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[1] Using the World Wide Web for Medical Education: Start With a Needs Assessment (Medical Education Web Page Series – Part 1)

Toronto, Ontario

The World Wide Web (WWW) has been in existence for less than a decade and has already proven to be as important an information and communications tool as Gutenberg's printing press. As almost everyone who owns a computer knows, most Web pages are constructed using a formatting language known as HyperText Markup Language (HTML) and are made available at a particular address on the Web using a "server" computer residing on the Internet and containing HTML files that are sought by various "client" computers. Persons ("clients" of the "server") who wish to access a Web page do so using a "Web browser" running on a client computer connected to the Internet in order to access appropriate HTML files on the server. This connection is usually either a slow dial up line or a fast permanent connection (cable, DSL).

The WWW has proven to be a particularly useful tool for medical education, with many well-constructed teaching resources now becoming available. Even a cursory search at http://google.com (or other search engine) will reveal hundreds of valuable resources. There is even a medical education "Web ring" with 240 member sites accessible at http://nav.webring.yahoo.com/hub?ring=mededrg&list

In addition, searches of the indexed medical journals at PubMed(http://www.ncbi.nlm.nih.gov/PubMed/) will provide abstracts of papers on virtually any medical topic, with links to many free full papers, such as those published by the British Medical Journal (http://bmj.com) or the Canadian Medical Association Journal (http://www.cma.ca/cmaj/). Indeed, the key challenge in using the WWW to obtain medical information is not in getting results, but in separating out quality resources that can be relied on from self-published but well-formatted rubbish (more about this later).

I believe that the future of the WWW for medical education is particularly promising. With the (slowly developing) recognition among academics that the production of peer-reviewed Web pages with high educational value will lead to promotion and honours, the number of high-quality Web pages devoted to medical education (as well as thousands of other things) will grow boundlessly. Vast amounts of high-quality educational materials will be available free for the taking, making the market for pay-per-view materials restricted in practice to the distribution of very highly specialized, commercially valuable information. Many educational, scientific and medical facilities will choose to make available freely accessible Web pages on topics of interest to their patrons. The Massachusetts Institute of Technology (http://mit.edu), for instance, will be posting on the Web unrestricted access to course study guides and other teaching materials as part of their "MIT OpenCourseWare" initiative.

This free access to information will almost certainly diminish the demand for paper, magazines, journals and textbooks, altering the economics of their production and distribution. Consider, for instance, the advertiser-supported site http://emedicine.com that offers readers a complete textbook of emergency medicine that is not only free but is also likely to be more current than regular textbooks because it is updated several times a year. A large editorial board also serves to ensure that the materials are of high-quality and not influenced by advertising sponsorship, just as with classical paper journals.

This being said, however, one problem with the huge quantity of information on the Internet is that mixed with high-quality, well-researched information is an unknown but considerable amount of misinformation, typographical errors and outdated material. A system for evaluating medical information on the Internet must be developed. One way one can do this is to look for the "Health on the Net" (http://www.hon.ch) seal of approval at each Web page, but very many (indeed almost all) quality medical Web sites have not bothered with obtaining HON "certification", particularly the non-European sites.

Another way to increase the chance of getting quality material is to concentrate on Web sites that are affiliated with reputable universities and clinical organizations. After all, what reasonable person would mistrust (securely obtained) information made available at a Harvard University Web site or posted by the Canadian Medical Association?

Some day there will even be a formal rating system for medical education Web pages, such as the scheme outlined in Table I that I have been advocating for some time.

Many clinicians, particularly those who do occasional teaching or are asked to speak at conferences, are interested in making teaching materials available on the WWW. In the remaining portion of this article I would like to briefly cover the issues centering around designing and implementing a medical education Web page.

The first task in any such initiative is to perform a "needs assessment" - to ask whether there is a need for the proposed resource, and if so, ask what should be its scope and its format, and how should the resource be organized. For instance, before embarking on a hypothetical effort to put up a clinical pharmacology page on the WWW aimed at clinical clerks learning resuscitation, it would be wise to ask a number of clerks approaching the end of their medical school training about what, if anything, was flawed in their pharmacology learning experience and to seek their opinion on how the situation might be remedied. In my own case, for example, I learned from several clerks that in addition to materials available in HTML format, some would also like the material available in formats suitable for use with their hand-held computers (Palm Pilot^TM, Pocket PC^TM, Psion^TM etc.).

Of course, the needs assessment process can be far more formal, involving structured interview forms, postal questionnaires, focus groups and other techniques, but I have found that simple informal discussions with medical students and residents can be reasonably helpful yet are invariably effortless and inexpensive.

Once you have decided that you wish to develop a medical education Web page, it is necessary to find a host for it. It is possible to start simply and very inexpensively using a free Web page hosting service such as http://geocities.com or http://freeyellow.com (both services add a small banner ad in exchange for being free. The freeyellow site provides a massive 50 MB of free disk space to users.) Alternately, far more sophisticated Web hosting services without banner ads are available for about $40 monthly from http://topchoice.com (my favourite) and dozens of other reputable companies, many with very competitive pricing. Finally, many Internet Service Providers (ISP) give you a free Web site package of modest size as part of their commercial offerings.

Once the web hosting issue is decided, consider the content issues for your Web page. In many cases the content is an existing text article written in Microsoft Word or a teaching slide set in Microsoft PowerPoint format.

The easiest way to proceed is to start with a completed text document in Microsoft Word and simply upload the file "as is" to your web site's root directory using a file transfer protocol (FTP) program (such as "WS_FTP LE", available by free download at http://www.ipswitch.com/Support/ws_ftp_le_support.html.) The same can be done for PowerPoint documents.

For instance, suppose that the information you want to share is in a single Microsoft Word file in the root directory called info.doc and further suppose that your Web address (universal resource locator, URL) is anesthesiaeducation.org (this URL was still available at the time of writing). Then the URL for the information file would be anesthesiaeducation.org/info.doc and that is what users would merely have to type into the browser address box to access the posted information.

Similarly, when posting a teaching slide set in Microsoft PowerPoint format named info.ppt, the URL for the slide set would be anesthesiaeducation.org/info.ppt

The one drawback to this particular solution is that while recent versions of Microsoft Internet Explorer will correctly display these files with the formatting intact, other browsers like Netscape Navigator or Opera will generally not do so, at least not without the bother of installing a "plug-in", a software upgrade usually obtained by download.

An alternate means to make a Web page would be to automatically convert the Microsoft Word file (again called, say, info.doc) to HTML format (with a new name, say, info.htm). This is almost trivial to do with recent releases of Word (versions 2000 and 2002) but the process suffers from the drawback that the automatic conversion often produces a Web page that is "esthetically awkward" and occasionally produces a page that is simply dreadful. Consequently, post conversion editing by hand (using Microsoft FrontPage^TM , Evrsoft 1st 2000^TM , or other Web page development environment) is frequently necessary to obtain a respectable result. In this regard you may wish to first consider 1st 2000^TM since it is free (Table II). In addition, there are a large number of sites with Web authoring tools which you may find to be quite useful (Table III).

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