Orthopaedic Web Links

Myles Clough
OWL Senior Editor
President, Internet Society of Orthopaedic Surgery and Trauma (ISOST)
Clinical Instructor, Department of Orthopaedics University of British Columbia

OWL www.orthopaedicweblinks.com is an Index to sites of interest to orthopaedic surgeons on the Internet. Owl is also the focus of an attempt to improve the quality of orthopaedic information on the Internet.

The logic goes like this

OWL is the largest index to orthopaedic sites on the Internet already. It aims to become or contribute to becoming the single authoritative index site to the orthopaedic internet run for and by orthopaedic surgeons.
We can
          offer opinions about quality
         Give quality ratings
But unless those who post the sites care about the comment there will be no effect on quality
Becoming an authority is critical

Were does OWL get content?
          Users make site recommendation (Register as a user of OWL, log on and enter the address and information about the site)
          Editors undertake site review -

1. enter the administrative part of the site,
2. review the entries submitted by users,
3. visit the recommended sites
4. make sure the entry is on an orthopaedic subject and meets minimum quality standards
5. make sure the entry is in the right category
6. scan the rest of the site to see if there are any other pages which should be added to OWL

Editors also are active searching the Internet for more material. We plan to obtain a links Spider program to help collect this information.

Other Housekeeping activities also include copying, moving & revalidating links. There is a tendency for links to become out of date rapidly (link rot).

The rewards for undertaking such a "low level" job include the interest of seeing what people have written about orthopaedic subjects and participation in an important academic activity. (In other words no rewards)

To understand why anyone would do that we have to backtrack somewhat and remember the original promise of the Internet

It offers a cheap, fast, and interactive way to present material that is updatable, uses a layered structure and is international in focus. These advantages lead to firmly held beliefs which may seem irrational to some. The first is that academic communication will move from paper to electronic form and be greatly enriched by the process. The second is that this change will also transform all aspects of orthopaedics including doctor/patient relationships, research; concepts of authorship may change as research uses open databases and an interactive consensus in discussion of the results. If this happens, the way we teach will perforce have to change as well.

Speech, Writing and Printing were comparable changes in Information Technology which transformed the world and the ecosystem in which we live. Printing, for example, led to the Renaissance, the development of science and technology and the evolution of political systems in the direction of democracy.  Whereas printing made general knowledge widely available, the Internet make specialized knowledge accessible to everyone. Coupled with direct point to point contact with experts, this accessiblitiy for patients, journalistsm, lawyers, administrators and politicians makes the Internet a potent force for change. Specialized knowledge will be de-mystified.

This comes at the same time as Information Overload is threatening the ability of orthopaedic surgeons to organize their knowledge. In the MedLine database there are 105 Orthopaedic journals. Assuming that there are 25 articles per journal, and 8 editions a year and that you can skim an article in 5 minutes, it would take you 70 days per year to "keep up". Since this is an obvious impossibility we either pretend that we can "keep up" by going to conferences and reading a tiny selection of the orthopaedic literature or we accept that we cannot keep current in all fields of orthopaedics.

This requires a change in mind-set and a move towards evidence based medicine, just-in-time information, learning to search rather than relying on memory and perhaps using the patient's own committment to pursuing information as an informal research assistant. Certainly it will be neither possible nor ethical to pose as all-knowing when the patient can easily call your bluff. These changes will require a tremendous adjustment for us and will necessitate a change in the way we educate ourselves.

The quality of orthopaedic information on the Internet

Like with the weather,  everyone complains about the quality of information on the Internet but nobody does anything. It may well be for the same reason; neither phenomenon seems to be controllable. Information on the Internet seems to be chaotic, mostly rubbish; it is difficult to find anything worthwhile. The whole situation is disillusioning, particularly when one recalls the hope and hype that greeted the Internet. Yet, it is also true that excellent material is posted on the Internet and that institutions to make sense of it all are still in development. More to the point, the Internet won't go away and the changes it will promote will happen whether we think about them or not, whether we like it or not and whether we are prepared or not.

Quality is a problem because no one can stop poor quality material being posted. The best one could hope for is to reduce readership of poor quality information by directing readers to good quality. To confound the situation further quality would be defined differently for different audiences. It would be an extraordinary piece of scholarship that was equally valuable to highly informed professionals, trainees studying the subject and patients anxious about it. Most attempts to study quality have concentrated on the provenance (because it is easer to assess); content quality is what is important and we are only just beginning to work up ways to assess quality that are more reproducible than "I don't like it".

The institutions to make the Internet work well for Orthopaedics take some thinking about.

• Orthopaedic Subject Headings This may not be obvious, but without an agreed set of Orthopaedic Subject Headings it will never be possible to find information. One solution to the problem of finding information would be to assign codes for each subject heading; these codes would be placed on the relevant pages as a keyword and the users could search for the specific and rarely used code rather than the imprecise and often used words.
• An Authoritative Index Site is another vital institution. There needs to be a site one can visit with a high likelihood of finding good quality information on the subject you are interested in. Once such a site exists it would be in the interests of those who post information to keep the site up to date. The site would form the link between providers and users of information. We believe that this site should form by co-operation rather than competition. There needs to be only one site so that those who post and those who use information don't have to go looking. A prolonged period of competition and attrition would not serve our needs.
• Content Quality Criteria If these were then developed they could be applied by reviewers to document the extent to which a given site covers the subject. Pointing out such deficiencies on the Index site would be a powerful stimulus to improvement if (and only if) that site truely was authoritative.
• A cadre of people is required to undertake the tasks of Orthopaedic Informatics; to identify the subjects we are interested in (subject headings), populate the index site with the webpages we would find informative, to devise the content quality criteria and to review the sites. This is work which only orthopaedic surgeons can do so the critical need is for people to form an Orthopaedic Information Technology special interest group.

The Internet Society of Orthopaedic Surgery and Trauma (ISOST) was founded in 1999 with by-laws adapted from the orthopaedic specialty societies such as the Hip and Knee Society. It was conceived as the academic body that might evolve into its own Specialty Society, the specialty being Orthopaedic Informatics. ISOST is the international group of people who are managing the Orthogate Project. Three roles have been identified for the society -

• Educating orthopaedic surgeons about information technology. This is primarily accomplished through the Orthopaedist's Guide to the Internet
• Maintaining the OWL portal site
• Fostering communication using the Orthopod and other mailing lists.

OWL is attempting to pre-empt the position of dominant authoritative site. At 7000 links, it is the largest index site by an order of magnitude. It offers a "straight to the meat" approach instead of leading you to the front page of a large site and leaving you to find your way. It has an interactive community format and it is run for and by orthopaedic surgeons. The project has been steadily growing for the last 5 years and those involved have been steadfast in the face of lack of interest and lack of funding.

For all that OWL is nowhere near the first goal, that of becoming the authoritative index to the orthopaedic Internet. Johnson & Clough estimated in 2001 that the Orthopaedic Internet is at least 100,000 pages and it can only have increased in size. OWL has links to 7000 pages which is ten times larger than any other index. But it still cannot claim to be comprehensive. OWL is not well known with 135,000 page views in 2002 and is without any financial support. The content quality task is barely begun and the number of people willing to undertake these tasks is still tiny. Is the whole effort quixotic?

Before we try to answer that, we must face other questions.

• Is the quality of orthopaedic information on the Internet important ?
• Is there another way to affect quality on the Internet?
• Is it a good idea to let someone else do this?

Other mechanisms

Legislation

Making it illegal to post orthopaedic material unless it has been "passed" by a greybeard committee? Unenforceable, laughable and wrongheaded.

Peer pressure

You cannot pressurize the suppliers of suspect information any more than you can pressure the suppliers of spam to stop polluting the Internet. While they believe that they are going to make money they will continue. So peer-pressure would have to work by pressuring the readership to seek out good quality. Unfortunately, the least sophisticated are most in need of good quality material. Anyway, how do you exert pressure to find good quality sites on someone who has just broken their leg?

Who else might take on the tasks?

• Governments?
• Librarians?
• Yahoo?
• Who do we want to be setting the standards and making quality assessments about orthopaedic information? If not orthopaedic surgeons?

OWL Funding Dilemma

Non-zero costs. The effort to produce OWL requires outlay for hosting, software, database and HTML Programming. Not least there is a need for thousands of hours of labor by orthopaedic surgeons. We need a public relations program to explain what we are trying to do.

Zero income. On the one hand we need the whole orthopaedic community to support the concept and supply OWL with notification of sites, reviews and feedback. On the other, so deep are the suspicions about the Internet that we risk losing the support of that community if we are seen to be running a commercial enterprise. Why should anyone help us make money?!

Currently the site is hosted for free and the other expenses including travel for educational and PR efforts are funded by the orthopaedic surgeons involved.

Future OWL Funding Options

• For-profit organization funded by advertising (like journals). As noted, there are deep suspicions about this model.
• Charge a service fee to ISOST since members use the Internet and benefit from OWL's activities. However, the same applies to all orthopaedic organizations. They have an obligation to supply their membership with information about the Internet to satisfy members information needs. They can off-load this obligation onto OWL. The second problem with this option is that it merely shifts the problem, as ISOST has no income either.
• University or Organization support: Despite the argument that OWL/ISOST supplies a service which organizations benefit from, few organizations are likely to agree that this conveys an obligation to support OWL. They would have to decide that the effort is worthy and would reflect credit on their organization.
• User pay. If the aim is to become a dominating source of information on the Internet this model would never work. Users of the Internet expect their information to be available for free.

To recap the question of how  a portal site can make a contribution to the problem of information quality on the Internet

The ISOST Plan is to engage the orthopaedic community in building a portal site. When the portal site is the authority on the orthopaedic Internet, the positon could then be used to affect quality by directing users to good quality sites and identifying deficiencies to authors.

We have no funding with which to continue and most funding options seem to be blocked off by the nature of the Internet and the need for enthusiastic support from the orthopaedic community.

What should Orthopaedic Organizations do in the face of this situation?

1. Establish whether our analysis is correct and whether it is important to the members of the organization
2. Formulate the official position of the organization. This may be that the situation is not important and requires no action. Otherwise the options for action would seem to be
   • Support the ISOST plan
   • Design the organization's own portal in competition
   • Devise and support another plan
3. Whichever option is chosen it should be pursued persistently but flexibly. If it turns out that another direction is preferable then changes should be made
4. If this subject is important then letting it go by default is not an option for an honorable organization.

Summary

OWL is a functioning index and as such is useful in its own right

OWL sees itself as the germ of a quality improvement mechanism for the orthopaedic internet

Is it important?
Is it well conceived?
Is there an alternative?
Can it succeed?
What can we all do to help?

Is the whole effort quixotic? Show me the alternative and I can answer the question.

Myles Clough
OWL Senior Editor
President, Internet Society of Orthopaedic Surgery and Trauma (ISOST)
Clinical Instructor, Department of Orthopaedics University of British Columbia

J.F.M.Clough, J.A.J.Van Der Bauwhede, C.W.Oliver 1998 Orthogate - The Rationale For An Internet Gateway Site In Orthopaedics http://www.mcmaster.ca/inabis98/biomededu/clough0546/index.html

J.F.M.Clough 2000 The Orthopaedic Surgeon and the Internet COA Basic Science Course http://mypage.direct.ca/c/cloughs/orthopaedics/basci.htm