Peer assessment of professionalism in undergraduate medical education.

BACKGROUND: Fostering professional behaviour has become increasingly important in medical education and non-traditional approaches to assessment of professionalism may offer a more holistic representation of students' professional behaviour development. Emerging evidence suggests peer assessment may offer potential as an alternative method of professionalism assessment. We introduced peer assessment of professionalism in pre-clerkship phases of undergraduate medical education curriculum at our institution and evaluated suitability of adopting a professional behaviour scale for longitudinal tracking of student development, and student comfort and acceptance of peer assessment. METHODS: Peer assessment was introduced using a validated professional behaviours scale. Students conducted repeated, longitudinal assessments of their peers from small-group, clinical skills learning activities. An electronic assessment system was used to collect peer assessments, collate and provide reports to students. Student opinions of peer assessment were initially surveyed before introducing the process, confirmatory analyses were conducted of the adopted scale, and students were surveyed to explore satisfaction with the peer assessment process. RESULTS: Students across all phases of the curriculum were initially supportive of anonymous peer assessment using small-group learning sessions. Peer scores showed improvement over time, however the magnitude of increase was limited by ceiling effects attributed to the adopted scale. Students agreed that the professional behaviours scale was easy to use and understand, however a majority disagreed that peer assessment improved their understanding of professionalism or was a useful learning experience. CONCLUSIONS: Peer assessment of professional behaviours does expose students to the process of assessing one's peers, however the value of such processes at early stages of medical education may not be fully recognized nor appreciated by students. Electronic means for administering peer assessment is feasible for collecting and reporting peer feedback. Improvement in peer assessed scores was observed over time, however student opinions of the educational value were mixed and indeterminate.

A Phenomenological Study of Postgraduate Medical Trainees' Incidental Learning Experiences and Psychological Well-Being During the COVID-19 Pandemic.

BACKGROUND:  During the COVID-19 pandemic, postgraduate medical trainees contributed significantly to the healthcare workforce, as multiple vulnerabilities in the healthcare system and medical training were expounded. The burden of training, learning, and working at this time introduced unique psychological and emotional stressors within a context of generalized volatility and radically different ways to work and learn. This study explored postgraduate trainees' experiences with coping, managing, and learning during the COVID-19 pandemic. METHODOLOGY:  Using a phenomenological approach, semistructured interviews were conducted with an intradisciplinary sample (n = 8) of postgraduate trainees in Newfoundland and Labrador, Canada, between May and October 2022. Five researchers performed inductive and deductive thematic analysis to develop a coding structure and identify common themes. RESULTS:  The COVID-19 pandemic prompted the use of restrictive public health measures and an unprecedented shift from in-person to virtual learning. This affected trainees' exposure to normalized learning experiences, training rotations, and opportunities to learn from peers and staff. Certainly, trainees reported that virtual learning improved their educational experiences in unique ways, increased engagement and attendance, and enabled regular meetings and learning when in-person options were unavailable. Trainees also reported enhanced self-directed learning skills, greater ownership of and leadership in their education, and increased confidence and experience with virtual care. Some also reported a perceived increase in elements of emotional intelligence (e.g., self-awareness, empathy, and compassion). CONCLUSIONS:  Trainees reported a variety of incidental learning experiences from working and training during COVID-19. Although some experiences were challenging, there was a perception that such experiences led to new learnings that were beneficial to one's professional development and future career, as well as implications for future training provided to trainees. While there was a reported shift in the culture surrounding postgraduate trainees' health and safety, respondents also described the need for additional support for postgraduate trainees' well-being during a pandemic.

Patient Experiences With Virtual Care During the COVID-19 Pandemic: Phenomenological Focus Group Study.

BACKGROUND: Virtual care has expanded during the COVID-19 pandemic and enabled greater access and continuity of care for many patients. From a patient-oriented research perspective, understanding the patient experience with virtual care appointments is an important first step in identifying ways to better support patient use and satisfaction. OBJECTIVE: The purpose of this qualitative study was (1) to explore patients' experiences and perspectives with the adoption and use of virtual care during COVID-19 in Newfoundland and Labrador, Canada, and (2) identify the education and informational needs of patients to inform future strategies for supporting patient use of virtual care. METHODS: Using a phenomenological approach, we conducted a focus group interview with a purposive sample of patient representatives representing a cross-section of the population of the province of Newfoundland and Labrador. Five patient representatives were recruited from the Newfoundland and Labrador Support Patient Advisory Council and participated in the focus group. The focus group was conducted in February 2022 via videoconferencing technology. Using thematic analysis, we identified several recurrent themes that described respondents' experiences with the use of virtual care during COVID-19, as well as their perceptions of education and informational needs to support more effective patient use of virtual care. RESULTS: Respondents felt that virtual care is a beneficial addition to the health care system, enabling greater convenience and access to health care services. Key barriers and challenges in adopting and using virtual care appear to primarily arise from patients' lack of knowledge, understanding, and familiarity with respect to virtual care. Cost, technological access, connectivity, and low digital literacy were challenges for some patients, particularly in rural communities and among older patient population. Patient education and support were critical and needed to be inclusive, easy to understand, and include information regarding privacy, security, consent, and the technology itself. The types of patient education experiences regarded as most helpful included peer support and knowledge sharing among patients themselves. CONCLUSIONS: Beyond the COVID-19 pandemic, virtual care will have a continuing role in enhancing the continuity of care for patients through more convenient access. The education and informational needs of patients are important considerations in promoting the adoption and use of virtual care. Key education and informational needs and strategies were identified to enable and empower patients with the knowledge, digital literacy skills, and support to effectively use virtual care.

Use of Extended Reality in Medical Education: An Integrative Review.

Extended reality (XR) has emerged as an innovative simulation-based learning modality. An integrative review was undertaken to explore the nature of evidence, usage, and effectiveness of XR modalities in medical education. One hundred and thirty-three (N = 133) studies and articles were reviewed. XR technologies are commonly reported in surgical and anatomical education, and the evidence suggests XR may be as effective as traditional medical education teaching methods and, potentially, a more cost-effective means of curriculum delivery. Further research to compare different variations of XR technologies and best applications in medical education and training are required to advance the field. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-022-01698-4.

Virtual care and COVID-19: A survey study of adoption, satisfaction and continuing education preferences of healthcare providers in Newfoundland and Labrador, Canada.

Introduction: Virtual care has expanded during COVID-19 and enabled continued access to healthcare services. For many healthcare providers, the adoption of virtual care has been a new experience in the provision of healthcare services. The purpose of this survey study was to explore healthcare providers' experiences with virtual care during COVID-19. Methods: A web-based survey-questionnaire was developed by applying Rogers' theory of diffusion of innovation and distributed to healthcare providers (physicians, nurses and allied health professionals) in Newfoundland and Labrador, Canada to explore virtual care experiences, satisfaction and continuing professional development (CPD) needs. Analyses included descriptive statistics and thematic analysis of survey responses. Results: Fifty-one percent of respondents (n = 432) indicated they were currently offering virtual care and a majority (68.9%) reported it has improved their work experience. Telephone appointments were preferred over videoconferencing by respondents, with key challenges including the inability to conduct a physical exam, patients' cell phone services being unreliable and patients knowing how to use videoconferencing. Majority of respondents (57.5%) reported quality of care by telephone was lower than in-person, whereas quality of care by videoconferencing was equivalent to in-person. Main benefits of virtual care included increased patient access, ability to work from home, and reduction in no-show appointments. Key supports for adopting virtual care included in-house organizational supports (e.g., technical support staff), local colleague support, and technology training. Important topics for virtual care CPD included complying with regulatory standards/rules, understanding privacy or ethical boundaries, and developing competency and digital professionalism while engaging in virtual care. Discussion: Beyond the COVID-19 pandemic, virtual care will have a continuing role in enhancing continuity of care through access that is more convenient. Survey findings reveal a number of opportunities for supporting healthcare providers in use of virtual care, including CPD, guidelines and resources to support adaptation to virtual care provision (e.g., virtual examinations/assessments), as well as patient educational support.

Using mobile technology in assessment of entrustable professional activities in undergraduate medical education.

BACKGROUND: The adoption of competency-based medical education requires objective assessments of a learner's capability to carry out clinical tasks within workplace-based learning settings. This study involved an evaluation of the use of mobile technology to record entrustable professional activity assessments in an undergraduate clerkship curriculum. APPROACH: A paper-based form was adapted to a mobile platform called eClinic Card. Students documented workplace-based assessments throughout core clerkship and preceptors confirmed accuracy via mobile phones. Assessment scores for the 2017-2018 academic year were collated and analyzed for all core rotations, and preceptors and students were surveyed regarding the mobile assessment experience. EVALUATION: The mobile system enabled 80 students and 624 preceptors to document 6850 assessment submissions across 47 clinical sites over a 48-week core clerkship curriculum. Students' scores demonstrated progressive improvement across all entrustable professional activities with stage-appropriate levels of independence reported by end of core clerkship. Preceptors and students were satisfied with ease of use and dependability of the mobile assessment platform; however, students felt quality of formative coaching feedback could be improved. REFLECTION: Our preliminary evaluation suggests the use of mobile technology to assess entrustable professional activity achievement across a core clerkship curriculum is a feasible and acceptable modality for workplace-based assessment. The use of mobile technology supported a programmatic assessment approach. However, meaningful coaching feedback, as well as faculty development and support, emerged as key factors influencing successful adoption and usage of entrustable professional activities within an undergraduate medical curriculum.

A comparative evaluation of the effect of Internet-based CME delivery format on satisfaction, knowledge and confidence.

BACKGROUND: Internet-based instruction in continuing medical education (CME) has been associated with favorable outcomes. However, more direct comparative studies of different Internet-based interventions, instructional methods, presentation formats, and approaches to implementation are needed. The purpose of this study was to conduct a comparative evaluation of two Internet-based CME delivery formats and the effect on satisfaction, knowledge and confidence outcomes. METHODS: Evaluative outcomes of two differing formats of an Internet-based CME course with identical subject matter were compared. A Scheduled Group Learning format involved case-based asynchronous discussions with peers and a facilitator over a scheduled 3-week delivery period. An eCME On Demand format did not include facilitated discussion and was not based on a schedule; participants could start and finish at any time. A retrospective, pre-post evaluation study design comparing identical satisfaction, knowledge and confidence outcome measures was conducted. RESULTS: Participants in the Scheduled Group Learning format reported significantly higher mean satisfaction ratings in some areas, performed significantly higher on a post-knowledge assessment and reported significantly higher post-confidence scores than participants in the eCME On Demand format that was not scheduled and did not include facilitated discussion activity. CONCLUSIONS: The findings support the instructional benefits of a scheduled delivery format and facilitated asynchronous discussion in Internet-based CME.

A longitudinal study of the effect of an interprofessional education curriculum on student satisfaction and attitudes towards interprofessional teamwork and education.

There has been limited research on the effect of interprofessional education (IPE) over time on the attitudes of undergraduate health and human service professional students. Previous research in this area has suggested that students from different professions report differing attitudes towards IPE and interprofessional teamwork, and such attitudes may also be influenced by other background characteristics of the students themselves (e.g., gender, age). The purpose of this study was to evaluate the longitudinal effect of the introduction of an IPE curriculum on students' attitudes towards IPE and teamwork. A time series study design was conducted to assess the attitudes of undergraduate health and human service professional students towards IPE and teamwork, and students were also asked to complete satisfaction surveys after IPE curriculum activities. Significant differences in the attitudes of students from different professions and their satisfaction with participation in IPE were reported over the duration of the study. Overall, student satisfaction with IPE participation was relatively positive; however the introduction of IPE curriculum during their undergraduate education did not appear to have a significant longitudinal effect on attitudes towards IPE or interprofessional teamwork. The findings have implications for the design and integration of IPE curriculum within existing uni-professional curriculum.

Student satisfaction and perceptions of small group process in case-based interprofessional learning.

BACKGROUND: The small group, case-based learning approach is believed to be a useful strategy for facilitating interprofessional learning and interaction factors are said to have a significant effect on student interest, learning and satisfaction with such approaches. AIM: The purpose of our study was twofold: assess students' satisfaction with a blended approach to interprofessional learning which combined computer-mediated and face-to-face, case-based learning; and examine the relationship between student satisfaction and perceptions of the collaborative learning process. METHOD: We introduced six interprofessional learning modules to approximately 520 undergraduate health professional students from medicine (61), nursing (351), pharmacy (20), and social work (89). All students were invited to complete an evaluation survey which assessed student satisfaction with the interprofessional learning experience and students' perceptions of the small group learning process. RESULTS: Students' satisfaction with interprofessional education was related to professional background. Students from across professions reported greater satisfaction with face-to-face, case-based learning when compared with other learning methods. A more positive perception of face-to-face, case-based learning was related to greater satisfaction with interprofessional learning. CONCLUSIONS: The findings support the case-based method in facilitating interprofessional learning and highlight the importance of effective facilitation of small-group collaborative learning to enhance student satisfaction with interprofessional learning experiences.

Evaluation of the Characteristics of a Workplace Assessment Form to Assess Entrustable Professional Activities (EPAs) in an Undergraduate Surgery Core Clerkship.

OBJECTIVE: Entrustable Professional Activities (EPAs) are explicit, directly observable tasks requiring the demonstration of specific knowledge, skills, and behaviors that learners are expected to perform without direct supervision once they have gained sufficient competence. Undergraduate level implementation of EPAs is relatively new. We examined the characteristics of a workplace assessment form (clinic card) as part of a formative programmatic assessment process of EPAs for a core undergraduate surgery rotation. DESIGN: A clinic card was introduced to assess progression towards EPA achievement in the clerkship curriculum phase. Students completing their core eight (8) week clerkship surgery rotation submitted at least 1 clinic card per week. We compiled assessment scores for the 2015 to 2016 academic year, in which EPAs were introduced, and analyzed relationships between scores and time, EPA, training site, and assessor role. We surveyed preceptors and students, and conducted a focus group with clinical discipline coordinators of all core rotations. SETTING: This study took place at the Faculty of Medicine, Memorial University in St. John's, Newfoundland, Canada. PARTICIPANTS: Third year medical students (n = 79) who completed their core eight (8) week surgery clerkship rotation during the 2015 to 2016 academic year, preceptors, and clinical discipline coordinators participated in this study. RESULTS: EPAs reflecting tasks commonly performed by students were more likely to be assessed. EPAs frequently observed during preceptor-student encounters had higher entrustment ratings. Most EPAs showed increased entrustment scores over time and no significant differences in ratings between teaching sites nor preceptors and residents. Survey and focus group feedback suggest clinic cards fostered direct observation by preceptors and promoted constructive feedback on clinical tasks. A binary rating scale (entrustable/pre-entrustable) was not educationally beneficial. CONCLUSIONS: The findings support the feasibility, utility, catalytic and educational benefits of clinic cards in assessing EPAs in a core surgery rotation in undergraduate medical education.

Evaluation of the usefulness of simulated clinical examination in family-medicine residency program.

BACKGROUND: This study reports on an evaluation of the usefulness of the Simulated Clinical Examination (SCE) method as a means of assessing the clinical-skill competencies of entering Postgraduate year 1 (PGY1) family-medicine residents. METHODS: PGY1 family-medicine residents participated in a SCE encompassing clinical encounters with standardized patients. Residents were asked to complete pre-evaluation and post-evaluation surveys, and faculty and residents participated in separate focus groups. RESULTS: The SCE was perceived as a useful method during the early phases of postgraduate training for assessing clinical-skill competencies, providing constructive feedback to residents, enhancing self-awareness, and enhancing confidence. CONCLUSIONS: This exploratory study suggests that the SCE, as an assessment method, can have beneficial effects on learning and the fostering of clinical-skill competencies during postgraduate training.

A comparative analysis of the perceived continuing medical education needs of a cohort of rural and urban Canadian family physicians.

OBJECTIVE: To assess the perceived continuing medical education (CME) needs of a cohort of Canadian family physicians. METHODS: We distributed a questionnaire survey to Canadian family physicians who became Certificant members of the College of Family Physicians in 2001 and practised outside the province of Quebec. Main outcome measures were self-reported CME needs, professional development needs and preferences for CME delivery methods. RESULTS: We distributed 482 surveys and 197 questionnaires were returned for a response rate of 40.9%. Significant differences between rural and urban respondents' self-reported CME needs were found in the clinical areas of dermatology, endocrinology, emergency medicine, musculoskeletal, ophthalmology, otolaryngology, psychiatry and urology. Generally, a greater proportion of rural respondents reported significantly higher CME needs in emergency medicine. Urban respondents reported a significant preference for consulting colleagues as a method of CME, while rural respondents reported a significant preference for videoconferencing. CONCLUSION: Self-reported CME needs and preferences for CME delivery methods differ on the basis of region of practice and size of the community in which family physicians' practise.

A survey of rural medical education strategies throughout the medical education continuum in Canada.

In many countries the sustainability of rural health care systems is being challenged by a shortage of rural physicians and difficulties in recruiting and retaining physicians in rural practice. Research does suggest that specific medical education strategies can be introduced to enhance rural physician recruitment and retention initiatives. The purpose of this paper is to summarize the current strategies of Canadian rural medical education programs. A survey of all Canadian medical schools was undertaken to profile specific programs and activities at the undergraduate, postgraduate, and continuing medical education/continuing professional development (CME/CPD) levels. The majority of medical schools reported either mandatory or elective rural medicine placement/learning experiences during undergraduate medical education, as well as Rural Family Medicine streams or programs as components of postgraduate medical education. The majority of medical schools reported that they provide clinical traineeships to enhance clinical competencies in rural medicine as well as CME outreach programming, including the use of telehealth or distance learning technologies. Canadian medical schools all have substantial programs covering the full range of approaches found in the literature to help recruit and retain rural physicians. Not surprisingly, the most extensive programs are found in medical schools that have a specific rural mandate.

Tele-education.

Tele-education has been used for many years to deliver continuing education programmes to rural health-care professionals. The main modes are audio, video and computer. Audio technologies involve the transmission of the spoken word (voice) between learners and instructors, either synchronously or asynchronously. Examples of the former include audioconferencing and short-wave radio; examples of the latter include audiotape or audiocassette. Video for distance learning, like audio, can be used in either synchronous or asynchronous fashion. Videoconferencing, or interactive television, are considered synchronous because there is the opportunity for live visual and verbal interaction between instructors and learners. Asynchronous instructional video tools include slow-scan video, interactive videodiscs and videotapes. Computer-assisted learning or instruction can be defined as any learning that is mediated by a computer and which requires no direct interaction between the user and a human instructor in order to run. It is becoming increasingly common. Examples include: the Internet and World Wide Web, email, synchronous and asynchronous computer-mediated communication applications and interactive multimedia applications on CD-ROM. Tele-education technologies have an important role to play in addressing the professional isolation which is experienced by rural and remote health-care professionals.

A comparison of face-to-face versus remote assessment of neonatal resuscitation skills.

The neonatal resuscitation skills of 30 third-year medical students were assessed in real time by a face-to-face examiner in the same room as the student, and by a remote examiner located in a separate room using the ANAKIN system. The ANAKIN system combines an instrumented manikin simulator, computer-based assessment and high-bandwidth videoconferencing. The students were assessed while performing a neonatal resuscitation megacode using the ANAKIN system. Students were satisfied with the ANAKIN system as an assessment system and were not intimidated by its use. However, the correlation between the face-to-face and remote examiner's mean total performance assessment scores was 0.27, which was not significant (P=0.14). The results indicated variation between the examiners' performance scores in a number of key technical skill areas. The findings from this study have implications for the use of technology-mediated systems in assessing resuscitation skills. Examiner orientation is critical for individuals using such systems. These persons must be comfortable and confident in using the technology. Interface and design features of the system need to be carefully scrutinized and tested.

Rural professionals' perceptions of interprofessional continuing education in mental health.

We describe the impact of an interprofessional education programme in mental health for professionals in six rural Canadian communities. The 10-session programme, offered primarily via videoconference, focussed on eight domains of mental health practice. One hundred and twenty-five professionals, representing 15 professions, attended at least some sessions, although attendance was variable. Data were collected between September 2006 and December 2007. The programme was evaluated using a mixed methods approach. Participants reported high levels of satisfaction for all topics and all aspects of the presentations: they were most satisfied with the opportunity to interact with other professionals and least satisfied with the videoconference technology. Professionals' confidence (n = 49) with mental health interventions, issues and populations was measured pre- and post-programme. There was a significant increase in confidence for seven of the eight mental health interventions and four of the six mental health issues that had been taught in the programme. Participants reported developing a more reflective mental health practice, becoming more aware of mental health issues, integrating new knowledge and skills into their work and they expressed a desire for further mental health training. They noted that interprofessional referrals, inter-agency linkages and collaborations had increased. Conditions that appeared to underpin the programme's success included: scheduling the programme over an extended time period, a positive relationship between the facilitator and participants, experiential learning format and community co-ordinators as liaisons. Participants' dissatisfaction with the videoconference technology was mitigated by the strong connection between the facilitator and participants. One challenge was designing a curriculum that met the needs of professionals with varied expertise and work demands. The programme seemed to benefit most of those professionals who had a mental health background. This programme has the potential to be of use in rural communities where professionals often do not have access to professional development in mental health.

Attitudes of health sciences faculty members towards interprofessional teamwork and education.

OBJECTIVES: Faculty attitudes are believed to be a barrier to successful implementation of interprofessional education (IPE) initiatives within academic health sciences settings. The purpose of this study was to examine specific attributes of faculty members, which might relate to attitudes towards IPE and interprofessional teamwork. METHODS: A survey was distributed to all faculty members in the medicine, nursing, pharmacy and social work programmes at our institution. Respondents were asked to rate their attitudes towards interprofessional health care teams, IPE and interprofessional learning in an academic setting using scales adopted from the peer-reviewed literature. Information on the characteristics of the respondents was also collected, including data on gender, prior experience with IPE, age and years of practice experience. RESULTS: A total response rate of 63.0% was achieved. Medicine faculty members reported significantly lower mean scores (P < 0.05) than nursing faculty on attitudes towards IPE, interprofessional teams and interprofessional learning in the academic setting. Female faculty and faculty who reported prior experience in IPE reported significantly higher mean scores (P < 0.05). Neither age, years of practice experience nor experience as a health professional educator appeared to be related to overall attitudinal responses towards IPE or interprofessional teamwork. CONCLUSIONS: The findings have implications for both the advancement of IPE within academic institutions and strategies to promote faculty development initiatives. In terms of IPE evaluation, the findings also highlight the importance of measuring baseline attitudinal constructs as part of systematic evaluative activities when introducing new IPE initiatives within academic settings.

Factors influencing rural health care professionals' access to continuing professional education.

OBJECTIVES: The purposes of this study were to explore the perceived barriers and challenges to continuing professional education (CPE) access for Canadian health care professionals and to identify best practices for improving access to CPE. DESIGN: Key informant interviews and Web-based online surveys were conducted. PARTICIPANTS: Key informant interviews were conducted with national CPE accreditation bodies and health professional associations. An online survey was distributed to health professional education programs, as well as provincial professional associations, licensing and professional regulatory bodies. MAIN OUTCOME MEASURES: The perceived barriers and challenges to CPE access for Canadian health care professionals and best practices for improving access to CPE. RESULTS AND CONCLUSIONS: Geographic isolation and poor technological and telecommunications infrastructure were identified as key barriers to CPE delivery and access. Financial factors, such as funding to support travel or cost of attendance, were also identified as major challenges. Tele-education programming was identified as a best practice approach to improve CPE access, as were regional CPE activities and self-directed learning programs. Employer-sponsored initiatives, including staff coverage or locum support, remuneration for time off and paid travel expenses for CPE participation were also identified as best practice approaches.

A review of evaluation outcomes of web-based continuing medical education.

INTRODUCTION: The Internet and worldwide web have expanded opportunities for the provision of a flexible, convenient and interactive form of continuing medical education (CME). Larger numbers of doctors are accessing and using the Internet to locate and seek medical information. It has been suggested that a significant proportion of this usage is directly related to questions that arise from patient care. A variety of Internet technologies are being used to provide both asynchronous and synchronous forms of web-based CME. Various models for designing and facilitating web-based CME learning have also been reported. The purpose of this study was to examine the nature and characteristics of the web-based CME evaluative outcomes reported in the peer-reviewed literature. METHODS: A search of Medline was undertaken and the level of evaluative outcomes reported was categorised using Kirkpatrick's model for levels of summative evaluation. RESULTS: The results of this analysis revealed that the majority of evaluative research on web-based CME is based on participant satisfaction data. There was limited research demonstrating performance change in clinical practices and there were no studies reported in the literature that demonstrated that web-based CME was effective in influencing patient or health outcomes. DISCUSSION: The findings suggest an important need to examine in greater detail the nature and characteristics of those web-based learning technologies, environments and systems which are most effective in enhancing practice change and ultimately impacting patient and health outcomes. This is particularly important as the Internet grows in popularity as a medium for knowledge transfer.