A number of organizations [1- 3] have identified deficiencies in physician communication-skills training. Strengthening instruction in communication skills is a priority national objective for US medical schools [4]. Learning effective communication requires a cognitive foundation of interviewing theories and concepts [4]. A curriculum on communication concepts and strategies should provide understanding of fundamental skills and processes, and will establish a sound foundation for learning skills [4]. Such knowledge objectives have typically been best taught in years one and two of the curriculum [4]. Decentralization [5], a growing emphasis on adult learning principles, and use of distance education requires new thinking about curricular design and delivery. This paper reports our experiences with a new online method for teaching communication concepts to medical students.

Of the 10 students who started the course, one student dropped out of the course due to schedule conflicts, while 9 students completed the course and evaluations. Students made an average of 14 written postings during the 4-week course.

A qualitative analysis of the postings from course assignments consistently provided evidence of concept acquisition. A representative posting:

Major themes to emerge from the focus group are presented in Textbox 1.

Open-ended comments on the course evaluation form supported these themes, and provided more detail about advantages of online learning in this course over more conventional methods. Two students provided representative viewpoints:

The students completing this course participated at a high level and rated it highly on learning process and achievement of course goals. Our data suggests that it increased student understanding of basic concepts underlying effective clinical communication. The course's acceptance was in large part due to its congruence with principles of adult learning [11] such as self pacing, reflective learning, and collaborative learning from peers [11]. Participants noted a number of advantages of online learning. Although there are only rare examples in the literature of online courses on communication skills for medical professionals or students [12], this study does add to the growing literature in medicine and in fields outside of medicine [13- 15], suggesting the effectiveness of Internet-based distance education. However, more-rigorous evaluations with control groups and a larger number of participants are required to establish which factors and participant characteristics are determinants of effective learning. Medical-education studies generally show that Internet-based instruction is at least as effective as conventional methods [16- 18] and in some cases superior [19- 21]. However, a recent meta-analysis of Web-based learning in medical education did not find this method superior to conventional methods, but did acknowledge that studies are needed that better compare instructional methods rather than comparing instructional media, as has been the focus of many studies to date, rendering conclusions about the relative merits of online vs face-to-face methods difficult to make [22]. A carefully-designed, carefully-taught, and carefully-evaluated online course may effect better learning outcomes than face to face instruction [23]. Based on the limitations of research to date, it is clear that further work is needed to assess the impact and acceptance of small group online education, and the role of faculty or other moderators in online medical education courses [19,24- 26]. The acceptance of this method in a broader, unselected student population will be of interest. Evidence suggests that most learners will ultimately be successful online learners [27]. We also note that self report of learning is less reliable than direct measurement of knowledge acquisition. However, there was consistency of findings from the mixed-method approach used to evaluate this course. Given the favorable results from this elective, we plan to integrate elements of this online course into the preclinical-years' communication-skills curricula for use by all first-year students.

Jordan Cohen, the President of the Association of American Medical Colleges (AAMC), in a speech once exhorted medical educators to seize "the potential of the technological revolution to transform the way students learn" [28]. In response, we have developed a new method of introducing the cognitive basis for communication using electronic technology. It should also be applicable to other content areas and is likely to prove particularly useful as medical education becomes increasingly decentralized.