Two Views of the Future PDF Print E-mail

Myles Clough, M.D., FRCSC
Kamloops, BC

The teenage patient with knee pain is a familiar, if somewhat daunting visitor, to the office of many Canadian orthopaedic surgeons with a general scope of practice. Let's presuppose such a patient is visiting your office not many years from now. Let's also up the ante in this scenario by imagining that her mother is a schoolteacher. This patient has seen her family doctor because of anterior knee pain and has been told she may have chondromalacia (how do you spell that doc?) and should do some quadriceps strengthening exercises. Under some pressure, a referral to an orthopaedic surgeon has been made and they are coming to see you some three months later. The prediction of this article is that they will have spent some of the intervening time looking for information about this problem on the Internet and as a consequence, your interview will resemble one of these two views of the future.  

Scenario 1
In this first scenario, you have asked your referral base of family doctors to make sure that all the patients they refer to you are given the Internet address of your practice web site. This site contains the usual information about how to find the office, confirm the appointment etc; it has some details of your training, affiliations and scope of practice; more to the point it has two big patient information sections, one for people waiting to see you and one for patients you have already treated. Your patient and her mother have looked up the section on anterior knee pain and have found the following information.

  • General information about the nature and pathogenesis of anterior knee pain with the most likely diagnoses described in greater detail. This section has either been written by you or personally approved by you. Likely, it also includes links to further information on the subject prepared by the COA, the AAOS, the American Academy of Family Practice and many other highly reputable organizations (see Table 1).
  • A section on why it is important to do the exercise programme suggested by the GP and physiotherapist. Reassurance that this may be painful but not harmful. It may be useful to say that exercises are necessary after surgery and hurt a lot more; so it doesn't make any sense to prefer surgery to exercises! Many sites have specific information about what exercises to do.
  • Reassurance about how rare cancer is in this situation and what investigations are usually done. You may want to remind the patients that appropriate x-rays should be taken before the consultation and be sent to the office.

On arrival, your patient tells you how cool your web site is and says that she (and her Mom) having been doing the Invisible Chair exercise every day. She can do five minutes (wimpy Mom can only do two) and her knee pain has hardly bothered her for the last month. The rest of the consultation goes smoothly.

Scenario 2
In the second scenario, you and the medical profession in general have ignored the impact of the Internet on patient information because of pressures of time, unfamiliarity with the medium and a general wish that the whole pesky subject would go away. The interview starts like this:

"My doctor told me I have chondromalacia. If I have to have a kneecap replacement, I want you to do a SmoothieSurg ceramic on ceramic operation. Oh, and by the way kneepain.com gives me a 1.5% chance of having cancer so Mom and I think you should check that out too. I've heard there is a six month waiting period for MRI - am I on the waiting list for that already?"

After you and everyone else have calmed down, you find that the patient has been researching the subject using standard Internet search engines. These favour highly professional sites that are designed specifically to attract search engines. In general, the sites at the top of the search engine's list will be selling something.

It is up to us which of these two scenarios we will face. It is futile, and a waste of a great opportunity, to imagine that patients can be persuaded not to use the Internet for information. We cannot control what information patients select from the vast array of Internet resources and where they obtain it from. What we can and must do to balance the information our patients find on their own is provide reputable and "approved" information and links to valuable sites with credible information. It's not that the information from www.veggie.org is wrong or even slanted; as a matter of fact I thought that page was quite good. The provenance is worrisome however, and I would prefer my patients to see a lot of other stuff as well. The idea that patients are going to read one page and be satisfied should be rejected. Surfers of the Internet are not like that. The best we can do is to select a group of sites (Table 1) to offset the bias they may encounter if they use a standard Internet search engine (Table 2).

Table 1: Possible sites selected by an Orthopaedic Surgeon
Sites selected from the Orthopaedic Web Links (OWL) database
1. Adolescent Anterior Knee Pain - AAOS Online Service Fact sheet
2. Patellofemoral Pain Syndrome - American Academy of Family Physicians
3. Anterior Knee Pain - Orthopaedic Center of the Rockies (Colarado USA) - Ask the Doctor section
4. Patellofemoral Pain - American Orthopaedic Society for Sports Medicine
5. Orthopaedic Web Links (OWL) Patient Information - Anterior Knee Pain - Ongoing collection of sites selected by the editors of Orthopaedic Web Links
6. Chondromalacia Patella - Wheeless' Textbook of Orthopaedics
7. Anterior Knee Pain (Orthoteers - a site prepared for candidates reviewing for the Royal College examination)


Table 2: Sites found by AltaVista search for Chondromalacia Kneecap (top 7 out of 828)
Sites found by AltaVista search for Chondromalacia kneecap
1. Chondromalacia Medical College of Wisconsin HealthLINK
2. Patella Chondromalacia The Center for Orthopaedics and Sports Medicine; Marietta, Ga
3. Anterior Knee Pain Syndrome - Johns Hopkins Bayview Medical Center
4. A Common Cause of Knee Pain in Sports Chondromalacia Patella - Veggie Sports Association
5. Conditions We Treat - Kneecap (Patella) - Rockford Orthopaedic Associate, Illinois
6. Chondromalacia Orthopaedic Services Company, LLP (Hawaii)
7. Chondromalacia Knee Pain -Knee Ache -Relief with Goode Wraps (knee support manufacturer)

Setting up a page for your office practice can be quite painless. The AAOS offers the service to all their members for free (for example see http://orthodoc.aaos.org/MylesClough/) and although the site is similar for all doctors, you have the freedom to insert as many links as you like. Writing your own pages is also much easier than you may think. With modern programmes it is essentially an administrative function. You could dictate the content and the page can be created directly from the word processing programme. Your Internet Service Provider probably sets aside some space on their server for your personal web site so you may already have some "free" space where you can post your site.

What isn't so painless is the question of selecting "approved" sites. This is an expert job, best done by an orthopaedic surgeon. It is quite time consuming; it requires Internet searching skills that few of us adequately possess. The idea of assembling the "best" patient information on orthopaedic subjects makes several suppositions – we know what subjects to choose, we know what "best" is, there is an organization which will set this up and which will make available the results when it has been done. None of these suppositions are valid – we don't even have a good list of orthopaedic subjects, there is no agreement on what the content of orthopaedic patient information pages should be and we certainly cannot turn to an organization that will give us the answers. If we are going to avoid the second of my two scenarios, we need to devote time, energy and money to these tasks. The initiative of the Canadian Orthopaedic Foundation to provide a framework of patient information for Canadian patients was a laudable one, although it did not get far off the ground. Without a structure of this sort, we will have to do much of the work ourselves and most importantly, communicate our progress amongst ourselves. Furthermore the surfing patient will not be satisfied with just one source of information. So a widespread effort to provide more of this information for Canadian patients is needed. We don't all have to do everything, though. If we each did a little and told everyone where that little is, we would be able to assemble a body of valuable information in short order.

The Orthogate group has redesigned the Orthopaedic Web Links (OWL) database (http://orthopaedicweblinks.com) with this need in mind. Any member of the orthopaedic community can become a member (free) and add links to the database. Editors for specific subjects are also welcome. They have the function of reviewing the sites that are submitted and accepting the sites that are of value to orthopaedic surgeons and our patients. So, a site in the OWL database has been vetted, often by two orthopaedic surgeons, the one who submits the site and the editor. If we use this mechanism we can find valuable patient information and go on building up the collection for our patients to use. Currently the OWL Patient Information collection http://owl.orthogate.com/Patient_Information/index.html stands at 1115 pages which is comparable to the collection of the US National Library of Medicine Medline Plus (http://www.nlm.nih.gov/medlineplus/bonesjointsandmuscles.html). Even so, there are many subjects that are poorly covered. If you research the OWL database and look at the patient information which is available on a subject which interests you, most likely you will have one of three reactions –

a) There is a lot of good stuff out there. I must make sure my patients know about this.
b) This coverage is pretty scanty; why don't they have the pages put out by X and Y
c) I can do better than this.

In case a), this article will have achieved its objective. In case b), please collect the links to the valuable pages posted by X & Y and send them to OWL. In case c), I know you can do better; please, please do so; post the results and send OWL the address.

There may be other ways to prepare our patients and ourselves for the revolution in information which the Internet is ushering in. If you know of any, please tell us about them. Naturally, we promote the idea of cooperating to build up an orthopaedic database as a service to the orthopaedic community because of the time, money and effort devoted by the senior editors: Drs. Christian Veillette, Chris Oliver, Randale Sechrest and myself to developing OWL (http://www.orthopaedicweblinks.com/about.html). There may be better options. It is certain, however, that if we leave it to go by default, we will be faced with the more uncomfortable of these two futures.