Extract
The Internet is a rapidly expanding source of information that has gained a
valued place in the knowledge armamentarium of the orthopaedic surgeon. Access
to current knowledge, published literature, and a vast array of academic,
federal, and commercial information has changed the information landscape for
both orthopaedic surgeons and their patients.This article presents highlights of readily available information for
orthopaedic surgeons to use for continuing medical education, literature
updates, patient education materials, and presentations. We present multiple
techniques for accessing and organizing orthopaedic information as well as for
identifying and utilizing specific, high-quality, frequently updated Internet
sources of information.
The Internet is a rapidly expanding source of information that has gained a
valued place in the knowledge armamentarium of the orthopaedic surgeon. Access
to current knowledge, published literature, and a vast array of academic,
federal, and commercial information has changed the information landscape for
both orthopaedic surgeons and their patients.
This article presents highlights of readily available information for
orthopaedic surgeons to use for continuing medical education, literature
updates, patient education materials, and presentations. We present multiple
techniques for accessing and organizing orthopaedic information as well as for
identifying and utilizing specific, high-quality, frequently updated Internet
sources of information.
The traditional source of medical information was the medical library.
While traditional brick and mortar libraries still clearly play a role, the
expansion of the Internet has allowed most library resources to be accessed
online from the desktop computer (Table
I). Additionally, the union of electronic communications with the
vastness of the Internet has engendered a number of unique mechanisms for
information delivery and exchange.
Perhaps the oldest generally used Internet source for obtaining medical
information is the National Library of Medicine's MEDLINE
database1. One
component of this database is PubMed
(),
which is the National Library of Medicine's journal literature search system.
PubMed is freely available through the World Wide Web. MEDLINE, accessed
through PubMed, is primarily useful for searching English-language journals;
it contains more than 4000 searchable publications and more than 15 million
records dating back to the mid-1960s. Updated weekly, it is the most commonly
used database for the search of scientific papers and abstracts.
PubMed contains the MEDLINE database as well as some additional material,
including selected citations from before 1966 and some nonmedical scientific
literature (general science, chemistry, and
physics)2. PubMed
also contains links (segments of text or graphical items that serve as a cross
reference between parts of a hypertext document or between files or hypertext
documents) to many sites providing full-text articles and other related
resources, a clinical queries search filter, a single citation matcher, the
ability to save and automatically update searches, a spell checker, and
filters that enable the user to group search results.
Certain features of PubMed bear special mention. A brief online tutorial,
targeted primarily at the novice user, is accessible on the site, and taking
this tutorial is an excellent time investment as it can markedly increase the
rate of retrieval of useful articles. A medical librarian is another valuable
resource for obtaining help in using PubMed in general or for obtaining
assistance with a specific search. The Orthogate web site also contains a
three-part tutorial that provides step-by-step explanations of how searches
can be optimized. This tutorial details the importance of utilization of
accepted terms as well as understanding the logic that PubMed employs in
generating search matches
().
One feature of particular interest to orthopaedic surgeons is the ability
to identify and link to "related articles." Once a particularly
germane article is identified, clicking on the associated link will take you
directly to that citation. You also have the ability to save searches for
later review.
The MEDLINE database can be accessed through a number of web sites besides
PubMed. These sites all use the same database, but the search interface is
tailored to the specific site. Examples include Medscape
()
and myMedline
().
These sites offer a different type of user interface, usually with some
functions available for saving or customizing searches. Since these sites use
the PubMed searching capabilities, they do not actually add searching or
sorting capabilities or citations.
The Internet is not only disorganized, but it resists organization. A
massive amount of orthopaedic information is posted. A high proportion of this
mass has a commercial message and is therefore suspect with regard to the
objectivity of the information. Search engines may be our best tool for
sorting information, but they have unique idiosyncrasies. Using them takes
little time or talent, but using them effectively requires learning and
practice. There is no effective mechanism for ensuring, or even screening for,
the quality of information on the Internet. Several studies have shown the
variability in content and completeness of Internet-derived
information3,4.
Search Engines and Directories
The two most common means with which to find information on the Internet
are "directories" and "search engines." Directories
are lists of resources, usually in the form of links directing the user to the
Internet addresses of useful sites. Institutions or individuals have collected
these lists.
Search engines are the most commonly used methods for finding information
on the Web. However, there is considerable variability in how search engines
work, and consequently the quality and validity of the information returned by
the search vary as well. The rate of technological advances is such that the
search parameters change from year to year. Search engines, unlike
directories, are robotic devices that search a database to find pages that
contain the "search string," the words that the user presents to
the search engine. The databases searched by the search engines vary
enormously. Some engines search only one web site, whereas others search a
substantial fraction of the entire Internet. The most commonly used search
engine, Google
(),
searches the largest number of sites on the Internet.
Depending on the type of information for which you are searching, an
alternative is to use a "web directory" such as Yahoo
(),
in which sites are generally viewed by a human and classified into groups of
interest. However, with the advance of technology and the exponential
proliferation of Web material, the importance of directories as a solution to
the problem of facilitating good searches is likely to wane.
Most search engines use software programs known as "robots,"
"spiders," or "crawlers." This technology accesses new
pages, categorizes it, and sends information back to the parent database
without a human ever seeing it. Commercial webmasters design their sites to be
attractive to search engines by inserting relevant "keywords" in
the title and metadata pages, and as a result the engines "find"
commercial sites preferentially. Framing search strings to find orthopaedic
content requires use of as many jargon, or specific medical, terms as the
searcher thinks might be on the target site. Doing so will help to restrict
the search results to valuable orthopaedic content. For example, searching for
"hip arthroplasty" rather than "hip replacement" will
likely yield more content of interest to the medical professional. In another
example, in January 2006, a search on
for "cartilage tear" yielded in excess of 395,000 pages. Nineteen
of the first twenty pages were directed at informing patients or attracting
patients to a particular clinician. Using the more specific term
"meniscus tear" yielded 270,000 pages. Three of the first twenty
pages were directed at professionals, and the rest were patient-information
pages. The search string "meniscus tear portal" still yielded
11,000 pages, but thirteen of the first twenty were directed at physicians.
Defining exactly what you want to find is the most important and most
difficult skill in searching the Internet.
In the early years of searching the World Wide Web, it was critical to use
exact search terms such as AND, OR, and NOT to include or exclude search
parameters. Nowadays, most search engines have sufficient sophistication to
allow information to be entered into a query field with use of common language
terms. When a general search engine is used to look for medical information
for professionals, it is generally best to employ the "advanced
search" function that most search engines offer. Whereas the standard
search assumes that the user requires "all of the words" of the
search string to be present on the target page, the advanced search allows one
to define "the exact phrase," "at least one of the
words," or "without the words"
(Table II). Other features of
the Google advanced search
()
restrict the results by language, file format, date of updating, and domain.
It is also possible to search for pages that link to a specific page.
If one wanted to frame a search for the subject bone-grafting in
the treatment of ununited femoral shaft fractures, one might want to
combine all four subjects of Table
II. It is much easier to do this with the advanced search feature
rather than by constructing the search string (nonunion femoral shaft OR
diaphysis "bone-grafting"-supracondylar-hip-neck) oneself.
Incidentally, this search yielded 293 pages in January 2006.
Quality of Information
Even with a successful search, one needs to be careful about accepting
Internet-derived information.
In general, a health information site should be evaluated on the basis of
several critical factors. The first factor is authorship—the credibility
of the individual who wrote the material, or posted the information. The
second is currency. Old information is often more dangerous than no
information. The third is the presence of advertising on the site; whether it
be for a product, goods, or a specific method of care, advertising should
alert the reader to potential bias in the article. The completeness of an
article—i.e., whether it presents all relevant information on a
particular subject—is important. Obviously, the accuracy of the
information is also of importance.
Some sites rate health information. One such site, Health on the Net (HON)
(),
is maintained by a nonprofit organization that provides a search mechanism
that can help ensure that searches are limited to credible sites. However, HON
cannot realistically hope to evaluate every potential site or to ensure that
updates to a given site will comply with HON standards after the site has
received the HON rating.
It is recommended that physicians maintain a list of credible sites to give
to patients, and the list may be customized according to practice type and
physician preference. Examples of credible sites include those provided by the
American Academy of Orthopaedic Surgeons
(),
the Arthritis Foundation
(),
and Orthopaedic Web Links
().
Textbook Sites
Textbook sites can be ideal for users seeking fairly general orthopaedic
information about a broad range of topics. The best of these sites are
documents covering the whole of a subject, laid out with the overarching idea
of a textbook in mind. Many textbook sites are more superficial, some are
revision notes from trainees, and some are "book dumps," meaning
that a document originally designed for paper has been transferred unaltered
to the Internet, often leading to navigation and formatting difficulties.
Some, however, are well thought out and planned for the Internet and examples
are listed in Table III.
Of the sites listed in Table
III, Wheeless' Textbook of Orthopaedics
()
is the most comprehensive and the best illustrated, cross-referenced, and
organized. It was assembled during the author's residency at Duke University
and has been taken over by that institution and updated regularly. It is one
of the most outstanding examples of the use of hypertext in a reference work
in the whole of medicine. The eMedicine collection of orthopaedic subjects
()
is not as complete and is less intensively cross-referenced, but its
individual articles are clear, up-to-date reviews written by experts. Medscape
()
also provides very full treatment of orthopaedic subjects with full-text
articles adapted from recent published work.
Orthopaedic Directory Sites (Link Pages)
Orthopaedic directory sites are lists of links to topics that have been
selected as germane to the subject. Orthopaedic Web Links (OWL)
()
is the largest dirvectory of links to sites of orthopaedic interest. The sites
are selected and validated by orthopaedic surgeons. OWL is large enough, with
more than 5000 links, to have been set up as a searchable database.
Alternatively, one can browse through the subdivisions (e.g., Orthopedic
Topics > Trauma > Femur).
Directories are most useful when the need is to find an entry to a subject,
not necessarily everything there is to find. They are most helpful if you
repeatedly refer to a particular area, as you can bookmark the directory for
future use. The most valuable aspect of many directory sites is that a human,
not a robot, selected the resources. While these types of sites can be quite
helpful, as new material is added constantly on the Web, they are necessarily
incomplete, and they may also suffer from "link-rot" as the sites
that they originally collected are withdrawn or change addresses.
Patient-Information Sites
The advent of the Internet has accelerated what was a gradual progression
from a physician-centered culvture to a patient-centered culture, enabling the
process of shared decision-making. In many orthopaedic practices, surgeons are
finding that patients are frequently using the Internet to obtain information
about their diagnoses and
treatment5-7.
Fortunately, there are many excellent sources of patient information on the
Internet. Peer-reviewed, current information is maintained on Your Orthopaedic
Connection
(),
the patient information arm of the American Academy of Orthopaedic Surgeons
(AAOS) web site. Medline-Plus, the public information arm of the National
Library of Medicine web site, contains material and links to patient
information in medicine. The orthopaedic arm of this is found as "Bones,
Joints and Muscles Topics"
().
Finally, Orthopaedic Web Links maintains a site with extensive links to a wide
variety of patient education materials
().
Acquiring Images
The Internet is a rich source of orthopaedics-related images, which current
search engines allow you to search and access with relative ease. Google and
Yahoo are two of the most popular general search engines that allow you to
specify "images" as a search item and type in search terms. The
images that are returned from the search are viewed originally as thumbnails
but are actually links to the original source. Double-clicking on the
thumbnail takes you to the original site on which the image appeared. If you
wish to save an image for educational purposes, you can usually do so by
right-clicking over the image (for PC users) and then clicking on the
"save as" feature in the dialog box. Keep in mind that most images
on Internet sites are low resolution, designed for fast web-page-loading, and
they do not enlarge well. However, they are suitable for electronic
presentations.
Most Windows operating systems have an option to save and print the entire
active screen with the "Print Screen" key on the keyboard, which
saves the entire screen image to your computer clipboard. However, images
saved in this way contain excess material such as menu bars and headers and
may require electronic cropping before use. If you want to save only an image,
chart, or graph, you may want to consider a stand-alone screen capture
program. Using your web browser to search for "screen capture" or
"screen print programs" will reveal a long list of available
programs from which to choose, and many have free trial downloads.
Most professional journals are offered online. Portable document format
(PDF) files are becoming a universal format for viewing documents on any
computer. These documents can be found and downloaded from the Internet. Most
familiar to the orthopaedist will be The Journal of Bone and Joint
Surgery (JBJS) and the Journal of the American Academy of Orthopaedic
Surgeons (JAAOS) articles and subspecialty journals such as the
Journal of Orthopaedic Trauma that are available to subscribers.
These are relatively high-quality files that contain not only the text, but
also the images, charts, and graphs from articles that may be of use to an
orthopaedist preparing for a presentation. Usually, these files open in the
free application Adobe Acrobat Reader (Adobe Systems, San Jose, California).
However, as indicated by the name, you can only read these files. You cannot
select and save images or charts or modify text with this version of Adobe
Acrobat. If you own the full version of Adobe Acrobat, you can select and save
any of the images, graphs, or charts. In addition, many new programs with
which to create and manipulate PDF files are available. Your search engine in
your web browser will give you a list of the newest programs from which you
can choose to suit your needs. As mentioned above, stand-alone screen-capture
programs may also be used to select and copy these images.
Online Sources of Images Related to Orthopaedics
Several Internet sites have free or available-by-subscription images. A
brief listing is presented in Table
IV.
Image Archiving and Retrieving
There are dozens of image-archiving and retrieval applications on the
market. How to organize your images on your home or office computer is a
personal choice based on your organizational preferences, the nature of the
images that you are saving, and how you want them to be retrieved for use. In
many orthopaedic practices, images are saved either according to the
pathological condition (e.g., ankle or hip fractures, or knee arthroscopy
images) or specific patients. The features that are most important for medical
image retrieval include the name and medical record number of the patient; the
date of injury, surgery, or follow-up; and the diagnosis. All images of a
specific patient can be saved within a single folder on your computer. Each
folder should have a unique identifier (name) to aid in retrieval. Within each
folder, the individual images for each patient are often arranged
chronologically by date of injury, surgery, or follow-up. An understanding of
how the computer organizes files will aid you in your organization. Dates are
usually written by year, month, and day, from left to right (e.g.,
2006/01/21), and only image files starting with this date format will be
displayed chronologically.
Once you have organized your images of a patient, you may want another
physician to view them. For example, you may wish to send images to the
referring physician for follow-up, send them to a colleague for a second
opinion, or loan them to a friend for a presentation. Keep in mind that the
privacy rules that apply to protection of confidential patient information
also apply to images and information transferred by means of the Internet. You
may not include patient identification information on or with the images.
Internet resources will help in this regard. Commercial services allow you to
store medical images on a secure server, where they can be viewed by others by
invitation and password only. MyViewBox
()
is a service for physicians that allows, for a small fee, secure server
storage, storage of multiple images in a separate folder for each patient, and
transmission of e-mails to an invited reviewer with a password for viewing,
allowing images to be immediately available to your consultants. Commercial
e-mail programs such as America Online (AOL), Yahoo, and Microsoft Online
(MSN) are unsuitable for transmission of patient images because of both the
lack of security and restrictions on the size of transmitted images. Recently,
several secured e-mail services have become available. These transmit
"encrypted" messages, including images, and usually require
password verification. Because of the encryption, many may be HIPAA-compliant
and suitable for transmittal of patient information to colleagues. To search
for these applications, enter "secured email" as the search term
in your web brower and look specifically for the ones that state that they are
HIPAA-compliant.
You must assume that any work that is published on paper or on the Internet
falls under the protection of the Copyright Act (title 17, U.S. Code), and you
should get permission from the author or publisher to use all or any portion
of that material unless you can determine that the material is no longer
covered by copyright protection and now belongs in the "public
domain." All works published in the United States prior to 1923 are in
the "public domain." After that date, the copyright status may be
difficult to determine. The absence of a copyright symbol or notice is not
sufficient to establish the lack of copyright protection. For example, works
published after March 1, 1989, do not need to display a copyright notice or
symbol to be protected.
The only exception to the copyright rule, and the one most important to us
as orthopaedic surgeons, pertains to materials that are used under the
"fair use" rule as outlined in section 107 of the Copyright Act.
This rule recognizes that society may benefit from the unauthorized use of
copyrighted material only if the purpose is for criticism, comment, news
reporting, teaching, scholarship, or research.
Section 107 stipulates that four factors be considered when determining
whether a particular use is "fair":
The purpose and character of the use, including commercial or noncommercial
nature or nonprofit educational use.The nature of the copyrighted work.The amount of the copyrighted material used.The effect of the use on the potential market for or value of the
copyrighted work.
The purpose and character of the use, including commercial or noncommercial
nature or nonprofit educational use.
The nature of the copyrighted work.
The amount of the copyrighted material used.
The effect of the use on the potential market for or value of the
copyrighted work.
Certainly, many of our intended purposes for "borrowing"
material, images, charts, and graphs from published works fall under this
exception. As a general rule, if you are using a small portion of somebody
else's work, such as an image, graph, or chart, in a noncommercial way and the
purpose of the use is for education, research, or teaching, then you are on
pretty safe ground.
It is still a good idea to make every attempt to identify the author of the
image or material and ask for permission for use. Even if you decide that your
work falls under the "fair use" category you must still give
credit to the author by naming your source as a reference.
Additional information can be found at
and at
.
Arguably the most comprehensive resource for the orthopaedic practitioner,
the AAOS web site contains a multitude of information related to the practice
and knowledge of orthopaedic surgery.
Professional education resources include access, review, and search of
JAAOS and the American volume of JBJS. Orthopaedic Knowledge Online is a
peer-reviewed source of topically organized medically related information
available to AAOS members and, on a fee basis, to non-members. Use of video in
this section for procedurally oriented material is particularly helpful.
Extensive continuing medical education (CME) materials on the AAOS site are
listed topically and include the AAOS-produced Self-Assessment Exams.
Practice tools on the AAOS web site include prefabricated, customizable
PowerPoint presentations (Community Orthopaedic Awareness Program) on a
variety of general orthopaedic topics, Current Procedural Terminology (CPT)
coding articles and monographs, practice management information and advice
center, the Orthopaedic Medical Legal Advisor (OMLA), a publication with hints
on risk management, the "Pitfalls and Pearls" section, and the
opportunity for participation by AAOS fellows.
Finally, the AAOS supports free web-hosting of members' web sites, for
individual and group practices, with use of a template-guided, customizable
site. AAOS fellows may log onto "Create Your Own Website" under
"Member Services" using their AAOS password (available by calling
the AAOS if you don't know yours). Once the fellow is there, an overview
introduces him or her to the process of creating a web site, and this is
followed by directions for creating the site, including design examples, help
screens, and examples of suggested text. This is all done online, and
additional e-mail assistance is available from AAOS Member Services. One
particularly useful element of the "Create Your Own Website"
process is a feature that shows one how to link the AAOS patient information
topics so that the selected ones appear on the fellow's individual or group
practice web site. These patient information topics may also be printed by
patients visiting the web site, or by the fellow for use as
patient-information handouts. Each printout includes the logo for the
individual web site as well as the AAOS logo. Return visits to "Create
Your Own Website" are possible at any time to update and/or change
information.
Another important feature of the AAOS web site is "Your Orthopaedic
Connection." There, a direct link to patient-based orthopaedic
information written and peer-reviewed by AAOS members is readily available for
review and download. Additionally, AAOS press releases and other public media
productions, including streaming videotapes and public service announcements,
are available there. As mentioned above, all articles can be linked directly
to the AAOS member's individual and group web sites. The "Your
Orthopaedic Connection" web site has grown rapidly, with more than 450
articles on a wide variety of patient-education-related topics and the recent
development of indepth "informed choice" modules.
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