Every week, we email a case-based board-style question to tens of thousands of clinicians as part of our NEJM Knowledge+ Question of the Week program. Our initial offering focused on internal medicine, but we’ve expanded to include family medicine board review questions as well.

Each week, about 14,500 physicians answer our featured question — and the average score for those questions is just over 50%. As you might expect, we see a lot of variation from question to question — with some answered correctly by 80% of respondents and some by as few as 20%.

Respondents post comments related to the question, its answer choices, and the detailed feedback.  Some people point out ways that we can make the question better. Some provide feedback or ask for further information on the specifics of the question.

In the NEJM Knowledge+ product, we regularly rely on challenges from our learners to help us improve our content. And this happens in the Question of the Week discussion as well, but what most excites us is the dialogue — when a commenter makes a point or question, and another provides a thoughtful response with an “answer” or “solution.” We think it’s wonderful that the readers are learning from one another.

What Makes This Process an Online Learning Community?

Although the commenting process is asynchronous, respondents to Question of the Week are engaging with one another in close to real time: over the course of a week or two, dozens of comments fly back and forth, building on one another in a way that reminds us of forums, message boards, and other forms of online learning communities.

In forums and message boards (originally developed in the 1970s and thus the earliest examples of virtual communities) threads on far-ranging topics from video games to religion blossom over months and years, and members of these communities get to know one another. Social media groups and feeds have more recently added to the more traditional forums; they all thrive and become a way (maybe the primary way, for some people) to connect to other people in sometimes far-flung locations who work in the same field or have the same passion.

Online classrooms — often chunked up into small bite-size pieces — are also an immensely popular way to gain knowledge, mostly through videos published by both professionals and amateurs, and formal university-provided virtual classes. Physicians take advantage of online sources of continuing medical education and cite its convenience and low cost compared with flying to take a CME course. For some people, it may be more likely that they would make connections in online classrooms with a peer-to-peer network forum than in an in-person conference. Once the conference ends, are you going to “keep in touch” if you don’t have a designated place to meet? The asynchronous nature of online learning communities means that you can pop online when you have a moment, type in a comment or post a new thread, and check back later for responses.

Developing a Community of Practice

Through sharing knowledge and experience with the group, members learn from one another and develop in their field. Without an end-date in mind, members of an online learning community can continue to grow in breadth and depth, ever building on previously acquired information and skill.

The virtual community of practice of internal medicine and family medicine providers, as well as residents, PAs, and others that respond to Question of the Week, begins a new thread each week, touched off by the question itself.

Recently, we ran the following question on managing genital herpes:

Which one of the following treatment approaches is most appropriate for a woman with frequent outbreaks of genital herpes who wishes to reduce the likelihood of transmission to her uninfected female partner?

The correct answer was to initiate daily suppressive oral acyclovir, and we provided reasoning in the key learning point and detailed feedback.

Key learning point:

The most effective therapy for reducing the likelihood that a patient with frequent outbreaks of herpes simplex virus will transmit the virus to an uninfected sexual partner is daily suppressive treatment with oral acyclovir, famciclovir, or valacyclovir.

Detailed Feedback:

Herpes simplex virus (HSV) infection can be transmitted readily between sexual partners. Patients with frequent outbreaks of HSV, either type 1 or type 2, can opt for suppressive therapy. Oral acyclovir, famciclovir, and valacyclovir are all appropriate suppressive agents when used daily to prevent frequent outbreaks. Because subclinical viral shedding may occur in the absence of a visible ulceration, episodic therapy is much less effective than continuous suppressive treatment at reducing the number of risk days for transmission.

Topical acyclovir has no role as suppressive therapy for HSV.

Valganciclovir has antiviral activity against HSV (as well as against cytomegalovirus) but is not a first-line option because of its potential toxicity and the lack of need for a broadly active agent.

We observed a perfect example of a virtual community of practice in the dialogue that ensued in the comments:

Scott Helmers, MD, March 15, 2016 at 3:18 pm: If she has current ulcerations, is it not likely she has an active recurrence? She would certainly benefit from suppressive therapy, but is that sufficient for an active recurrence? Would there be benefit of initiating active treatment to be followed by daily suppressive dosage?

Mary Louise C. Ashur, MD, March 15, 2016 at 3:18 pm: There are three clinical issues in this case: 1) treatment of recurrent outbreak of herpes simplex virus (HSV) for the patient, 2) suppression of recurrent HSV for the patient, and 3) prevention of transmission of HSV to the partner.
Since this patient has a recurrent outbreak of HSV type 2, now with active labial ulcers, I would initiate episodic therapy before starting suppressive therapy to shorten the course and reduce symptoms. Episodic therapy should start within 48 hours of first symptoms — tingling, erythema, or herpetic lesion. There are various recipes for episodic treatment for recurrent HSV type 2 outbreaks; most often I use acyclovir 800 mg 3 times daily for 2 to 3 days; some use acyclovir 800 mg twice daily for 5 days; alternatively acyclovir 200 mg 5 times daily for 5 days is very well tolerated and inexpensive ($4 for 30 pills with no insurance at a pharmacy in a large department store chain). In men, 800 mg twice daily for 5 days probably has the best efficacy of shortening the duration of painful lesions. It should be noted that the same applies to HSV type 1 infection in the genitals.

After treating the recurrent outbreak, I would discuss with the patient initiation of a preventive suppressive daily regimen to both prevent recurrence and reduce the chance of transmission. After one or two years of daily suppression therapy, using shared decision making, the patient decides on whether or not to take a drug holiday from HSV suppressive treatment.

I counsel my patient to disclose to current and future sexual partners the history of HSV type 2, while explaining that she is doing all she can to prevent transmission of the virus.

Dr. Tareq Burgan, March 15, 2016 at 3:51 pm: Very good question, very easy answer, but I am sorry to say that we have expected to clear the two most important lingering questions:
1. For how long to give suppressive therapy? Lifelong?!
2. What is the dose of that therapy? Is 400 mg twice daily enough?

By the way, at present I have a male patient who has recurrent herpes in left gluteal region for >20 years. It is quite painful, radiating along the lower limb. Unfortunately, diagnosis was missed until 2 years ago. Recurrences used to be 2 to 3 times a year. I put him on acyclovir 400 mg twice daily, and luckily he had no recurrences.

The patient is very hesitant to stop the drug and see what happens. Accordingly, I asked my above mentioned question!

Grateful for any feedback.

Janaki Munasinghe, March 15, 2016 at 8:57 pm: I prefer Dr. Ashur’s method of treatment, initially treat the acute infection and then the suppressive therapy. It is explained nicely. Thank you, Dr. Louise.

Encouraging Engagement and Connection

We think the above thread is a prime example of Question of the Week acting as an online learning community. In medical education, learning communities of practice are an important way for clinicians to engage and connect with one another. In this online space, they can learn and gain valuable insights and disparate points of view.

If time allows, we like to join in these discussions by having our subject experts weigh in on questions from the community and by posting additional links to medical journal articles when appropriate. Sometimes it turns out that the question was not as straightforward as we initially thought, and it’s these fruitful conversations in each Question of the Week comment thread that allow us to see where a question, its feedback, or its citations can be improved — augmented by insights put forth by our learning community members. And unlike in the adaptive learning product itself (NEJM Knowledge+), where learners can offer comments to the editors as “challenges,” the comments section on Question of the Week offers a kind of forum for learners to engage with one another as well as the learning material.

We encourage readers to respond to Question of the Week with comments that can help us see how you are thinking and what you can provide to the discussion. A richer online learning community can ensue. We look forward to seeing and participating in these engaging conversations!

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