Canadian Medical Association Journal 1996; 155: 316-317
© 1996 Canadian Medical Association (text and abstract/résumé)
Several months after launching the World Wide Web site known as CMA Online (http://www.cma.ca), the CMA began offering another Internet service, one that is much simpler than a Web site but potentially far more useful to individual clinicians. The only technologic requirement is the most basic Internet access: an old computer and a slow modem are not a disadvantage.
The service, called Clinical Q&A, is the CMA's first "mailing-list discussion group." It is designed to encourage discussion of diagnosis and treatment, and to provide an informal way for physicians to consult privately about unusual or difficult cases.
Quick and convenient communication was the original raison d'être for the global network of computers that constitutes the Internet, and it remains the principal attraction for enthusiasts. Most of us who use the Internet for professional purposes spend far more time sending and answering email than we do searching the multimedia Web in hopes of finding valuable information.
But the Internet does put a new twist on correspondence by computer. Through mailing-list discussion groups, people with similar interests who were not previously acquainted can pose questions to one another, offer their own opinions and discuss issues of common concern.
About 150 physicians now belong to Clinical Q&A; 99% are from North America, 95% from Canada. There is usually at least one message in members' mailboxes each day. (Some Internet discussion groups generate hundreds of messages a day, but this volume quickly becomes overwhelming.)
Any practising physician is welcome to join, or "subscribe", through a written request on professional letterhead to the CMA Online Webmaster, Publications Department, CMA, PO Box 8650, Ottawa ON K1G 0G8 (fax: 613 523-0937). The physician's email address and CMA membership number or licensure number must be included; American physicians may use their Drug Enforcement Agency number.
Once the subscriber's identity has been verified, the physician is added to the electronic list and receives a letter of welcome that includes simple instructions on how to post and reply to messages. Subscribers are warned that constructive discussion and the free exchange of ideas are welcome, but abusive or offensive messages and advertising are not. Physicians are asked to respect patient confidentiality and not to disclose names or identification numbers during case discussions. They are also warned that discussions are not moderated and that statements of fact are not authenticated by the CMA. In other words, caveat emptor.
email posted to the group is received by a computer that automatically delivers a mail message to the Internet mailbox of each group member. Recipients may respond to the writer personally or to the group as a whole, or they may forward the message to another group, a move that will vastly increase the number of potential respondents. Usually this process elicits a helpful answer or initiates a discussion.
Most interaction in Clinical Q&A over the past 14 months has involved a question-answer format, as opposed to true discussion. The questions usually have been about diagnostic or, more often, management dilemmas. The cases described are often complex, and the physician may be uncertain about what to do or try next after the usual management options have failed.
Nearly as common are questions about observed or potential adverse effects -- or potential benefits -- that might be related to drug therapy. The physician has usually studied the literature and found nothing relevant to the problem case, so asks the group if anyone has pertinent knowledge or experience.
Occasionally questions deal with patients' concerns about their risks for certain diseases and whether diagnostic procedures exist or are warranted. Sometimes questions hinge on ethical or moral issues.
Responses tend to arrive quickly; email is compelling and can be answered fast and without letterhead, envelopes and stamps. However, this ease of use also means that responses are unlikely to be as thorough as those found in a peer-reviewed journal -- or even a hospital corridor. Full literature references are seldom cited, and the scientific evidence underlying a practice or an opinion is usually not offered. Of course, it is easy to request background information from the respondent in order to follow up with the literature.
Not all postings to a discussion group elicit a public response to the entire group. However, thus far only 11 questions and one request for views on a particular issue have not received a public response in Clinical Q&A. In each case there could have been personal replies to the writer.
Over the same period there has been only one posting that the group deemed unacceptable -- it had to do with a political rather than clinical issue. Each Internet discussion group has a defined purpose that members are expected to respect. Anyone posting an inappropriate message will be reminded of this "rule" immediately by group members -- as happened in Clinical Q&A.
Eligibility for participation is similarly strictly defined in some discussion groups. Clinical Q&A is restricted to practising physicians who have formally joined the discussion group, although sometimes a member will forward a question from another group of which he/she is a member. Last fall, in response to requests, the group was polled to determine whether participation should be extended to other health care professionals, and the answer was a resounding "No!" However, if the group grows so large that the volume of mail received by each member became unmanageable, the group might choose to split into special-interest subgroups.
Clinical Q&A is only a starting point for the CMA. After the success of this venture, we plan to offer the health care community other Internet forums. These will include mailing-list discussion groups, Internet "bulletin boards" and "chat rooms" in which participants discuss and debate issues in real time. Some forums will be created specifically for affiliate societies of the CMA, and others will reflect suggestions received from CMA members.
If you have identified a discussion area needed by Canadian physicians that does not currently exist on the Internet, I'd like to hear from you (800 663-7336 or 613 731-8610, x2117; [fax] 613 523-0937; bolsta@cma.ca).
New groups will be announced in the discussion groups area of CMA Online (/groups/) as well as in CMAJ and CMA News.
We are grateful to Health Canada, whose Information Systems staff, notably Terry Moorby and Lynne Mulvihill, provided technical support for the CMA's discussion group, as well as server space and support for the CMA's web site during its first 18 months of operation.