E-Learning, is there an evidence base?

When we set out to find an answer to a question we look to the most accessible option and rely on our inner confirmation biases to stop when we conclude that we have found what we are looking for.

An interesting adjunct to thinking about gaps in learning is the Dunning-Kruger effect which describes misplaced self-evaluation of skills sets both by low and high educational achievers, pithily summarised by Bertrand Russell who said that ‘the trouble with the world is that the stupid are cocksure and the intelligent are full of doubt.’

Doubt is a foundation stone of medical education. ‘Guessing’ is anathema. If you don’t know then ask someone who does. This is the cornerstone of patient referral guidance between generalists and specialists. In addition, we were often told that at graduation 50% of what we had learnt would be obsolete and that within 5 years of leaving medical school, all our knowledge would be out of date. It was therefore incumbent on us to maintain our clinical expertise employing any approach, which proved useful.

Presently there is growing interest in clinical e-learning, defined as ‘any educational intervention mediated electronically via the internet’. Usually incorporating some interactivity and active participation on the part of the learner, these courses are designed to be undertaken asynchronously and at a self-directed pace and time.

They have the added advantages of allowing students to access content remotely without incurring travel costs, providing rapidly updated course content, personalized instruction and allows spontaneous learning, when facing the demand of a new clinical query.

These benefits seem self-evident, but there are questions which remain such as, ‘are these courses any good?’ or ‘are we able to assert that learners find them useful?’ And perhaps most importantly, ‘Do they make a difference to outcomes?’

Interestingly the sequential answers to these questions seem to be ‘sometimes, yes and maybe’.

It has been found that well-structured e-learning based on high quality, up-to-date content can be relied upon by learners to provide them with answers to clinical questions and appropriate continuing professional development. Learners have also found that e-learning can be a valuable adjunct to their approaches to knowledge acquisition.

However, as to the question ‘does e-learning have a positive impact on patient care?’ There is conflicting evidence from published data. A meta-analysis published in 2009 asserted that e-learning was associated with ‘large positive effects’ notably improved skills of clinicians. In comparison a Cochrane review from 2018 concluded that although ‘no worse’ than standard learning methodologies e-learning there was ‘no difference between e-learning and traditional learning on patient outcomes at one year’. This included an evaluation of skills and knowledge.

Should we therefore conclude that e-learning may have merits for users but none for patients? Not quite. The Cochrane review admitted that the research underpinning their meta-analysis contained ‘very low certainty of evidence’. The jury may therefore be ‘out’ on patient benefits, but for clinicians quality e-learning is useful, important and delivers a key source of continuing professional development.