The times they are a changing

With the era of Generation Y doctors, open-source publishing, micro-blogging, ‘stumbling’ and ‘tweeting’ upon us, now is an important time to review the implications of the internet age on emergency medicine. As emergency physicians it is important to stay in touch with developments. We are not immune to the effect of the internet on our daily work practice, just as a generational transition behind this digital revolution has occurred in many other employment sectors.

But already as you read this, I wonder if you have decided to move to the next article? Already time-poor, patient-rich and work incumbent, why should you have to partake in or develop an understanding of a non-institutional based health informatics revolution? The fact is that the development of web 2.0, Medicine 2.0 and the new generation of web services will play an important role in the future of medicine. 1 These web tools, expert-based community sites, medical blogs and wikis will facilitate the rapid dissemination of information, and will improve the efficiency of physicians, scientists, medical students and medical librarians.

The current internet era web 2.0 is an evolutionary response to a generational change, and not simply a conglomeration of websites with more aesthetic interfaces, more curved textboxes and enhanced reactivity. The development of web 2.0 has led to increasingly formalized and dynamic information sharing and creation, and has transformed websites from isolated information silos to interlinked computing platforms. Enhanced online collaboration now enables individuals to take control of content on the web.

The exponentially expanding array of high quality clinical media such as digital imaging, audio podcasts, shockwave flash animations and streaming video are set to redefine medical learning, and the medium for their distribution is the internet. Content is being presented in readily editable, easily assimilated, ‘bite-sized’ chunks for immediate online consumption. The synergistic ‘wisdom of the crowds’ model of social interrogation is allowing the best of this material to preferentially rise to the top of our search horizons.

The relevance is that the format of information presentation has changed. Traditional ownership of collated musings is being revoked and the way in which we organise, store, retrieve and share relevant resources has been re-invented. The days of computer desktops cluttered with html-links, and filing cabinets with photocopied journal articles stacked on top have gone – or at least they should have!

Information collated in databases and websites is now rapidly disseminated through web-logs (blogs), RSS (Really Simple Syndication) and social bookmarking feeds. For instance, delays in paper publication and the peer-review process are being bypassed via open-source channels with dramatic effect. Blogs provide information, updates and views on a particular subject matter. A typical blog combines text, images, and commentary into a brief and informative article. Initially these were deemed to be solely the domain of the computer ‘demonic ubergeek’. However, with the advent of the WYSIWYG (what you see is what you get) text editor, and free online blogging resources such as wordpress.com and medbrains.net, the process has been simplified. Even now the emergency medicine blogging community is slowly expanding. 2

Blogs can be entertaining and informative, and offer insightful views, opinion and rhetoric. Most medical bloggers adhere to the Healthcare Blogger Code of Ethics (MedBloggers Code) and comply with the rules and regulations of the Health On the Net foundation (HON). The HON was created in 1995 to “promote and guide the deployment of useful and reliable online medical and health information, and its appropriate and efficient use”. HON is a non-profit, non-governmental organization, accredited to the Economic and Social Council of the United Nations. 3

Faced with this rapid growth in information, the average physician may feel overwhelmed, but help is at hand. Most blogs, micro-blogs and news aggregators provide access to an RSS document (called a ‘feed’ or ‘channel’). Once requested, an RSS feed is delivered automatically to your preferred feed reader (e.g. iGoogle or PageFlakes) either as a summary, or as the full text article from the affiliated website. You may then choose how, when and where to indulge in your need information feed. Typically it takes about 20 minutes reviewing your feed reader content to keep you up to date with new postings from your favourite medical blogs. RSS feeds are now provided by most leading online medical journals, and medical resources on the internet, such as PubMed, the BMJ and Medscape. I personally enjoy a more eclectic mix of feeds ranging from health news sites such as New York Times Health and MedPage Today, to health commentary sites such as Dr Rant, AppleQuack and SymTym.

Yet these are but the tip of the MedBlog iceberg. To really explore the expanse of health information you have to enter the realm of the feed aggregator site. Feed aggregators constantly trawl the blogosphere for new feeds and health related information. The most comprehensive of these aggregators is MedWorm.com which accesses over 6,000 authoritative data sources every day. MedWorm provides new outgoing RSS feeds from the data collected on a variety of medical categories you can subscribe to in your own feed reader that includes emergency medicine. Too complicated? Then go to AllTop.com and look in the health category to find displayed the latest five articles from each of 150 medical journals and websites!

Less dynamic, yet just as information packed and up to date is the ‘wiki’ – a software tool that allows users to create, edit, and link web pages together. Wiki is derived from the Hawaiian word for ‘fast’, although some have suggested that wiki actually means ‘What I Know Is’ (a backronym). Wikis are used to create collaborative websites and facilitate structured repositories of collated online information. The best known is Wikipedia, but of more local interest, Dr Gary Ayton an emergency physician in Australia, is collating the first online emergency medicine wiki in OzeMedicine. 4

Medical blog sites are also developing into advanced information repositories pooling written pages with other web pages to create aggregated learning resources, which are readily updated, and extensively referenced. A good example of this blog-based approach to medical information provision is the clinical cases website hosted by Dr Ves Dimov. 5

A new approach to a perceived lack of time to read or write long posts is Twitter, which is a free social networking and micro-blogging service where users send and read updates (tweets). 6 The 140 character posts on Twitter are enough to share interesting bits of information that otherwise would have gone unpublished, and are often the formative foundation of future blog posts and clinical research. A recent trend has been to post to the Twitter community (tweeple) 7 using the iPhone and other portable devices ‘live’ from medical conferences. 8

The most useful tweets contain shortened Uniform Resource Locator (URL) to documents and articles that your colleague may be currently reading. This provides a massive collaborative reading pool from which to draw inspiration and knowledge. However, it is important to carefully choose those tweeple you follow, to prevent being bombarded by inappropriate messages describing the mundane daily routines of other twits!

Increasingly sophisticated professional search engines are now being created to provide access to diagnostically accurate, peer reviewed and validated information for physicians. The race is on to find the most efficient way for health professionals to search for clinical images, textbook and or journal articles, or answers to key clinical questions. Traditionally this search has been labour intensive and frustrating, as  physicians search the web for medical information using locally hosted library sites, PubMed, MedLinePlus, MD Consult or a generic search engine such as Google.

However, with the development of ontological and semantic data tagging, deeper and more complex interrogation of the depth and breadth of medical knowledge is possible. Cognition’s semantic natural language processing (NLP) technology adds word and phrase meaning and understanding to computer applications. Using a mix of linguistics and mathematical algorithms Cognition.com has effectively taught the computer the meanings of words, word associations and context. 9

Semantic search uses knowledge of the relations between words and phrases such as a ‘finger’ or a ‘digit’, taxonomy (a ‘finger’ is part of a ‘hand’, a ‘cow’ is ‘bovine’ and is a ‘mammal’) and syntax or grammatical structure to enhance search refinement. This allows the user to type a plain English question into the search engine, rather than entering a disjointed series of non-sequiturs. Such user-friendly engines are still in early beta development, but the initial results are promising. 10

One of the best examples of fully functional medicine 2.0 semantic search is GoPubMed.org. This is a knowledge-based search engine for biomedical texts based on GO (gene ontology) and medical subject headings (MeSH). GoPubMed retrieves PubMed abstracts from a search query and delivers relevant results in the categories of ‘What, Who, Where or When’. The search is simpler and more efficient than using PubMed alone, and the search refinement functions produce a more relevant shortlist of search returns.

Once you have sourced your information, the web 2.0 structure encourages users to collate, tag, annotate and share pertinent resources. However, with the plethora of social bookmarking and tagging domains available online, it is difficult to know where and how to start. The author has slowly developed a routine for collating, highlighting and annotating results from the pixelated universe with a combinational collation using the browser based tools of Stumble Upon, Delicious and Diigo. 11 Working with friends and colleagues to read, review, digest and share online resources is a valuable learning experience, and when done collaboratively, it becomes an essential future-proofing skill.12

Social bookmarking tools such as Delicious and Diigo rely on the user to tag articles, images, documents or websites with keywords. Instead of saving a webpage resource as an html-link to your desktop, or embedding the link in the browser toolbar, your link is now saved to a virtual server and can retrieved from any computer, PDA or phone when required. The optimal social impact of bookmarking is the ability to share your discovered resource with like-minded colleagues with a single click. Study groups can rapidly research, review and share resources so that searching for a website tagged with ‘FACEM, anatomy, MCQ’ will yield a useful result.

Reading becomes social when information, knowledge and community come together. The ability to highlight text and annotate with sticky notes online retains the contextualization that is often lost when ‘clipping’ text, and iteration with group research becomes a high yield and rewarding task.

The integration of medicine 2.0 within our daily work routine may appear to be a complex and non-intuitive burden. However the web 2.0 rollercoaster is definitely a ride we should all take, with the deployment of progressive and adaptive internet based tools, the integration of high quality media and the evolution of semantic search. If the attitudinal wind of change is embraced and colleagues collectively combine their online knowledge, the clinical, educational, social and timely benefits are enormous. Generation Y will not, and should not, leave the rest of us behind. The author hopes this article stimulates as many people as possible to rise to the challenge and get with the times!


McLean R, Richards BH, Wardman JI. The effect of Web 2.0 on the future of medical practice and education: Darwikinian evolution or folksonomic revolution? Med J Aust 2007; 187(3):174-177.

BA MA (Oxon) MBChB (Edin) FACEM FFSEM. Emergency physician, Sir Charles Gairdner Hospital.  Passion for rugby; medical history; medical education; and asynchronous learning #FOAMed evangelist. Co-founder and CTO of Life in the Fast lane | Eponyms | Books | Twitter |

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