Medical Education Part 1      (Part II)
 
by Marjorie Lazoff, MD
Emergency Medicine
Philadelphia, Pennsylvania
Medical Editor
Medical Computing Today

accepted for publication in Medical Computing Today June 1997
(updated) December 1997
 
Originally published in edited form June 1997 in Medical Software Reviews.


Sections
Part I:
Educational Resources (multimedia - CAI - text - multiuser) - CME
Part II: Educators - Computers in Med Ed - Med Ed Software - Institutions - Non-Academic - List of lists


From gross anatomy labs conducted amid formaldehyde and lifeless tissue to CME courses conducted amid sun and sand, Medical Education is an ongoing presence in our professional lives. So, with another July looming up, it seems fitting to evaluate medical education's scope and depth on the World Wide Web (WWW). This overview is divided into seven somewhat overlapping sections: Educational Resources for physicians, residents/fellows, and medical students; CME; Resources for Medical Educators; Computers in Medical Education; Medical Education Software; Medical Schools and Post-Graduate Training Programs, and Non-Academic Resources for medical students and residents/fellows. Within each category unusually strong, characteristic or controversial sites are described in greater detail. Testifying to the depth and breadth of educational resources on the Web is the number of excellent sites that did not make their way into this overview. For those readers desiring a more comprehensive reference, the article concludes with several Medical Education Lists of Links.
 
The first category, Educational Resources, does not group sites by specialty. For those looking for specific sites, most browsers' menu bar includes a Find feature (look under Edit, or try ctrl+F). Enter key portions of the term(s) to be searched, such as neurosurg or pathol, to capture all variants of the prefix and suffix.
Sections Educational Resources
Hundreds of sites showcase tomes of lecture notes, multimedia atlases, online texts, and preclinical and clinical curricula; the number is even more extensive if one includes clinical references that double as education resources. Curmudgeons might protest, but a solid reference with a search engine, interactivity, timely updates and/or multimedia could be a stellar educational resource. Its disadvantages are those common to all Web references: variable access and cost of an Internet connection, content and site upkeep, copyright issues, author and content verification, and technical problems with multimedia presentations and browser incompatibilities.
 
But these disadvantages pale in comparison to online medical education's potential strengths. Indeed, it is humbling to experience the present breadth, variety, creativity and quality of materials contributed gratis by academicians, medical school departments, organizations and companies throughout the world. This is even more impressive considering the WWW is only a few years old, and that crass commercialism, hate groups, and get-rich-quick schemes are equally characteristic of today's Internet.
 
Most medical education sites appear to be built upon one of four basic Web strengths discussed under their respective headings below: relatively easy and inexpensive multimedia programming; rapid computations and advanced programming for interactive learning, including simulations; quick text search, retrieval and storage; or interactivity characteristic of multiuser discussions and presentations among colleagues. Focusing on technology deviates from the more traditional classification by medical subjects and/or categories, which while directing users to areas of content tend to downplay sites' structure and function. A review such as this, which concentrates on these latter aspects, can highlight those sites where technology and content combine to create unique educational experiences.
 
The reliability and validity of online medical educational resources deserve comment. While educational resources in general should be approached with caution, common sense dictates that when elaborate programming reflecting multimedia or interactivity is present on a mainstream university, organization, or company site, chances are lessened that the educational material is significantly in error, particularly when the individual(s) responsible for the content are identified. In contrast, primarily text sites, given their relative ease of creation coupled with the fact that anyone can call himself and his site anything he wants, are especially suspect. Titles and credentials can be added, the name of a legitimate physician can be used by another, and e-mail addresses that appear to come from a university can be easily forged. Indeed, were it not for the hundreds of good-to-superior medical education sites, the educational merit would hardly be worth the uncertainty.
 
Physicians familiar with the Internet know to question all online educational or clinical materials, and in general to remain within familiar, peer-reviewed resources such as a respected journal or university site. Note the article's date, since dated material is common. Sadly, many journal sites offer only abstracts on line; even for the best journals physician-educators advise skepticism until the article can be assessed for quality of the research, statistical analysis, and references. Ideally sites reviewed here will prove to be educationally reliable, but at best that is true at the time of writing and ignores the errors and omissions all sites possess.
 
Nowadays, physician-educators need to familiarize themselves with online resources so as to direct their students and residents toward quality sites, and students and residents should seek out their attendings' suggestions rather than trustingly browse.
 
 
Sections Multimedia
Programming standards, improvements in bandwidth transmission and modem speeds, and free browser plug-ins have literally revolutionized online multimedia. Already available in early stages are 3-D visualizations of molecular biochemical reactions and computerized images within interactive atlases with user-controlled features such as zoom and navigation. In the next few years we can anticipate educational resources using telemedicine, telesurgery, and teleradiology, and thereafter the potential of virtual reality projects should begin to be realized on line. At a minimum, multimedia technology will revolutionize medical education by making accessible difficult pathophysiologic, molecular and anatomic visualizations, and by helping physicians acquire sense memory and practice in performing procedures without risk to patients. Though not reviewed here, with the recent advent of quick and inexpensive streaming and televised Internet technology, we can anticipate a flurry of sites advertising audio and/or video lectures over the next 12-18 months. Time will tell whether they become the pay-per-view equivalents of the same lectures students have been falling asleep to and vacationing physicians have been sneaking out from for decades, or prove to be a more worthy educational adjunct.
Easily the best known medical multimedia event on the Internet, the National Library of Medicine's Visible Human Project is a database of computer-dissected cadaver slices made available to the public for educational, research or clinical purposes. Be certain to scroll down the home page, as many developers have placed generous samples of their work on line. While resolution is limited, interactivity is often superb, trumping print atlases in their ability to navigate along multi-dimensional planes and regions.
 
The University of Washington Department of Biological Structure's Digital Anatomist introduces itself as "structural informatics" and details how they accomplished computationally intensive tasks such as 3-D graphics or image processing. Instead of the more common Java applets or programmed scripts, these developers devised a unique client-server distribution framework that relates individual C programming language modules using the programming language Slisp (Skandha lisp). More information is available at the Web site, and in Drs. Brinkley and Rosse's June 1997 JAMIA article (abstract and full reference).
 
The resultant site is quick (with a 28.8 kbps modem), rich in graphic interactivity and accessible using most browsers without plug-ins or additional software. Online work includes atlases of the brain, thoracic viscera and the knee, and a work-in-progress laboratory manual in neurodevelopment and neuroanatomy. One great feature: users can ask the name of a structure or answer a quiz question by clicking over the particular spot on the image. In the face of such a well-conceived technology, it is sacrilege to bring up its somewhat clumsy interface, limited graphical resolution, and non-intuitive graphical table of contents.
 
An equally impressive neuroanatomical reference is Harvard University's Whole Brain Atlas. Keith Johnson, MD, and MIT's J. Alex Becker compare MRIs, CTs, SPECTs, and other radiographs side-by-side and grouped by neuropathology, which makes this site particulary relevant to neuroradiology and clinical neurology students and educators. Resolution is near-perfect, and navigation is available not only across anatomic planes but also between different modalities and across time. The Atlas accommodates those desiring structured education by offering Tours within some disorders, where users click through a predetermined set of images and accompanying text. There is a link to a neuroimaging primer on the home page, and a separate slower-loading Java-based navigator atlas produces a window-based menu to ease navigation across the entire Atlas.
 
Java Man is a single Web page with two images: a model head on the left with an adjustable line controlling the brain's coronal cut on the right. This elegant product was developed by the University of Virginia Neurovisualization Laboratory, and it does help visualize the various brain structures within the head. Talajava, which allows users to define locations in the brain, requires a Netscape VRML plug-in. I was unable to access the images on Cal Tech's Interactive Volume Browser, reputed to be an in-depth guide to head and upper torso anatomy. It appears to be well designed, with many user controls.
 
Only the overview chapter of University of Pennsylvania's Basic Embryology Review Program is available to the public, but it is enough to encourage students to ask their universities for full access. The overview includes a nicely illustrated embryo thoughtfully labeled, all under the user's control. Three other universities have online samples of embryology projects: Duke University's Magnetic Resonance Microscopy of Embryos, Carnegie Collection's Visible Embryo Project, and UCSF's The Visible Embryo.
 
The University of Massachusetts' impressive Animated Tutorial on Biomolecular Structures requires downloading freeware. A number of MPEG and 3-D files along with requisite plug-ins are available from University of Iowa Division of Physiologic Imaging's 3-D Gallery and Application-Specific Tutorials.
 
The general anatomy available on Informative Graphic's Inner Learning may be of help to undergraduate and new medical students (and grease monkey wannabes should check out their sister project in automotive learning). Portions of Vesalius' Interactive Anatomy Project's surgical anatomy demonstrations use the Shockwave plug-in but the site is otherwise easily accessible though most browsers. University of Texas at Houston's The Interactive Ankle gives an axial view and the opportunity to label its various components.
 
Download Shockwave to appreciate the influence of each of 12 eye muscles and six cranial nerves on EyeSim by Rick Lasslo from UC Davis. Japan's Mie University offers interactive electron micrographs of Ultrastructure of the Skin. Those with more advanced browsers can probably listen on line to University of Kansas' Atlas of Heart Murmurs, University of Singapore's Cardiovascular Education, and Synapse Company's Heart Sounds!.
 
 
Sections Computer Assisted Instruction (including simulations)
Computer-assisted instruction (CAI), including simulators, should attract anyone who enjoys Dubin's EKG programmed instruction text or who find themselves joyous, guilt-ridden, or otherwise involved with their "magic highlighter" patient management cases.
 
Given the present level of computer sophistication and potential of this modality for medical instruction and practice, interactive learning has yet to be fully realized -- and with good reason. More than other types of medical education, good CAI requires a combination of (1) an excellent command of often complex medical content, (2) strong educational skills to incorporate user errors, common pitfalls, and feedback into the teaching scenario, and (3) sophisticated programming hidden behind an intuitive, transparent software design. Multimedia may add elements of believability, ease of function, or fun, but at the core of these Web sites and programs is solid teaching with skilled programming.
 
Spurred by industry and government grants and partnerships, many of these programs are used locally as adjunct learning within a medical school curriculum, but some have been made available for general distribution on the web or by software downloads as described below. Now that the Web supports powerful programming languages that cross-platform different servers and browsers, medical CAI is posed to actualize its potential, and take advantage of the Web's ease of distribution and accessibility. Even now, there are a number of excellent sites on line.
The granddaddy of online patient simulators, Marshall University's The Interactive Patient has perfected its sole 1995 case, which now runs quickly and without discernible bugs. Excellent features include fuzzy logic in history taking, audio auscultation of lungs and heart, and nicely resolved x-rays with a clever zoom feature. Unfortunately, the physical exam is clumsy to perform on line, and I've yet to receive my results in e-mail.
 
Southwestern Ontario Regional Academic Health Science Network's patient simulation, CE Trauma Case, combines an intuitive design with a well thought out educational approach, including a review of key steps in emergency procedures. See also Trauma Org, which has two excellent moulage scenarios, both requiring good reasoning and a sense of humor. University of North Carolina has begun a Neurosimulations site with a case of low back pain and leg weakness.
 
University of Utah's Knowledge Weavers houses several online clinical science tutorials, with many more in progress. At present there is an EKG tutorial, human reproduction series, an interactive skeletal section, a multiple sclerosis tutorial and two biochemistry tutorials: one, Biochemistry Animations requires a Shockwave plug-in to view animations on fatty acid processes and glycolysis/gluconeogenesis, and a second, the popular java-based clinical biochemistry simulator Frank from the University of Manitoba. Frank is not difficult to diagnose; the task is to highlight the correct findings and clinch the diagnosis, and in the process the user gains a nice clinical perspective of the disorder. The Java-based programming is quick and accurate, so much so that despite its solid educational value it was disappointing to use those cases at the Manitoba site that were not interactive.
 
Cyberpatient Simulator by NetMedicine, an extension of the popular EMBBS site for emergency medicine and primary care, showcases three adult and two pediatric cases. In general these simulations are fairly well designed, with an intuitive interface, clever image maps, and simple (if not boring) acute care algorithms. Unfortunately, the second adult Megacode simulator stopped functioning midway, permitting me to overdose the patient with epinephrine and lidocaine but refusing to let me perform any other action. Also, the diabetic patient in the first case was treated for chronic hypertension with oral diltiazem, while not far away banners advertising injectable diltiazem waved conspicuously.
 
User input (interactivity) can be either an integral part of a site's educational process or an essential aspect of the site's navigation, resource selection, and overall presentation. Although titled Patient Simulation, this page from the critically-acclaimed University of Iowa's Virtual Hospital is actually interactive presentations. It includes pediatric airway abnormalities, nuclear medicine in gastroenterology, and an unusually compelling resource: 30 case presentations of pulmonary embolism. Students and residents resistant to including pulmonary embolism within patients' differential diagnoses may come to appreciate PE's subtle presentation upon reading these patient vignettes and viewing the accompanying radiographs.
 
Medconnect's Interactive Education is a free resource offering many cases (most Java-scripted) for registered users. I wish the educational content were as consistent as its programming but several sections are solid, such as Selected Cases in Toxicology written by the Rocky Mountain Poison and Drug Center.
 
Kudos to Tulane's elegant Case Studies in Endocrinology, which demonstrate how much can be accomplished educationally with little gadgetry. Thoughtful features like direct e-mail to the author and repeating significant lab findings complement the short but excellent explanations. Another good example of a straightforward online educational resource is University of Florida's Geriatric Education. Here, two teaching cases and a short topics resource highlight medical student clinical issues such as mental status assessment, falls, and urinary incontinence. Other noteworthy clinically-oriented sites include University of Virginia's Pediatric Clinical Case Studies, which offers six short and two long (for CME credit) case studies. The University of Illinois at Chicago's Toxikon Project has excellent topical cases, thumbnail journal reviews, toxidromes and other site features, including a bulletin board. Five other cases can be found on EMBBS's Toxicology Corner, authored by New York City's Poison Center, as can Academic Emergency Medicine's Clinical Pearls. Sadly, its 19 emergency medicine cases --many with photos and all with excellent discussions -- seem to have been dropped in mid-case presentation over a year ago. Vanderbilt's Emergency Medicine Teaching Files also provides clinical pearls, by posting an x-ray or other graphic alongside its one-sentence case descriptions of mainstream yet important cases. The University of Texas Health Sciences at San Antonio's Trauma site includes a dozen or so cases presented with radiographs and some discussion.
 
Radiology has extended the specialty's education with online resources of interest to all physicians, residents and fellows. Of the many fine radiology educational resources online, several of the best are included here. Proof of the success of University of Hawaii's Radiology Cases in Pediatric Emergency Medicine is that Loren Yamamoto, MD, site creator, is now completing volume six. At present there are 100 case studies with accompanying radiographs. Users may improve image processing by downloading the site's files or requesting free software. The University of Washington's Radiology Webserver presents teaching files as known or unknown cases, for students and physicians (online CME available). BrighamRAD offers similarly excellent cases; for interactivity, select Find-The-Path files. Canada's LARGnet I-way groups radiographs within a case illustrating a specific illness. The resolution is far from ideal but multiple thumbnail images embedded within its 36 cases helps the download speed.
 
Pathology cases relate basic science to clinical practice and so serve a broad audience of students and physicians. Some pages use Shockwave and other plug-ins. The University of Pittsburgh's Pathology Case Index lists more than 100 cases by patient diagnosis (recommended) or history, all with nice graphics and satisfying exposition. The Uniformed Services of the Health Sciences offers CME credit for Pathology Cases for Diagnosis, but these 30 cases should offer a good review for students and pathology residents, too. New York University (NYU)'s Pathology Case Studies is slow loading, and the cases up at present are limited to hemopathology of lymph nodes and aspiration cytology of the breast. However, the site is notable for its sharp design and navigation, multiple slides/case, and accompanying summaries. The University of Virginia's Case Studies in Pathology approaches each of its 10 cases as unknowns (recommended) or by diagnoses. The University of Southern California's Renal Pathology site links case presentations with its tutorial, organized by clinical entity and presented in outline format. Gastrointestinal pathology is presented in case format from the Armed Forces Institute of Pathology's Virtual Gastrointestinal Endoscopic Biopsy Course. This site offers online CME credit, or slide review for students and specialists.
 
Most of Kansas University Medical Center's Clinical Medical Education is under construction, but the Cardiology section houses beginning atlases on EKGs and echocardiograms, and Dermatology includes graphics of skin disorders.
 
Loyola University Medical Education Network, LUMEN, has a number of hidden treasures amid its more traditional basic science (histology, anatomy, and neuroscience) and clinical (medicine and subspecialties) online offerings. For a "one animated GIF is worth a thousand HTML words" experience, visit Descent of Testes; for best effect let the animation load and then replay. A number of interesting questions appear on the most active of LUMEN's Web Forums, and not all were from the Structure of Human Body's excellent moderator, Dr. John McNutley. While technically flawed, the Web Forum has obvious educational advantages for at least the subset of computer-savvy students. Curiously, there is no forum activity for the Winter or Spring terms.
 
Several sites seem designed specifically with first and second year medical students in mind. Hundreds of gross and microanatomy specimens and illustrations are categorized by subject (soon by search engine) under Digital Slice of Life, a cooperative project with the Slice of Life office, KUED Media Solutions, and the Knowledge Weavers Project. Edward C Klatt, MD's WebPath is a popular resource of more than 1,800 high-quality images of gross and pathologic findings, with accompanying text, tutorials, and quizzes. Portions of Tulane's excellent Medical Pathology Course provide lectures with java-scripted links to clinically-related topics in pathology; sadly, not all are accessible to the general public. The University of Kansas has an interesting Pathology frames-based site, in that it uses the browser format to relate a number of educated activities along a top navigation panel: course objectives, slides, quizzes, an image search engine, and Medline. SUNY at Stony Brook's Hematopathology Tutorial presents Hodgkin's and Non-Hodgkin's lymphomas and plasma cell dyscrasias, accompanied by quick-loading microanatomy slides. The search engines and quizzes are temporarily unavailable.
 
Kansas' medical students created HistoWeb, another well designed frames-based site that provides hundreds of microscopic anatomical images. An innovative educational resource, University of Florida's Histology Review is a group of interactive tests, with excellent answers.
 
The University of Texas at Houston's Neurobiology Anatomy has been newly revised, and now includes lecture notes with graphics and charts on developmental and gross anatomy. The Levitt Radiographic Institute at Anderson Cancer Center has posted high quality but unlabeled gross anatomy dissections of the elbow, arm, hand, knee, and foot. The University of Washington's Anatomy Module List uses radiology teaching files in tutorials on selected extremity, temporal-mandibular joint, and skeletal anatomy.
 
Keith Bookstein of Tulane University created Neuroanatomy Study Slides with dozens of selected brain cuts in unlabeled, marked, and labeled formats. Another nice online resource for first year neuroscience students to review and self-test is Loyola's Two Neuroanatomy Laboratories: Diencephalon-Based Ganglia and Brainstem.
 
The University of Leeds' Biochemical Learning Resources offers a design-it-yourself glycolysis tutorial, monosaccharide browser and the preclinical case study Peter X University of Cape Town's Virus Ultrastructure is a wonderful introduction to viral microscopy.
 
Finally, the National Center for Biotechnology Information's The Human Genome Project is the online outpost for the ambitious task of sequencing human DNA. A highly interactive site for geneticists, this site also includes a treat for the rest of us: general mappings of each set of chromosomes, with examples and explanations of known inheritable disorders found to sit on that chromosome pair.
 
 
Sections Text-based
Unlike the above sites, which depend completely on sophisticated Web programming, the technology behind online medical education textual resources has been available on other parts of the Internet (Telnet, FTP sites) for decades. These sites are popular because they are easy to construct and because medical instruction via reading is familiar and does not require elaborate user hardware or software. Now, all resources can benefit from the Web's hypertext format, table and footnote references, embedded small GIF or JPEG images, search and storage capacities, and ease of international distribution and access. Fortunately, most physicians are too familiar with throwaway medical journals and too skeptical by training and experience to be dazzled by the pseudovalidation that technology or a Web site on the Internet sometimes brings.
Many medical schools use the Web to distribute educational resources to their students, but several have created whole repositories outlining their education curricula. A search engine has been recently added to Lecture Links, a partially public set of resources for Johns Hopkins medical students including course information, lecture notes, handouts, relevant links from outside the institution, and sample exams. The home page explains "the rationale for this Web site is that by collecting relevant links and organizing them in a time-critical format, students can be exposed to a wider range of educational materials than they would normally have time to seek out." Kansas University Medical Center provides a wonderful two year study guide to the major medical school courses. The site, typical of KUMC, is technically sophisticated and well-conceived. Each department's guide can be used with or without frames, and additional Web references are included. The University of Florida's Medical Education Server is an excellent online educational resource, menu-laden but with a number of innovative and well-executed departmental offerings. Sadly, on a revisit, this reviewer found that the vast majority of these resources are now password protected, but random resources are still available. One thoughtful interactive idea never fully realized: a Web page for students to submit questions for pharmacology professors to answer. The University of Virginia's Medical Education home page links to course information, medical education resources and an especially comprehensive set of medical Internet listings.
 
Clinical resources include Stanford/ UCSF Division of General Internal Medicine's Primary Care Teaching Modules, which share 17 clinical modules of review articles, case studies and quizzes with their colleagues and students. The University of Chicago's incomplete and often-dated Topics in Primary Care is a beginning resource with some helpful outlines. Its Primary Care Group Medicine home page is a frame-designed wonder, linking to most online journals and many clinical Web sites. EMBBS posts Robin Hemphill, MD's Clinical Reviews In-Depth, excellent reviews on asthma, diabetes ketoacidosis and nonketotic hyperosmolarity, acute renal failure, and toxic alcohols. Oregon Health Science University's Dr. Deloughery's Famous Handouts appears to be too good a resource to allow it to become dated. The University of Washington's Gynecologic Oncology Tutorial was designed for residents, but is also a nice text-and-graphics resource for med students and physicians. Less successful is Vanderbilt Pediatric Interactive Digital Library, which has a well organized but incomplete resource that has not been updated since 1995.
 
In England, the University of Birmingham's MedWeb Computer Assisted Assessment has banks of clinical and multiple choice questions, with answers a click away. Graphics are variable but several are beautiful and all are quick-loading. Ignore the request for student ID.
 
The University of Arizona's The Biology Project is a beautiful Web site with a large series of quiz tutorials on some of the more clinical aspects of basic sciences (biochemistry, cell biology, developmental biology, human biology, genetics, immunology, and molecular biology). Although designed for high school and college students, I suspect many medical students (and physicians) will find the material well-presented and an interesting review, if not challenging. Another excellent site, MIT's Biology HyperText may be helpful despite its dated references.
 
Among other worthwhile basic science sites, University of Rochester's Microbiology and Immunology has excellent introductory articles on virology, and includes a mirror site from the University of Leicester's well regarded lecture series and list links. Cornell University's Courseware includes strong course lectures on pathology, and some nice case studies with graphics and summaries (1996-97 answers still not posted). Washington University's Neuromuscular and CNS Syndromes is in outline and tabular format appropriate only for review, but links to NCBI's wonderful reference of genetic disorders, the Online Mendelian Inheritance in Man.
 
For those who prefer reading on line, Indiana State University's Web site includes William Anderson, PhD's Neurotext and Michael King, PhD's Medical Biochemistry, the latter with a search engine and occasionally links outside Web sites. Once learned, Biochemistry tests are available on the Uniformed Health Services Web site, divided into topics and including one timed exam. Allegheny University's NetBioChem aims to become the Biochemistry center on the Internet. Indiana University offers lecture note outlines (no graphics) on Gross Anatomy and Embryology. The University of Minnesota's Internet Self Assessment in Pharmacology offers course outlines and quizzes, but its big draw is drug flashcards for self-testing.
 
Two commercial sources of clinical information for physicians in training and practice: Medscape is an advertising-supported site full of clinical articles primarily from SCP Communications-affiliated journals. Strengths include online reference links following most articles and a clean intuitive interface. Some of the articles are top notch, but scholarship is spotty. The site also offers case presentations for CME credit. Another commercial site for free registrants, Avicenna's Outlines in Clinical Medicine provides outline form summaries categorized by specialty/diseases, and a bank of review internal medical questions, authored by Harvard-affiliated faculty. An arguably good idea with an impressive database on line, it is weakened by lack of peer-review and failure to update on an ongoing basis as promised in its introduction.
 
Johns Hopkins' medical house staff's semiannual Osler Medical Journal includes solid case studies, topic reviews, and basic and clinical science articles. The reference links have been fixed, and the November 1997 issue is now on line.
 
The University of Florida's Primary Care Baseline is largely successful in its creative adaptation of the ACLS algorithm format to a text-based interface. Unfortunately the content is uneven and several areas, such as wide-complex tachyarrhythmias and acute MI protocol, bypass critical diagnostic/treatment pearls together. Vanderbilt's Trauma Review of Initial Management is a one-page summary of the essentials of trauma resuscitation. Conceived to assist emergency medicine residents prepare for the Boards, Jonathan Handler, MD's Question-A-Day presents acute care questions and referenced answers according to selected weekly topics. It is accessible on line at NCEMI off their main menu, or as a daily e-mail treat (see instructions).
 
A project of the University of Dundee and the Cancer Relief Macmillin Fund, Helpful Links to Palliative Care presents issues surrounding pain, distressful symptoms, and doctor-patient communications from the perspective of, but certainly not limited to, cancer care.
 
The Internet Dermatology Society's Electronic Textbook of Dermatology is a thoughtful but uneven online text resource for nondermatologists containing slow-loading but nice graphics, many from the impressive University of Erlangen collection. Global Textbook of Anesthesiology is a well-constructed electronic textbook that seems to benefit from its academic/commercial collaboration. Although generally well-referenced, the articles are not peer-reviewed and scholarship is variable, as expected with any multiauthored text. The University of Queensland's Postgraduate Course Material includes some interesting articles from the Department of Anesthesiology and Intensive Care.
 
Finally, two extensive hypertext projects from the earliest days of the Web remain extremely popular today. The Virtual Hospital is a collection of online texts, cases, and other items classified according to information type, department, and organ system. The Medical College of Wisconsin's peer-reviewed Collaborative HyperText of Radiology, CHORUS, is a "quick reference" initially created to assist radiologists in subject review and for diagnostic decision support. User submissions are encouraged.
 
 
Sections Multiuser Discussions and Case Presentations
Rather than design solely for the single user, these clinical sites depend at least in part on online group contribution and collaboration. Sometimes, the result is a warm and open communal spirit between physicians and students throughout the world.
Online journal club-type sites are among the best Web offerings for physicians and physician-trainees. That Emergency Medicine News at Your Desktop has not posted since this summer is hopefully a temporary situation. For over a year it has summarized a half-dozen or more acute care journal articles, each with commentary and an occasional guest editorial. The excellent abstract summaries are written under editor Joseph Sachter, MD's tutelage by upper year housestaff from Brooklyn Hospital Center's Emergency Medicine Residency Program. Medconnect forces free registration on its readers, but also provides well designed interactivity so users can easily post and read others' comments. Journal Club on the Web is a perennial physician favorite. Two to three internal medicine articles are summarized monthly, concluding with thoughtful comments by Michael Jacobson, MD, site creator (and one of Medical Computing Today's editors). Its international audience provided an interesting discussion on partial left ventriculectomy (Batista procedure). The site has recently added a bulletin board. The Journal of Family Practice's Journal Club is a popular online resource for those who prefer less interactivity and a more evidence-based analysis. Each of the eight monthly articles is summarized by family physicians, educators and/or pharmacologists. This easily-navigated resource is at its strongest when it critiques the studies' limitations or highlights evidence-based statistics and reasoning. The American College of Physicians' ACP Journal Club teases users with a sample half dozen of their scholarly article reviews and commentaries. Group discussion is limited to ACP members.
 
CyberRounds has academic physician-moderators presenting topical and well-referenced articles and case studies in primary care and medical subspecialties. The database is small but growing. Users register free but must document physician status. An excellent resource for residents, fellows, and interested neurosurgeons, the University of North Carolina's Neurosurgery Internet Grand Rounds lists what must be 100 cases from Harvard's Massachusetts General Hospital, New York University, and Louisiana State University, coupled with a usually active bulletin board. Cases vary with the university, but almost all are excellent; the integration of resources and sophisticated interactivity makes this site a wonderful model for other specialties to emulate.
 
Web Interesting Case Conference, from Massachusetts General Hospital's Department of Emergency Medicine, presents a straightforward case, then solicits e-mail diagnoses prior to posting the diagnosis, most popular answers and the names of those who diagnosed correctly. The University of South Florida supervises a group of honors medical students as they posted cases and solicit users to submit diagnostic hunches. Bullseye! The Interactive Diagnostic Dilemma has a great deal of potential -- assuming the graduating group hasn't left this resource hanging. And the University of Colorado's Medical Rounds introduces a case, then a moderator adds information within an interactive discussion format. The site is buggy but the concept is visionary and the international audience seems to enjoy it.
 
Traditional basic science curriculums are based in deductive logic, but there is no a priori reason why induction is not equally appropriate. An adequate discussion and review of Web sites in Problem-Based Learning (PBL) could fill its own Medical Surfing Today. Those interested in a quick Web review of the practical aspects of PBL are frequently directed to a dated but helpful Web reference list on Problem-Based Learning.
 
 
Sections Continuing Medical Education
A rapidly growing number of universities, organizations, and companies accredited by the Accreditation Council for Continuing Medical Education (ACCME) as CME providers are offering online educational resources for physicians. Online CME combines the advantages of the educational resources described above with ease of modem registration and secure credit card transaction. The physician then submits answers to multiple choice questions after completing an article or multimedia presentation, or during and after a patient management case.
 
An annotated listing of online CME sites is maintained on Medical Computing Today.
 
The Internet can also be used to locate CME conferences. AMA's Online CME Finder is a useful database of more than 2,000 AMA PRA Category 1 activities, although software and online CME are poorly represented and the search engine is less than elegant.
 
 
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