Objectives
How do I use it?
How do my colleagues use it?
Other business uses
How I do not use it?
Finding what you need

Search Engines
Metasites
Medline
Focused Web Sites

Judging Quality
Communities
Keeping current
Bookmarks that follow you
Getting Started

• Understand the role the Internet can play in your practice
• Understand the difference between, search engine sites, meta-indices, Medline search engines and focused web sites
• Understand which situation is best served by which tool
• Become familiar with several techniques for efficient web searching
• Judging the quality of what you find.
• Understand the "Communities" on the web.
• How to get your favorite bookmarks to follow you wherever you go.
• Know what is required to make this useful in your office.

• Looking up information on signs and symptoms of a diseases of which I’ve never heard - "Gianotti-Crosti"
• Remembering a diagnosis based on a lesion that I recognize: "Herald patch"
• Looking up information on a newly released drug that all my patients suddenly want: "Xenical"
• Finding an article in the Star Tribune that my patient recalls reading.
• Finding patient information handouts when ours is not available or out of date "Mononucleosis." "Gynecomastia in adolescence"
• Find "Information for Patients" when I give them a sample from the cabinet.
• Get labs and reports from the hospital on that patient who shows up for follow-up after discharge (and whom you did not see in the hospital).
• Read clinical updates that are mailed to me (NEJM Index, InteliHealth Online)
• Browse Medline for the latest articles in my field of interest.
• Browse the medical news: NewsRounds
• Use the online versions of Harrison’s Online and Scientific American Medicine

At first my colleagues used it for things of personal interest:

• Watch the regional radar summaries
• Check their portfolio value
• Read the CNN Headlines
• Choose an outboard motor for his boat
• Track the outside temperature

But now they are finding more clinical uses for it:
• Use the online versions of Harrison’s and Scientific American Medicine.
• Look-up dosing information on medications.
• Look for patient information sheets.

Other business uses:

• Using e-mail to stay in touch with colleagues
• Generate maps and directions for travel
• Look up phone numbers
• Book flights for travel
• Register for CME programs in other cities
• Check for info on conferences I frequently attend

How I do not use it?

• On-line CME
• Videoconferencing
• Searching a commercial on-line medical library of texts.
• Communicating with my patients via e-mail

Finding what you need

There are four types of tools that you can use to search for answers to medical questions that they have. They are search engines, meta-index sites, Medline search tools and focused web sites. Each has its own strengths and weaknesses.
• Search engine sites indiscriminately index the Internet. They are not exhaustive and they can be random. Examples AltaVista, Google, Northern Lights and All the Web.
• Meta-Index sites use a panel of editors to gather links to other web sites and group them according to content. They may provide their own internal search engine that searches only the sites to which they have pointers. Examples Medical Matrix and Yahoo.
• Medline search engines provide access to peer-reviewed medical literature. Carefully indexed but generally less current than the Web. Examples: PubMed and Internet Grateful Med.
• Focused web sites are dedicated to a particular disease, drug or specialty. Can have information for both patient and provider. Examples: OncoLink, Xenical and the AAFP.

Search Engines

• There are a growing number of search engines that randomly index pages on the web. Though many will say that search engines give unsatisfactory results, I maintain that a well tuned search will give you excellent results in short order - faster than looking it up in a text in your library
• To use a search engine you must understand how your results are arranged. With most search engines such as AltaVista and Northern Light the results are arranged according to the frequency of times the target term appears in the document. The more a term appears on a web page, the closer that page moves up to the beginning of your search results.
• If you use multiple terms, the first results will contain links to documents that have your search terms appearing in it the most frequently. Be aware however that not all your terms have to appear in the results if you perform a simple search. That rare medical term, though it may be the most important to you, might not appear among your first few results.
• Google is a search engine that uses a unique method for ranking the results you get. Rather than merely measuring the frequency of your target terms in its database of documents, it also includes in its ranking the number of other sites that link to the target document. In a sense it is using an unorthodox method of peer review by assuming that if a lot of sites link to the page, it must be good.
• Regardless of the search engine you use be sure to use terms that are quite specific to the issue at hand and only those terms. It is inefficient to use free text entry when only one or two terms will do.
• With many search engines can also specify the domain of the search results. For example with AltaVista using the search fibromyalgia and domain:gov will give you links to only government sites. The same can be done with Northern Light by entering the statement fibromyalgia and url:gov.
• Putting double quotes around a phrase will retrieve only the documents in which the terms appear in exactly that sequence. For example herald patch will result in lots of links to newspapers while "herald patch" gives only links that focus on Pityriasis rosea.
• Using Boolian operators can greatly enhance the results of your search. Terms such as and, or, and not and near will tell the search engine whether both terms must appear (and), whether either of them must appear (or), to exclude documents in which the second term appears (and not) or where the two terms appear within a certain distance of each other in the document (near).
• Many of the search engines will offer an advanced search option. As search engines have matured, my need to use advanced search techniques have declined. Advanced search can allow you to customize your search even more but is different from one search engine to the next.
• I recommend that you become familiar with the advanced techniques in one or two search engines and use them for your quick and dirty searches. AltaVista used to be my favorite site but I have found it harder to get results that I want from it as it evolves.

Metasites

• Useful when you are browsing for information. Web resources are arranged according to their focus and you are much more likely to find items of interest by just browsing. You may find resources that you may wish to bookmark so that you have direct access to them when you need them. Examples could be patient information sites, a good dermatology site with images or a site listing CME opportunities arranged by topic, date and/or location. Two of my favorite metasites are Medical Matrix or Yahoo.

Medline Search Engines:

• Search the peer reviewed medical literature. There are many conduits for searching Medline and just like with Internet search engines it is good to become familiar with one of them and stick with it. Three examples of these conduits are PubMed, Internet Grateful Med and the new PubMed interface. It is my understanding that Internet Grateful Med is being retired sometime soon (it was my favorite interface) and PubMed is being replaced with the new interface that has just been developed.
• You can periodically run a saved search so that you can familiarize yourself with recently published articles in areas of interest to you. Internet Grateful Med gives detailed instructions to help you build your own searches as a URL that you can merely click in your browser. Very valuable but not for the faint of heart. The New PubMed also has instructions which appear to be a bit simpler.

Focused Web Sites

• Focus on a specific disease, drug or medical specialty.
• Can serve as your starting point when looking for specific information. Again examples are OncoLink, Xenical, AAFP or the On-Line Mendellian Inheritance in Man database (OMIM).
• Usually discovered by using a search engine, browsing a meta-index or merely by guessing though guessing can sometimes give amusing results.

Judging Quality

Just as one would evaluate a medical journal or any other article appearing in printed media, it is important to look at the publication (web site) the publication’s source of funding and the source of funding for the study. When evaluating websites, a quick glance of the site’s domain can tell you a great deal:

.com	commercial site
.edu	educational institution
.edu/~paul	Paul’s web pages at the educational institution
.org	Non-profit organization
.net	A regional internet provider
.mil	Military institution
.gov	Government site
.us	United States
.jp	Japan
.uk	United Kingdom
.md	Republic of Moldovia (some were sold to physicians)

A more thorough discussion of judging quality writen by Allina Health System’s Medical Librarians can be found at http://fpen.org/train/web/evaluating-sites.html

Sometimes the most significant hurdle to overcome is not one’s distaste for using a computer, but to actually have access to one in the clinical setting. If you are lucky enough to have a machine available to you that is connected to the Internet, you are the exception and not the rule. Computers have been considered to be too expensive, they take up too much space and break too easily. Largely this is still true but these issues are rapidly changing. This perspective on computers has served to perpetuate the myth of the computer-phobic physician. If we don’t have one available to us, how can we ever learn to use one?

Lets assume you wish to use the Internet in the clinical setting. The following are a few suggestions to make your journey a bit more successful and pleasant:

• The most important factor is having a computer in your clinic that
1. can be continuously connected to the Internet,
2. has enough memory to allow Netscape or Explorer to stay running whether or not they are currently being used,
3. readily accessable from your clinical work area.
4. attached to a printer which is capable of printing documents rapidly.
5. is free and does not have someone who has to spend > 50% of their time in front of it in order to get their work done.

• If you do not have access to a computer at the office, consider getting a small laptop, with a cheap color printer. Install a phone line for it and get an account with an Internet Service Provider who will allow you to stay connected at all times. When you get to work, plug in your laptop, connect to the Internet, get your browser running and start your normal work day. I have found that the time spent in starting and concluding a successful search takes considerably less time than it takes a computer to start up or to connect to the internet. Since using it is convenient, I am more likely to turn to it when I have a question and the more I use it, the more useful I find it.
• Take the time to explore and play. Skills gained during unstructured exploration will make searching for information when under-the-gun a great deal easier and consequently you will be able to find your information much faster.

Paul Kleeberg, M.D.          O   o           paul@fpen.org
Allina Health System        -+---+-    Voice: 612-775-1338
1375 Willow Street           |_o_|       Family Practice &
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