention and the likelihood of changing behavior.

As a result of our evolving understanding of adult learning, the focus of CME is shifting from national to local sites where care is delivered.9 This trend fits with the emerging concept of "situated cognition" in which "authentic activity" is considered a cornerstone in acquiring knowledge.10 In other words, physicians will learn more effectively when they see the material as relevant to their professional activity and when it is learned where and when they need it. The combination of this concept of apprenticeship with point-of-care CME allows physicians to focus on self-direction and problem solving during the learning process.10 11 This approach is supported by Manning and Debakey12 who stated, "We believe that greater progress will ensue from improved methods of linking keenly focused CME objectives to actual events in individual office and hospital practice."

Over the last 10 years, computers and computer networks have grown at an astounding rate. Computer-based electronic education delivered over networks has the potential to deliver information that is linked to patient care issues in a timely and interactive fashion. Computer-based education has been shown to be at least as effective in promoting short-term and long-term learning as traditional classroom instruction that includes lectures, self-teaching booklets, lecture discussions, and videos.13 14 15

Although CME materials are beginning to appear on the Internet, there has been limited evaluation of the usefulness, acceptance, and interest among physicians for this mode of education. Beginning in August 1996, we began delivering CME over the Internet by means of the Virtual Hospital (http://www.vh.org). The purpose of this study is to evaluate our initial experience in developing and delivering CME over the Internet.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Content Development
Content Creation and Review: The Virtual Hospital is a digital health sciences library created in 1992 through a partnership involving content providers, content reviewers, content translation to digital format, a digital library, and users around the world.

Most of the content on the Virtual Hospital is created especially for the Virtual Hospital by University of Iowa faculty, but some of the material is contributed by faculty from other institutions. In each case, the faculty holds the copyright to its material. For CME materials, content is reviewed at two levels. In the first review, the content is reviewed for accuracy by a peer review board established by appropriate departments in the University of Iowa College of Medicine (http://www.vh.org/Providers/TeachingFiles/PulmonaryCoreCurric/Editorial Board.html). All CME content is anonymously reviewed by at least two experts in the area. Once published, the material is identified as "internally peer reviewed" if both reviewers are from the University of Iowa faculty, or it is identified as "externally reviewed" if at least one of the reviewers is from another institution. A member of the peer review board functions as an editor to communicate reviewers' comments to the author and to review changes to the material prior to publication. Each of the modules evaluated in this study were improved in some way after internal or external review.

The second review is conducted for CME accreditation. The Accreditation Council for Continuing Medical Education (ACCME) is the ultimate authority in the United States for approving educational content for CME. It delegates this authority by accrediting medical educational institutions and medical professional organizations, which must ensure that their educational content fulfills the ACCME guidelines before they are approved for CME. Computer-based educational materials are classified as "enduring materials" by the ACCME. Enduring materials include essentially all CME instructional activities except live lectures attended in person. To be considered as AMA category 1 CME, enduring materials must meet the following criteria: they must (1) be based on identified educational needs; (2) have clearly stated educational objectives; (3) employ an appropriate instructional medium to convey the educational information; (4) have built-in user evaluation of educational objectives, content, and user satisfaction; and (5) include the date of content creation, most recent content review, and next content review. The University of Iowa College of Medicine is accredited by the ACCME to offer CME, and this responsibility is administered through the Office of Continuing Medical Education.

Before being published, the CME content is reviewed first by the department peer review board in consultation with content experts and is then reviewed by the Office of Continuing Medical Education to ensure that it fulfills ACCME criteria for AMA category 1 accreditation for enduring medical materials.

Content Translation to Digital Format: The Electric Differential Multimedia Laboratory in the Department of Radiology in the University of Iowa College of Medicine serves the Virtual Hospital by digitizing, organizing, and distributing all content for the digital library. Content is digitized and converted rapidly to a CME module by using a technique developed 3 years ago.16 By analyzing remote connections, we have found that 77% of the Virtual Hospital's users access the Virtual Hospital by means of slow-speed modem connections. In addition, the number of Web users who prefer simple designs with few technical innovations is increasing.17 Therefore, the goals of the Virtual Hospital's information design are: (1) to make navigation intuitive by consistently branding the site and explaining how to navigate through it; (2) to make it easy to view the information in standard Web browsers by storing information in industry standard file formats (ie, HTML for text, and the graphics interchange format and joint photographic experts group for images) ; and (3) to make it quick and responsive to the user by making each page small and limiting the use of graphics on the site. The dominant medium used in these CME modules is text annotated with appropriate images and video because text is an efficient and effective means for delivering information.18

Upon completing a CME module, the users' knowledge must be tested to see if they have learned from the activity. This is accomplished by using on-line tests created by the content author and by using a software program that uses common gateway interface (CGI) script (TestMaker; Interactive Educational Software; Spring, TX). The CGI script is an Internet standard protocol for adding interactive features to a World Wide Web server.

Digital Library: The architecture for the Virtual Hospital digital library is as follows. The CME modules are stored as HTML documents. The repository for these HTML documents is the World Wide Web, an Internet standard protocol for organizing hypermedia databases.19 The Virtual Hospital resides on an IBM server (RS-6000; IBM; Armonk, NY) running the World Wide Web server software (Netscape Enterprise Server; Netscape; Mountain View, CA). The Virtual Hospital is indexed and made searchable by the Glimpse search engine (University of Arizona; Tucson, AZ), an Internet standard protocol for indexing and free text searching of textual information.20 The Virtual Hospital is completely interoperable with other World Wide Web sites through means of the http. The Internet communications standard protocol, the transmission control protocol/Internet protocol, transmits the CME modules across the Internet to workstations equipped with a World Wide Web browser.

World Wide Users: The Internet provides universal access to the Virtual Hospital digital library to users around the globe. Users study a CME module on the Virtual Hospital by choosing the CME module they wish to study and then reading it. After they are finished reading, users take the test that was created by the TestMaker CGI to evaluate what they have learned. Before starting the test, they register by filling out an on-line form, which appears at the beginning of the first test page, and submitting it to the Virtual Hospital. The TestMaker CGI script automatically grades their tests and informs them whether they have passed or failed. The results of the test are shipped electronically to the section editor. If users answer >= 70% of the questions on the test correctly, they have passed, and they receive 1 h of AMA category 1 CME credit at a cost of $15/h of CME. Before receiving the CME credit, users must fill out an on-line form that evaluates the educational content of the CME module.

Evaluation
Overall Use of CME Modules: To assess the overall frequency with which CME modules were accessed from August 1, 1996, to January 31, 1998, World Wide Web server log file analysis was performed by using a log file analysis program (Analog 1.2.3; University of Cambridge Statistical Laboratory; Cambridge, UK). By identifying the Internet protocol (IP) address for remote computers accessing the CME modules, each unique remote computer was identified. This allowed us to determine the number of users accessing the CME modules. Because multiple users may use the same computer, and not all Internet service providers assign unique IP numbers to their users (eg, AOL), this method will potentially underestimate the number of users.

Electronic Survey Instrument: In addition to collecting user statistics, we collected all completed tests and evaluation forms submitted by registered users between August 1, 1996, and January 31, 1998. We limited our evaluation to registered users because it was the best way to be sure that we were collecting evaluations from healthcare professionals.

Paper-Based Survey Instrument: To learn more from physicians who were not using the on-line CME, we surveyed two groups of physicians attending traditional CME programs. In both surveys, physicians were asked how they received their CME over the previous year and what factors were important to them in their choice of CME activities. In the second survey, we also asked physicians about their computer skills, their accessibility to computers, and their perceived barriers to using the Internet for CME.


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
Between August 1996 and August 1997, we introduced a total of 21 CME modules in the areas of radiology and pulmonary medicine: 3 in the Radiology for the Chest Physician course (http://www.vh.org/Providers/Simulations/ATS/ATS.html), 15 in the Adult Pulmonary Core Curriculum course (http://www.vh.org/Providers/TeachingFiles/PulmonaryCoreCurric/PulmCoreCurric.html), and 3 in the Adult Critical Care Core Curriculum course (http://www.vh.org/Providers/TeachingFiles/AdultCriticalCare/CriticalCare.html). Each CME module offers 30 or 60 min of AMA category 1 CME credit.

First, we wanted to determine whether these educational modules would be accessed. Over the 18-month period from August 1, 1996, to January 31, 1998, 81,546 pages were accessed from the Radiology for Chest Physicians course by 11,058 individual users (identified by unique IP addresses). The frequency with which this course was accessed has increased gradually over that time from 1,964 pages in August 1996 to 5,499 pages in January 1998 (Fig 1 ) .



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  		Figure 1. The American Thoracic Society (ATS) Radiology for Chest Physicians course was initially made available on-line in August 1996. The frequency with which this course is accessed increased over the first 12 months and has remained stable at approximately 6,000 pages/mo.

 
Over the 10-month period from April 1, 1997, to January 31, 1998, 20,120 individual users accessed 122,479 pages from the Adult Pulmonary Core Curriculum course. Again, the frequency with which this course was accessed gradually increased from 8,428 pages in April 1997 to 17,147 pages in January 1998 (Fig 2 ).



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  		Figure 2. The Pulmonary Core Curriculum course, a collection of modules that are based on pulmonary care cases, was initially made available on-line in April 1997. Except for a brief decrease during the early summer months, the frequency with which this course is accessed has been steadily increasing, with 17,147 pages accessed in January 1998.

 
Similarly, over the 8-month period from June 1, 1997, to January 31, 1998, 40,260 pages of information were accessed from the Adult Critical Care Core Curriculum course by 6,407 individual users (Fig 3 ). As shown in Figures 1 2 3 , the overall frequency with which the courses are being accessed is doubling every 6 months, with 12,143 pages of information accessed from all 21 modules in June 1997 and 28,715 pages accessed from the same 21 modules in December 1997. The majority of those who use the CME modules come from the United States; however, 18% of the users are from countries outside the United States.



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  		Figure 3. The Adult Critical Care Core Curriculum course, a collection of modules that are based on adult critical care cases, was initially made available for CME in June 1997. Since that time, the frequency with which this course is accessed has been steadily increasing, with 7,816 pages accessed in January 1998.

 
We next determined the number of users who registered and submitted examinations with a score of >= 70%. Between August 1996 and January 1998, registered users submitted 169 completed CME examinations. Of the users who submitted these examinations, 15 paid CME fees and received 52 h of AMA category 1 CME credit. The physicians who successfully completed the remaining 117 modules elected not to pay for formal CME credit.

During this same time, we collected 54 evaluation forms electronically submitted by the users of the 169 completed modules. This resulted in a sampling of 32% of the used modules. Because we collected the evaluations anonymously, we do not know how many individual users this represents. However, because we limited the evaluations to registered users, we are assured that we collected information from physicians. The evaluation forms for each of the modules contained three questions focusing on the technology (Table 1 ), one question addressing the overall impression the user had of the module at enhancing professional performance, and three questions specifically addressing the content of the module. The responses for questions 1 through 4 were combined among the modules for analysis. As shown in Figure 4 , users rated the format and quality of material highly, and they felt that the on-line CME was relatively easy to use and enhanced their professional activity. Although the questions on specific educational goals and objectives differed among the varied modules, the answers were quite consistent in the evaluation forms. For that reason, we combined them for an overall score on specific content. Again, as shown in Figure 4 , users generally found the content to be of high quality.


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  		Table 1. Evaluation Questions*

 


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  		Figure 4. Each CME module has an on-line evaluation form available for users. The questions in the evaluation form are described in Table 1 . The responses are scored from 1 (strongly agree) to 5 (strongly disagree). Since introducing the on-line CME modules, we have collected 54 evaluation forms. The mean scores, which rated each module on how easy it was to use, the quality of its technical characteristics, and the quality of its content, were very high, ranging from 1.5 to 2.0 (bars represent mean ± SEM)

 
These data suggest that physicians who use our on-line CME find it easy to access, useful, and of high quality; however, very few physicians paid to receive CME credit through the Virtual Hospital. To begin to understand why so few physicians use on-line CME, we have completed two local surveys of physicians attending traditional CME programs. In the first survey, we questioned 80 physicians attending the 1997 Iowa Medical Society Spring Meeting. Most physicians attending this meeting are family physicians. All of the physicians had obtained CME from a lecture during the preceding year, 5% had obtained CME from the Internet, 10% had obtained CME from CD-ROMs, and 48% had obtained CME from self-study materials, including monographs, audiotapes, and videotapes. Eighty percent of the physicians stated that they would participate in a CME program delivered to the point of care and tied directly to their clinical practice.

We next surveyed 44 physicians attending the Progress in Internal Medicine CME program at the University of Iowa in October 1997. This group differed from the first group because they were primarily internal medicine physicians, and they had an established relationship with the University of Iowa's CME. In addition to surveying them about their CME activities, we also surveyed this group about computer expertise and access. Similar to the first group of physicians, these physicians estimated that they earned 35% of their CME through lectures, 48% from conferences away from home, 6% from audiotapes, 17% from videotapes, 7% from self-study monographs, but only 1.5% from CD-ROMs and < 1% from the Internet in the 3 years preceding the conference. Only 57% of these physicians currently had Internet access (of these physicians, 80% had access at home, 36% had access at clinics, and 28% had access at hospitals); however, 55% of those currently without Internet access anticipate getting Internet access within 12 months. After demonstrating Internet-delivered CME to the physicians, 88% stated that they would use Internet-delivered CME and would be willing to pay from $5 to $15/h for the CME. When asked what they perceived as the greatest obstacle to their using the Internet for CME, 58% expressed that they had inadequate skills for using the Internet, 10% perceived that they had technical limitations in their ability to connect to the internet, and 18% said they had inadequate time to learn how to use the Internet. Only 10% expressed concern about the quality of the medical content on the Internet.


   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
The information needs of primary care physicians and of other health care practitioners are well-documented. In one study, > 50% of patient visits in a nonacademic primary care setting generated a patient care question; however, only 30% of these questions were pursued, and 24% were answered.21 Similarly, a study of general internists found that seeing patients in an office setting generated 12 patient management questions/day. Again, these physicians sought answers to only about 33% of these questions.22 Studies in both the primary care setting and the academic medicine setting consistently find that physicians have a need for information on a daily basis.23 24 25

When deciding where to seek an answer, physicians primarily consider the easiest way to acquire information and, once the resource is accessed, they choose the easiest search mechanism.24 Hence, most physicians choose to ask a colleague.23 25 Thus, the easy availability of information is more important than the credibility of the source.26 Clearly, this response is suboptimal, and new information sources and techniques need to be developed. Many current on-line sources fall short. Although MEDLINE is important in improving patient care27 28 and reducing the length of stay and costs in hospitalized patients,29 it has limited use as a point-of-care system in the outpatient setting. The average search by an experienced user takes about 27 min, yields only abstracts25 , and retrieves only a portion of the relevant information.30 As a result, there remains a persistent barrier between scientific observations and the daily practice of clinical medicine.

Current systems for CME do not successfully bridge this gap between scientific findings and clinical guidelines and clinical practice. A recent study in the Journal of the American Medical Association reported that only 21% of patients received ß-blockers after having myocardial infarctions despite clear evidence in the literature that treatment with ß-blockers after myocardial infarction is effective at reducing mortality. Even cardiologists used ß-blockers in only 48% of eligible elderly patients.31 A similar problem exists with the diagnostic algorithm for pulmonary embolus.32 33 Despite well-developed guidelines, the majority of patients who are considered for the diagnosis of pulmonary embolus are inadequately assessed. Finally, traditional CME has not been effective in improving the treatment of asthma, another common and costly disease. Despite having the National Asthma Guidelines published and presented in a plenary session at their national meeting, only 16% of occupational health nurses were aware of the standards, and only 14.7% based their treatment on the standards 1 year later.34 Similarly, in a survey of emergency room physicians, it was shown that the care of these physicians conformed to the published standards only 38 to 75% of the time.35

Clearly, traditional CME is not affecting the behavior of physicians. Computer-based CME delivered over the Internet provides several theoretical advantages over traditional CME. First, computer-based CME allows the user to select the content, pace, and place of learning. Second, it allows physicians to obtain CME from regional, national, and international experts without needing to travel. Third, it allows CME to be easily delivered to the site of clinical activity. Our data show that the future for computer-based CME is promising. Over the 18-month time period since we introduced our CME materials, > 250,000 pages of information have been accessed by 37,585 users. Our own survey results suggest that the "market" for on-line CME may be even greater, with > 80% of physicians surveyed interested in on-line CME. These results also agree with two recent national surveys. In an on-line survey of 317 health care providers conducted on the Internet, 84% of the respondents indicated an interest in obtaining an average of 15 CME credit hours/year.36 In a separate mail-based survey of physician CME activity, only 3% of physicians received CME credit from computer-based resources (Internet and CD-ROMs) in 1996; however, 15% had received CME credit from computer-based resources in 1997.37

Despite these encouraging numbers, the majority of physicians are not using computer-based resources for CME, and in our own experience, only a small percentage of users who access the CME pages register and take the exam. An even smaller percentage actually pay a fee to receive formal CME accreditation. Future growth in on-line CME depends on expanding these numbers. Our own survey suggests that one obstacle may be that the majority of practicing physicians do not know how to use the Internet and do not see themselves as having the time to learn. We are actively involved in training physicians to use the Internet for professional information, and hopefully, professional organizations will assume some role in providing this CME activity for practicing physicians. Clearly, most medical students are graduating from medical school with solid computer skills. While generations of physicians differ in their computer experience, age does not explain the reluctance of physicians to use computers for CME. When physicians who have practiced < 20 years were compared with physicians who have practiced > 20 years, there is no difference in their comfort level with computers or their use of the Virtual Hospital to access medical information, and older physicians expressed more interest in using the Internet than did younger physicians.38 Another obstacle appears to be the reluctance of physicians to conduct electronic commerce over the Internet because they believe that on-line transactions lack security.39 This barrier to electronic commerce is slowly being removed with the widespread introduction of secure electronic commerce systems on the Internet. Finally, it is likely that even as computer-based resources are developing, some portion of CME will continue to be delivered "in person" and in pleasant surroundings.

Another important obstacle may be that we have not yet designed and implemented CME that can be easily incorporated into the workflow of a busy clinician. Previous studies have demonstrated that busy clinicians tend to choose answers that are easily accessible even if they don't necessarily come from quality resources. Therefore, we think it is important that we use the full power of computers to make delivery easier. We define the point-of-care CME that is delivered in small "packets" of personalized information as "granular" CME. Such granular CME may consist of as little as one page of information and one question. Physicians would be awarded CME credits according to the number of minutes that they use the resource. By designing the CME materials to easily answer clinicians' specific questions in small granules, we think that physicians will be more likely to use these resources at the point of care.39 The concept of receiving CME credit for "granules" of CME is new and not yet endorsed by the ACCME. However, with the ability of computers to easily maintain user logs, it is a concept that is technically achievable. It will await formal review and the approval by the ACCME to be realized.

Our current study was not designed to test whether computer-delivered CME is more effective in changing practice habits than is traditional CME. Rather, as a first step in testing its effectiveness as an educational tool, this study was designed to determine whether physicians would use Internet-delivered CME. We found that well-designed patient-based CME modules will be accessed by some physicians and that other physicians expressed interest in using them. The frequency with which they are used should increase as more physicians gain skills in using the Internet, as barriers to electronic commerce are removed, and when "granular" CME can be delivered to the point of care. We think that designing such CME modules is the next step in delivering computer-based CME to physicians.


   Footnotes
 
The development of the educational modules was supported by a Synergy grant from the University of Iowa, a CME grant from the University of Iowa College of Medicine, and an unrestricted educational grant from Glaxo Wellcome. The operation of the Virtual Hospital was supported by the National Library of Medicine (contract number N01-LM-4–3511) and the University of Iowa Clinical Enterprise.

Abbreviations: ACCME = Accreditation Council for Continuing Medical Education; AMA = American Medical Association; CGI = common gateway interface; CME = continuing medical education; IP = Internet protocol

Received for publication July 28, 1998. Accepted for publication December 17, 1998.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

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