Trust me; trust me not

Welcome the breadth and convenience of online resources, but use them with caution. Christopher Hands reports

Has the availability of electronic resources made the lives of medical students a bit easier? It would seem so, thanks to the proliferation of broadband connections and of websites filled with biomedical information. No surprise then that the answers to many students' questions can seem tantalisingly accessible. It is a rarity-at least in the developed world-for a medical student not to have looked up something on Google, or more recently, Wikipedia, for a diagnosis or other pathophysiological information. And the BMJ gave additional reasons to do so: a recent paper suggested that Google might be a useful tool in helping to diagnose "conditions with unique symptoms and signs that can easily be used as search terms"(BMJ 2006;333:1143-5, doi: 10.1136/bmj.39003.640567.AE

However, with ease of access to online compendiums come complicated questions about how well medical professionals search and sort such material. The Google article prompted a flurry of responses to the BMJ, many of which pointed out that to get the best evidence from a search algorithm like Google's, or even from the medical database Medline, much experience and discernment are necessary. As Dean Giustini, medical librarian at the University of British Columbia, points out, "The information that you find there may have integrity, and may have the kind of authority that you need, but it requires a lot of advanced critical appraisal and evaluation skills."

It is not only through search engines, such as Google or its offshoot Google Scholar (which only returns peer reviewed articles), that biomedical information is being made available electronically. Increasingly, medical schools are making use of online materials, usually posted on university intranets, to complement and reinforce students' practical learning. Undergraduate practical classes in anatomy at Oxford University are now supported by computer assisted learning packages, which make use of text, illustrations, questions, and case scenarios and which are available a week before the session.

John Morris, professor of human anatomy at Oxford, remarks that the introduction of these resources has made students' learning more effective: "We have certainly found that they're coming in to the practical class much better prepared."This approach might also help to stop the problem of students returning from internet trawls with inaccurate information. Professor Morris comments that, in anatomy at least, Oxford students seem to use other internet resources "relatively little, because I guess they use mostly what we've provided for them."

The sources available on the internet include the materials at the visible human project (www.nlm.nih.gov/research/visible/visible_human.html), which offers a complete tour through the human body in three dimensional slices, and its offshoots Anatline and Anatquest (http://anatquest.nlm.nih.gov), which aim to make anatomical information available to the general public. This educational project has been funded by the National Library of Medicine, the information wing of the US National Institutes of Health.

Traditional, for-profit medical publishers are also keen to take advantage of being able continuously both to access and to update information, and are offering their textbooks in online form, with bonus content for those who register. This trend is exemplified by Elsevier's Student Consult (www.studentconsult.com), which affords an ever expanding database of additional information and crosslinks within its reference works. The more textbooks you buy the more bonus material you can access. Louise Crowe, publishing director in e-learning at Elsevier, is upbeat about maintaining high levels of accuracy in these formats: "Accuracy and content quality can be ensured through formal review by editorial boards and planned content releases. Tight content management and crafting of content prevent resources becoming unwieldy and difficult to navigate. With medical information, accuracy is a key factor. It will be customers who will decide what is and is not acceptable."

The newest and most hotly contested formats are those that can be truly continuously updated. Many of these fall into the category of "Web 2.0"-software that allows greater interaction and connection between users. Wikipedia, "the free encyclopedia that anyone can edit,"is perhaps the best known example of these formats and is a tempting site for medical students in search of the answers to their problem based learning questions. The encyclopedia works on the "wiki" model, which allows anyone to modify the content of an individual article and also allows anyone to reverse those changes. Evidently this allows contributors to post erroneous information, but, in theory at least, the community of editors filters out mistakes over time.

Because of the scope for error offered by the wiki format, many people involved in medical education remain suspicious. However, room for compromise exists between different models of editorial authority. Ganfyd (get a note from your doctor) is a medical encyclopedia, which may only be edited by registered medical practitioners. The founders of Ganfyd have thus attempted to keep the flexibility of the wiki format while ensuring that there is a minimum standard for the accuracy of the information that is included in its articles. Ms Crowe is enthusiastic about the new media, saying that Web 2.0 offers traditional publishers many opportunities to get closer to customers. "We are very excited by the changes in the marketplace and the space this creates to deliver content in new and creative ways. We aim to work alongside medical students and faculty to produce content solutions tailored to their changing needs."

For Mr Giustini, the main boon of Web 2.0 is how it allows medical practitioners to communicate more effectively with each other. When doctors talk to each other, he says, "The discussions that they have together actually create knowledge-they're continually teaching each other."The technologies of Web 2.0 can allow these conversations to become more fluid, resulting in a "continual process of sharing, information, and repurposing information."Such a process might be facilitated by a wiki, by a medical blog containing clinical information, such as Clinical Cases and Images (http://clinicalcases.blogspot.com), or by a blog recording the thoughts and activities of an individual clinician, such as the popular NHS Blog Doctor (http://nhsblogdoc.blogspot.com). In every case, Mr Giustini notes, "The challenge is finding ways for people to share information without something happening along the way that has a negative outcome."

Medical librarians and their counterparts in online technology provision will continue to produce imaginative solutions to the challenge of providing the most reliable, accurate, and up to date information. But it will always be possible for error to emerge in source material or its interpretation, just as it has been when dealing with printed materials. Perhaps it is comforting to reflect that when working in these exciting new fields of knowledge creation and synthesis, traditional skills of knowledge evaluation and appraisal will be as important as ever-if not more so.