Canadian Medical Association Journal 1996; 154: 382-384
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Introduction
Many clinicians, having read about the Internet in the popular press, books and in CMAJ (Medical publishing on the Internet: The CMA goes online. 152: 1103-1107 and Navigating physician resources on the Internet. 152: 1303-1307), are interested in using this resource. I hope that some of my recent Internet experiences will interest other clinicians.
Although I first heard of the Internet several years ago, I had no idea that it had the potential to be of clinical value. I considered it a technical curiosity, of interest only to experts.
However, my own clinical interest was aroused by a 1993 letter to the editor in Anesthesiology from Dr. Keith Ruskin (now at the Yale University Medical Center), which described how to subscribe to Anesthesiology Digest, an Internet-based medical discussion group.
As a subscriber to an Internet server, I obtained easy - but not inexpensive - access to the digest via electronic mail. However, I soon became frustrated with the limited access my server offered at that time (this has since been improved), and soon signed on with a local full-access provider (Inforamp email: staff@inforamp.net) that offered more extensive services such as gopher, ftp (file transfer protocol), telnet and World Wide Web access for $30/month. This allows up to 80 hours of use each month.
Before long I had obtained, installed and evaluated a number of shareware Internet packages such as Netscape, Mosaic and Eudora, as well as Internet-in-a-Box, an excellent commercial package available in many computer stores. I also spent many late evenings exploring the Internet in search of useful clinical resources, mostly in preparation for a clinical Internet symposium I organized at my hospital. I also spent some time exploring nonclinical Internet resources (see sidebar for some useful
Universal Resource Locators, or URLs.
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Tips for new users
The easiest way to get connected to the Internet is to sign up with a full-feature Internet provider such as CompuServe, Delphi or any of the many local service providers. One advantage of a multinational provider such as CompuServe is the ability to access the Internet in cities around the globe, allowing inexpensive Internet access for the frequent traveller. Clinicians should avoid "freenets." They may be either free or charge low fees, but this rarely offsets the frustration accompanying their frequent busy signals.
Since I organized the clinical Internet symposium at my hospital, I have often been asked for Internet-related advice in the hallway or in the operating-room locker area. More experienced users share their favourite sites with me or ask about arcane technical issues. Judging from the requests for a second offering of our symposium, interest in the Internet at our hospital is growing quickly.
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Useful aspects
The most useful aspect of Internet access is email. I use it to keep in touch with people around the world, many whom I have never met face-to-face but know via the Internet because of mutual interests.
I also use it to subscribe to Anesthesiology Digest and to receive Educational Synopses in Anesthesiology and Critical Care Medicine, a free peer-reviewed journal focusing on resident education (archives for both are available at http://gasnet.med.yale.edu/).
One underappreciated aspect of email is that not only text messages but also word-processing files, images, sound files, programs and even video clips can be sent by using the "send attachment" of most email programs. This can be especially useful for collaborative work between clinicians in different cities.
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Clinical resources
Clinical resources available on the Internet can be overwhelming and, regrettably, of varying quality. The novice will be well advised to take advantage of the toil of those who have already gone exploring. Some of this knowledge is found in reports that are released periodically and are usually available by gopher, email, ftp or other means. The Medical Matrix Web Guide to Internet Clinical Medicine Resources is particularly useful, as are several of my favourite clinical resources (see sidebar).
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Medical discussion groups
Although numerous Internet discussion groups exist on topics ranging from astronomy to zoology, the development of professional discussion groups on medical topics is a relatively recent but very important development. This forum warrants some discussion.
Simply stated, an Internet medical discussion group (IMDG) is a network of users who share a common interest in some medical field. For example, IMDGs for AIDS, cancer treatment, chronic fatigue syndrome, dentistry, epilepsy, forensic medicine, medical physics, nursing and occupational medicine are all available (see Hahn H, Stout R: The Internet Yellow Pages, Osborne McGraw Hill, Berkeley, 1994).
These discussion groups offer participants the chance to meet new people, share clinical experiences, obtain advice and learn new perspectives on a variety of clinical topics. Because participants tend to be distributed internationally, fresh perspectives on clinical issues are often available.
Participation in an IMDG usually begins by "posting a note" -- in essence, sending an electronic letter to all group members. There is no need to keep a mailing list; the letter (actually an email message) is sent to a "list server" or "list processor" that takes care of message distribution. Once distributed, the letter is available to all IMDG members to read and discuss.
Because responding to a message involves only a few keystrokes, lively and helpful discussions often follow. If they wish, members can also reply privately rather than to the whole group. The sequence of messages following the original message is known as a "thread." Here is a slightly edited sample thread from Anesthesiology Digest about instructing postoperative day-stay patients (identifying data have been deleted).
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Original posting
"We have recently been criticized by one of our day-stay surgeons for the postoperative instructions that we give to patients. Basically they are told that they must not drive a car, ride a bike, operate any machinery or electrical equipment, do any cooking, make any important decisions, drink alcohol or take any sedative drugs for 24 hours after surgery. The literature contains statements similar to this (from the `80s), but no evidence that I can find supports reducing this time for more modern anesthetics. What are people's instructions to their day-stay patients and how do they justify them? Thanks."
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Reply one
"I generally reassure patients in our ambulatory anesthesia area that their mental abilities will be near normal within a few hours but that they should not drive a car, operate dangerous machinery or sign any legal document because their judgement may later be called into question because they have had an anesthetic that day. In today's litigious atmosphere, nearly everyone understands and agrees. I think it is also desirable to have patients be sedentary for at least 24 hours to avoid surgical complications. When I was a surgery resident I encouraged them to lift `nothing heavier than a newspaper or a fork' for 24 hours."
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Reply two
"My suggestion is to ask the surgeon if he would like to ride in the car with the patient as the driver following the procedure. Our guidelines are similar to yours, and I usually tell patients to avoid similar activities until the next day."
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Expanding communication
Before the advent of the IMDGs, one could only resort to telephone calls to known experts and literature searches to find out some specialized clinical information. The IMDG serves as yet another source of topical information. Among the many and varied topics discussed in the anesthesiology IMDG are premedication of children, the use of positive end-expiratory pressure (PEEP) valves, testing of the anesthesia machine, presence of spouses in the operating room during cesarean sections and management of the difficult airway. Meetings, conferences and symposia are also announced.
I often use the anesthesiology discussion group to obtain information that is difficult to get by other means. In one instance, after providing anesthesia during a liver transplantation that required 142 units of packed cells, I described the case to "the list" and initiated a lengthy thread that provided clinical hints to all who do transplantation anesthesia. In another case I asked about the clinical use of pentastarch for cardiac surgery and was put in touch with clinicians experienced with use of the product. Another time, as I prepared for a planned animal experiment, I wrote privately to a veterinary anesthetist who frequently contributes to the list to inquire about using propofol for canine anesthesia.
A large variety of resources of potential interest to the clinician awaits those willing to take the steps to get access to the Internet: medical discussion groups, teaching files, electronic journals and digitized images such as x-rays or colour photomicrographs. Make use of them! Happy venturing on the net.
Sidebar: Some favourite clinical resources