Validation of knowledge is more and more under the supervision of governments with their own requirements of nationally approved CME for physicians in order to maintain medical licensure. In the United States, the accreditation of CME activities is provided by the Accreditation Council for Continuing Medical Education (ACCME) . Today the Internet represents one of the typical means of obtaining CME. With the geometric expansion of information exchange via the Internet, online CME activities have become a new, inexpensive, and convenient way of obtaining CME credit hours. According to the 2003 Annual Report from the ACCME, 8,376 CME activities were obtained (275 were available online, for a total 34,535 credit hours). These opportunities were characterized as both live online webcast and/or enduring materials, directly or jointly sponsored.
At present, the WebSurg website offers 24 hours of category 1 credit through different accredited educational sessions with the partnership of the University of Mc Master University (Canada). In 2004, 467 website members validated a number of 1,120 CME credit hours. The WebSurg chapters comply with the requirements of the ACCME, since they are structured like a self-containing learning program that can be viewed independently. Self-assessment questions in the form of a posttest follow each learning session and provide the validation of major concepts in the learning activity.
Web-based learning is considered an effective, well-accepted, and efficient means of educating physicians . It allows for fast access to information, which has never been realized before. However, the credibility and reliability of this information remains a factor that the physician must confirm while obtaining this information on the Web. Furthermore, many of the Web evaluation systems commonly evaluate a website, not just a webpage. For example, a website may fulfill all the requirements for an acceptable site, but then only offer various degrees in the quality of information given. Therefore, with the current Web evaluation systems, a verification of the whole site is not possible, nor is the attribution of a guarantee of quality to the whole site possible. Because of this, CME chapters must be validated one after the other for their entire content, which has sometimes to be partially rewritten or re-edited to reflect the standard practice but not the innovative technique. Therefore, an entire website cannot be validated for CME globally.
In the evaluation of websites, the number of active members and pages viewed are not as important as the total number of returning visitors. The number of registered members and pages viewed cannot be considered the major indicator of guaranteeing quality for any website. The total number of returning visitors may appear to be a good token of satisfaction concerning the quality of the scientific surgical content provided. As an example, the website, www.websurg.com has over 35,000 registered members and 17,474 active members who get connected to the website more than one time in a 12-month time span. In our example, the number of returning visitors has increased 1,118% on a monthly basis, from 428 in January 2004 to more than 5,000 in December 2004 (Fig. 4.4). This is apparently related to the diffusion of regularly renewed live videos of surgical procedures. This high rate of return of visitors means that surgeons, when looking for a specific piece of information on the website, consider the content of the site as credible and reliable, allowing them to return on the website for further information.
The sense of quality is also correlated with the Internet connectivity and access speed dependent on the technology used for hosting and streaming of information. WebSurg has chosen a high-quality professional hosting center. France Telecom technology offers dedicated servers, allowing high-speed connection as well as security and firewall systems. This has been made available thanks to redundant server, load balancer, and a support service working 24 hours a day. The content delivery network is ensured by the Akamai Platform, allowing the streamlining and broadcasting of videos and operative technique chapters all over the world through 14,000 servers located in 65 countries.
The global quality of the website is also reinforced as all partners, contributors, and users are in agreement.
The factors that may compromise the reputation of an information media source were listed by Davis et al. :
• Publishing material not subjected to a rigorous peer review process
• Apparent favoritism towards specific authors, institutions, or even topics
• Strategic placement or advertisement next to relevant articles
• Frequent publication of symposia or of single products
• Product placement in report on supposedly independent studies
• Promotion of sectarian interest disguised as independent commentary
• Failure to disclose conflict of interest
"Transgression in any of these areas leads to a rapid diminution of trust in the journal's standards and thus a falling reputation, a downwards spiral to mediocrity and scientific marginalization" . Therefore, editors and authors must acquire and comply with the constraints of reading on the Internet. The way of presenting information has to be adapted, the text shortened, and the imagination stimulated for a new way of illustration. The peer review process must also be adapted to this type of format. The most original part of Web-Surg's Virtual University is the possibility of adding videos of experts' opinions in a form of peer review. Therefore, reviewers do not influence the content, but have the possibility to add further information in order to moderate the conclusions made by the authors. In fact, the functions of a website owner and editors of that site must be different in order to avoid any con flict of interest. Advertisement has to be separated from the scientific content. This aspect pinpoints the issue of the funding of websites. Educational websites are not to be compared to the "business-to-consumer" model. Independent institutions have to establish a clear partnership with industries, universities, and government institutions to have the possibility of keeping their independence in the development of the website. The Internet represents an entirely new media with an unlimited potential to create, manage, and distribute knowledge. With this in mind, the re-engineering of the knowledge base of a standard university led to the concept of World Virtual University as a service institution for surgeons. Typically, a single institution cannot provide all the data for education in any topic. The Virtual University Institution structures and categorizes knowledge by managing the data available. The role of the Virtual University is to diffuse this knowledge to its participants in the most efficient manner possible.
WebSurg, with approximately 30,000 monthly visitors' sessions, represents an original contribution to what is now referred to as multimedia e-learning and e-training by using the latest technologies to display videos, texts, and illustrations simultaneously. To achieve such goals, it must be noted that the extraordinary influence of WebSurg is the result of significantly great effort put into the project by professionals as well as significant costs. In fact, the development of www. websurg.com has required a financial investment of $20 million over a 5-year period, involving over 45 fulltime salaried employees. The success can only be the result of professional self-commitment and positive attitude.
The dramatic worldwide increase in bandwidths helps to increase the speed of this information, as it is displayed and stored all over the world. It will certainly help in the development of nations that had, until recently, under-equipped transmission systems, such as China or India. It is countries and cultures such as these that now represent the future economic power of the world due to their size as these two countries alone represent a third of the worldwide population. The very nature of the Virtual University, with its multilingual abilities, follows this and other growing trends to educate the surgeons of today and the future.
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