review

ROLE OF INTERNET IN PEDIATRIC SURGERY

by : Humberto L. Lugo-Vicente, MD, FACS, FAAP *

San Juan, Puerto Rico

Abstract

Internet, the largest network of connected computers, is becoming the ultimate frontier to access information for health providers. This review focus on how developments of this communication technology have become a useful educational resource in Pediatric Surgery, and describes modest ideas in computer network use.

Internet basic resources are electronic mailing (E-mail), discussion groups, file transfer, and browsing the World Wide Web (WWW). E-mail brings physicians with common interest together. Surgeons employ it as a communicating tool. Legal and social responsibility is bounded with its use. Discussion groups permits debate including clinical cases, operations, techniques, research, career opportunities, and meetings. File transfer provides the opportunity of retrieving archives from public libraries. The WWW is the most resourceful tool due to its friendly interface and ease of navigation.

The average physician needs to know almost nothing on how computers work or where they came from to navigate through this pandemonium of information. Click and play with today graphical applications encourage the computer illiterate to connect. Establishing the connections envelops the need of hardware, software and a service provider.

Future development consists of online journals with new ideas in peer-review and authentication, telemedicine progression, international chatting, and centralization of pediatric surgery cyber space information into database or keyword search engines.

INDEX WORDS: pediatrics, surgery, internet

Introduction

Internet is the largest network of connected computers. More than 30 million computers exchanging physical links through a standard protocol of communication. A super avenue of information and transactions (1). The Net is affecting every aspect of life and dissemination of information relevant to medicine for the health community is not immune to this technology.

The busy surgeon who invests little time searching the literature could find himself with a clinical practice that does not keep pace with recent medical advances. Informatics option to stay updated in the discipline of Pediatric Surgery includes access to printed periodical publications, regular meetings, congress assistance, digital database storage, and Internet resources.

Text, journals, and books are usually outdated by the time they reach the regular subscriber. Not to mention cost of subscription, printing and storage capabilities needed. Meeting and congress dynamic regular sessions can be costly, and access to the full written report is almost never achieved until print publication of the paper is obtained usually six months to one year later. Digital databases (i.e., CD-ROM) store large amount of information, but prices of CD are overwhelming. An additional driver is needed as hardware for reading the stored material. Information is becoming an unlimited commodity, we can have as much as we want at no cost, but are limited by our storage capacity (2).

By agreeing to a set of operating protocols, users have developed innovative techniques to seek out information from different databases accessible via the network along with methods for sharing documents. Internet provides immediate downloadable information and dynamic information on every aspect of life. Still the idea that it represents a frustrating educational event in computing persists. The average person needs to know almost nothing on how computers work or where they came from to navigate through this network. Click and play with today graphical applications encourage the computer illiterate to connect.

The purpose of this review is to highlight how newly ways of communication using Internet navigational technology can be useful educational resources in Pediatric Surgery, and clarify concepts of network communication for future use by physicians.

History of Internet

After the postwar years military intelligence was searching for strategic forms of communication in the after-match of a nuclear holocaust, a system that would defeat current centralized tendencies in communication. The notion of creating several nodes of super computers that convey each other through standard telephones line was developed. Sending the information in small packages that would meet at the other end of the line using a uniform protocol of communication and regrouping (TCP/IP). These nodes would be created around different parts of the world divided in either top level geographical or institutional domains like: government (gov), commercial (com), educational, (edu), military (mil), network resources (net), and other organizations (org).

Scientists were the first to use this system in an effort to consolidate research and establish electronic communication in the flow of new projects. This created an atmosphere of social behavior and effective long distance communication as more nodes grew in each country. Curiously, the initial electronic discussion group developed among scientists was called the Science-Fiction list (3, 4).

World Wide Web (WWW), the crowning glory of the Internet, is developed in Geneva, Switzerland in 1989. The WWW provides a user friendly interface with the capacity to send and receive information through Internet using text, graphics, audio and video utilizing a protocol of marked language (5). Seen today as the best resource to post information that can reach and be accessed in almost every corner of the planet.

Uses of Internet for the Pediatric Surgery community

Internet basic resources are:

electronic mailing (E-mailing),

discussion groups (news groups and list servers),

file transfer,

and the WWW.

Through the initial effort of scientists to establish communication using electronic text mailing convenience over the postal service was foreseen. E-mailing is faster than postal mail. It takes an average of two to eight minutes for messages to arrive to another computer node in very distant geographical zones. The message is stored by the internet service provider (ISP) until the electronic box owner retrieves the message. You do not have to pay extra for e-mailing, and is global in scope. Files can be attached to messages up to half a megabyte in size (a megabyte represents one million characters).

News groups and list servers with discussion interest have developed both in pediatrics and surgery. Messages posted by authors to the list or discussion group are automatically mailed to all subscribers. Posting growth to such lists includes United States, Central and South America, Europe, Middle East, Africa, and Australasia to mention a few. List servers for different surgery and pediatric sub-specialties exist: NICU-Net, PICU-Net, cardiology, gastroenterology, neurology, emergency medicine, critical care, Pediatric pain, etc. (6, 7).

A popular list among Pediatric Surgeons worldwide is called the Pediatric Surgery List. Originally developed by Thomas Whalen for topics discussion that includes clinical cases, operations, techniques, research, career opportunities, and meetings. Intended for pediatric surgeons and interested general surgeons and residents (8). Although the list is in embryological phase, growth will inevitably create a medium of international discussion without precedent. A constant forum for exchange of ideas, difficult cases, consensus on management, and development of our specialty.

File transfer provides the unique opportunity of retrieving archives from public file libraries. Free software is also available. Downloading of data into the hard disk of your computer is very straightforward. Anti-viral programs are available to monitor each access file that can become part of your system whenever you download them from Internet.

Recent poll of the Pediatric Surgery Internet list server members regarding what resource of the Net they use most of the time was done. Almost one-fourth (23%) of the list population (58/246) answered the survey. Electronic mailing (personal and list server/discussion groups) occupied 83% of resources, web browsing 16%, and long distance computing 1%. Pediatric surgeons with access to the Net use it mostly as a communication tool. WWW browsing is slowly developing as a second alternative probably due to absent access to a web browser connection.

E-mailing uses and responsibility

Electronic mailing is the most useful resource of Internet. Mailing lists bring people with common interest together (9). Through it physicians have developed news, chat, and list group discussion. This creates the perfect environment to consult colleagues on a clinical problem, send draft of a paper for peer revision, read journals without paying subscription rates, maintain your continuing medical education credits, and retrieve anything the same day that it is published (1). It will become an essential tool in medical research, teaching medical students, clinical practice, postgraduate studies, and continuing medical education. The lack of a traditional peer-review process and author identification might prevent E-mail text from being taken as authoritative (10).

The common user of the Net is a professional. Environmental motivations have created an informal code of conduct known as net-etiquette. By this is meant politeness in replying. Along with accessibility, identification and social responsibility (11).

Netters (defined as common user of the Net), resent several iatrogenic web disorders: not waste the carrying capacity of the Net (bandwidth), posting unsolicited advertising (spamming), and observing inappropriate online behavior (1). Chain E-mail letters can overcrowd your electronic site. Other problems related to the nature of e-mailing that we must be aware are: sign your posting so that we can know who is writing, do not reply publicly to the whole group when answering privately to one person, and avoid including the entire text of the original message in your reply.

A hot debate among frequent E-mail list servers involves being careful when answering or replying, specially when the answer will hit many members of a list server group. The inclusion of your name and address at the end of your E-mail text represents a legal signature for all aspect of the law: the author name type in ASCII characters (10). Simple rules to observe are: avoid using patients' names, address, record numbers or institutional demographics. When personally responding to electronic medical consultation by an unknown online patient ask yourself: Is he your patient behind the monitor? Have you examined him or review his past medical record? Will my answer be used as possible legal evidence in case this is unintended? The potential for abuse while looking at this information will always exist.

Disclaimers notice stating the medico-legal responsibility behind frequent response to complex medical problems are being asked for to list server administrators (12). This if a response from some member commentator triggers a change in diagnosis or therapy in a given discussion case that causes ultimate damage to the patient involved. The commentator cannot be held responsible of his answer in as much as he had no clear physician-patient relationship, was not paid for this service, or had the opportunity to examine the patient or his medical charts. The disclaimer should include that particular consultation or advice was not the idea of the answer, reliance on this comments should not be done, and printed versions of the E-mail should not appear in any patient medical record (12).

WWW and Pediatric Surgery

WWW can be seen as an endless book, where each page has a divergent story. The web page is the basic unit of information and hypertext provides links to other pages in the same directory, or in different domain sites of the network (5). What makes the WWW the most resourceful area of Internet is the ability to watch text, images, video, audio, and real time pictures embedded in web pages.

Each page has a unique address, also known as uniform resource locator (URL). URL essential ingredients are protocol, domain name, and directory. For example the URL of ‘Pediatric Surgery Update' is: http://home.coqui.net/titolugo/index.htm. This means that the protocol is http, the domain name /home.coqui.net/, and the file "index.htm" is the web index page under "/titolugo/" directory.

‘Pediatric Surgery Update', the periodical electronic newsletter started on July 1993 as a print form. Initially covered short issues and reviews in the discipline of pediatric surgery. December 1995 marked its development as a web site. The WWW introduction of the print version permitted development of further areas such as: review articles with images, graphs and tables, survey section, technical innovation area, a Pediatric Surgery Online Handbook for residents and medical students, and an area for medical students to developed research and writing skills (13).

Departments and Section of Pediatric Surgery have developed their own web page in the WWW. Through them we have access to such content as: faculty members, facilities, research programs, interests, residency and fellowship programs, and other pediatric and medically relevant links. Continuous medical education credits are part of some web site offering.

Page in the Net, HTML and graphic applications

A web page, the basic unit of the WWW consists of all one medium, such as text, or can include multiple media including graphics, sounds, animation, and video (14). The web page is built using a mark language that is plain text tagged with handles <text>. This is known as hypertext mark-up language (HTML). HTML can easily be learned for later production of a web page. The National Center of Supercomputing Application (NCSA) Beginner's Guide to HTML is used by many to start to understand the hypertext markup language used on the WWW. It is an introduction and does not pretend to offer instructions on every aspect of HTML (15). Computer applications developed as web editors provide the functionality needed to construct a web page with little knowledge of HTML. They are called WYSISYG (What You See Is What You Get) Editors.

Movement between web pages is accomplished by links to other universal resource locators or Internet address. Links can be in different color or underlined text where the cursor of your pointer device changes as though sensing an executable movement. By either clicking the device or hitting the return key, you will be moving to that link. Some links are just libraries composed of downloadable files.

Web editors can be downloaded from different suppliers in the Net. Some are free but most can be obtained as shareware to try them for a limited period. For a list of HTML editing tools or programs available the reader is referred to URL: http://sdg.ncsa.uiuc.edu/~mag/work/HTMLEditors/windowslist.html

Establish the Connection

To gain access to Internet you will need hardware, software, and a service provider.

Hardware is your computer. This includes a monitor, central processing until (CPU) and keyboard. Macintosh and Widows operating systems ease of use graphical environments have prevailed during the last years over the more text-based disk operating system (DOS). A modem is another piece of hardware needed that will provide the telephone line communication.

Computer software that help you navigate the web is known as web browser. Web browsers are in essence a navigational aid for moving around and between the various nodes and links of the WWW (14). Some web browsers are non-graphic like Lynx, and graphical like: Mosaic, Netscape, and MS Internet Explorer. Netscape is the most widely used and industry standard full-features web browser. Latest versions of this software can be downloaded free from their respective site (URL) in the web (16,17).

Internet service providers (ISP) are either private or universities based. The service provider will give you access to the Net using a local or toll-free telephone number. Some may include web space with the monthly rate offer. A university-based ISP usually provides service for a nominal or none rate. Electronic addresses of such users usually end in the suffix -edu. Most physicians with Internet access have it through academic affiliation (9)

Once connected, the Net is a pandemonium of information with no central index. The user will rely on automated index or search engines. Search engines collect database, retrieve programs, or harvest them (2). A collection of search engines can be found at URL: http://www.webcom.com/ (The WebCom Power Index). Specific search engines in the field of medicine will help create an atmosphere of librarian resource.

Editors like Spooner's Ped-Info and Lehmann's Points of Pediatric Interest, have developed web sites with collection of information specifically oriented toward pediatric content. The web site has been maintained as a set of WWW pages through which you can link to: Departments of Pediatrics, professional organizations, pediatric practices, Children Hospitals, medical and surgical subspecialties, on-line publications, and pediatric software of interest. Criteria for entry into the database are that the resources must have appeal to pediatricians, and specific pediatric content. Both web sites allow easy access to pediatric information on the WWW for health care professionals and parents (18, 19).

Future of the Net in Pediatric Surgery

The future of Internet will be an unbounded multimedia circus. Real time video and audio technology will permit us view recorded in vivo sessions made in another location paid for through a local phone call. In vivo videos of laparoscopic procedures have already taken place between two continents (United States and Argentina). With the use of a personal computer and a modem, they have transmitted the surgical procedure through live broadcast, via the Net, for the nominal price of a local phone call. Resident surgeons watched and interacted during the surgical procedure. This opens an area by which academic medicine can be telecasted to other parts of the world with least bearing on economical resources (20).

Since anyone can publish in the Net online, electronic journals will develop with new peer-review concepts. Editors, reviewers, and authors will need to adjust to the use of this information technology. Online publication in Pediatric Surgery will increase as printed form of actual journal joins the cyberspace domain. Less paper work on publishing companies may mean a reduction in subscription price, with e-mailing guarantees of providing manuscript of written and published articles.

Cyber citations as proposed by the American Psychological Association or Modern Language Association have yet to be standardized by the American Medical Association to be used as bibliographical style (21). Authors that use Online references will need to keep printed or digital file copy of such articles, since there is no way to avoid drastic changes or movement done to this domain address (22).

International chatting is another area of future development for our pediatric surgery community. Using simple downloadable application like mIRC (internet relay chat) you can connect to an undernet organization channel and chat with groups of people at the same time (23). The International Pediatric Chat channel developed by J. Edlavitch use two weekly sessions to maintain the group online (24).

Telemedicine refers to the use of telecommunication technology to simplify health care delivery or distribute medical informatics. Some specific projects represented by this technologic are: Multi campuses linking of hospitals and research centers, linkages between rural health clinics and central hospital, physician-to-hospital links for transfer of patient information, diagnostic consultations, patient scheduling, research, literature searches, video program distribution for public education on health care issues, use of video and satellite relay to train health care professionals in widely distributed or remote clinical settings, and transfer of diagnostic information such as electrocardiograms or X-rays. Some benefits are improved access to areas in needs of health service, reduce cost of traveling, reduces professional isolation, and improving the quality of care given. Development of the infrastructure needed along with cost containment issues are two of the problems faced by this technological advance (25).

Most Pediatric Surgery Organizations (Surgical section AAP, APSA, CAPS, BAPS, etc.) will find themselves generating web sites of their own during the next few years. This will add to the pandemonium of information already established. A future trend in development will be the need to gather all this information in a Pediatric Surgery Cyber Web site with database keyword access. This way a centralized path will exist to organize the varied information buried in the Net.

We must be aware of the negative effects of expansion of computerized information. The WWW can be an intoxicating and seductive place. Long hours glued to the small screen, surfing the cyberspace, and reading E-mail can cause social degradation, increasing disparity and isolation of the individual. Fragmentation of knowledge can be the result. Users must continue to maintain an equilibrium to avoid such side-effects (26,27).

Conclusions

The exponential growth of Internet in the disciplines of Pediatric Surgery will cause a change in patient care, teaching and research. Changes in our specialty will be nurtured through the international use of information posted in the Net. Main use by contemporary pediatric surgeons is as a communicating tool using electronic mailing with WWW browsing slowly growing.

Future developments consist of online journals with new concepts in peer-review and authentication, telemedicine, international chatting, and centralization of cyber space information into database or keyword search engines. Marketing is another frontier in the development of medical informatics technology.

References

1- Pallen M: Guide to the Internet: Introducing the Internet. BMJ 311: 1422-1424, 1995

2- Thomas P. Copley (September 17, 1996) Make the Link Workshop: Tutorial Number Five [Online] Available: http://www.crl.com/~gorgon/links.html [September 20, 1996]

3- Johnson Phillip (May 8, 1996) History of the Internet [Online] Available: http://dragonfire.net/~Flux/ihistory.html [September 15, 1996]

4- Sterling Bruce (July 5, 1994) Short History of the Internet [Online] Available: http://www.forthnet.gr/forthnet/isoc/short.history.of.internet [September 15, 1996]

5- Pallen M: Guide to the Internet: The World Wide Web. BMJ 311: 1552-1556, 1995

6- Christopher U. Lehmann (1996) Point of Pediatric Interest E-mail Discussion Lists [Online] Available: http://www.med.jhu.edu/peds/neonatology/elists.html#elists [September 6, 1996]

7-Tarczy-Hornoch P: NICU-Net: An Electronic Forum for Neonatology. Pediatrics 97(3): 398-399, 1996

8- PEDIATRIC SURGERY Mail List Subscription Address: Majordomo@UMDNJ.edu Subscription Message: Subscribe PEDSURG-L Human administrator: Thomas V. Whalen, Professor, Robert Wood Johnson Medical School, E-mail: whalen@umdnj.edu

9- Spooner SA: On-Line Resources for Pediatricians. Arch Pediatr Adolesc Med 149: 1160-1168, 1995

10- Elliot SJ, Elliot RG: Internet List Servers and Pediatrics: Newly Emerging Legal and Clinical Practice Issues. Pediatrics 97(3); 399-400, 1996

11- Frisse ME, Kell EA, Metcalfe ES: An Internet Primer: Resources and Responsibilities. Academic Medicine 69(1): 20-24, 1994

12- De Ville, K.A. Internet Listservers and Pediatrics: Newly Emerging Legal and Clinical Practice Issues II. Pediatrics 98: 453-454, 1996

13- Lugo-Vicente HL (September 16, 1996) Pediatric Surgery Update [Online] Available: http://home.coqui.net/titolugo/index.htm [September 18, 1996]

14- Thomas P. Copley (September 17, 1996) Make the Link Workshop: Tutorial Number Four [Online] Available: http://www.crl.com/~gorgon/links.html [September 20, 1996]

15- NCSA (September 1996) A Beginner's Guide to HTML [Online] Available: http://www.ncsa.uiuc.edu/General/Internet/WWW/HTMLPrimer.html#A1.10.1 [September 18, 1996]

16- Microsoft Corp (1996) Internet Explorer Home [Online] Available: http://www.microsoft.com/ie/ [September 21, 1996]

17- Netscape Communication Corp (1996) Download Netscape Navigator Software [Online] Available: http://home.netscape.com/comprod/mirror/client_download.html [September 21, 1996]

18- Spooner SA (August 1994) Ped Info a Pediatric Web Server [Online] Available: http://www.uab.edu/ped-info [September 16, 1996]

19- Lehmann C (1996) Points of Pediatric Interest [Online] Available: http://www.med.jhu.edu/peds/neonatology/poi.html [September 22, 1996]

20- Telbelian A (September 1996) NOMC broadcasts live surgery via the Internet [Online] Available: http://laparoscopy.com/pictures/vdconf.html [September 17, 1996]

21- Li X., Crane N. (May 20, 1996) Bibliographic Formats for Citing Electronic Information [online]. Available: http://www.uvm.edu/~xli/reference/estyles.html [September 15, 1996]

22- Aruzen MA: Cyber Citations: Documenting Internet Sources Presents Some Thorny Problems. Internet World Sept 1996, pag 72-74

23- mIRC Co. Ltd. (1996) Homepage of mIRC [Online] Available: http://www.geocities.com/SiliconValley/Park/6000/ [September 22, 1996]

24- Edlavitch Julius (September 1996) Home Page of International Pediatric Chat [Online] Available: http://www.pedschat.org/ [September 19, 1996]

25- William Frederick, Moore Mary (August 1995)Telemedicine: Its Place on the Information Highway [Online] Available: http://naftalab.bus.utexas.edu/nafta-7/telepap.html [September 7, 1996]

26- Thomas P. Copley (September 17, 1996) Make the Link Workshop: Tutorial Number Two [Online] Available: http://www.crl.com/~gorgon/links.html [September 20, 1996]

27- Gravanis MB: Computers and social isolation [Letter to the editor] The Pharos 59 (3): 50, 1996

____________________________
* Associate Professor in Pediatric Surgery, University of Puerto Rico School of Medicine. Member of SCOT (Section of Computers and Other Technologies) Section of the American Academy of Pediatrics.
Address reprints request to: Humberto Lugo-Vicente, MD- P.O. Box 10426, Caparra Heights Station, San Juan, Puerto Rico 00922-0426 Tel. 787 / 786-3495 Fax 787 / 720-6103 E-mail: titolugo@coqui.net

Date posted: March 1, 1997

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ROLE OF INTERNET IN PEDIATRIC SURGERY