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Orthopaedic Web L inks.
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Orthopaedic Web L inks.
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This page is set up to archive editorials which appeared on the Orthopaedic Links Page and Orthopaedic Web Links from Sept. 1996 on.CONTENTS
Use back button to return to OWL pages. The following is the first 'guest editorial' that I have received. It was in response to my query about whether I should continue the editorials. From: 104373.1546@compuserve.com Date: Mon, 20 May 1996 00:22:53 -0400 (EDT) To: cloughs@netshop.net Subject: Editorials I certainly think that you should continue your editorials. In fact, as a member of a commercial organization involved in servicing orthopaedic surgeons, I am most interested in surgeons' opinions on our changing marketplace. I am Director of Marketing for Biomet, Inc. (consider this full disclosure!), and would be very interested in an editorial (and subsequent responses from other readers) on where this science/discipline/market is heading. We are observing a shift in decision-making, and I'm not sure that surgeons are entirely comfortable with it. It seems as if more and more orthopaedic surgeons are finding themselves in a position of having to abdicate their freedom to prescribe certain orthopaedic appliances in order to comply with contracts negotiated, not by surgeons, but by administrators and purchasing departments. We certainly understand the need to reduce costs and get the best prices possible, and applaud free market dynamics. However, when patient advocacy takes a back seat to other considerations, a red flag should be raised. My question to you and your readers: Are we truly seeing patient advocacy being diminished in response to cost reduction pressures? How do we all feel about that? And if we don't like it, but feel powerless to do anything about it, how do we become empowered again? Finally, do surgeons feel "demonized", ie, being cast as part of the problem in healthcare cost escalation? There was a time when the critical skill of the orthopedic surgeon was recognized and valued, as opposed to being treated as a commodity. Is this no longer the case? I would appreciate your response and that of your readers. Respectfully, Bill Kolter Director of Marketing, Biomet, Inc. The following response was received Sun, 27 Oct 1996 23:10:26 GMT I submit the following response as food for thought. Interestingly, Mr. Kolter fails to query the audience as to whether the implant manufacturer may have had some impact on the fact that orthopaedic surgeons are being "cast as part of healthcare cost escalation." Biomet has historically chosen not to participate in purchasing contracts (particularly on a national basis) and, as a result, find themselves being challenged quite frequently on a local basis by hospital administrators and purchasing departments for cost concessions on implants as well as instrumentation and related products. Admittedly, surgeons are not and should not be comfortable with being told what to use. However, the "good old days" have long since passed us by when hospitals could afford to lose money on 75+% of total joint procedures. Todays environment will simply eliminate such programs as we become increasingly penetrated by managed care. The HCFA project will also illuminate the weaknesses in these institutions as well. On a national basis, implant expenditures for hospitals have slowly declined due to open minded, progressive surgeons agreeing to sit down with administration and purchasing departments to determine just how much they want to spend on implants, and with whom, on an annual basis. Over the last three years, I've witnessed several major drivers to high costs in the orthopaedic implant industry but two stand out. First, implant standardization has become a necessity due to the implant industry's history of high margins as well as excessive sales rep and surgeon perks. We all know that many a surgeon is receiving, as one prominent orthopod called it, "Juice Money", for agreeing to utilize a particular manufacturers products. Is this how surgeons have chosen supplement battered incomes? Could this increased cost be occuring at the hospitals expense? On the other side of the coin, high costs have to be borne by the implant manufacturers and distributors due to the fact that in many instances the rep must remain in the O.R. suite to assist the surgeon on nearly every implant procedure. Would a sales rep need to be in the room if an institution had worked with their surgeons to standardize on two, perhaps three companies products? Would the hospitals implant cost be as high as they are today if cooperation and standardization were to occur? Maybe if the hospital admin. and surgeons could focus on outcomes, patient satisfaction, product usability AND cost, a happy medium could be achieved. However, as long as surgeons choose implants based on sales rep relationships, Juice Money, and the "I have to use this because this is what I used as a resident"syndrome, the surgeons, implant manufacturers, hospital admin. and purchasing departments will continue to waste endless hours arguing over something that could be accomplished relatively simply via a bit of cooperation. Footnote: How many hospitals are sharing the savings with the orthopaedic surgeons who have agreed to standardize? Don't forget that they had to learn new systems and techniques resulting from the standardization? What if the hospital contributes a portion of the savings toward new, unbudgeted equipment or the orthopaedic library? Keep in mind that the key word here is COOPERATION. Wheeless' Textbook of Orthopaedics - Myles Clough The orthopaedic internet has been enormously enriched by the posting of Wheeless' Textbook of Orthopaedics. This ambitious site is obviously the result of years of note taking and assimilation of information. In scope at any rate it matches some of the most popular textbooks. Is it the first medical hypertextbook? It differs from them however, by being a true hypertext. The accounts of various subjects are richly studded with hypertext markers which lead to other topics which he has written about or summaries of papers he is quoting. As a result the reader can either read right through a subject or stop and be diverted into greater depth or follow up the references. Every orthopaedic surgeon on the internet should spend some time browsing this site looking up subjects they know about and can assess as well as subjects they would like to know about. Like any publication it may have its shortcomings and it would be interesting to see an authoritative review. As the most complete treatment of the whole subject of orthopaedics on the internet, it is a landmark. One way to improve it would be to add links to illustrations which are already on the net. There are a number of radiology sites which could be mined to good effect. Equally it might be useful to add links to other textual internet sites which bear on the same subject. It would make a good site even better if these were added. If, during your reading, you come across a place which would be enhanced by an internet link or by an illustration you know about send Dr.Wheeless the URL (in ref his URL so he knows what you are referring to). Congratulations and good wishes are due Dr.Wheeless for his enterprise. We should try to ensure that the site enlarges and grows in stature. Mr. Kolter sent the follwing response after reading Dr Weeksmo's editorial. I would like to thank Dr. Weeksmo for his response to my questions to the visitors of this site. A few points require clarification, I believe, based on the response. First: standardization saves money if: Hospitals don't generally purchase inventory; it is usually either consigned or carried in on a case-by-case basis, the cost of which is borne entirely by the orthopaedic company. Pricing based on volume requires, in many cases, surgeons to switch from a system they have chosen (hopefully, for sound clinical reasons) and are comfortable with. As such, achieving compliance to contracts has been a problem in many cases. It makes more sense for surgeons and administrators to cooperate with manufacturers to develop programs which result in win-win-win situations. In this regard, Dr. Weeksmo is right on the money. This is the direction Biomet has chosen to pursue, as opposed to signing national contracts, which seem to reduce the freedom of choice that surgeons should have. We believe that surgeons should be free to choose whichever implant system works best for them. We believe that these types of issues are best worked out locally, where surgeons can be involved directly. For these reasons, we have chosen to work with our customers directly, as opposed to indirectly, via a purchasing group or umbrella organization. And as far as all implant systems being the same in all surgeons' hands, obviously I have a vested interest in arguing the contrary. Nonetheless, it should be the surgeons' choice as to which system they use. And again, hopefully they are choosing for the right reasons. We have faith that they are. As far as "juice money," this is, I believe, a fallacy. Certainly, orthopaedic companies enter into agreements with surgeons for the purpose of licensing technology or patents, offsetting the clerical costs of performing clinical studies, or even honoraria for participating in educational symposia. For these types of legitimate reimbursements to be considered "juice money" is an unfair characterization. I know of no manufacturer that would condone any such practices. And I have to believe virtually all orthopaedic surgeons would be offended by any such activity. As such, it's inaccurate to characterize "juice money" as a significant contributing factor in the cost of orthopaedic care. As far as "excessive profits," that would depend on your definition of "excessive." Biomet, in the fiscal year ended May, 1996, Made 17.6 cents on the dollar. The year before, 17.5. The year before, 18.7. Certainly, we're not whining about our profitability. But are we ripping anyone off? Again, certainly not, especially when you consider the risk involved in engaging in the manufacture of orthopaedic devices. These devices must be designed, tested, manufactured, marketed, cleared for implantation through a rigorous regulatory process, indemnified against liability, evaluated, modified, etc. It's expensive, time-consuming, and comes with significant legal risk. Our competitors are in the same profit range. We all have the same objective: to provide excellent care in a fashion that allows us all to make a living. I agree completely with Dr. Weeksmo that this is attainable with cooperation and communication. As a company, we happen to believe that the closer we are to the surgeon, as opposed to a national buying group, the more productive that communication will be, resulting in surgeon freedom of choice and ultimately better care. Jan 1st 1997 Myles Clough May I take the opportunity to wish everyone a happy, fulfilling and rewarding NewYear. The last year has been one of great interest for me with the Orthopaedics Links Page being one of the most exciting and challenging aspects. In the year since it was started it has grown to be the largest collections of orthopaedic links on the net, one of the largest single topic links collection in medicine and a pace setter in several areas. I was stimulated to present two papers on Orthopaedics on the internet last year. One was Orthopaedic Information on the Internet presented at Mednet96, the conference of the European Society for the internet in medicine. This reviewed the way the links page has been growing and argued that comprehensiveness was more desirable than content review at this stage. Further, it suggested that merging of orthopaedic links pages and sharing the work was the only way to keep on top of the explosive growth of orthopaedic information on the net. At the conference I met up with George Kernohan and Brendan Loughlin, now managing LinkOrthopaedics and we agreed to merge the content of these pages. Later Jan Van Der Bauwhede who manages the ambitious Belgian Orthoweb site, proposed that we merge content. As a result we have formed an international group of orthopaedic surgeons with an interest in orthopaedics on the internet and will be sharing all our information from now on. The aim hasn't changed; it is to provide such a valuable resource to orthopaedic surgeons that these pages will become a reference authority, the place to start a search for orthopaedic material, and the site authors notify to make sure their pages are noticed. The second paper was sent to an internet virtual conference, the 3rd Internet World Congress on Biomedicine which took place in December 1996. The paper, entitled "The Evolution of Orthopaedics on the Internet" will be posted to the conference page shortly and consists of a mini-review of what is available on the orthopaedic internet and some predictions about how it will evolve. Other activities that arose out of Orthopaedic Links Page activities include being invited to participate in preparation of a virtual conference hosted by the Association for Medical Informatics of America Internet Working Group (AMIA/IWG). So it is not an exaggeration to say that the project is transforming my life, or at least my spare time! The greatest benefit has been the feeling of belonging to a group of interesting people with a common and valuable purpose. And now for my 1997 wish list. Top of the list is a hope that academic orthopaedic departments throughout the world recognize the potential of the internet for teaching and communication. All to many of the web pages put out by academia are BORING and contain very little information of interest to orthopaedic surgeons in general. When one considers how many interesting cases are presented and how much work the trainees put into reviewing topics it seems a shame that so little is preserved, posted and disseminated. An outstanding example of what can be done is the Dupont Institute Clinical Case Presentations. 42 cases have been presented and are posted with illustrations a brief review of the subject and references. While lists of faculty members and an overview of the training program may be of interest to a limited number of people, the potential readership is vast. If you want your internet site to attract orthopaedic readership you must provide something that draws them in. My second wish is a consequence of the first; more notification of pages of orthopaedic interest. So far I and my colleagues on the other pages have had to dig out the location of interesting stuff. It amazes me that so few authors take the trouble to notify us after taking all the trouble to write the page in the first place. Perhaps it is because there are so many orthopaedic links pages; this is one of the factors motivating merging - to create a monolith. Thirdly I would wish for some spectacular gaps in the coverage of orthopaedics on the internet to be closed. Prime among these would be a fracture classification. Another area poorly covered is orthopaedic meetings. Wheeless' Orthopaedic Textbook needs a serious review. The technical achievement of creating a hypertext textbook is so impressive that one tends to shy away from a critical review of the content. But someone authoritative should give it the same attention that publication of a major textbook in print would attract. The The Visible Human Project could be used for creation of 3D models of normal anatomy using VRML. A fly-through of the knee or the synovial sheaths of the hand would be truely fascinating and instructive. Lastly, I would wish for continued and increasing co-operation between orthopaedic surgeons with an interest in the internet. There is so much to do, between content review, fostering and moderating newsgroups and mailing lists, collecting links and stimulating new authorship. It would be a shame to waste or duplicate effort. Orthopaedic Web Links (OWL) It has been obvious for a long time that the job of keeping up with the expansion of the orthopaedic internet is too big for one person, especially a busy, practicing orthopaedic surgeon. It's also been clear that a number of orthopaedic surgeons and onstitutions have been trying to do the same thing - establish a definitive collection of links. While these collections are in competition with each other the orthopaedic community will not be well served. For any collection to keep up, it must receive notification of new sites, changes and additions to existing sites. There are more than 700 different pages cited on the Orthopaedic Links Page (OLP). There is no way I can check that they still exist, haven't expanded or been added to and keep up the search for new sites. On the other hand why would the webmaster of an orthopaedic site send me notification of changes when this site is only one among many doing the same thing. One answer would be, "the OLP is the biggest so if I'm going to notify anyone it should be them"; and this is certainly part of the motivation to keep getting bigger and better. But that is surely foolish in the long run as it would set all the pages competing with each other, jealously guarding their collections and wasting effort publicizing their collections. I argued that amalgamation of effort and collections seems a much better way in a paper presented at the 3rd Internet World Congress on Biomedical Science. Since the second half of 1996 I and a few others have been trying to lay a foundation for the future by amalgamating our efforts. Mike Dolan and George Kernohan from LinkOrthopaedics, Jan Van der Bauwhede from Belgian OrthoWeb and I have co-foundered Orthopaedic Web Links (OWL) which has the declared aim of becoming the authoritative collection of orthopaedic links on the internet. We discovered a common purpose through correspondence with each other and all agree that we should spend our energies building not competing. We have now agreed on a common page structure and common content so that each OWL page has the same information. Even more to the point each one of us now "edits" a particular page. If you hit the "mailto button" on the "Topics" page you will be sending a message to me; from the "university" page the message will go to Mike. At the end of each month or so the pages will be updated by the author and the html file for the update distributed to each site for posting. People who post to the internet are egoists (on the whole) and it has been an interesting exercise getting everyone to modify the way they do things. Because of that we have kept the intital number of amalgamated pages small. However, once we have the wrinkles smoothed out, the aim is for everyone who wants to post a comprehensive collection of orthopaedic links to join, either as a full participant or as a mirror. Full participants will take on the editing of one or more pages while mirrors will simply post the collection that OWL assembles. We hope that the combination of an excellent basic collection and openness will persuade everyone on the orthopaedic internet to combine rather than compete. But the true test of success will be when authors who post new material notify us of their contributions as soon as they are up. Unless that happens we will never get beyond the present stage of frantic efforts to find the information to a point where some form of evaluation can be added. Vacuum cleaner, broom, forceps or
nitpicker? The resources that exist on the internet to find information come in a variety of forms. The major search engines (vacuum cleaners) find every mention of the search string on every page which is registered with them. Such institutions as AltaVista, HotBot and Excite will offer up hundreds or thousands of pages which contain the search string. These are extremely useful to someone who is looking for everything there is but the indiscriminate nature of the result makes for a daunting amount of "dust" which you have to sift through. The "broom" resources are those that try to do a complete job of sweeping up the available information and making it accessible. The discrimination, however, is still rather coarse and the "brooms" do not offer much information about the page beyond its title and URL. There is an implicit suggestion that the page is worthwhile visiting, otherwise the collector would not have collected it; apart from that there are no comments about content. Perhaps the ideal that all internet links collections are aiming at is a comprehensive collection so completely annotated that readers can "pick out" exactly what they are looking for. Such "forceps" pages are rare indeed and none exist in orthopaedics. The main deficiency is in comprehensiveness. It's no good having excellent review of content if the page the reader is looking for didn't make it to the list. There is a strong body of opinion that states that "forceps" collections must be based on elaborate peer review mechanisms. Those that adhere to these principles have collections in orthopaedics so small that "nit-picker" is not too unkind a term! Elaborate vetting of pages condemns the collection always to be trying to catch up with the expanding internet. OWL is a "broom" with aspirations to become a "forceps". We believe our readership, in common with most medical readership, values comprehensivenss above content review. We are far from providing comprehensive coverage of the orthopaedic internet even with over 1000 links at last count. We are trying to solve that part of the problem by expanding and recruiting more web page editors with an interest in collecting links. A recent guestimate based on overlap between large collections is that there are about 10000 web pages with content interesting to orthopaedic surgeons. Currently our goal is to improve our coverage; the transformation to "forceps" raises a host of thorny problems. Whose opinions are more valuable, the reviewer or the writer? What readership are you reviewing for? How do you allow for the international nature of the internet? Where do you find the manpower to do the work? The internet is about immediacy, how can you do any reviewing in that sort of time scale? I believe that the internet will evolve methods to solve these problems. The solutions may be sudden; some technological or institutional juggernaut may arise to sweep away our pathetic attempts! But I am betting on gradual evolution along the following lines. First we establish a comprehensive guide to orthopaedics on the internet through continued collection and amalgamation. Next we annotate on content enough to describe what the page is about without making judgements. At that stage the resource will be so valuable that readers will use it virtually exclusively for an entry into the orthopaedic internet. Then it will become neccessary for authors to be listed on the collection if they wish for readers. A delicate insistence on standards before being listed might then produce some form of functioning content review in a situation which is inherently uncontrolable. In this environment a heavy handed insistence on review and process will be ignored. We have to make ourselves invaluable before anyone will take any notice. Wish us luck! Please send comments on these editorials to Myles Clough email cloughs@mail.netshop.net Other sites are grouped under the following headings: |
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© 1997 Greek Orthoweb
founded : Aprile 1997,from Nicolas Vachaviolos and supported by the :
Orthopaedic Department "I.K.A." Hospital of Thessaloniki, Orthopaedic Department of "424 General Military
Hospital" of Thessaloniki, Orthopaedic Department "Saint
Paul" Hospital of Thessaloniki, Orthopaedic Department "Hippocration" Hospital of Thessaloniki, Orthopaedic Department
"Saint Demetrious" Hospital of Thessaloniki