These interactions and the variety of possible combinations, while beneficial for learners, create major study design problems and potential confounders when conducting research on the effectiveness of any single dimension or sets of dimensions. Was knowledge gained because of multimedia interventions or single vs multiple exposures or because multimedia may simply represent multiple exposures to the same content? Cook64 discussed these design issues in the context of conducting research on computer-based instruction. Using a slightly different taxonomy, he identified the following four dimensions of educational interventions that need to be controlled across experimental and control groups when comparing different instructional interventions: the medium (eg, classroom, audiotapes, Web based), the configuration (eg, discussion boards, tutorials, simulations), the instructional method (eg, practice, feedback), and the presentation (eg, color, sound, fidelity). To understand the unique contribution of each dimension (or specific sets of dimensions), the researcher must vary only one dimension (or set) at a time, holding the other dimensions constant. Comparisons must be made within dimensions and not between dimensions to avoid confounding variables. Even a perfectly designed and executed randomized clinical trial is still subject to confounding variables if the interventions being compared differ in multiple ways. Two of the main problems encountered in the studies reviewed were the heterogeneity of the dimensions across studies and the presence of confounding variables. A more systematic approach is needed to better assess the unique and combined contributions of media, techniques, and frequency of exposure and their impact on outcomes, including physician knowledge and performance and patient outcomes following CME interventions. Much of the research conducted in CME, and medical education in general, is done in isolation and on an opportunistic basis because of either available funding or an investigator's passing interest. Programmatic and collaborative research is needed to better assess the unique and combined contributions of the various dimensions of CME,65 such as media, techniques, and frequency of exposure.