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The Information Age - Implications for Orthopaedic Education PDF Print E-mail

Christian J.H. Veillette, M.D.
University of Toronto, Division of Orthopaedic Surgery
Edward J. Harvey, M.D., FRCSC
McGill University, Division of Orthopaedic Surgery

In 1970, Alvin Toffler wrote prophetically about the need to recognize and manage the dramatic changes that he foresaw in our society with the coming of the Information Age1. That change is certainly upon us and is being driven by a multitude of technological and economic developments. The rapid development and popularization of the Internet have profoundly changed the accessibility of information for those involved in health care decisions (residents, physicians, patients, nurses). Rapid developments in basic and clinical science, diagnostic and therapeutic technologies place their own pressures on learning orthopaedics. Now, more than ever, we need to be equipped with the mental attitude and intellectual tools to deal with and to exploit these changes.

Information technology and medical institutions

The Internet will have a profound influence on academics. Academic medicine and the Internet share several fundamental similarities. The primary mission of academic medical centres is the creation and dissemination of biomedical knowledge. We create information, we use information and we promulgate information2. Our ability to be effective in our research, education, and clinical affairs depends on the ability to manage information. The Internet provides the ultimate medium to harness the vast information needs of orthopaedic surgeons.

Unfortunately, our bureaucracies and attitudes have been trailing edge rather than leading edge. Most institutions have not made even the necessary infrastructure investments (or plans) to take advantage of digital information and techniques at the enterprise level. A minimum investment of 5-8% of an institution's operating budget and 10-15% of capital investment is required to provide the necessary infrastructure. Planning is frequently even farther behind than the infrastructure. As a result, patients, residents, and staff often look outside their respective institution for innovations in information technology. The Internet, information revolution and network economy are transforming every aspect of health care and academic medicine at a rampant pace. There are many reasons the Internet has transformed the way academic medical centres conduct their affairs. Currently, the two largest institutions in Canada are in the process of switching to digital imaging, or PACS. This is a process that is occurring as new technology and imaging techniques are coming on-line. The 400 images from a spiral CT scanner will not fit in the standard envelope so the only place the physicians will be able to view them are on-line. Ostensibly this could make the medical job easier; no films are lost and images can be viewed from home without the delay of travelling to the hospital. But due to the inadequate infrastructure in all our hospitals to handle the digital information of the images, the physicians' job has only become more difficult.

Outside of digital imaging, our medical institutions are still coping with the explosion in the availability and demand for biomedical information that would not have been possible without the rapid growth in the scope and sophistication of the Internet. The Internet has eased communication across the globe with the widespread use of e-mail. It has changed the economics of information by transforming previously scarce and obscure information into digital commodities easily obtained at low cost. Digital patient charts and files are in the near future. The trickle down effect of these new technologies will have an impact on the teaching institutions immediately, but will soon also impact the smaller hospitals and clinics as new imaging and information resources are adapted elsewhere. The medical institutions of today and the clinics and physician offices of tomorrow will be under siege as a more sophisticated clientele demands real time image transfer and second opinions as well as digital copies of their dossiers. The cost of this ramping up of technology will put the orthopaedic surgeon in an awkward position unless new tools can be found and more importantly adopted.

Information technology and medical education

The current educational methods are not designed to take advantage of the information explosion. The growth of the Internet has changed the pace of everyday work with widespread effects on patient-physician relationships that are becoming more evident. Developing strategies to deal with information overload have become mandatory and the faculty-resident relationship will show a fundamental shift as the information resources become integrated into clinical activities. Orthopaedic education needs a fundamental change of focus from simply delivering content to developing the ability to manage these changes.

The major guiding influence in the development of orthopaedic curriculum should be learning to learn and learning for life3. These principles are often assumed to be developed by residents during their training, however, without learning information management strategies, many residents will unfortunately not be able to effectively & efficiently manage the information overload they will be presented with.

Several caveats exist, however, when discussing the use of Internet resources and these must be kept in mind.

Caveat 1:

“Internet resources are unquestionably powerful tools. Used badly they do indeed waste time & money, create inefficiency, and dehumanize interactions. Used well they are neither to be feared, loved nor loathed. They are simply to be used”4

Caveat 2:

“Basic computer skills are not the same as being skilled in the management of information”3

Caveat 3:

“Our dependence on information and communication technology will only deepen and the inability to use this technology will be as debilitating as the inability to read or write”5

Caveat 4:

“Any attempt to use information technology will fail dramatically when the motivation is the application of technology for its own sake rather than the solution of a clinical problem”4

The advantages and limitations of the “orthocentric” internet

The Internet presents several key advantages for orthopaedic education and the dissemination of orthopaedic knowledge.

  1. As a tool, the Internet provides ready, available access. Most hospitals now have computers with network links on the wards, the OR, ER, in clinics, libraries, and lecture theatres. Most residents have Internet access from home.
  2. The Internet has the dynamic nature necessary to harness the rapid explosion of information unlike print material and CD-ROM based educational material.
  3. Multimedia capabilities exist with Internet resources that cannot be implemented into print resources.
  4. Maintaining Internet resources are cost effective compared with traditional methods (paper handouts, schedules, journals).
  5. The Internet affords efficient global collaborative capabilities. Distance does not create any barriers for collaborative efforts on educational resources.
  6. Allows the customization of educational opportunities with respect to content, time and media type most effective for each resident. In addition, it allows a “hyperlink” concept to provide layered learning as necessary to meet needs of the resident.
  7. Finally, it creates a continued learning environment that does not end in the lecture theatre. Lectures can be revisited, revised and expanded beyond the time constraints of a lecture to provide a more complete learning experience.

While the Internet and Information Technology tools appear on the surface to provide answers to many of our educational needs, there are several elements of using these tools in residency education that limit their integration.

  1. The time constraints of an academic centre may limit the ability to produce Internet based resources by both faculty and residents. However, with current applications and collaborative efforts, producing an Internet based lecture is almost as easy as creating a handout and saving it to a computer hard drive. As more surgeons and secretaries become comfortable with using Internet resources, this will no longer be a limitation.
  2. Maintaining computer systems and networks to take advantage of Internet resources requires expenses like any other evolving technology. Many divisions and hospitals are unwilling to provide the funds to update software/hardware on an ongoing basis.
  3. Quality control of resources is a major issue that must be addressed by collaborative efforts by respected academic centres.
  4. A lack of resident training in medical informatics and familiarity with available Internet resources and their appropriate implementation continues to plague their widespread use.
  5. Difficulty (and lack of acceptance) with integration of resources into daily clinical care. Information systems are still evolving to optimize the efficient delivery of relevant material at point of care.

The changing patient-physician relationship

The relationships between patients and the nurses, residents and surgeons responsible for their care are being transformed by the routine availability of Internet resources. Physician-centred decision-making is evolving into patient-physician shared decision-making in part as more patients utilize Internet based resources themselves. Patients are now becoming more autonomous in their health care decision-making and residents need to develop strategies to cope with the growing number of patients who gather information from the Internet before consultation and need to be aware of the types of information available.

On-line educational resources

The scope of resources available to enhance orthopaedic education includes textbooks converted into web-based formats, images, video clips, multimedia and case presentations, bibliographic databases, e-mail and e-mail discussion lists, and electronic forums and conferences.

Learning resources such as the Wheeless Textbook of Orthopaedics (www.medmedia.com) provide an example of the powerful hyperguide capabilities of the Internet. Originally, Bob Wheeless conceived the textbook as a CD text, with quarterly updates that he planned to market to institutions at a low price in order to further resident education. As the ability to easily post information on the web became evident, he was one of the first to exploit the hypertext capabilities for educational purposes. The Internet provides an easily accessible, point-of-care resource that residents can utilize in clinic, emergency room or operating room scenarios in between cases. It allows the integration of information into clinical workflow to maximize learning potential. While it provides a relatively high level of quality, it needs a committed global editorial review board and constant updates to remain an effective resource and improve its acceptance.

Another example of a textbook based resource is MD Consult (www.mdconsult.com) which contains Rockwood & Green’s Adult Fractures, Campbell’s Operative Orthopaedics, Orthopaedic Clinics of North America, and Hand Clinics of North America with an integrated search engine.

The AAOS has indicated that their goal is to be the dominant Internet publisher in orthopaedics – where people want to publish and users want to go6. The launch of OKO – Orthopaedic Knowledge On-line is an indication of their dedication to achieving this goal.

Several other excellent, well-developed learning resources exist on the orthopaedic Internet. WorldOrtho (www.worldortho.com) was one of the first on-line educational resources for orthopaedics. It provides an extensive array of resources including textbook based notes, slide shows, practice exams, and an overview of the history of orthopaedics. E-hand (www.eatonhand.com) is a high quality inclusive resource for hand surgery and illustrates the ability to integrate the Internet into a clinical practice. ShoulderScope (www.shoulderscope.com) provides an example of the type of high quality content that can be acquired through a collaborative effort by respected surgeons in a subspecialty.

Evidence based medicine has evolved into the standard of care and several resources are available for residents to integrate these practices into their daily clinical work such as PubMed (www.ncbi.nlm.nih.gov/PubMed/) and various electronic journal resources like the JBJS (www.ejbjs.org).

As information retrieval systems become more advanced and linked to Electronic Patient Resources, this process will become more efficient. However, residents still need to know how to make appropriate decisions and tailor treatment to each patient. A cookbook Internet based approach is definitely not the answer.

Case studies are often used as an educational method during orthopaedic residency both for teaching and evaluation purposes. The Dupont Hospital for Children (http://gait.aidi.udel.edu) provides an example of a high quality case study presentation archive with reviews of the topic and integrated bibliography. The creation of such an archive allows for continued learning outside of rounds, re-use of the case for additional purposes, and enhancement of the case with multimedia material (gait analysis, clinical pictures, intraoperative video) to further enhance the educational experience.

Commercial information resources are arising as potential high quality sources for orthopaedic information for faculty and residents. These “orthopaedic desktops” such as Medscape (www.medscape.com) and DoctorsGuide (www.docguide.com) provide summaries of conferences, journal updates, CME resources, review articles and case presentations. These are beneficial to keep orthopaedic residents up-to-date on the dynamic nature of the specialty and reinforce the life-long learning concept.

E-mail discussion lists take the advantages of e-mail and implement the educational opportunities from discussion based on cases. For an in-depth review on discussion lists refer to The Orthopaedist’s Guide to the Internet (www.orthogate.org). This guide was created by members of the ISOST (www.isost.org) as an educational tool for orthopaedic surgeons to develop a common baseline of knowledge on the most important aspects of the orthopaedic Internet. Orthogate is a uniquely dynamic and knowledge-rich resource for all subjects in the orthopaedic sphere. It is a collection of links, references and case reports second to none on the web.

Patients are also becoming seekers of high quality information on the Internet in order to guide them in their health care decisions. Without a doubt, there are a number of “vanity sites” that simply create propaganda on orthopaedic topics for patients, however, there are several useful sites such as Orthopaedic Patient Education Collection (www.sechrest.com/mmg/opectoc.html) that can improve the level of knowledge of patients beyond the clinic/office visit discussion.

The orthopaedic Internet in Canada: a collaborative resource

In Canada, academic orthopaedic surgery departments underutilize the Internet as a source of clinical and educational services. Despite its demonstrated educational potential 7,8, only two programmes post teaching cases or conference material on-line, three post presentations from seminars, and only one provides detailed descriptions of departmental research projects, although such information could promote interdepartmental cooperation. In fact, a review of the CaRMS (Canadian Residency Matching Service) web site (www.carms.ca) reveals that of the 13 orthopaedic training programmes listed, only five programmes had a web site listed with their programme description. One of these five was an invalid web address. Despite having one or two web sites for their programme, several programmes failed to list these as resources for additional information with CaRMS.

OrthoNet was created at the University of Toronto (www.orthonet.on.ca) in 1997 by an orthopaedic resident, Joel Lobo, to fill several gaps not addressed by the then non-existent departmental web site. It is maintained by orthopaedic residents and has been designed with the following objectives:

· to increase the awareness of orthopaedic residents on available Internet resources;

· to create a useful starting point for orthopaedic residents to improve their fluency with information technology and become more comfortable with implementing available Internet resources into their daily educational needs;

· to provide a medium to improve the communication and collaboration among orthopaedic residents at the University of Toronto and across other orthopaedic programmes;

· to enhance the dedication to life long learning and illustrate the utility of the Internet in this endeavor.

We have setup several novel Internet based resources in order to enhance orthopaedic residency education. The OrthoNet Links section provides a starting point for orthopaedic residents to develop a familiarity with useful web sites to potentially enhance their training. One recent endeavor is the development of the OrthoNet Seminar Series. The objective is to provide the infrastructure to create a directory of lectures, presentations, case studies from the orthopaedic curriculum at the U of T and other orthopaedic programmes as an on-line resource. Residents, Fellows and Staff can submit their resources to the directory and either upload files to the server or create links to their current on-line resources. Further goals are to establish linked resources to multimedia case presentations, an orthopaedic specific image archive and evidence based summaries on selected orthopaedic topics. Many of these tasks are performed by residents, fellows or staff on an individual basis and require only a collaborative shift in attitude to make them a reality. The OrthoNet Cases section provides several case presentations compiled by residents in the programme. As of yet, no staff surgeon has submitted a case to the archive. This is in contrast to McGill Orthopaedics (www.mcgill.ca/orthopedics) where staff members have compiled an extensive series of case presentations. The McGill site which was created at around the same time as the University of Toronto site was constructed by the staff with the express primary purpose to enable a virtual department for staff and resident evaluations, record keeping, schedules, education, expenses and rounds. This was in response to both resident and staff input for clarification of department workings. From this, an educational module for the residents has been developed to ensure access to not only relevant teaching cases, handouts for readings and assignments but also to give the residents a central presence, or home base, in the programme.

The Division of Orthopaedics at both McGill University and the University of Toronto have been working with ThinClient Corporation (www.thinclientcorp.com) on the development of an integrated on-line surgical logbook and residency management system for orthopaedic surgery. The objective is to improve the collaboration and communication between faculty and residents on both an intra- and interdivisional basis. Our aim is also to minimize the continued duplication of resources and provide a much more efficient method for maintenance of administrative tasks by the programme. An integrated on-line surgical logbook will more effectively allow residents to track their case experiences and allow the programme administration to monitor collective resident experiences for hospitals and postgraduate years and to develop the quality improvement process for orthopaedic training programmes.


The prospect of on-line information resources’ enhancing the quality of orthopaedic residency education has definite promise, however, the realization of this goal requires the collaborative efforts of the entire orthopaedic community, not just individual residents or staff physicians.

Internet resources are unquestionably powerful tools. Used properly they can enhance the educational experience of orthopaedic residents and the ability to harness the transformation of health care by the Information Age. However, at present, academic orthopaedic surgery departments in Canada vastly underutilize the Internet as a means of enhancing patient and physician education and fostering an exchange of information between faculty and residents.


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Last Updated on Sunday, 28 August 2011 02:40