Psychiatrists naturally want to keep up with their field, and since 1994, the American Board of Psychiatry and Neurology (ABPN) has required them to become recertified by successfully completing the recertification exam to maintain their certification (3). It is part of the Maintenance of Certification developed by the American Board of Medical Specialties. It has four components, including 1) professional standing (licensure); 2) lifelong learning and self-assessment; 3) cognitive expertise (examination); and 4) practice performance assessment. It also includes several competencies, such as 1) medical knowledge; 2) patient care; 3) interpersonal and communication skills; 4) professionalism; 5) practice-based learning and improvement; and 6) systems-based practice (3). In particular, we are interested in lifelong learning and self-assessment.
Lifelong learning requires evidence of participation, and diplomates are expected to conform to specialty-specific standards. This can be accomplished by self-directed learning, which is done at one’s own pace, alone, or directed self-learning, which can be real-time and interactive. For board recertification, the goal is to document competence. The following activities are accepted by the ABPN as documentation of lifelong learning: 1) the Psychiatrist in Practice Examination (PIPE); 2) post-reading questions from FOCUS; and 3) organized Category 1 continuing medical education (CME) activities (4).
Lifelong learning is also guided by the content areas outlined in Section 3, cognitive expertise, which is assessed by examinees completing a 5-hour 200-item multiple-choice examination from the ABPN administered by computer. The following content areas are assessed: mood, psychotic, substance-related, anxiety, personality, delirium, dementia, and cognitive disorders; ethics and forensic issues; life cycle and adjustment disorders; childhood disorders that persist into adolescence and adulthood; somatoform and factitious, eating, sexual and gender identity, dissociative, impulse-control, and sleep disorders. For each content area, the following areas of interest are addressed: 1) evaluation and diagnosis; 2) clinical neuroscience; 3) psychopharmacology; 4) psychotherapies; 5) age issues; 6) gender issues; 7) cultural issues; 8) comorbidity; and 9) risk issues (5).
Rationale for the Use of Technology
Not many years ago, lifelong learning looked very different. CME credits had to be earned by subscribing to journals, completing questionnaires, paying fees for CME, attending Grand Rounds or traveling to meetings, which would incur associated costs, such as airfare, accommodations, and registration. Alternatively, a psychiatrist could subscribe to key journals but miss out on articles in unsubscribed journals. Journals are bulky and heavy, difficult to search, and they only involve one learning modality, that of reading, not making use of audio or animated modalities. Live presentations may have limitations, such as diminished objectivity if sponsored by a pharmaceutical company, and there many be a lack of durable materials, or they may not be of good quality, and audio or videotapes may not be readily available. Looking up a review or research article in a journal meant going to the local medical library (assuming there was one), doing a literature search, getting the journal, and making a photocopy. Reference books are large, heavy, expensive, and often outdated as soon as they are printed. Today, anyone with a computer and an Internet connection can download articles, either in text or PDF (postscript document format) version, and read or watch CME content right on the computer, which saves time and money.
Information distributed over the Internet can be almost instantaneously updated. Compare this to print journal articles, which usually require more than 6 months from submission to distribution, or printed editions of textbooks, which are published every few years. In the past, medical publishers and physicians were forced to accept these delays, but the rapid development of the Internet has raised the standard for timely content dispersal.
Another advantage to using the Web is that Web pages can link to other pages within the site, other sites, or other online resources (6). Physicians can follow these links to obtain the most current MEDLINE abstracts, selected clinical information, multimedia presentations, and thus can create clinical information sets with input from a wide variety of experts and perspectives (7). These multimedia presentations can use video, audio, animation, and interactive technologies to engage the physician’s attention in multiple ways and increase retention of the information at the physician’s own pace.
Finally, as mentioned earlier, the mastery of basic computer skills, as well as more advanced skills, such as accessing online textbooks, bibliographic databases, online journals and CME, and e-mail, have been recommended by the Council on Graduate Education and the American Academy of Family Physicians, for medical students and residents, respectively (2, 8).
Barriers to the Use of Technology
In 2001, the American Academy of Orthopaedic Surgeons Bulletin reported that “physicians lack the skills for computer CME (9).” Their survey determined that it was a preference for in-person instruction that was the most frequent reason for not accessing CME on the computer. The second most common reason was that clinicians did not know how to use the Internet or a CD-ROM (compact disk read-only memory). More than 80% already had home computers. Other surveys have mentioned a lack of time to learn the skills (10). For some physicians, the cost of a computer or Internet access may be an obstacle. The variable quality of online information and the relative disorganization of the Web may also put off physicians accustomed to traditional journals and textbooks.
Basic Equipment and Skills for Using Electronic Resources
Psychiatrists interested in accessing electronic resources will need a computer and an Internet service provider (ISP). Any new computer available today will have enough processing power to access electronic databases, run CME programs on CD-ROM, and play netcasts (audiovisual presentations broadcast over the Internet). The lifelong learner will need a monitor (screen [CRT] versus LCD [liquid crystal display], which is flat and takes up less desk space), CPU (central processing unit [chip that runs the computer] with its speed expressed in gigahertz [Ghz]), including a 40 GB or larger hard drive, and sufficient RAM (random access memory) to run their software with a CD-ROM drive, and a printer to document their CME participation. Any brand will be adequate, as long as the operating system is Windows 2000 or Windows XP, or Mac OS X. As far as Internet access is concerned, we recommend broadband or high-speed access, such as satellite (1.0 mbps [megabits per second]), DSL (digital subscriber line) (1.50 mbps) or a cable modem (3.0 mbps). Dial-up service is much too slow for multimedia presentations (53 kbps [kilobits per second] maximum, or 1,000 times as slow), and should be avoided for lifelong learning purposes, due to most presentations’ large file size. The reader is referred to magazines such as Consumer Reports, Smart Computing, PC World, Macworld, or their Web sites, and cnet.com for buying recommendations.
A more advanced setup might include a PDA (personal digital assistant). PDAs are handheld devices running the Palm OS or Windows CE operating system. Examples are the Tungsten T5, HP iPAQ hpx-4700, or the Treo 650, which combines a PDA with a cellular phone. Software like Epocrates (www.epocrates.com) allows for quick access to drug-prescribing information. Books can be downloaded and read on the screen between patients, and e-mail may be received and sent if the PDA has wireless capabilities or when it is synchronized (has its files updated) with a desktop or laptop computer. See Appendix 1 for more resources.
In addition to the proper equipment, the lifelong learner also needs certain skills to access medical information online. As mentioned previously, the Council on Graduate Medical Education requires Medical Informatics skills acquisition during training as one of nine objectives in the Undergraduate Medical Education curriculum (2), and the American Academy of Family Physicians recommends that graduating residents have minimal computer skills to access online textbooks, bibliographic databases, online journals and CME, and e-mail (10).
General Electronic Resources
Online information can also be easily found with general search engines, such as Google. One must be mindful, however, of the quality of the information obtained online. Not all sources are equally reputable, but neither is relevant information from reputable sources always available. Usually, information from universities, colleges, professional organizations (APA, etc.), government agencies (e.g., Substance Abuse and Mental Health Services Administration [SAMHSA]), and national support groups, such as the National Alliance for the Mentally Ill (NAMI), are trustworthy.
PubMed (www.pubmed.gov) is an excellent Web site that provides access to the National Library of Medicine’s MEDLINE database of citations and abstracts. It is free and can be used with some training. The full text (as opposed to just the abstract) of more recent journal articles is often available online. A personal subscription, medical library privileges, or payment per article is usually required. Stone and Sharp (6) wrote an excellent review of Internet resources for psychiatrists in 2003 (Appendices 2 and 3).
Lifelong learning is not necessarily impersonal learning. Electronic mailing lists enable clinicians to learn from, teach, and support each other. We find the following to be particularly helpful: group psychotherapy (www.group-psychotherapy.com/listinfo.htm), International Society for Mental Health Online (ISMHO) members (health.groups.yahoo.com/group/ismho-members), and psycho-pharm (firstname.lastname@example.org). However, CME credit cannot be earned by reading postings on newsgroups or mailing lists.
APA and American College of Psychiatrists Electronic Resources
The APA has done its part to provide the following resources for lifelong learning. FOCUS: The Journal of Lifelong Learning in Psychiatry (focus.psychiatryonline.org) is a clinical review journal with annual self-assessment examinations. A clinician can earn up to 40 CME credits per year using the journal. For APA members, its annual cost is $264, and for nonmembers, it is $423. There are also APA Practice Guideline CME courses (www.psych.org/cme), which are free to APA members. Eleven Practice Guideline courses with multiple choice tests are available. In addition, there are APA Self-Assessments (cme.psychiatryonline.org), which are online self-assessment companions to textbooks from American Psychiatric Publishing, Inc. Subjects covered are clinical, forensic, and geriatric psychiatry, substance abuse, psychosomatic medicine, and neuropsychiatry and clinical neurosciences. Content from the 2005 annual meeting is also available for CME credit (www.psych.org/edu/ann_mtgs/am/05/amlibrary.cfm). The APA also offers “Psychiatry on the Internet,” a set of links to information on psychiatry (www.psych.org/public_info/libr_publ/psychguide.cfm?pf=y) (Appendix 4). Finally, there is the Psychiatrists In-Practice Examination (PIPE) (www.acpsych.org/pipe/pipe.html) from the American College of Psychiatrists (ACP), which can enable a clinician to study for recertification while earning 30 CME credits for $249.
Learning Lifelong Education Skills in Medical School, Residency, and Beyond
Efforts have been made to teach lifelong learning skills in undergraduate and post-graduate medical education. Although this topic is mentioned in other articles in this issue, a discussion here will serve to inform the busy clinician how to approach lifelong learning as it is currently conceived of and taught in medical school and residency. Alper and Vincent (11) describe an experiential curriculum, given to third-year medical students at the University of Missouri-Columbia during their family practice rotation, that could serve as a useful model for teaching these skills in other disciplines. Students were assigned time in a computer lab where they were introduced to a Web page that linked to various clinical Web sites (12). Approaches to finding clinical information were addressed in a Tutor Guide (13), and students were shown how to evaluate Web-based content in a document entitled “Teaching Points” (14). A similar system could be constructed for psychiatry, and the Tutor Guide and Teaching Points could be adapted as well and posted on the Internet.
Slawson and Shaughnessy (15) suggest that psychiatric educators should be stressing information management. Trainees should be taught three skills: 1) foraging, or generally keeping up with the field by selectively looking for information that screens for relevance and validity; 2) hunting, or finding pre-filtered information that is relevant to specific clinical situations; and 3) making clinical decisions based on empirical clinical evidence and the individual patient’s needs. Students should be taught how to use foraging tools, such as Daily InfoPOEMs (www.infopoems.com) or Psychiatry Journal Watch (psychiatry.jwatch.org). The APA and ACP electronic resources could be considered foraging tools for practitioners. Hunting tools include Dynamed (www.dynamicmedical.com), although it only references two psychiatric journals, and InfoRetriever (www.infopoems.com/irsearch/irsearch.cfm) as well as Epocrates, Google, PubMed, and mailing lists. The third skill, clinical judgment, cannot be found on a Web site. The clinician is required to take a patient-centered approach. Clinical judgment is best taught using SORT (Strength of Recommendation Taxonomy) (15). Clinicians are taught to look for outcomes that patients care about and that help them to lead better lives, as well as to rate the intervention on its feasibility in the given situation.
Information management skills are more likely to be adopted if they are integrated into the clinical curriculum as opposed to taught in a stand-alone course or module. Additionally, since much of learning in medicine uses apprenticeship, supervisors and mentors should demonstrate the value of these skills as they take care of patients, encouraging trainees to acquire these skills themselves.
A survey conducted by Chew et al. (10) suggested that family practitioners have an interest in learning how to use computers, but lack the time. Their data suggested that gender and training recency had no impact on Internet use, and their recommendation was to offer a CME course on developing and enhancing Internet skills.
Lifelong Learning and Information Technology
Psychiatrists in the electronic age will use information technology not only to pursue lifelong learning about psychiatry, but also, as described above, in their practice of psychiatry. Lifelong learning about information technology is also needed.
Slawson and Shaughnessy differentiate between the educational needs of clinicians, teachers, and researchers (15). Garde and Hovenga (16), of the Health and Medical Informatics Education working group of the International Medical Informatics Association (www.imia.org/wg1), add Benner’s levels of skill acquisition (novice, advanced beginner, competent, proficient, and expert) (17), Bloom’s levels of cognitive learning (knowledge, comprehension, application, analysis, synthesis, and evaluation) (18), and their own categories of medical information technology subject areas (19). According to Garde and Hovenga, clinicians need not rise above the advanced beginner level in any information technology subject areas. Advanced beginners are, however, expected to possess a good amount of knowledge, moderate comprehension, and some application ability. Connecting to the Internet, downloading articles, watching netcasts, conducting simple searches, subscribing to mailing lists, and using Dynamed, InfoRetriever, and APA and ACP electronic resources could be considered advanced beginner skills. Conducting complex searches, constructing personal filters for relevance and validity, and using a PDA could be considered competent-level skills.
Psychiatrists today are busier than ever, and many are required to renew their board certification every 10 years, as well as to document attendance of at least 30 hours of CME per year. Starting with electronic resources from APA and the ACP, the busy clinician can easily meet these requirements with a minimum of cost, travel, and time. By buying and using a basic computer system with broadband Internet access, the clinician can gain access to CME netcasts, online databases, CME self-assessment questions, and other clinical resources to keep up with the burgeoning psychiatric literature. In addition, psychiatric educators need to look for ways to teach medical students, residents, and practicing clinicians basic computer skills, as well as a range of clinical information retrieval, analysis, evaluation, and application skills.
1. Subscribe to Psychiatry Journal Watch
2. Upgrade or purchase multimedia capable desktop or laptop computer equipment
3. Have a broadband or high-speed connection to the Internet
4. Be familiar with multiple sources of psychiatric information
5. Have an academic affiliation that grants library privileges for downloading articles
1. Travel only for CME units. Instead, travel to see interesting places
2. Wait until the last minute to obtain CME units for recertification
3. Use dial-up for Internet access
4. Hide from technology; learn new tricks
5. Forget to keep up-to-date with the latest clinical information—things change fast!