N Balachandran Lecture 2003

The Future of the Orthopaedic Internet

Dr Fong Shee Yan
22 June 2003


Just in case you haven't noticed, the Internet is a revolution in communication and commerce that will rival the other great media revolutions of the past such as radio and television. Depending upon your viewpoint, it may rank up there with the industrial revolution or the invention of printing for the degree of change that it will make in our lives, or due to it's lurid content, it may simply be the instrument of the devil. It is impossible to predict just how this will unfold in the next few years, but if the past decade is any indication, it will be fast-paced and exciting. There will be a few setbacks, like the recent dot.com fiasco, wrong directions taken, but the end result is going to change the way we communicate, teach, learn, buy, bank, book our travel, search for medical information and so on.

The orthopaedic surgeon uses the Internet to find information quickly, to communicate with other surgeons in his field and to occasionally ask for help in managing a difficult or unusual case. After the dot.com and e-commerce shake up, the Internet is returning to its 2 primary functions, finding information fast and communication with people. The tradition of the Internet has been that the information is free and available to everyone. When people discovered that you could not sell information, then it was left to the conventional suppliers of information, such as Encyclopedia Britannica, professional associations, such as The American Academy of Orthopaedic Surgeons to supply the free high quality information. The traditional book publishers are still searching for the best model to provide online content. It is clear that the Internet and computer are not going to completely replace paper to access information. Many people still like to turn paper pages and read their information from a book.

Although the Internet has not yet assumed a dominant role in orthopaedic communication and academics the speed with which things are moving in that direction makes it likely that it will. A change comparable to that which occurred after the introduction of printing is upon us. It's doubtful if Gutenberg's fellow burghers could have sat down and predicted the Renaissance, the Reformation, the birth of science and the flowering of literature. How could they have foreseen religious wars, propaganda, pornography and cultural extinction? But if they could and had taken a few insightful actions just think how much trouble might have been saved! Business as usual when a tidal wave of change is approaching is simply nonsensical. Now that the Internet has demonstrated its potential and some of its problems, we need to consider the changes that are likely to occur in our subject and how we should react.

A View From The Future

There is a technique in physics for solving difficult theoretical problems. One assumes the answer is correct and searches for the phenomena that would exist if it were. From a study of those phenomena one may often gain insight into the process and finally make the proof by a backdoor approach. We are going to apply a similar approach by assuming the future and then think about how to get there from here.

If technological civilization survives we are assuming that a computer network will be the dominant provider of information in the 22nd century. When faced with a need to obtain more information on an orthopaedic subject the first step would be to interact with a site to define exactly what subject you are interested in. This would take you to a level of granularity that might be exemplified by "predictors of outcomes after different forms of treatment for a Pipkin I fracture dislocation of the femoral head". The network would have a classification system, which would consult with you to establish exactly what it is that you wished to research. Once you have mutually established that, the system would ask whether you wish a consensus view, whether you want to know the issues and controversies surrounding the topic or whether you want up to date research data about it. The output options would thus be a limited number of sites offering the current consensus, or a larger number of sites covering the issues, or a connection to the main research thread on the subject or finally access to all the information around on the subject arranged into "folders" like Northern Light does.

The information then made available to you would be a layered presentation with a simple summary on top from which you could explore down to the bedrock of data if you so wished. Competing and contrasting points of view would be offered and unresolved controversies identified. There would be no doubt where "evidence based practice" was and where controversial treatment options began. In addition, case presentations and the addresses of experts on the subject, who were willing to give advice, could be found by the same search process.

Now, what are the structural components which would have to exist for such a system to work and be valuable? The least obvious of these is a universally accepted classification of orthopaedic subjects. English is a rich language with many ways of saying the same thing; and it is only one of hundreds of major languages. If you are looking for avascular necrosis you must recognize that aseptic necrosis, osteonecrosis and AVN plus all the terms in other languages must be brought in to the search paradigm. The simplest way to achieve the precision needed to start a comprehensive search is to generate a code. The dialogue between searcher and the system can take place in any language and go via any route but it would end up with a unique code for every orthopaedic topic. Then the system uses the code as a search string. In our glimpsed future we assume that anyone who posts information and who wants people to find it, will know that they have to include the subject code in the title or keywords of the document. They will also know that notification of the search site is a critical step once they have posted the new document. Both from the point of view of those searching for orthopaedic information and those posting it there should be only one gateway site. Everyone who wants to find orthopaedic information and everyone who is offering orthopaedic information will be literally "on the same page".

The second less-than-obvious conclusion is that achieving this is a "people" problem, not a technical problem. The computer techniques to achieve all this exist already and are being put to daily use in the many orthopaedic sites we all know. Although advances in artificial intelligence might make a difference, the main problems are the economic, institutional and organizational barriers. We need people to review sites and to determine "best practice" and the consensus, we need editors of research threads, moderators of discussion groups; we need people who will organize research projects over the Internet. And these people must be orthopaedic surgeons with experience in teaching and leading our subject; we just are not going to accept the opinions of librarians, generalists or self-appointed dot com entrepreneurs. The greatest challenge is to create an academic body with Information Technology expertise, whose orthopaedic opinions will be respected.

Don Johnson, MD, University of Ottawa, and Myles Clough, MD, University of British Columbia from Canada (founders of the Orthopaedic Web Links and the Orthogate, as well as hosts of the Orthpod mailing list), and Jan Van Der Bauwhede and Dick Vandelvelde from Belgium (founders of the Belgian OrthoWeb and hosts of the BeneluxOrth mailing list) are the notable doctors among the small group of orthopaedic surgeons who predicted that this would occur sooner or later and have been actively working to ensure that it is "sooner" and that the development is controlled for the benefit of orthopaedic surgery and our patients. A gateway site that would more or less control what people found out about orthopaedic surgery on the Internet, is one which could very easily be misused or abused. The work of keeping up such a site is well beyond what an individual could accomplish and an individual gatekeeper makes no sense anyway. So the next corollary of this view of the future is that an organization of orthopaedic surgeons must come together to create, maintain and guard the gateway. Until this organization becomes stronger than the tiny group of "orthogeeks" who meet annually during the American Academy of Orthopaedic Surgeons (AAOS) Annual Meeting, development will be stalled.

Personal Changes

We have known for some time that it is impossible to keep current with more than a small corner of orthopaedics; yet our patients expect that we are current in whatever problem they face. To a large extent the information is out there on the net but if it's not in our head we either ignore it, or feel ashamed that we have to go look. Both are dangerous. Now that looking things up is easy and rapid, we should recognize that it is more appropriate than relying on memory. This has implications in personal habits, education, CME. Far from creating information overload, the Internet offers a solution, an ectopic brain. We have to change our behaviour to accommodate that. Perhaps for 90% or even more of our cases what we "know" is enough and we don't have to rush to references to treat every hip fracture. Yet, even with hip fractures there are still surprises, else why would we still be doing research on the subject. Another personal change we may need is a reminder to review common problems once in a while, or some form of "push" technology to prod us when a significant change in the knowledge base comes up.

Another valuable change would be recognition that we are members of a global community and that there are friendly, helpful people out there who would be pleased to offer insight into the problems you share with your patients. The orthopaedic email lists have been described as the "Global Corridor Consult" and this description does give the flavour of the interaction.

Relations with Patients

This is the biggest part of the tidal wave. We are going to have to relate to patients who have researched their own personal problem in great detail. Their confusion may be greater than their understanding but they will be much more persistent than we are over seeking out everything they can find. Trying to ignore that or urging them to ignore this source of information will not work for long. Instead we will need to look for productive ways to form a partnership with inquisitive patients and make them into research assistants. As a first step, we should guide them to reputable resources. But we should accept and encourage further exploration, so long as they discuss what they find with the treating team. We need to be frank that they may find out some things new to us in this process. This may be a big change for surgeons. The prevailing attitude still is "I'm the doctor; I know what is best for you". A more appropriate stance might be - "I'm an expert on your problem; it's my job to give you the information you need to make the treatment decision which is right for you" With that attitude the Internet is a reality check - does what I say to my patients gibe with what they find in reputable sites? But there's no denying that it is more work. Or that I am not ready for a patient pointing out something I didn't know. I know that I don't know things but do I want my patient to know that? But we cannot put the genie back in the bottle. We are committed to dealing with enquiring patients who will make more work for us; we must make sure we and they get value for that work. We might consider saying to a patient "You have such severe arthritis of the hip that the only thing which will make much difference is an operation. Here is a list of sites with information for people in your position. Come back in a week and we will discuss it further; I will answer any questions to the best of my knowledge and will pursue any open questions. Email me if you run into any problems as you go along. You are the person who decides what to do based on our joint learning and my advice." That is the relationship we foresee as becoming common and indeed being desirable.

There are a couple of corollaries. The first is that we must be active in ensuring that good information sites are out there and that orthopods in general know where they are and can/will direct their patients there. Which brings up the questions of "what is good?", "who says so?" and "how do I find them?" We should expect organized orthopaedics to establish what should be covered in a patient information site; another expectation is getting patients themselves involved in the evaluation of sites. The second corollary is that restricting patients to approved sites won't work; if they want to, they will swim with the sharks. So shark recognition kits should be issued and survivors' narratives heeded. The AAOS website is doing a significant service by providing good quality patient information - "Your Orthopaedic Connection" at orthinfo.aaos.org (Winner 2002 and 2003 Web Marketing Association Standard of Excellence Award) and more organizations need to do the same. It will never satisfy the patient's thirst for information, though. If I develop osteolysis of my hip replacement I am not going to be content with what the AAOS tells me. Or my doctor, or Dr Huddlestone, or the Rothman Institute or Zimmer. I will want to make my own synthesis and see if my doctor agrees.

Feedback and Communication

Feedback is so easy on the Internet but the attitudes that inhibit it remain. "Who-am-I-to-have-an-opinion?" is very prevalent and has allowed the few us who are less inhibited about offering advice, a rapid and no doubt undeserved reputation as gurus. This ought to change. When a colleague asks you a question in the corridor you give an answer. The Internet allows the sum of those answers to add up to something quite a lot more valuable. We are not saying we should be flooded with "I agree" messages but we need the behaviour change that permits us to offer thoughtful opinion without being inhibited.

Research Communication

Who knows how this is going to develop? "The Journals" offer priceless experience, editorial and review skills but little of that is paid for. Instead we pay through the nose for what we don't need - printing and distribution. Commitment to the "paper" model also prevents us from pursuing three innovations made possible by IT. One is the concept of a layered presentation instead of a sequential one. We do this already by skimming the methods unless we dislike the results and feel the need to discredit the findings! In a hypertext presentation the top layer could be a summary couched in terms that a lay person could understand but which would convey to the expert what the research is about and what the new findings are. Lay people are going to read abstracts anyway so we may as well take advantage of that. The next "layer" would be much more like our current Introduction/Methods/Results/Discussion format but split up into small chunks so that if someone wants to refer to your work they can link directly to the point they want to cite rather than make the reader go through the whole thing. At an even deeper layer you might expect the database which was analyzed to produce the conclusions reported. Thus if someone wanted to re-do the statistics or do a meta-analysis it would be easier.

The second innovation would be open peer review. We all accept that peer review is valuable and necessary but it takes place in secret. In part this is to reduce the humiliation of authors and in part it is to protect the anonymity of reviewers. We should loosen up a little and accept that the editing and reviewing function is a way to improve the work. If we bring the process into the open we can see the comments of the editors and reviewers and most importantly add our own. In this way, the work will really be reviewed by peers, not just by a secret coterie. Instant feedback and easy updating allow us to do this. It would still be the responsibility of the editor finally to accept or reject the piece of work and incorporate it into the "journal" but we would all learn more from an open process. Weller A.C., author of "Editorial Peer Review: its Strengths and Weaknesses", re-affirms the value of peer review but points out significant and disturbing unanswered questions such as "Is there an exact, measurable benefit of editorial peer review? Do researchers from major institutions and departments publish more because of a bias in their favor or because they produce a better piece of research or scholarly communication?"

The third innovation would be the concept of research as a thread. At the moment we do the work, write the paper, accept the editor's and reviewers' amendments, do the proofs; at last it is published and we draw a line underneath (at least in our own minds). But it shouldn't be like that. A good piece of work should set up numerous new questions and provoke a stimulating discussion, which would lead to new work or an expansion of the old. If all the researchers who are interested in the same subject contributed to the same on-going discussion, how much easier it would be for the rest of us, trying to form an opinion that helps us take care of patients. This is so self-evidently valuable, it is achievable with current technology, so the pressure to build these institutions will be irresistible. Journals and journal editors should be experimenting with new formats and ways of presenting orthopaedic research information; many of them are. The "Nature" Publishing Group maintains an interesting forum on electronic publishing with many diverse points of view represented. The flashpoint at the moment is the issue of copyright. The publishing houses insist on the retention of copyright as a commercial asset to maintain the viability of the journals. Those in favour of free transfer of information argue that the copyright should revert to the authors after a period of time.

Orthopaedic Teaching

The orthopaedic trainee acquires a knowledge set concerning orthopaedic conditions and their treatment, a skill set to do with surgical technique and patient evaluation and a mind set, to do with how to manage orthopaedic problems and the person they are attached to. The knowledge set is changing rapidly and the mind-set we currently teach is not well adapted to the IT world. Even the skill set changes but not as fast. Trainees need to be taught to rely on their memory less than on looking things up, to know how to find the information they need, to join in discussions when they have a worthwhile opinion, to see research as a thread and information as a seam to be mined. They must learn to enter into an information partnership with their patients, where they do the leading but expect surprises from their followers.

Redundant Effort

Every day around the world many minor and some major efforts of scholarship are being wasted. The reading list, the presentation at rounds, the seminar, even the medico-legal opinion require that someone with significant orthopaedic knowledge and skills, sets about reviewing a subject and "writing it up" in some form or other. Then the message is delivered and may make an impact on the audience but goes no further. Turning that piece of scholarship into a paper, or a chapter in a textbook is such an enormous effort that it is very rarely done. Yet it is easy to post on the Internet and examples such as Wheeless' Textbook from Duke, United States (www.medmedia.com), the Orthoteers from United Kingdom (www.orthoteers.co.uk), World Ortho from Sydney, Australia (www.worldortho.com), OrthoNet from Toronto, Canada (orthonet.on.ca), and the Chinese University of Hong Kong Orthopaedic Learning Centre (www.olc.ort.c uhk.edu.hk/index.ht m) show how valuable such collections of minor scholarship can become. Then the next person who needs to review that subject can get a flying start and devote their energies to improving the work rather than starting from scratch. Implicit in this process of iterative improvement of reviews of orthopaedic subjects is the concept of a clearing house for information so that someone who want to use and improve the treatment of the topic can find the current "best" version. Yet another behaviour change, which is needed is that people who post or update orthopaedic information should notify the clearing house. That goes for people who make valuable literature searches or Internet searches. There is no need to have to repeat them.

Clearing House for Orthopaedic Information

The need for such an institution is clear but it is much less clear how it will rise to a position of authority. We need one site where users can go with a reasonable expectation of being able to find what they are looking for and reasonable certainty that it will be on subject and of acceptable provenance. That same site would be the natural place for providers of orthopaedic information to notify about their postings. Mechanisms of comment, bibliographies, iterative reviews, research threads, and many of the other helpful innovations can develop around a clearing house. Without one it's difficult to see how they can. A clearing house for orthopaedic information will be much more than a list of links. Because of the traffic expected it would valuable commercially, but because it would need to act for the benefit of orthopaedic surgeons and ultimately of their patients, it would need to have solid academic and institutional backing. To put it another way, we need agreement from the national and international orthopaedic organizations that a clearing house is necessary and serves the interests of their members. Because the Internet is international even the most powerful national body cannot accomplish this task on its own.

The Internet Society of Orthopaedic Surgery and Trauma (ISOST) was founded in 1999 to promote the development of an orthopaedic clearing house and to educate orthopaedic surgeons in the use of information technology. It is a non-profit society with by-laws modelled on the Hip and Knee Society. The officers are barred from profiting by the activities of the society. Using its Orthogate site the society has fostered the embryos of the institutions which may grow into a viable clearing house. These include the Orthopaedic Web Links (owl.orthogate.com) collection of links to orthopaedic subjects on the Internet, the Orthopaedists' Guide to the Internet (guide.orthogate.com) with teaching files and workshops, the Orthogate Patient Information collection (owl.orthogate.com/orthpat.html) which serves as a yardstick. There are orthopaedic special interest mailing lists hosted on the site with archives and an image bank. OCOSH, the Orthogate Classification of Orthopaedic Subject Headings is created as accurate classification of subjects and images on the Internet will be necessary if we are to find them. Perhaps ISOST's most valuable role is to show what can be done. It is far from certain that the orthopaedic clearing house envisaged in our view from the future, will actually grow from this effort.

Other ways would include the commercial route. There are already dozens of commercial sites which would like to be the "one gateway" to orthopaedics on the Internet. Examples include Orthopedics Hyperguide sponsored by Stryker-Howmedica (www.ortho.hyperguide.com), the Zimmer website which provides Medical Profession CME and Patient Information (www.zimmer.com), and the Hip-Knee-Shoulder Interactive websites of Johnson & Johnson (www.smithnephew.com). The attractiveness of the commercial prize makes it unlikely that any one site will become dominant enough to act as a clearing house and it seems unlikely that orthopaedic surgeons would willingly give that sort of power to a commercial organization. Another alternative would be for a major national organization like the AAOS (the largest in the world) to devote resources to providing a clearing house for American orthopaedics. Because of the number of users in the USA this might become a dominant international institution and other nations would have to "join in" once it became clear that following their own path would not serve their members as well. On ideological grounds one might hope or prefer that competing institutions might vie with each other to set up the best possible service. We aplaud the recent "rebirth" of the Singapore Orthopaedic Association website (www.soa.org.sg). However, keeping up with new posting on the Internet is inherently impossible unless the gateway site is notified and updated 24-7. That is only likely to occur if one site predominates.

As for you and me on the ground level, from the trainee registrar to the senior consultant, one of the most necessary changes in the behaviour of orthopaedic surgeons would be to pay attention to these issues and make sure that they are not settled by default. The Internet doesn't need to be promoted by orthopaedic surgeons; it is self-evidently valuable. But orthopaedic surgery on the Internet does need promotion and fostering to make sure that it grows and develops in a ways best adapted to our subject and our challenging times.

Dr Fong Shee Yan
22 June 2003