How should orthopaedic surgeons respond to unsolicited e-mail?

How should orthopaedic surgeons respond to unsolicited e-mail? / Authors’ reply

McDermott, I D


I read with interest the annotation in the May 2001 issue by Wakelin and Oliver1 entitled `How should orthopaedic surgeons respond to unsolicited e-mail?’ It highlights some very important issues which will affect all surgeons increasingly with the massive growth in the use of the Internet. The latter has become invaluable for communication between surgical colleagues, and is becoming the foremost tool for the dissemination of information among trainees. The British Orthopaedic Trainees’ Association (BOTA) has its own website which posts information regarding fellowships, events and current news. It also hosts a discussion forum. In the environment of potential change, as announced within the Government’s NHS plan,3 the BOTA website has proved to be of immense value for trainees wishing to exchange opinions and enter into frank discussion with colleagues from different areas of the country. However, concerns regarding unsolicited queries from patients are also of direct relevance within the setting of websites. The BOTA website, including its discussion page, is open to anyone browsing the web, and recently a query asking for medical information was posted by a patient.

When healthcare professionals are expressing frank opinions to colleagues on a website, there is a strong argument for restricted access, as is the case in sites such as Furthermore, Wakelin and Oliver have highlighted the absence of tried and tested legal standpoints is the patient-doctor relationship with telemedicine and the Internet, and it would seem wise that such caution should extend to communication with patients on website discussion forums.


Imperial College, London, UK.

1. Wakelin S, Oliver CW. Annotation: how should orthopaedic surgeons respond to unsolicited e-mail? J Bone Joint Surg [Br] 2001;83-B: 482-5.


3. Department of Health. The NHS plan. London: Department of Health, 2000.


Authors’ reply:


We thank Mr McDermott for his letter. The use of the Internet by orthopaedic trainees is very much to be encouraged, but `information overload’ can be a major problem for busy orthopaedic and trauma surgeons with little time.1

The senior author (CWO) first established the websites of the British Orthopaedic Association2 and the British Orthopaedic Trainees’ Association3 in 1998 and is delighted to see these flourish. He also established the global Orthopod e-mail list in 1997 which by 1998 had become the largest orthopaedic and trauma e-mail list of quality in the world.4 There was a considerable learning curve in running this open electronic list and extensive disclaimers were written in an attempt to protect the list owners from legal action.5 These were fortunately never tested in court. Legal opinion at that time was that it was better to have a list disclaimer than not to have one at all.

Patient intrusion on the Orthopod list occurred frequently, often with medico-legal undertones. Because of concerns about potential global legal actions, the senior author stopped the Orthopod lists in 2000 and they are now run in an open environment in the USA by Orthogate.6

With global lists such as Orthopod which have an international membership it is very difficult to authenticate users’ credentials and therefore this has never been attempted. We could not find an acceptable way of doing this.

We believe that all specialist orthopaedic and trauma e-mail lists, web-based discussion forums and newsgroups should move to a closed environment on secure websites with authenticated membership log-on and passwords. This should block all access from patients. The same caution should apply to acting on the advice of an unknown surgeon in a closed list. We suggest that the same General Medical Council Guidelines to responding to unsolicited patient e-mails should be followed in closed surgical lists.

The quality and depth of discussion on open e-mail lists are not to be compared with human face-to-face clinical meetings with peers. The best use of closed lists is for small specialist groups who wish to have knowledge of each others’ skills and competence. We note that the American Academy of Orthopaedic Surgeons has admirable closed specialist lists for its members. in the UK has an embryonic closed orthopaedic forums,8 which is to be encouraged.

We recommend that all Internet and e-mail discussion postings, in whatever surgical environment, are clearly marked with the name, grade and institution of the author. Eventually, when the technology becomes easier to use by orthopaedic and trauma surgeons we suggest that all messages in a closed forum should be signed digitally and sent by encryption. This would confirm the exact identity of the sender and also prevent the message being opened while traversing the Internet. To help with this surgeons should consider taking a qualification in medical informatics.

C. W. OLIVER, DM, FRCS (Tr & Orth). FRCP


Royal Infirmary of Edinburgh, UK.

1. Oliver CW. How to avoid drowning in e-mail. American Academy of Orthopaedic Surgeons Bulletin 1999;47:2. wordhtml/bulletin/apr99/fline7.htm.



4. McLauchlan GJ, Cadogan M, Oliver CW. Assessment of an electronic mailing list for orthopaedic and trauma surgery. J R Coll Surg 1999;44:36-9.



7. http://www,



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