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Original Research

Distance Education for Physicians: Adaptation of a Canadian Experience to Uruguay

LAURA LLAMBÍ, MD; ALVARO MARGOLIS, MD, MS; JOHN TOEWS, MD; JUAN DAPUETO, MD; ELBA ESTEVES, MD; ELISA MARTÍNEZ, BA; THAIS FORSTER, PHARMD, MSC; ANTONIO LÓPEZ, ENG; JOCELYN LOCKYER, PHD Introduction: The production of online high-quality continuing professional development is a complex process that demands familiarity with effective program and content design. Collaboration and sharing across nations would appear to be a reasonable way to improve quality, increase access, and reduce costs. Methods: In this case report, the process of adapting and modifying a course to improve the management of Alzheimer’s disease developed for the Canadian context for use in Uruguay is described. Results: Both quantitative and qualitative data on the process are shown. The original course was developed by the University of Calgary in the 1990s, and taught initially face to face and later online. The adaptation included using a distance education system developed and widely used in Uruguay, called eviDoctor. Discussion: The key aspects of transforming this course from one country to another with different resources, health care systems, culture, and language are analyzed. Problems encountered are described, as well as their possible solutions. Key Words: continuing medical education, continuing professional development, Internet, Uruguay, South America, Canada, international collaboration, online learning

Introduction Development of high-quality online continuing professional development is often resource-intensive. An internal study carried out by the authors in Uruguay showed that the process of creating a 2-month course to deliver in a distance education online modality, requiring 20 hours of participant Dr. Llambí: Physician member of permanent team, EviMed, Montevideo, Uruguay; Dr. Margolis: Medical Director, EviMed, Montevideo, Uruguay, and Profesor Adjunto, Facultad de Medicina, Universidad de la República, Uruguay; Dr. Toews: Professor of Psychiatry, Faculty of Medicine, University of Calgary, Calgary, Canada; Dr. Dapueto: Physician Expert, EviMed, Montevideo, Uruguay and Profesor Agregado, Facultad de Medicina, Universidad de la República, Uruguay; Dr. Esteves: Physician member of permanent team, EviMed, Montevideo, Uruguay; Ms. Martínez: Researcher, EviMed, Facultad de Ciencias de la Comunicación, Universidad de la República, Uruguay; Dr. Forster: Medical documentation specialist of permanent team, EviMed, Montevideo, Uruguay; Mr. López: Informatics Director, EviMed, Montevideo, Uruguay, and Profesor Adjunto, Facultad de Ingeniería, Universidad de la República, Uruguay; Dr. Lockyer: Associate Dean, Continuing Medical Education & Professional Development, Faculty of Medicine, University of Calgary, Calgary, Canada. Correspondence: Laura Llambí, EviMed, Quebracho 2733 bis, CP 11300, Montevideo, Uruguay; e-mail: [email protected]. © 2008 The Alliance for Continuing Medical Education, the Society for Academic Continuing Medical Education, and the Council on CME, Association for Hospital Medical Education. • Published online in Wiley InterScience ~www.interscience.wiley.com!. DOI: 10.10020chp.161

study, required approximately 340 hours of professional work. This work included experts’ analyses of objectives and content; the development of custom-designed study materials by clinicians, educational experts, and graphic designers; as well as patient education information. This was in addition to the work required initially to develop a Web-based platform. Collaboration and sharing across nations would appear to be a reasonable way to improve quality, increase access, and reduce costs in the long term, by adapting successful and carefully developed courses that have already been designed in terms of objectives, content, and reading materials. However, there are challenges when one shares educational content across nations. Medicine is practiced within very different systems and cultural contexts. Systems of payment for physicians may determine which services are provided and which health care provider assumes responsibility for the different aspects of care. Funding for medications may make therapeutic decisions different at the practitioner level. Availability of diagnostic facilities may also affect the reliability of the diagnosis. Cultural norms, particularly those related to life tyle, maintenance of life, and support for aging, can also influence diagnostic and treatment decisions. When the educational program originates in one language but requires adaptation into a second language, local clinical, computer, and translator expertise is required. Sensitivity to differences in systems, personnel, resources, funding, and learning traditions all need to be accommodated within

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the planning, development, dissemination, and evaluation processes. In this case report, we describe the process of adapting a face0face course to improve the management of Alzheimer’s disease developed for the Canadian context for use in Uruguay. We provide a discussion about the key aspects of transforming content from one country to another country with different resources, health care systems, and languages. Context of Practice and Learning The context of the practice of medicine in Uruguay has been described elsewhere.1,2 In summary, there are more than 13,000 physicians ~for a population of 3.5 million!, onethird of whom work as generalists. The health care sector is divided equally into public providers and private not-forprofit prepaid insurers and providers. Uruguay has an accreditation system for continuing medical education ~CME! providers and events, coordinated by the School of Medicine of the University of the Republic ~Facultad de Medicina, Universidad de la República, Uruguay!. More than 30 CME providers are accredited, including scientific societies, medical organizations, health care institutions, and departments of the School of Medicine. Alzheimer’s Course The University of Calgary course Alzheimer and Other Dementias originated in the mid-1990s 3 with updates up to 2004, with separate programs for novices and experienced physicians. Over time, the program evolved into three separate modular programs focused on diagnosis and pharmacotherapy and care of patients with mild to moderate and latestage dementia, as described elsewhere.4,5 The content of the first module was adapted into an online course through www.mdCME.ca. The program was designed for generalist physicians, primarily family physicians and general internists. The online course, while suited for the Canadian accreditation context, provided limitations for transferability to other settings with different requirements. For example, accreditation standards in Canada require that online courses be highly structured and interactive with a formal registration system and fixed times when the course begins and ends. While most of the physicians in Uruguay have access to the Internet and more than 75% use e-mail, less than half use it on a daily basis.6 High-speed Internet connections were still relatively scarce at the time we began this work. Nevertheless, it was believed an online educational program would meet the needs of physicians, particularly those who live inland and are isolated, some distance from centers of population. Moreover, many health care providers and institutions do not have the resources to provide structured, high-quality CME programs. Consequently, many physicians in Uruguay feel the need to seek other sources of information and continuing professional development away from their regular places of work. 80

Alzheimer’s Course as Adapted for Online Use in Uruguay EviDoctor ~www.evimed.net! is a system developed by EviMed in Uruguay with support from a grant for innovation programs from the secretary of education ~Inter American Development Bank funds! and from the state-owned Uruguayan Laboratory of Technology ~LATU! and its business incubator program called Ingenio. EviDoctor ~meaning the evidence-based physician! was designed to provide access to scientific information and continuing education of primary care physicians and their patients. Through eviDoctor, blended CME programs are developed that may combine distance education through the Internet with group-based learning and traditional on-site CME activities. The distance education component of eviDoctor is developed on a continuing basis by a multidisciplinary team of experts, mentioned later as the permanent team ~clinicians, educational experts, system engineers, graphic designers, among others!. This educational component includes a weekly electronic newsletter, reading materials for physicians and their patients, as well as electronic clinical rounds. Its target audience is mainly generalists. Currently 3,800 physicians participate in this service. Several Uruguayan health care delivery organizations and scientific societies have contracted with the service at an institutional level. Many of these organizations are also accredited CME providers. In developing an educational program, EviMed’s Scientific Committee holds a monthly planning meeting where the conceptual and the educational objectives are discussed. Then the knowledge domain experts together with EviMed’s permanent team develop the course methodology and materials. It was into this environment that the Alzheimer’s and Other Dementias course ~version 2004! was adapted for physicians in Uruguay. The course was part of the ongoing support that the University of Calgary has been providing to Uruguay in order to develop local capacity in CME. Some key facts were taken into account for the adaptation: •

•

•

In Uruguay, one-third of physicians work as general practitioners or generalists. The remainder have a specialty. Family medicine is only beginning to emerge as a specialty. General practitioners usually work in isolation, with a reduced scope of clinical decisions because of a lack of training and the way the health care system is designed. There is easy access to neurologists and psychiatrists for some cities in Uruguay, but it is more difficult for those practicing inland. As the course was designed for generalists, proper referral to these specialists was a special issue that had to be considered within the content of the course. Health care resources are limited and access to computed tomography ~CT! and other testing requires appropriate referral and an appropriate rationale. This did not affect recommendations for care in general, but for example one section of the course was entirely dedicated to proper indication of CT.

JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS—28(2), 2008 DOI: 10.1002/chp

Distance Education for Physicians

•

•

Placement in long-term care facilities is expensive in Uruguay and not covered by the health system. Again content prepared for Canadian physicians had to be rewritten and some unique content created for caregivers was produced. At the time the program was developed, the availability and use of information technology by Uruguayan physicians were more limited than in the Canadian context, conditions that necessitated some changes to the program. For example, a video component ~on CD-ROM and available online!, which provided direction on how to conduct a Mini-Mental State Examination ~MMSE!, could not be used as sufficient bandwidth was not available.

The EviMed team began to develop the program by examining the original Canadian course objectives 4 and modifying them for the Uruguayan context. Only the final objective, number 14, was altered. 1. Take a thorough history of the person with cognitive problems, including functional issues. 2. Note the neurological findings associated with Alzheimer’s disease. 3. Administer the Mini-Mental State Examination ~MMSE! while being aware of the limitations of the test. 4. Describe the natural course of Alzheimer’s disease. 5. Determine the appropriate laboratory tests to rule out causes of reversible cognitive impairment. 6. Determine when a brain CT scan is indicated. 7. Differentiate among common types of dementia. 8. Describe indications of specific medication for Alzheimer’s disease, 9. Detect caregiver burden and stress and outline strategies to deal with them. 10. Stage dementia. 11. Outline an approach to the initial management of the common behavioral and psychological symptoms of dementia. 12. Define delirium, describe its manifestations, and outline an approach to the detection and management of this problem when it arises in the setting of preexisting dementia. 13. Describe an approach to the management of incontinence and inappropriate sexual behavior in the setting of severe dementia. 14. Demonstrate awareness of relevant Uruguayan laws: Living Will and Advance Directive Projects, presently at parliament; Uruguayan laws about euthanasia.

special attention was paid to using familiar terminology, local epidemiology data, and pharmacologic names for drugs along with the local ~Uruguayan! commercial names. Each of the two modules was developed with two components: a reading and an e-round component. Each one was carried out within a single month, and materials released during the first module were also available while the second module was running. Furthermore, for registered users of eviDoctor the materials are permanently available in a document database, while the e-round was only carried out during the months the modules were done. Physicians received eviDoctor’s weekly e-newsletter by e-mail, which provided them with access to two or three new reading materials each week. This newsletter was also available on the Web ~FIGURE 1!. Tests such as MMSE, Functional Assessment Staging ~FAST!, or Yesavage Depression Scale were also available on the Web site and newsletter ~FIGURE 2!. The first module had 13 reading materials and the second 10. These were gradually released with each weekly electronic newsletter. The e-round was performed each month. The e-round consisted of a clinical case, provided at the beginning of the module ~FIGURE 3!. It was e-mailed to physicians and Web-published, followed by three key questions to prompt discussion. Clinical cases were chosen from among those in the Canadian facilitators’ guide, with minimal changes. Physicians e-mailed their comments and answers, individually or in groups, to be read by the whole distribution list. The e-round coordinator made weekly comments, guiding discussion to new issues, pointing out significant comments, and clarifying physicians’ doubts and questions. Comments from the coordinator were e-mailed to the physicians. The e-round was an asynchronous e-mail discussion group coordinated by an expert.a This modality allowed physicians to participate whenever they could and wished to, lacking a fixed schedule or timetable to access the e-round. Physicians’ comments were translated into English and e-mailed to Canadian experts. Reading materials for patients and caregivers were also published in the newsletter ~FIGURE 4! to address caregiving issues and support. These were prepared in simple conversational language so this information could be printed and handed out in the physicians’ offices.

Program Implementation The whole activity was carried out in distance education modality, although there were some small groups of physicians who studied together using the material. The course was divided into two modules; the first took place in November 2005 and the second in March 2006. Objectives 1 to 9 were addressed in the first module; numbers 10 to 14, in the second one. Reading materials were prepared, using the Canadian program’s resources. EviMed’s permanent team and one domain expert ~two internists, a medical librarian, and a psychiatrist! carried out a contextual translation. In this,

Program Review At the time of both Alzheimer’s modules, there were approximately 1,200 physicians participating in eviDoctor’s educational activities, of whom 70 had complete access to all reading materials on Alzheimers’ disease. The remainder of the physicians had access to e-round only. a It is not a list serve, but a massive personalized e-mail following a standardized editing and merging procedure aimed at not overwhelming busy physicians with unrelated or too frequent e-mails.


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FIGURE 1. Weekly newsletter, available on the Web and by mail.

Fifty-one of 70 ~72.8%! physicians with complete access to materials read some or all reading materials on Alzheimer’s disease during the first module ~November 2005!. The materials were accessed 589 times, including the Clinical

Case ~free access!. The most commonly accessed documents were the Clinical Case under discussion, which was accessed 107 times. Regarding those materials that were only available to registered users of eviDoctor ~n ⫽ 70! the most

FIGURE 2. Reading resources. 82



FIGURE 3. Clinical case under discussion ~both e-mailed and on the Web!.

accessed were “Brain CT: is it always necessary?” ~n ⫽ 89!, “How do we manage Alzheimer’s disease?” ~n ⫽ 85!, “MMSE” ~65! and “Does the Patient Have a Dementia?” ~n ⫽ 56!. The number of times each material was accessed is

greater than the number of potential readers because some physicians accessed the same material more than once. Regarding the e-round a total of four physicians and one study group composed of five doctors participated in the

FIGURE 4. Reading resources for patients and their families. JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS—28(2), 2008 DOI: 10.1002/chp

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Llambí et al. TABLE 1. Physicians’ Participation n

%

Physicians with full access who read materials in Module 1

51070

72.8

Physicians with full access who read materials in Module 2

38070

54.3

Physicians who participated actively in the e-round. Module 1

9070

12.8

Physicians who participated actively in the e-round. Module 2

2070

2.8

Lessons for Practice • Meaningful international collaboration in CME needs to take into account many differences, such as culture, health care systems, clinical practice, language, CME accreditation systems, and economic development.

Discussion and Conclusions e-discussion with the Uruguayan experts during the first month. During the second month ~March 2006!, 38 of 70 ~54.3%! physicians accessed some or all the reading materials from either module, 1 or 2. There was a total of 321 accesses, including the Clinical Case ~free access!. The most accessed document was again the new Clinical Case, with 51 accesses. In addition to the online access, the clinical case was sent via e-mail to all participants. Two physicians along with the local experts participated in the e-mail round ~TABLE 1!.

Problems and Solutions As with any adaptation of programs across countries involving different cultures, systems, and languages, there were several problems that had to be overcome to develop a program that could be useful in Uruguay. 1. Language. The materials required translation and adaptation into Spanish from English by Uruguayan experts as it was felt a general professional translation would not capture Uruguayan approaches and culture. The two teams ~Canadian and Uruguayan! had to discuss the program before and during the course. These discussions took place in English. Comments from the participants were translated into English for the Canadian experts for their information. 2. Technological differences. High-speed Internet access was not widely accessible at the time of the course so that a video clip, which demonstrated how to undertake an MMSE, had to be provided in a text format. 3. Content. As stated before, differences in the way Alzheimer’s disease is managed in the two countries required that Uruguayan experts modify the content of educational materials. 4. Culture of e-learning in Uruguay. EviMed has evolved an approach of e-learning that physicians progressively accepted and used, which uses the Web to permit access to resources and e-mail for the discussion. EviMed’s method contrasts to the approach adopted by mdCME.ca, which formalized the course structure with all discussion taking place within an e-discussion board accessible only by password within a defined 4-week period. 84

The process of taking the course from a Canadian to a Uruguayan context was feasible. There are key concepts that we learned from this experience: 1. There needs to be flexibility in determining the content for a course delivered in another country. Resources, cultural differences, prevalence of diseases, and health care systems will all affect the appropriate content and acceptability of the course by practitioners. 2. Language needs to be considered when undertaking the translation especially if one wants to include experts from another country as discussants. 3. The culture of how physicians use e-learning needs to be understood as it will influence acceptance of the program and the ways physicians interact with one another in an e-environment. 4. Resources are needed to sustain collaboration in the long term. This probably requires some face0face meetings of the leaders from both countries.

E-learning has its limitations, even though we know from EviMed’s annual survey about topics of interest among its subscribers that Alzheimer’s disease and other dementias was one of the top three topics requested by physicians. Active participation in the e-round was low, even though the enrolled practitioners were interested in the clinical discussion ~as noted by their access to both Clinical Cases!. Further, in another survey conducted by EviMed, 52% of subscribers stated that they “always read peer and coordinator’s comments and sometimes participated actively by sending comments or queries to the e-round,” and 42% answered they “only read others’ comments but did not send their own.” It will be important in future work to try to ensure that course participants offer comments, as CME studies have shown that better learning outcomes and participant satisfaction result from higher interaction 7 and involvement in multifaceted activities. 8 It appears that physician participation in online activities is increasing. In a blended online and on-site course on palliative care carried out by EviMed in May 2006, 2 months after the second part of the Alzheimer’s disease course, there was much higher active participation and interaction of phy-



sicians compared to the Alzheimer’s course.9 In that course, there were 385 professionals registered for this course, of whom 161 ~42%! read the study materials and 101 ~26%! participated in the e-round. Almost half ~49%! participated in some way in the distance modality part of the course, in preparation for the face-to-face workshop. It must also be noted that the palliative care course was carried out in conjunction with a local government agency related to cancer prevention and management, which likely increased enrollment and participation in the course. It is possible that other methods of stimulating interest in e-round such as smaller groups, use of blogs, and warm–up activities such as sending each participant’s photograph and profile are being planned to stimulate better outcomes in future e-rounds. This initiative has given us confidence to continue with this type of collaboration. We plan to develop jointly a formal blended course at the beginning of 2008 ~on global cardiovascular risk!, in conjunction with the appropriate Uruguayan Scientific Society, and to extend this experience to other Latin American countries. In that regard, in September 2007 EviMed was starting a project in Puerto Rico with a health insurance company that covers one-fourth of the Puerto Rican population, to adapt eviDoctor’s educational proposal to their reality. Acknowledgments This work was partially supported by a grant for innovation programs through the governmental Programa de Desarrollo

Tecnológico, www.pdt.gub.uy ~with Inter American Development Bank funds!, and by the state-owned technology Incubator Ingenio, www.ingenio.org.uy. References 1. Alvariño F, Margolis A, Bordes D, Frau A, Viola L. Medical education and the physician workforce in Uruguay. J Contin Educ Health Prof. 2007;27~2!:81–85. 2. Margolis A, Alvariño F, Niski R, et al. Continuing professional development of physicians in Uruguay: Lessons from a countrywide experience. J Contin Educ Health Prof. 2007;27~2!:80. 3. Lockyer JM, Fidler HM, Hogan D, Pereles L, Lebeuf C, Wright B. Dual track CME: Accuracy and outcome. Acad Med. 2002;77~10!: S61–S63. 4. Lockyer J, Fidler H, Hogan D, et al. Assessing course outcomes through an examination of the congruence between course objectives and reflective work. J Contin Educ Health Prof. 2005;25~2!: 76–86. 5. Curran V, Kirby F, Parsons E, Lockyer J. Discourse analysis of computer-mediated conferencing in World Wide Web–based continuing medical education. J Contin Educ Health Prof. 2003;23~4!: 229–238. 6. Herrera T. EviMed’s market study, 2003. Accessed May 19, 2007, at: http:00www.evimed.net. 7. Sargeant J, Curran V, Allen M, Jarvis-Selinger S, Ho K. Facilitating interpersonal interaction and learning online: Linking theory and practice. J Contin Med Educ. 2006;26~2!:128–136. 8. Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician performance: A systematic review of the effect of continuing medical education strategies. JAMA. 1995;274:700–705. 9. Llambí L, Avas G, Margolis A, et al. Combinación de metodologías para la educación médica continua—Curso de Cuidados Paliativos en Pacientes Oncológicos. Arch Med Interna ~Uruguay!. 2007;29~2–3!:42– 45.


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