The Orthopaedic Surgeon and the Internet
Myles Clough
Clinical
Instructor, University of British Columbia
| Let me take you through a recent personal occurrence. October 14th 2000 I
was on call and this ten year old girl was referred
to me. She had been diagnosed as having Slipped Capital Femoral Epiphysis in September and
on 22nd of September had in situ screw
fixation with a cannulated screw done by a colleague. She had got tangled in her crutches
and fallen down some steps now
she has a subtrochanteric fracture through the screw hole. It’s not the sort of
injury you can leave alone although treating in traction is a possibility. My concern was
that removing the screw to do a DHS would perhaps compromise the treatment of the SCFE and
allow further slip or promote AVN |
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I’ve been in general orthopaedic practice for 20 years and have
treated 2 or 3 cases of SCFE. A Toronto study noted one such complication in 380 hips
treated by screw fixation for slips. This is a rare complication of a rare condition. But
rare things occur commonly! You don't know just which one! You have to have a strategy for
dealing with something you have never seen before and have never thought about.
So I formulated a plan, scanned some pictures and sent a message to the
Orthopaedic mailing list to ask what the members thought of it. Here are the responses. I was impressed with these suggestions, particularly
the idea of a blade plate providing compression of the fracture without disturbing the
screw.I summarized the responses and added the address
of the Medline bibliography I had searched. Finally I went ahead and fixed the
fracture with a blade plate and sent a post-op picture to the
mailing list to let people know what I decided to do.
I’m going to assume some familiarity with the features of
the Internet, which make it a valuable tool for communication and academic activity. So I
anticipate no blank looks when the terms email, web page, links and web browser are
bandied around. What about “mailing list”? This
is a useful internet institution in which a message sent to the “list” is
automatically emailed to all members of the list. In
orthopaedics there are three prominent mailing lists for
the discussion of orthopaedic topics – Orthopod, for general subjects, Hand, for hand
surgery and Sports Medicine.
The first topic for discussion offered when the Orthopod
Mailing list was formed in 1997 was “The Internet renders the current methods of
teaching orthopaedics obsolete”. It was
a deliberately provocative assertion and drew the expected defense of the status quo and
some passionate statements about the value of bedside teaching and the need for practical
experience. If I willingly concede these points and focus on the academic or learning part
of orthopaedic education I would refocus the contention –
“The Internet will transform the process
of learning and organizing orthopaedic information”. Are
meeting like this, where we interact with giants of the orthopaedic world obsolete? Is the
Journal of Bone and Joint Surgery a dinosaur? What about textbooks? Are lectures, seminar series, grand rounds and
resident’s presentations still the best way to put over orthopaedic information? Because they are no longer the only way.
The short answer is that an Internet extension can vastly
improve the educational experience offered by any of these teaching vehicles. The long
answer - this is the long answer!
Consider for a moment the fate of most lectures. Someone, just like
you, has, willingly or not, chosen a topic, read
up the subject, organized it, compiled a bibliography and done a review. The words and
pictures have been chosen and the whole becomes as polished a work of scholarship as
inclination , time, resources and talent may allow. The big moment arrives Then what
happens? The delivery sails out over the
sleepy heads of the audience into null-space and is lost. Only a shadow of this scholastic
endeavour is ever retained in the memories of the listeners or their scrawled notes. This
daily wastage of effort is stupendous when you think how many times and in how many places
this scene is played out. Like the Dupont
Institute Grand Rounds, teaching hospitals should ensure that these scholastic
activities are preserved on the Internet where they can be revisited.
Nor is the need for orthopaedic education quite the same as it
was. It is true that anatomy, pathology and disease processes have stayed the same but our
understanding of them, the techniques for
treating them and our knowledge of how we influence the outcomes, has changed
dramatically. I once tried to work out which operations I still do using the exact technique I was taught, and only
compression plating came to mind! So we no longer only fill up with knowledge during our
training and use it forever; we learn the
basics and the skills of continuous assessment and re-evaluation of the environment in
which we work. We learn to learn. All that changes, after we get “trained”, is
that we may lose the day to day access to teachers, scholars and libraries as we leave the
teaching environment. So at the same moment in the history of medicine that we are threatened with information overload, we
have also become aware of the need to keep current and have
been presented with amazing new methods for disseminating and organizing information.
For all the manifest improbabilities of the StarTrek world no one is in the least bit surprised that Dr
“Bones” McCoy (himself no friend to technology) gets the information he needs to
fight interstellar disease through a computer network. The United Federation of Planets
equivalent of the Internet serves to provide him with up
to date, searchable and abstractable information as he needs it. If technological civilization survives
for the next 200 years it is a virtual
certainty that this view of the future will become reality. Why? Because the amount of knowledge that we each need
to provide our patients with the best treatment has grown far larger that any individual
can maintain, because the complexity and pace of
change in our subject is steadily increasing and because the
electronic tools to maintain and organize the orthopaedic knowledge base already exist. If
anything can be foretold you can believe this
– the need to transform the
communication and dissemination of information will be answered. Like the inhabitants of Gutenberg in 1455 watching
the first printing press, we stand on the threshold of enormous change. And that is food
for thought; the Renaissance that followed the introduction of printing was interesting,
but hardly peaceful.
So the orthopaedic education and communication system now is based on
paper and the spoken word but will be transformed over the next 200 years (or less,
probably a lot less!). Let us take a moment to envisage the requirements of the electronic orthopaedic information system which
will deliver current, accurate and comprehensive
information to whomever needs it, whenever
they recognize and define that need.
The most fundamental need is, of course, that some people have
considered the subject, done research or reviews about it and
have stored the results of this scholarship on the network. A number of secondary
considerations arise at once – who are
these people and are their opinions and scholarship trustworthy? How current is the
information? Are there hidden influences or financial angles? What, in summary, is the
provenance of the information? Still, the fundamental requirement is that the information
is available.
Another fundamental need is an academic institution capable of speaking for orthopaedics and providing
guidelines for the management of the information system. This institution must be international in nature since both the information
and the network derives from all parts of the globe. Indeed, any attempt to make the
Internet parochial is bound to fail. There is a lot of mistrust of the motives of people
on the Internet so the institution must be academic in nature rather than commercial. This
doesn’t mean necessarily that it operates for free; clearly a major undertaking will
need a budget. But to be trusted, the institution must operate for the good of
orthopaedics and the benefit, in the end, of orthopaedic patients.
The next easily identified requirement is that the information can be
found. This actually has two components, an index and a classification of orthopaedic
subjects. The index is conceptually the simplest requirement. We need an address list for
the webpages that cover orthopaedic subjects on the Internet. The index needs to be
current, accurate with very few
“dead” links and organized so that users
can easily find their way to the subject of interest to them. From personal experience I can tell you that constructing
and maintaining such an index is a daunting task. The number of pages is growing daily,
the addresses keep changing and no one seems to think it is important to keep the
compilers of the index up to date. It’s as though people who post information on the
Internet expect me to find it by wading through the whole website, or by expert use of the
search engines. As you likely know, unskilled use of the search engines gets you thousands
of addresses for pages which are of no interest to you whatsoever! The more I collected orthopaedic links the more I
realized that the links had to be entered into a comprehensive classification system
otherwise they could not be found.
An agreed classification of orthopaedic subjects so that you can pick
out the subject that interests you, seems
like a simple thing to ask. But it promises to be rich with controversy. Librarians, British GPs and American pathologists
are busy constructing rival classification systems and none
of them are talking to orthopaedic surgeons. Academic orthopaedic surgeons have, in their
turn dreamed up a rich smorgasbord of classification systems for every sort of orthopaedic
condition and something like 30 different scoring systems for each part of the
musculoskeletal system! Unfortunately, to be useful, a classification system for finding
information on the Internet must be one which
we all agree on and will all use. Since non-orthopaedists will be using the same system to
find orthopaedic information the classification system will also be intuitive and user
friendly. It must be very specific so that
you can define your interest in great detail yet there must be redundancy so you can reach
the same subject by many different paths.
The next requirement of an electronic orthopaedic information system
is a narrowcast communication system – beamed out to the sort of people who can be
expected to share useful knowledge and experience with you. The current version of this is
the mailing list but it would be easy to
envisage “white pages” of orthopaedic email addresses classified by interest so
that you could present your problems to experts. Experts
may protest at the prospect of being so accessible, but one must expect that protection
mechanisms will also be evolved. Archiving
the discussion would likely be part of the package.
The archives of the current orthopaedic mailing lists contain
messages and images relating to hundreds of
“difficult” cases or concepts and the various responses to the problems
posed. It is fascinating to see how closely the subjects that are raised mirror the
hottest topics in orthopaedic surgery – Ilizarov methods, flexible IM rods for
childrens’ fractures or the value of viscosupplementation. The variety and international flavour of the
discussions is most attractive to me, as is the sense of community. The archives and images together form the
basis for an ongoing teaching resource “Current Orthopaedic Problems” – it
only needs editing and supplementation to fill in the gaps.
I was going to take it as given that
the journals will migrate to the Internet but the issue is not yet decided. There are compelling ethical and educational reasons why this should happen. All the real value of journal articles is provided
for free. The authors don’t get paid by
the journals to do research; nor do the journals pay the people who prepare the
illustrations, do the statistics or compile the bibliography. Most of the preparation work
is done on computers anyway so it is literally the work of a moment to post the material
on the web. The reviewers who critique the work and demand improvements are unpaid and
very often the editors are too. The costs for
the journals are the paper, the printing and the distribution. These are processes which
the Internet eliminates or does for virtually nothing. Currently journals are so expensive
that most hospitals and many nations cannot afford them. The national medical library of
Bangladesh has a budget sufficient for two journals for the whole of medicine! In an electronic environment which tolerates Napster with wholesale breach of copyright for pop
music, it is untenable that medical information is being hoarded and
“protected”. Publication on the web will be faster,
cheaper and more easily distributed. Another
overwhelming advantage of posting research results on the net is that it is so easy to improve what you have
posted. We need to make sure that the economic pressures in favour of the status quo are
reversed. It is not difficult to work out
that with hundreds of thousands of orthopaedic surgeons and millions of orthopaedic
patients, charging for articles at $1 each
would likely gain far more revenue than
charging $450 for a subscription and spending most of it on
the costs of production and distribution.
We have time for a rapid detour into the subject of “peer
review”. Those who decry the quality of
medical information on the Internet frequently assert that this information will never be
of good quality because it isn’t “peer reviewed”. The fact is that the vast majority of orthopaedic
information set out on paper or presented in
lectures isn’t peer reviewed either. Is anyone monitoring what the professor says as
he teaches by the bedside? Or scrupulously evaluating a surgeon who is teaching technique
in the operating theatre. How seriously does
the staff man go over the resident’s presentation before Grand Rounds? How many of
the faculty of this outstanding course have submitted their material to formal peer review
before presenting it. Overwhelmingly, we
learn from the people we are associated with, residents, fellows and staff men. The only
safeguard is that they have at some point have proved themselves worthy to be part of a
teaching institution. In the world of
journals, peer review applies mainly to research papers. It
is an arcane, time consuming process with secret critics having life and death powers over
your work. Most of those who have never been editors consider it to be arbitrary and
cliquish; most of those with editorial experience see it as vital protection against the
forces of rubbish and counter-science. Posting the material and the criticisms on the Internet and showing how the process works to improve the resulting
presentation would be immensely valuable. Once
again the ease with which suggestions and improvements can be incorporated into a computer
file shows to advantage against paper. How can true peer review be provided by two or
three individuals while there are thousands of other “peers”, orthopaedic
surgeons with experience of the problem? Far from eliminating peer review, the Internet
offers a way of vitalizing the process.
We think that the
Internet is different from paper, but we
haven’t quite worked out what the unique differences are. I believe there are two – the ability to readily incorporate feedback
from the readership and the uniquely personal
pathway through information which hyperlinked documents allow the reader. Documents can be
organized in layers, summary on top with links to ever increasing detail until the entire
factual basis of the thesis presented is accessible. This is quite different from the
current linear structure where you have to start at someone else’s beginning and
follow their pathway. When academic communications take full advantage of these two
elements they will be qualitatively different than what can be achieved on paper. They
will be richer.
Another rarity that came through my practice two years ago was a case
of Gorham’s Vanishing Bone Disease. We wrote it up
formally for the INABIS virtual conference held in
McMaster in 1998. My patient was known to have Gorham’s disease from four years back
and had had enormous problems healing a fracture of the distal radius. Eventually he had
been stabilized with a vascularised fibular graft replacing the forearm from proximal ulna
to 2nd metacarpal. He presented to me with an olecranon fracture in the same
limb. What I want to draw your attention to is the way in which this case can
be presented. Using a frame format the viewer can decide how much of the information
he or she want to look at. You can go down through this case in summary form, you can read
the full text of the case description or you can look at all the pictures. The space
limitations which apply to paper publications, don’t really apply to the Internet.
The same is true of references. The reference numbers in the discussion
are links to the bibliography
and it, in turn, contains links to the abstracts stored in the Medline Database of the National Library of
Medicine. So if you are connected to the Internet you can go from the discussion of the
paper into the literature and back more or less at will. When the papers themselves are
posted on the net this experience can be made even deeper, wider and more personal.
Returning to our central theme, what Dr McCoy and his
colleagues of the 23rd Century will use when they look up an orthopaedic
problem will amount to an electronic clearing house of orthopaedic information. They go
there, they interactively define the subject they are interested in and the site will
provide them with textbook entries, a list of pages to visit and perhaps some editorial comment on the content and provenance. Associated with the site there will be archives of discussion about the subject, an image
bank, a classification system, a search engine, a
bibliography, a contact list of experts in the
subject and a way to find the equipment you might
need. All of this will be organized so that they can call up the information they need
according to their own needs and priorities.
I have called it a “clearing house” of orthopaedic
information but in some senses this site is also the central “authority” on
orthopaedic information. If a reader wants to know about an orthopaedic subject he or she
starts there, and if people who post orthopaedic information want readers, they would
notify the site. Even now the Internet grows so quickly that it is not possible to keep up
with what is posted. The only way a gateway site is going to stay current is if authors
inform it as a matter of course when they post something. This is the reason that we
anticipate one and only one effective gateway site.
Any comments this site were to make about the information posted
would carry a lot of weight. In the
free-for-all information exchange on the Internet this is the only viable form of quality
review that can be envisaged. So the clearing house will not only serve the information
needs of the orthopaedic community but also exert considerable influence on the subject.
There are two ways in which we could get from here to there.
Here and now we have confusing, conflicting and competing institutions on the Internet,
most of them with an agenda that has little to do with serving orthopaedic surgery. One route to an authority on the orthopaedic
Internet would be the commercial one. Since we anticipate that all the Internet users who
want to find out about an orthopaedic subject will start by looking it up on the
orthopaedic gateway it is easy to be enthusiastic about the commercial potential of such a
site. With thousands of visitors the site would be a hot property for advertising. So
there is certainly incentive for commercial concerns to produce a portal; the trouble is
that there is so much incentive that there are dozens of sites trying to do the same thing
– and this, as we have already seen,
militates against success as an authority. Competition
between commercial sites would probably thin out the numbers and gradually a few of these
sites would grow to become sufficiently authoritative to stand above the crowd and be the
natural place for users and suppliers of orthopaedic information to turn. The very
richness of the commercial prize would make it unlikely that one concern would cede
victory to another. Suppose Zimmer decided to create an orthopaedic portal; do you think
Howmedica would allow it to gain undisputed pre-eminence? So the commercial route to a single
orthopaedic gateway site is bound to be a long and bitterly contested one.
The second route is for organized orthopaedics to understand
and recognize this process and pre-emptively occupy
the gateway site. This would make the statement that orthopaedic information should be
distributed on the Internet for the benefit of orthopaedic surgeons and their patients.
Furthermore, orthopods are the best people to organize this information and some aspects,
such as classification, can really only be done by orthopods. Already the portal site
collected and managed by orthopaedic surgeons is an order of magnitude more comprehensive
than any commercial or library site. The problem is that it requires the support of
current orthopaedic centers of power to create a new institution which then might usurp
some of their power. But no University, no Academy, no Orthopaedic Association is in a
position to manage orthopaedic information on the Internet. Only something supranational
like SICOT is in the right position to do this work and as yet they have not considered it
to be important enough.
The Orthogate Project is an
attempt to push this process along. The
institutions may be small and shaky, the budget non-existent and the rate of progress
sporadic but we have planted the seeds that
could grow into a valuable and comprehensive orthopaedic institution. We aim to become the
most valuable resource for orthopaedic surgery on the Internet and thereby to transform into the orthopaedic gateway.
If we look back, now, at the parts which, we said, were necessary for
an orthopaedic portal to grow to authoritative status, we can see the correspondence. Orthogate, the site is run by the non-profit academic
body ISOST
, the Internet Society of Orthopaedic Surgery and Trauma. ISOST is a non-profit society
with by-laws based on societies affiliated with AAOS such as the Hip and Knee Society. It
has membership of about 700 orthopaedic surgeons from all parts of the world. We believe
this is a necessity; it is unlikely that international orthopaedics would accept a
national organization as an authority in this area. ISOST has the mission to provide
orthopaedic surgeons with the tools to use the Internet effectively for orthopaedic
teaching and communication.
The next part of the
gateway site is the index. Orthopaedic Web
Links (OWL) is the core of the gateway function.
That is my main contribution and it is being
re-organized into a database format so it is easier to use. Also on the site is the
Orthogate Classification of Orthopaedic Subject Headings (OCOSH), which is an expansion of the
Medical Subject Headings (MeSH) classification system used by the National Library of
Medicine. We are also in the process of incorporating the classification system into OWL.
The Orthopaedic Search engines Orthosearch and Orthoguide are loosely associated with the project
and use a version of the OWL database. Orthogate
also hosts the main orthopaedic mailing lists,
Orthopod, Hand and Sports Medicine. We are in
the process of editing the archives and have made a start on an orthopaedic image bank based
on the images sent to the lists. Karim Brohi at trauma.org has started an orthopaedic
trauma image bank.
A part of the ISOST mission is addressed by the Orthopaedists’ Guide to the
Internet, a massive self-teaching site covering all aspects of Internet use from the
most basic to the relatively advanced. Subjects covered include email, searching, imaging, creating an office website and webpage editing.
Because of the interests of ISOST members Orthogate is also the host
for a number of other orthopaedic interest sites – reviews of the orthopaedic
Internet, ORCID, the Orthopaedic
Rare Condition Internet Database. In the works are a collection of bibliographies and a
collection of iterative reviews on core orthopaedic subjects.
What are Iterative Reviews? Basically they are, or should be
reviews of a topic which you can use, upgrade, improve and return to the site you took it
from with your improvements. I believe
that a good review which has been repeatedly improved will be better than one started from
scratch. I aim this particularly at the seminars that residents undertake to teach
themselves and their colleagues. Although
there may be a greater benefit to the presenter to work everything up de novo the
responsibility of the teaching program is to ensure that the group gets the best
teaching. If iterative reviews were posted at a gateway site you would know where to find
them.
So, what should you be doing about this?
Firstly, you should be prepared to think about the subject and
decide whether you feel that my concerns are on target or can the development of the
orthopaedic internet be safely left to chance and the dot com entrepreneurs. If you do
think the concerns are legitimate then there are many levels of engagement in the process
which you might consider.
At the very least you should learn to use the Internet to find
orthopaedic information and be critical of what you find. The ISOST Guide may the be best entry
into the subject. The Internet’s prime difference from the paper information system
is ease of feedback but taking advantage of that means a change in mind-set. Your opinion
of what someone has presented is important and is also the best way to improve it.
One step up in involvement would mean joining the Orthopod
mailing list. You will receive a daily dose of CME and can help to make the
discussions fruitful and interesting.
Contribute to the orthopaedic content on the Internet by posting
articles, case presentations, seminars and other teaching information. (This is the big
one). See the ISOST workshop
on webpage editing if you want to get a start on this.
Formal training in
orthopaedic informatics is rare indeed but this academic specialty is wide open and
implies studying the ways in which we use and disseminate orthopaedic information. There
are many research projects waiting for enthusiasts to investigate and delineate the
valuable parts of the orthopaedic Internet.
Joining ISOST implies another level of commitment to mission of
leading orthopaedics into the future on the Net.
Perhaps as important is
using your membership of the national and international orthopaedic institutions to push
them to look at Orthogate and decide if the project is worth supporting. The COA board of
directors agreed two years ago to support ISOST with a grant; we should insist they honour
this commitment.
If what I predict does take place, a new mindset will arise in the
near future. The Internet will become the primary medium for orthopaedic academic
communication. You will post your work, inform the gateway site or sites. Your work will
be layered and structured to use hyperlinks to best advantage and will invite and
accommodate feedback. You should be generous in providing feedback to improve others’
work and should avoid redundancy by improving and
updating the work of others rather than starting from scratch. All this will be made much
easier if we have a strong center to the orthopaedic internet.
If you join this
effort you may be part of the foundation of
orthopaedic institutions which will dominate the future – or you may be part of a heroic but doomed attempt
to ensure that orthopaedics on the Internet is controlled by orthopaedic surgeons for the
benefit of the subject and their patients.
What is a Basic Science course without a mnemonic? To help you
remember what I have been talking about and perhaps to underline the flavour of the
struggle here is the take-away from this talk -
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Quite |
| Does |
Unequivocally |
|
ISOST |
| Orthopaedics |
Xcellent |
|
Opportunity |
Need a gateway? |
To |
|
Enter the fray! |
Tilting at windmills or not, it is worth a try.
Myles Clough
Editor, Orthopaedic Web Links http://owl.orthogate.com
Chairman, Internet Society of Orthopaedic Surgery and Trauma http://www.isost.org
Canadian Orthopaedic Association Webmaster http://www.coa-aco.org
Editor, Orthopaedic Rare Conditions Internet Database, http://www.orthogate.com/orcid/index.htm
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