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Table 1. 
Distribution of Surginet Subscribers by Country
Distribution of Surginet Subscribers by Country
Table 2. 
Pattern of Use of the Mailing List
Pattern of Use of the Mailing List
Table 3. 
Reasons for Subscribing to Surginet
Reasons for Subscribing to Surginet
Table 4. 
How Could We Improve the List?
How Could We Improve the List?
Table 5. 
Why Do Other Surgeons Not Subscribe to Surginet?*
Why Do Other Surgeons Not Subscribe to Surginet?*
1.
Kelly  R Internet discussion lists. J R Soc Med. 1998;9116- 17
2.
Twomey  PL The future of surgical journals. Arch Surg. 1995;130749- 750Article
3.
Pignone  M The Internet and the journal [letter]. N Engl J Med. 1995;3331079
4.
Kuppersmith  RBHolsinger  CJenkins  HA The use of e-mail by otolaryngologists. Arch Otolaryngol Head Neck Surg. 1996;122921- 922Article
5.
Elliot  SJElliott  RG Internet list servers and pediatrics: newly emerging legal and clinical practice issues. Pediatrics. 1996;97399- 400
6.
Till  JE Discussion groups on the Internet: where to begin? Can J Oncol. 1995;5377- 378
7.
Doyle  DJ Informal clinical consulting via the Internet. CMAJ. 1996;1541150
8.
Renner  CRazeghli  SRichetr  TUeberall  MASchless  A Metab-L: an electronic mailing list on inborn errors of metabolism. Acta Paediatr. 1997;86892- 894Article
9.
Canady  JWCram  AThompson  SABarnes  IRicciarrdelli  EChang  P Using the Internet as an educational/survey tool. Plast Reconstr Surg. 1996;98908- 909Article
10.
Block  EFMire  EJ A new means of communication among trauma caregivers on the Internet. J Trauma. 1996;40674Article
11.
Schoch  NAShoosha  SE Communication on a listserv for health information professionals: uses and users of MEDLIB-L. Bull Med Libr Assoc. 1997;8523- 32
12.
Wulkan  MLSmith  SDWhalen  TVHardin  WD Pediatric surgeons on the Internet: a multi-institutional experience. J Pediatr Surg. 1997;32612- 614Article
13.
Jada  ARGagliardi  A Rating helath information on the Internet: navigating to knowledge or to Babel? JAMA. 1998;279611- 614Article
14.
Kassirer  JPAngell  M The Internet and the journal. N Engl J Med. 1995;3321709- 1710Article
15.
Parkin  AStretch  D The Internet: facilities on the Internet may be abused. BMJ. 1996;312977Article
16.
Gardner  JD The Internet and the journal [letter]. N Engl J Med. 1995;3321078
17.
Goldwein  JWBenjamin  I The Internet and the journal [letter]. N Engl J Med. 1995;3321078
18.
Davies  MW The Internet: a global coffee room. Lancet. 1996;347897Article
Special Article
October 1998

A Surgical Internet Discussion List (Surginet)A Novel Venue for International Communication Among Surgeons

Author Affiliations

From the Departments of Surgery, Toronto East General Hospital and the University of Toronto, Toronto, Ontario (Dr Gilas); New York Methodist Hospital and Cornell University Medical College, New York City (Dr Schein); and University of Florida Health Science Center, Jacksonville (Dr Frykberg).

Arch Surg. 1998;133(10):1126-1130. doi:10.1001/archsurg.133.10.1126
Abstract

Background  Internet discussion lists, also known as mailing lists, are subject-specific groups that are participated in and distributed by e-mail. Medical mailing lists have not been warmly received by the peer-reviewed medical literature.

Objective  To demonstrate the potential value of medical discussion lists on the Internet through a description of Surginet, the largest such mailing list dealing with general surgery, and a survey of its participants. Our hypothesis is that Internet discussion lists fill a unique niche in dissemination of medical information.

Design  A retrospective review of the electronic activities of one medical mailing list, and an e-mail questionnaire survey of its membership's demographics and practice patterns.

Participants  Four hundred eighty-nine subscribers to Surginet from 46 countries.

Main Outcome Measures  Electronic activity of the list, subscribers' demographics, and subscribers' perceptions concerning the list's activities and its value.

Results  Surginet currently has 489 subscribers from 46 countries. During 1997 an average of 12.5 messages per day and 375 per month were posted, all dealing with topics in general surgery. Completed questionnaires were received from 190 subscribers (39%), of which 93% are men and 73% are between the ages of 30 and 50 years practicing in 38 countries; 84% are practicing surgeons and 13% are surgical residents. Most (59%) are "passive" members who read, but do not actively participate in, the discussions. Improving knowledge base, interaction with other surgeons, and obtaining consults were the most common reasons given for list subscription.

Conclusions  Groups such as Surginet fill a niche involving the free exchange of ideas, methods, and attitudes relevant to the current practice of general surgery, which is different from the way medical information is disseminated by published literature and organized medical meetings. There is a perception among list subscribers that this is a valuable and useful modality for continuing education.

INTERNET DISCUSSION lists, also known as mailing lists or listserver groups, are subject-specific groups that communicate via e-mail through a central listserver managed by a moderator. Members of these lists may send postings directly to the list or reply to posts from others. Every post is copied to all members through their electronic mailboxes. Each discussion group has its own informal set of guidelines as to membership eligibility and list participation.1

Medical mailing lists have been criticized by the peer-reviewed medical literature for propagating useless and inaccurate information that is not appropriate to serve as a basis for clinical decisions.2,3 Our hypothesis, based on 3 years of experience with the largest surgical mailing list, is that medical mailing lists provide a valuable forum for honest discussion of clinical topics, insight into how clinical problems are approached by a variety of physicians, and what evidence exists to substantiate or refute prevalent ideas and methods. This should complement, rather than interfere with, existing peer-reviewed medical literature. A description of one medical mailing list and a survey of its members was carried out to test this hypothesis.

PARTICIPANTS AND METHODS

An Internet search on February 25, 1998, using L-soft International (http://www.lsoft.com/lists/listref.html), identified 72537 mailing lists, of which 16502 are public; ie, accessible to all without any selection process. A search through the Liszt mailing list directory (http://www.liszt.com/) named 137 lists dealing with health issues. Entering the keyword "surgery" named 16 mailing lists including Surginet (http://www3.sympatico.ca/tgilas/SURGINET.FAQ.htm). Surginet was founded in January 1995 by the list owner, Tom Gilas, MD, from Toronto, Ontario. Currently, it is the largest general surgical mailing list on the Internet and the only one that is truly international. Subscription to Surginet requires that an applicant e-mail the list owner (tgilas@sympatico.ca) with a brief resume. Although membership largely consists of surgeons, other health care providers are accepted selectively. Laypersons are not accepted to this group. Postings to the list are informally done by any member at any time, and members are free to respond as they wish. There is no organized agenda or program.

In January 1998 the list owner e-mailed a questionnaire to all Surginet members, requesting that it be completed and returned electronically. The results were collected and tabulated.

RESULTS

Currently there are 489 subscribers to Surginet from 46 countries, of whom 190 (39%) from 38 countries sent back a completed questionnaire (Table 1). Most responders were men (93%) between the ages of 30 and 50 years (73%). Responders spoke 28 primary languages, English being the most common (55%). All responders and list members are capable of communicating in English, and all discussions are conducted in English.

During 1997 the average number of messages posted to the list was 12.5 per day and 375 per month. During January 1998 the list transmitted 508 individual messages containing 1.0 megabytes. The entire archive for that month contains 148647 words. The volume of actual discussion, excluding headers and other electronic contamination, was 128327 words, the equivalent of 101 printed journal pages containing 1270 words per page.

PRACTICE PATTERNS

One hundred eighty-five responders were physicians and the remainder were nurses and medical students. This included 159 (84%) practicing surgeons and 24 (13%) surgical residents in training. The majority of responders (83%) had practiced more than 5 years and 58% more than 10 years. A majority (57%) work in teaching hospitals, and 71 (37%) have an academic appointment: professor (8), associate professor (13), assistant professor (20), and others (30).

USE OF SURGINET

Most responders (74%) have subscribed to Surginet for more than 1 year. In 90% of cases, responders connect to the list at least every 2 days. Eighty percent spend 15 to 30 minutes reading or sending messages, 88% read at least half of the postings, and 45% send 1 to 5 messages each month (Table 2). One hundred twelve responders (59%) considered themselves passive members who simply read the postings without participating in the discussions. The remaining 79 are active participants.

The most common reasons responders subscribe to the list involve improving knowledge and collegial interaction. Those features of the list that responders most enjoy are the free discussions of clinical cases and issues (Table 3). Suggestions as to how the list may be improved and conjectures as to why other surgeons do not subscribe to Surginet are listed in Table 4 and Table 5.

COMMENT

These data provide a snapshot of the largest Internet mailing list that deals with surgical topics. Subscribers are typically younger men who have been in practice more than 5 years and a substantial portion practice in academic settings. The large message load, the duration of subscriptions, the frequency with which members connect to the list, and the large number who passively read the postings without participating emphasize how important and useful this modality is to surgical practice.

Remarkably little has been published about Internet medical mailing lists. Anecdotal reports express enthusiasm with this novel and "extremely powerful form of communication,"4 but offer no descriptive or factual data.510 A MEDLINE search disclosed only 2 published surveys similar to this report, one from a mailing list for health information professionals,11 and the other from a pediatric surgery mailing list.12 Both studies involve smaller memberships and a lower volume of activity than this study.

It is clear that mailing lists are rapidly propagating and generating enthusiasm, although this does not necessarily mean they have real value. One conclusion that may be derived from the data reported herein is that this list does seem to positively contribute to the education and practice of member surgeons, which refutes published criticism of this modality.2,3 However, much of this interpretation is subjective, as there are no recognized methods to reliably assess the quality of health-related Internet sites.13

Surginet's discussions generated a monthly equivalent of 101 printed journal pages, which compares in length with, for example, the December 1997 issue of the British Journal of Surgery (120 pages including references). What are the contents of those "electronic pages"?

  1. Case presentations. Problem cases are often presented by members, which are commented on and critiqued in "real time."

  2. Broader clinical issues. Recently the issue of prophylactic antibiotics in laparoscopic cholecystectomy was raised. Within 24 hours there were 30 opinions from around the world reflecting international practice patterns.

  3. Various political, ethical, and financial issues related to surgery are often discussed, allowing international interaction.

  4. Medicolegal issues. Real but blinded cases are presented and provoke heated opinions from other members.

  5. Surgical complications. Surginet is an ongoing virtual surgical mortality and morbidity conference, where complications are objectively and openly discussed without the peer pressure and politico-economic restrictions that prevail in some hospital conferences.

The fact that 40% of Surginet members are active contributors can be considered an "author-reader ratio" of 2:3. This is very high when compared with peer-reviewed journals, where readers greatly outnumber authors. If we consider it a "speaker-listener ratio," it is also much higher than that found at organized medical meetings. This suggests that mailing lists stimulate an active discussion in which members feel more comfortable in offering their views.

Surgeons subscribe to Surginet not only to professionally interact with an international group of colleagues but also to enjoy surgical-social comradeship, often wrapped in a sense of humor (Table 3). At the end of a hard day it may be more attractive to seek an opinion about a problematic case from hundreds of surgeons around the world—who provide vivid personal experience and clinical judgment—than to browse humorless printed journals or search MEDLINE.

The open nature of Internet discussion groups has prompted concerns about quality and abuse.14,15 It has been suggested that "direct electronic publishing of scientific studies threatens to undermine time-tested traditions that help to insure the quality of the medical literature."14,15 Internet discussion lists occasionally contain a draft of an unpublished manuscript, but this should not substitute for a published manuscript in a peer-reviewed publication. In fact, the electronic pages of a mailing list do not represent a publication, but more accurately a meeting.16 Concern that the conversational and informal nature of a mailing list would result in the dissemination of inaccurate medical information is not supported by the 3-year experience with Surginet. In fact, this list shows how hundreds of surgeons manage to conduct a democratic and civilized exchange of ideas while striving for high academic and clinical values. Goldwein and Benjamin17 reflected this experience in their assertion that "we discovered that Internet publishing tests the fine line between free speech, academic freedom, and responsible dissemination of clinically relevant information."

Confidentiality and misinterpretation of medical discussions by those not trained in this area are other concerns that have been raised about abuse of medical Internet sites.15 These problems have not materialized on Surginet. The names of patients and hospitals are never mentioned. Laypersons are not admitted to the list, and it is among this population that postings are most likely to be misconstrued and abused. Physicians are perfectly capable of properly weighing advice, whether it comes from the Internet or from peer-reviewed journals, as this is a routine part of medical practice.

Responders to the survey called for more participation by "big-name" or "more enlightened" surgeons to achieve a better input to the list. Interestingly, only 11% of the responders were associate or full professors of surgery. Obviously, the time spent contributing to an Internet mailing list cannot be entered in one's list of publications; however, we contend that academicians belonging to a mailing list can both contribute and gain. The value of contributing wisdom and knowledge to less-privileged colleagues across the world is obvious, while the pleasures of discovering what the "average surgeon outside the academic ivory towers" thinks and does are acquired.

This reported experience suggests that medical mailing lists are neither designed to, nor do they, replace or challenge peer-reviewed medical journals, textbooks, or organized medical meetings. Groups such as Surginet do fulfill a valuable purpose, as perceived by the members, which is quite different from that of standard modalities of medical information dissemination. These groups function as a virtual operating room lounge where surgeons can exchange news and views, gossip, relax, and vent away anxieties.18 As such, this list is useful to surgeons and ultimately to their patients. Membership to Surginet remains open to qualified applicants, and is encouraged.

Back to top
Article Information

Corresponding author: Moshe Schein, MD, Department of Surgery, New York Methodist Hospital, 506 Sixth St, Brooklyn, NY 11215 (e mail: mschein@planet.earthcom.net).

References
1.
Kelly  R Internet discussion lists. J R Soc Med. 1998;9116- 17
2.
Twomey  PL The future of surgical journals. Arch Surg. 1995;130749- 750Article
3.
Pignone  M The Internet and the journal [letter]. N Engl J Med. 1995;3331079
4.
Kuppersmith  RBHolsinger  CJenkins  HA The use of e-mail by otolaryngologists. Arch Otolaryngol Head Neck Surg. 1996;122921- 922Article
5.
Elliot  SJElliott  RG Internet list servers and pediatrics: newly emerging legal and clinical practice issues. Pediatrics. 1996;97399- 400
6.
Till  JE Discussion groups on the Internet: where to begin? Can J Oncol. 1995;5377- 378
7.
Doyle  DJ Informal clinical consulting via the Internet. CMAJ. 1996;1541150
8.
Renner  CRazeghli  SRichetr  TUeberall  MASchless  A Metab-L: an electronic mailing list on inborn errors of metabolism. Acta Paediatr. 1997;86892- 894Article
9.
Canady  JWCram  AThompson  SABarnes  IRicciarrdelli  EChang  P Using the Internet as an educational/survey tool. Plast Reconstr Surg. 1996;98908- 909Article
10.
Block  EFMire  EJ A new means of communication among trauma caregivers on the Internet. J Trauma. 1996;40674Article
11.
Schoch  NAShoosha  SE Communication on a listserv for health information professionals: uses and users of MEDLIB-L. Bull Med Libr Assoc. 1997;8523- 32
12.
Wulkan  MLSmith  SDWhalen  TVHardin  WD Pediatric surgeons on the Internet: a multi-institutional experience. J Pediatr Surg. 1997;32612- 614Article
13.
Jada  ARGagliardi  A Rating helath information on the Internet: navigating to knowledge or to Babel? JAMA. 1998;279611- 614Article
14.
Kassirer  JPAngell  M The Internet and the journal. N Engl J Med. 1995;3321709- 1710Article
15.
Parkin  AStretch  D The Internet: facilities on the Internet may be abused. BMJ. 1996;312977Article
16.
Gardner  JD The Internet and the journal [letter]. N Engl J Med. 1995;3321078
17.
Goldwein  JWBenjamin  I The Internet and the journal [letter]. N Engl J Med. 1995;3321078
18.
Davies  MW The Internet: a global coffee room. Lancet. 1996;347897Article
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