Idaho State University Institute of Rural Health
National Child Traumatic Stress Network Rural Archive (coming soon!)
Creating Virtual Community:
Telemedicine and Self Care
Reprinted from Secondary Traumatic Stress: Self-Care Issues for Clinicians, Researchers & Educators
by permission of Sidran Press, All Rights Reserved
ã Sidran Press, 1995. You may make copies of this paper as long as you (a) do not change the document, (b) you do not sell it for a profit, and (c) you do give credit to the author and the publisher of this book: Stamm, B. H. & Pearce, F.W. (1995). Creating Virtual Community: Telemedicine and Self Care (179-207). In B. H. Stamm (Ed.) Secondary Traumatic Stress: Self-Care Issues for Clinicians, Researchers and Educators. Lutherville, MD: Sidran Press.
Over half of the chapters in this book direct one toward community for good Self-Care For many, however, connecting with community can be quite difficult. Obviously, this is the case for professionals who work in remote areas. Less obvious are those professionals whose isolation comes from their schedules or from working with colleagues who cannot or will not form a supportive community. Therefore, what kinds of community-based resources are available to these isolated professionals?
One expanding resource area is telemedicine. Broadly defined, telemedicine is any medical (or more correctly, health care) activity that uses telecommunications. Stereotypically, telecommunications conjures up images of fancy video transmissions, fiber optics or the use of other high-tech equipment, and/or savvy, sophisticated computer programmers. Yet the most common telemedicine techniques involve common garden-variety tools such as telephones, fax machines, and basic computer skills. Telemedicine applications encompass a broad range of activities including direct patient services, supervision, education, and research. This paper introduces some of these basic applications, particularly the use of e-mail, as a means of developing professional community for supporting the isolated professional.
Control, Competency, and Secondary Traumatic Stress
We think the professional’s susceptibility to Secondary Traumatic Stress stems from two basic areas: (a) lack of control and (b) questions of competency. These are related issues. Questions of competency, at least in part, arise from the professional’s feelings of lack of control of traumatic material. Therefore, controlling the trauma is a necessary component of competency. When people feel as if they are prepared, or at least have the ability to act positively during an event (that is, to exert some control during the event) there is a better eventual outcome (Hartsough & Myers, 1985, Janoff-Bulman, 1992, Stamm, 1993, 1995, Stamm, Varra & Sandberg, 1994). When people feel as if the have no control, the prognosis is quite poor (e.g. Herman, 1992).
Direct control, however, is not always possible when dealing with traumatic stress. In these situations, monitoring or limiting the professional’s exposure and/or validating their distress over lack of control may be the keys to regaining authority over the traumatic material, and thus a renewed sense of competency. Positive peer social support and supervision--perhaps the best method to deal with the consequences of exposure to other’s traumas--are crucial elements in preventing or at least blunting Secondary Traumatic Stress (e.g. Hartsough & Myers, 1985, McCann & Pearlman, 1990, Pearlman, in this volume, Pearlman & Saakvitne, 1995, Rosenbloom, Pratt & Pearlman, in this volume, Catherall, in this volume, Terry, in this volume, Sarason, Levine, Basham, & Saranson, 1983).
Consulting with colleagues yields other benefits--namely access to information, whether through direct links to the colleague or indirect through databases containing colleague’s work. This contact can increase competency, offer opportunities for direct control, or enhance the professional’s ability to understand and interpret their feelings about the situation. Difficult situations become easier to manage when one is well-informed; informed decision-making strengthens control and sustains competency. Therefore, issues of competency, as well as control, hinge to some degree on direct and indirect access to collegial information .
Medical Informatics: Indirect Access to Colleagues
Because of advances in technology, access to collections of collegial information is becoming easier and, in many cases cheaper. This emerging field of information science, or informatics, is often housed in the academic departments of Decision Science or Library Science. Most professionals are accustomed to searching professional electronic databases. With the advent of the Internet and the ability for computers to be linked to each other, it is possible to have a Virtual Library which has global online access. These resources can be text based or they may be multimedia--what is called the World Wide Web (WWW). One of the great advantages of this technology is hypertexting, or electronic links to other topics and papers. In a hypertexted journal article it is possible to link a citation in a paper to the actual paper. For example, if this book were online and hypertexted, when we said "(Stamm, in this book)," with the click of a mouse you would find yourself in the introduction written by Stamm. This is such a powerful medium, if you have used hypertexted materials once, you will probably notice when it is not there. While creating documents in Hypertext Markup Language (HTML) used to be difficult, automatic hypertexting will be standard in most of the word processing programs by the mid 1990s.
Websites, or multimedia resource locations, can be accessed in a number of ways, many from the home or office computer through the use of a modem or other one of the other direct communication links that are becoming available. Websites are available through commercial online services but the most powerful professional level ones are generally maintained by libraries or institutions. For example, at the University of California San Francisco, faculty can access the library’s journal collection complete with illustrations, from their office desktop computers. Because of this Red Sage Project, getting an article is as simple as searching for it on an electronic database and printing it on your own printer.
While not everyone can have access to something as spectacular as the Red Sage Project, many computers are equipped with CD-ROM. There are professional CDs which can be used for rapid and accurate access to information. These disks can replace the multitudes of diagnostic guides, medical texts and informational texts that have been traditionally been used.
Using a portable version of the electronic database, The Brigham & Woman’s Hospital at Harvard Medical School has replaced traditional texts with handled pocket computers called Personal Digital Assistants (PDAs). These PDAs, used by the residents, contain nearly all of the prescription and diagnostic information that a person could use--the equivalent of 10-15 large medical reference texts (Labkoff, 1995). Similar technology is being used to develop medical language translators--computers programmed to translate standard medical phrases into a multitude of languages. The caregiver simply chooses the appropriate term from the side written in the caregiver’s native language and the computer speaks the equivalent phrase in the language of the patient. These translators are constructed to give meaningfully equivalent phrases rather than literal translations (Brooks, 1995).
All of these tools can be used effectively and easily by the caregiver to improve patient care and improve his or her real and imagined competency. None of these tools can replace good clinical judgment, nor were they intended to do this. What they can do, and they can do well, is to provide rapid easy access to information so that the practitioner can make informed decisions.
E-mail and Discussion Lists: Direct Access to Colleagues
Beyond the telephone, e-mail is perhaps the most commonly used type of telemedicine. This technology is computer-based and uses a world-wide network of computers to relay messages to people who have access to the network. While most academics have network access through their institutional affiliations, rapidly proliferating commercial services like America Online, Prodigy and Delphi provide widely available access to e-mail options. Freenets--community-based free access organizations--offer yet other sources of connectivity.
Two basic types of messaging take place: mail sent by one person to another person (or private e-mail) and mail sent to a central distribution point for redistribution to anyone who subscribes to that distribution list. The latter type of e-mail comes in several forms commonly known as bulletin boards (bbs), listservs, chat lines, Usenet discussion lists, or electronic conferences. Moreover, these interactions can take place in delayed time (receiver picks up message after the sender has sent it) or real-time (receiver gets the message at the same time the sender sends it). Regardless of the form, the basic technology is the same.
This type of communication can be used for the development of friendships, for sharing data, for transferring papers and other files, for teaching, for consultation, and for supervision. Many people, who normally avoid writing letters because of time constraints, find excitement in this easy-to-use and expeditious form of information transfer. Moreover, the standards of good manners that have developed for e-mail are much less formal that letter writing and thus, e-mail communications take less time and effort to compose. Also, depending on the location of the sender or recipient, the widespread networks of computers result in negligible cost differences compared to other types of communication.
All of the features mentioned above work together to create one of the most interesting aspects of the Internet: most communications are world-wide. For example, one listserv conversation might have contributors from many countries. This results in providing global perspectives to solving practical problems. The net result has been to enlarge the scope of conceptual and/or theoretical discussions enhancing the opportunities for multcultural thinking and tolerance.
Virtual Community Developments
A practitioner can seek direct consults on difficult problems, ask for supervision, or simply discuss their experiences with other colleagues. In these ways, the professional can begin to create a peer-group network of support without leaving his or her office. The community is real in the sense that real relationships can develop, but, since the participants in this community may never meet face to face, it has a virtual aspect to it. These communities are developing world wide as a reflection of the changes the workplace and in technology.
These "Fingertip Communities" can improve the caregiver’s access to opportunities for Self-Care which in tern improves the probability of mentally healthier caregivers ultimately leading to better care-giving.
In the scope of continuing education, virtual community offers distinct advantages in that the Virtual Community takes the information to the person rather than taking the person to the information. Moreover, this type of continuing education is situation specific and has a regular flow that is directly connected to the caregiver’s life.
One of the most common forms of Virtual Community is the online professional forum. These forums can be used to discriminate new research and treatments or to discuss "hot topics." Requests for can be posted; answers are usually returned quickly and apply directly to the problem at hand. Several types of professional resources--supervision, mentoring and Professional Forums--are discussed below.
Training, Supervision & Consulting
One of the promising aspects of telemedicine is an improved ability to provide training, supervision and consultation. A number of training programs around the world are working toward incorporating e-mail into their curriculums. One bold vision, The Grand Junction Project, even suggested the possibility of doing the complete advanced degree program online (Seligman, 1992*). While it is not likely that entire accredited training programs will be online in the immediate future, portions of training programs are already being conducted online. For example, the psychologist author of this paper routinely uses e-mail for supervision of students, both while they are on campus, and when they are off campus on internships, practica or finishing dissertation. In one case, an entire dissertation was conceived, planned, and excited using the Internet. In this case, over 2000 miles separated the student and teacher. This e-mail supervision was supplemented by a two week residency during the data analysis phase and a 2 day pre-defense preparation. The proposal meeting was held using teleconference with the defense being the only face to face meeting of the entire committee.
Other programs in a number of disciplines are using e-mail for supervision. Marshall University School of Medicine is one of the leaders in using the Internet for training and supervision. "At the Marshall University School of Medicine students...serve extended rotations (up to 9 months in family practice, ob/gyn, peds, surgery, etc.) in rural clinics and hospitals around West Virginia. They submit their patient encounter logs and correspond with their faculty via e-mail who supervise their curriculum" (McCarthy, 1995). At the University of Maine, the U.S. government funded interdisciplinary program, the Training for Health Care for Rural Areas Project conducts graduate health professions training via the Internet, using computer conferencing and e-mail (Kovacich, 1995). The astute reader will quickly notice that many of the above examples are rural based. And, in fact, many of the developing applications are grassroots and born of necessity, --what one colleague called BWCW (Because We Can’t Wait) programs (Terry, personal communication, 16 March, 1995). In other places, they are becoming more formalized and may be known as EPSS (employee performance support system) (Brown, 1995). While e-mail systems are becoming more common in urban and rural settings, e-mail supervision can be of particular importance in remote areas. Recruiting and retaining health-care providers in remote areas is a difficult issue world wide. In Australia, studies over the past decade have indicated that (a) students from rural secondary schools are less likely than students from metropolitan secondary schools to take undergraduate medical courses and (b) those from rural areas are more likely to enter rural practice than those from metropolitan area. However, because of the low base rate for students from rural areas, the majority of rural providers originate from urban areas. Interestingly, recent work has indicated that there may not be a difference in retention based on geographic location of upbringing (Jones, 1994).
Regardless of the background of the provider, the practitioner in an isolated are face challenges not usually faced by those in urban areas. For example, the provider in a rural area may encounter a wider range of problems since they are the primary caregiver for an area. Thus, they may have to practice at the edges of their expertise, or even outside of it simply because they may be the sole caregiver in a region (for example, see Bills, in this volume). The following story, posted to Rural-Care, an Internet discussion list illustrates the point.
In sum, e-mail seems to have an important role to play in the training and supervision of people in many different types of settings. This style of supervision enhances the supervisors ability to serve the students needs and expands the physical training setting allowing the student to work in-vivo without having to move the supervisor with the student. Moreover, advanced training can be provided to the professional in the field from senior colleagues and from people with particular expertise. While there are technical and ethical difficulties that must be addressed, the benefits of this type of communication seem to justify solving these difficulties.
Friendships and Mentoring
One of the simplest and most effective methods of self-care is the establishment of friendships. While it is not likely that on-line relationships will, or should, replace face to face ones, they can be a boon to the professional caregiver. One of the advantages of professional relationships in comparison to personal ones is the shared interest in the professional topic. Online relationships afford the opportunity to discuss professional issues to one’s heart’ content without boring friends and family members with the details of one’s work. In addition, many people have found that their social connections have fallen prey to busy schedules. The advantage of e-mail is that the notes can be written at the convenience of the author, and read at the convenience of the recipient. It is not necessary for both people to be online at the same time.
Consulting with one’s colleagues and discussing ongoing work is easier. Because of the ease of transferring papers and other materials over the net, peers can provide feedback in a timely and easy manner regarding work in progress. For example, a number of the papers in this book were edited in a matter of days because of electronic transfer. Moreover, these relationships can provide a place to try on ideas about career directions. Because of the egalitarian access, it is also possible for junior colleagues and even students to correspond with senior scholars in a mutually productive interchange combining the senior member’s wisdom and the junior member’s zeal.
Professional Forums
While private e-mail can be satisfying, sometimes it is helpful to expand the size of your professional community. Discussion lists, also known as Electronic Conferences or Professional Forums, are ongoing on-line discussions in groups of professionals. Generally these conferences are organized around a particular topic; for example, Traumatic Stress. Individuals post a statement or question for distribution to all who are subscribed to the list. A discussion then ensues as interested parties make comments about the original and subsequent post. These "conversations" generally are designated as a thread. For example, a recent post to the Traumatic Stress Forum asked for information on structural models of Traumatic Stress. Several answers were posted to the forum so that all the subscribers saw the responses. In addition, there were "private" posts made to the originator of the post regarding his question. The thread continued for several days, with a number of other people entering and leaving the open discussion. After several days of public and private discussion, the originator of the post distributed a general summary of the deliberations to all Traumatic Stress subscribers. One of the interesting outcomes of this particular thread was that there was substantially more research in process on traumatic stress and structural models than the print media (academic journals) would lead one to believe. Multiple respondents indicated that they had papers under review, but faced reluctant publishers, ostensibly due to the "newness" of structural modeling. This was interesting information that would not have been gleaned easily using other methods of information transfer.
There are other uses of professional forums. For example, a person might need to locate a particular type of resource. During a recent disaster, a person in the affected area, Europe, made a request for help to an Internet list housed in Georgia (that is, the Internet address of the list "resided" on a computer in Georgia, US). This post was picked up in Alaska by one of the authors of this chapter, relayed through New York to a person in Eastern Europe, who then forwarded it to the appropriate disaster assistance people back in Europe. This seemingly "roundabout" connection made services available to the person who requested them less than 24 hours after the original post. Interestingly, the help had been physically close at hand but the person did not know whom to ask--the electronic relay easily connected the person to help (note, this story is altered slightly to protect the identity of the people involved).
Yet another common use of professional forums are announcements of conferences, calls for papers, and RFPs. This is a low cost, fast way for dissemination of information world wide. In sum, these ongoing topic-oriented discussions help keep people aware of issues, allow all involved to have an impact on the direction of the field, and provide ongoing continuing education. Moreover, it is quite common for individuals to connect in private conversations, sometimes known as "back-channel" discussions, which often lead to rewarding long-term professional relationships. Suggestions on how to become involved in professional forums are at the end of this chapter.
Other Telemedicine Applications
This section addresses some of the more stable emerging applications of telemedicine. While not all of the applications will be directly usable, the concepts driving them will probably influence the overall development of the field of telemedicine. Also, a number of the techniques, can be applied in settings outside of health care, such as the application of CHIN technology to student records in University settings.
CHINs
Sometimes the best support of the professional is to make information about the patient readily available. When a professional is trying to render services and information about the patient is not available this can be frustrating and at times frightening to the caregiver. One of the solutions to accessing patient records is the Community Health Information Networks (CHIN). These networks patient records to be accessed from more than one location. Thus, if a patient sees three caregivers and picks up a prescription in a single day, using a CHIN, each provider can access the complete records of that patient (for more information, see Terry, in this volume). Needless to say, this type of system warrants particular security measures, but it can be an effective method for managing patient records. It can also prevent duplication of services and reduce the risk of lifethreatening complications brought about by counterindicated procedures and prescriptions.
Mobile Medics
There are a multitude of telecommunications adaptations for traditional medical instruments and tests. For example, there are stethoscopes that connect to phone lines so that the sounds can be heard by someone remote to the patient. Originally developed for battle-field applications, the mobile medic is finding its way into emergency field medicine as well as routine care. The mobile medic is a suitcase sized kit that contains diagnostic apparatus like an electronic stethoscope, an ekg, some blood and chemical testing equipment, etc. All of this diagnostic equipment connects to a phone either through an existing line or through a direct link to a satellite. These kits can be taken into the field, such a disaster site, or they can be used to monitor chronic patients from their homes. A project of the Medical College of Georgia has linked patients to their physician’s offices through two-way TV. The patient logs in the morning and sends the doctor basic information on their medical status. With this increased monitoring, it should be possible to identify variations in the patients condition before they reach critical levels, allowing for earlier and more conservative treatment (Sanders, 1995).
Teleradiography
Teleradiography is perhaps the most established of the new technologies. Over the past couple of decades computers have taken a strong roll in the creation and examination of images. CT Scans, sonograms, MRIs and even some standard x-ray images are routinely translated through computers. This computer enhancement allow images to be rotated, enlarged and compared to other images. Translating these applications to telemedicine requires modest alterations. In the standard application of radiography, the image is developed and placed into a digitizer which is much like a copy machine. The digitizer is hooked through a computer to a phone line and the image is shipped to a remote computer which then translates the digital file into the diagnostic x-ray image. With this equipment, a technician can shoot the film and a Radiologist at a remote site can view it nearly instantaneously and make the diagnosis (Agnew, 1995). Thus, a primary care provider can get remote consult thereby improving their ability to provide competent patient care.
Teledermatology
Merging the Internet and remote consults, the Telemedicine group of the American Academy of Dermatology, headed by Rhett Drugge, M.D. has a well developed program that combines "dermatology teaching and telemedicine by providing a primary care residence training dynamic distance learning resource on the Internet" (Drugge, 1995a). According to Drugge, this multimedia interface uses a specially developed medical imaging protocol on the World Wide Web called Medpicts-L. This protocol us so efficient that it has been able to ship an image from Germany to the United States in an average of 20 seconds. The work of the Internet Dermatology Society is centered around the Global Dermatology Grand Rounds project <http://netaxis.com/IDS.html> and also produces the Online Journal of Dermatology (Drugge, 1995b).
Ethics, Computers and Approaching the Mathematics of Infinity
Harnard (1994*) suggests that current developments in technology have important implications for the modern world similar to those which the invention of the printing press fostered during the late Renaissance period. Harnard believes the changes wrought by this technology were so immense that he coined the phrase, the "Post Guttenburg World," to denote the importance of the change. From our experience, the extremely rapid pace of change in cyberspace perhaps heralds a technological "marker" equal to the printing press in historical significance. At the very least, these changes can be mind-boggling, especially considering the proliferation of available information. The click of a mouse allows one to search all of cyberspace (population about 25 million users) on any topic of interest. For example, we searched for information on PDA--small hand held computers that have been on the market approximately 2 years. In less than 2 minutes, we located 261 references to programming PDAs by using the Lycose search function (Carnegie-Mellon University)! This explosion of information leads us to ask: Is it possible to be responsible for all the information that we can access, just because it is possible?
We also raise the question of our human ability to comprehend the changes. Is Technological Evolution a more rapid process than Human Cognitive-Affective Evolution? Perhaps yes. But, this does not change the probability that the technology will be developed and that we will, most likely, have access to a great deal of it. Given these prospects, what are some of the ethical issues that can be considered in the context of Technology and telemedicine?
Before computers, research designs focused on identifying and controlling for a "few" variables. Computers, however, have allowed more complex designs and more involved analyses; researchers now address large data sets and vast numbers of variables. At the same time, this increased complexity and technological dependency enhances the probability of producing results without understanding the meaning (Stamm, 1994, Williams, Sommers, Stamm & Harris, 1994). Yet, technology is not at issue. The heart of the matter is the meaning that is derived from the use of the technology. So perhaps the most important question is "Can we really ‘make sense’ of the information produced by technology?" (Christian, Turner & Stamm, 1988, Harris, et al. 1994, Stamm, 1991, 1995b, Williams, Sommer & Stamm 1993, Williams, Sommer & Stamm, 1992, Williams, Sommers, Stamm & Harris, 1994 Williams, et al. 1992).
Security and Maintenance of Information
Maintaining the security of large databases, like those used in research projects, is difficult Maintaining the security of electronically held personal records is even more difficult. Consider patient records (or student records) held in a typical database. These databases offer instantaneous multi-point and multi-user access. While this gives the professional heretofore unknown ability to provide services for the patient (or student), it also extends opportunities for harm. There are two basic categories of risk: (a) risk directly from people, and (b) risks from technology.
Risks to records from people can come from criminal and malevolent intent or from accident or curiosity. Some compromises to security may come from an authorized person simply stumbling across information or from curious searching. This is a particular problem in areas with low population densities or in "closed" systems such as a university.
For example, what effect could there be if a student trainee in a mental health clinic encounters the records of a fellow student who has sought treatment at that clinic? Neither has intended to cause harm; however, the possibility exists for ethical compromise. Consider further that the students are friends. The employee student knows that the patient student has a diagnosis that, should it be discovered, will prevent them from obtaining their desired internship placement. The employee student alters the record in order to protect a friend. In this case several compromises have occurred, even though unintentionally. First, the student employee has committed an unauthorized viewing, compromising the confidentiality of the student patient. Second, the employee student has compromised the integrity of the data by altering it without the permission of the author of the data or the data manager. Finally, by deleting the diagnosis, an important part of the record has been destroyed, compromising the integrity of the database and potentially the patient’s care.
Needless to say, criminal access and malevolent intent magnify problems of database security. These types of compromises can be disastrous--with greater likelihood of more intensive alteration or destruction of records, and, more widespread invasions of privacy and unauthorized distribution of important confidential information.
Technological risks to a system do not come directly from a person, but from software or computer systems created by people. Some computer viruses, for example, are designed to destroy data and/or to confuse and disorient computer systems. A computer virus in a large system, especially when that system is connected to other machines via a LAN or the Internet, can wreak havoc on the entire system.
Other potential problems emanate from system programming errors or irregularities in use of a system. Because computer systems are not intuitively intelligent and cannot always make good judgments with extenuating circumstances, it is possible that an appropriate and approved individual can be denied access to a system. The effects of this denial become vastly more difficult if the access is desired in a medical crisis. Literally, lack of access to information, such as drug allergies, could compromise a patient’s safety.
Confidentiality and Encryption
Thus, security issues should be considered when computer-based systems are used for database management and record-keeping. This is particularly salient when the system is used to pass records from one location to another as in a CHIN. Each time a message passes though an Internet computer system, people working in that system can access that message. One solution for record security is encryption. There are multiple encryption software programs that can be easily modified for different users. Interestingly, many of these programs are downgraded security technology from previous wars. Encryption and other security measures are the tools for ethical management of data but the foundation is good planning and care by the administration of the database itself.
Perhaps the most important method of maintaining confidentiality is one that is already in use. As professionals know, it is possible to discuss the issues of a case without revealing the details nor the identity of the parties involved. Moreover, from a self-care perspective, it may be vastly more important to discuss the caregivers feelings about the case rather than the details of the case itself. Thus, the writer of the information is the originator of the information and has control over what is shared. A word of caution is appropriate here, security measures on the Internet are still developing. It is a good rule of thumb to write as if others will see your post. In the experience of the authors, posts have ended up in places that were unintended, but through human error (usually our own) more frequently that through malice or security breaches. However, it is good to remember that messages can find their way into unintended places.
A Professional’s Beginner Guide to The Information Superhighway
The connectivity of an estimated 25 million people (Musler, 1995) from around the world into one system is unprecedented in human history. Suddenly, people from multiple cultures are creating a new culture on the Internet, what is sometimes known as a virtual Global Village. Some of the difficulties in this emerging culture are related to who pays and who plays.
Establishing the cost for the use of the Internet is an ongoing battle. Originally a project of the United States government, the Internet has generally been perceived to be free. In the past, most people gained access to the Internet via universities and organizations that paid group fees (unbeknown to the end user). Now, many people access the Internet via on-line commercial services which makes costs more visible. Because of the differences between this technology and older, more established technologies, it is impossible to predict how this issue will ultimately turn out.
The emerging Internet culture is unique in the sense that one can make one’s voice heard. In many other societies, individuals need power, prestige, or other social accouterments in order to speak or share their thoughts. Because of the different culture of the Internet, anyone can say anything. This is both good and bad. People have a more egalitarian ability to share their views on issues that they perceive to be important. But, at times what is said will be offensive to some. Free speech is not without ambiguity and discomfort.
In an effort to make the culture open, but not hostile, general codes of behavior have emerged on the Internet. These guidelines are relatively simple. When you post a message, it is appropriate to include your address at the end of the post and a concise subject line in the address. The subject line is a 1-5 word abstract of sorts that identifies the nature of your comments. When you reply to a message, you should copy only that portion of the message to which you are responding (most software packages make this an automatic task) and delete the remaining text. Your post then consists of the original post plus your reply, with excess information deleted.
One of the difficulties with communication in text only is that it is sometimes difficult to understand the writer’s meaning without body language and other social cues. To solve this dilemma, a number of code systems have developed which can show affect, for example, the smileys. A :-) is a smiley face turned sideways. This is generally used to denote pleasure or humor. A ;-) is used to denote a wink and a smile. If there is sad affect, the mouth turns down :-(. These smileys can help the reader interpret the feelings of the writer. The following sentence could have multiple meanings depending on the smiley used.
I ran all the way home :-)
I ran all the way home :-(
In the first case, perhaps the writer was anticipating something positive waiting at home and thus could not contain his or her excitement. In the second case, perhaps the writer was afraid and seeking the shelter of his or her home. It is interesting to note that communicating affect via writing requires one to be able to articulate that affect. This is a psychological skill we tend to overlook. Learning to be able to articulate our affect is perhaps a positive side benefit of having to communicate complete thoughts and feelings via text only.
At times people find themselves extremely excited by what they encounter on the "net." When a person replies without consideration for moderating their affect, it is called a flame. Unfortunately, flames are generally personal attacks and may not have any real grounds upon which to reply. In these circumstances, the recipient may reply in like manner in which a flame war is begun. These battles can escalate and may include others who have no direct role in the original incident. In the culture of most discussion lists, the approach to flame wars is, in the best behavioral tradition, to ignore them. Without reinforcement to keep flaming, most people will cease and the war will be over. Flaming can become a difficult problem for the community. In these circumstances, if the list is managed by a person or team of people, they will generally try in private, to persuade the flamer to cease his or her behavior. In the most extreme cases, a person may be locked out of access to a particular group.
Some suggestions:
Printed descriptions of Internet operations have built-in limitations. Because of transmission speed and the ease of forwarding messages, the Internet works something like wildfire: hot topics quickly consume respondents’ thoughts, but just as quickly die out as other topics surface. Thus, what appears current on the Internet can be passé before it hits the print medium. Moreover, addresses and instructions for electronic resources must be precise; messages are often read by a machine looking for a perfect match. For example, a computer would likely interpret the following two addresses as being different while a human could likely see their similarity:
yourname@psych.university.edu
your_name@psych.university.edu.
Just to complicate things, electronic addresses and routings can change fairly often as the Internet expands--more people necessitate more information to route messages correctly. Therefore, any information that is as old as print text is subject to having been changed.
That being said, we have included information that is current about some of the resources that we find helpful and interesting and hope that you will be able to locate them. These addresses are current at press time but subject to change. If the addresses have changed, hopefully the information will at least put you on the right track to locating resources that intrigue you. The key to using the Information Superhighway is to be bold and to remember that you are in charge: you can always turn off the computer!
Traumatic Stress Informatics: The PILOTS Database
One of the most important on-line resources for traumatologists is the PILOTS database which contains about 7000 citations and references from the worldwide traumatic stress literature. PILOTS can be accessed free through the Dartmouth College Library On-line System <lib.dartmouth.edu> and is produced by the National Center for PTSD. You can log on to PILOTS directly by modem by dialing (603) 643-6310 for access at 2400 baud or less, or (603) 643-6300 for access at 9600 or 14400 baud. When you see an @ prompt, type c lib and at the -> prompt, type SELECT FILE PILOTS. If you are accessing PILOTS via the Internet --Telnet <lib.dartmouth.edu> , type SELECT FILE PILOTS at the prompt.
PILOTS has many help-screens along the way that can assist the new user. You can also access the PILOTS Database User's Guide via ftp from <ftp.dartmouth.edu directory/pub/ptsd> or you can obtain a copy from the Superintendent of Documents, U.S. Government Printing Office, PO Box 371954, Pittsburgh PA 15250-7954; stock number 051-000-00204-1, price $19.00 US, $23.75 to foreign addresses. You can also address questions <ptsd@dartmouth.edu> (Lerner, 1995).
General Telemedicine Resources
Below are several Websites that showcase information about telemedicine. The addresses were current at press time but are subject to change. You will need a graphical web browser such as Netscape or Mosaic or a text web brouser like Lynx to access the sites. You can consult your system operator for more information about how to access the http addresses from your system.
Harvard
The Harvard website is extremely well cross-referenced (hyperlinked) with other programs and efforts around the world. It is a good general jumping off spot for the field. The address is <http:// **>.
The U.S. Department of Defense Telemedicine Web
This website contains information about the United States’ Department of Defense’s efforts in telemedicine. As previously mentioned, much of the technology that is available in telemedicine originated with the U.S. military. This website shows their past and current efforts world wide, including testbed sites in Somalia and Croatia and Macedonia, where the medical translators previously mentioned were developed. The address is <http://ftdetrck-matmoweb.army.mil/pages/welcome/webMap/webMap.html>.
Oncolink
Oncolink is the Web site Oncology at University of Pennsylvania. Although not directly a mental health resource, it is relevant to the Traumatic Stress area since a cancer diagnosis radically alters a person’s life. There are many resources available on Oncolink but perhaps one of the most delightful features of Oncolink is the ever-changing gallery of children’s art. Oncolink can be accessed through <http://cnacer.med.upenn.edu/>.
Ruralnet
This rural-interest site is maintained at The Marshall University in West Virginia. It is particularly helpful in accessing information about U.S. legislation and programs for rural and underserved areas in the Unites States. The address is <http://ruralnet.mu.wvnet.edu/>.
Framework for European Services in Telemedicine (FEST)
FEST is a project of the European Community and has some 22 partners. The main objective is to develop a framework for those interested in developing telemedical services. It hopes to provide tools to address the complexities of developing, planning, implementing and assessing telemedicine services. It can be reached at <http://www.cee.hw.ac.uk/Databased/telemed.html>.
Professional Forums for Ongoing Discussion and Professional Community
InterPsych
InterPsych is an international multi-disciplinary non-profit organization that maintains numerous professional forums (aka mailing lists). Founded in February 1994 by Ian Pitchford of Sheffield England, these forums allow mental health and behavioral-science professionals, students, and interested others to keep up with discourse in their fields, as well as with each other. InterPsych attracted so much attention in its first half-year on-line that it had to leave the University of Sheffield because it had outgrown the University’s ability to house its growing e-mail traffic. Within a year after its founding, it serves approximately 8000 subscribers from over 30 countries who represent most fields of behavioral health care. As of April 1995, InterPsych manages over 40 separate forums, including such topics as assessment-psychometrics, child-adolescent-psych, depression, geriatric-neuropsychology, managed-behavioral-health care, mental-health-in-the-media, psyart, psychopharmacology, rural-care, thanatology, transcultural-psychology, and traumatic-stress. Because of the brevity of this chapter, and because of the rapidly growing nature of InterPsych, it is impossible to list all the forums.
However, two InterPsych Forums are particularly relevant to this chapter: Traumatic-Stress and Rural-Care. Both forums are discussed below with instructions for subscribing. More information about InterPsych can be obtained at < http://www.shef.ac.uk/~psysc/InterPsych/inter.html>
InterPsych: Traumatic-Stress
Traumatic-Stress is a professional forum founded and coordinated by Charles R. Figley, the co-founder of the field of Traumatic Stress. Since its inception in February 1994, the forum’s membership has expanded to nearly 1000 people. Traumatic Stress (the forum) promotes the investigation, assessment and treatment of immediate and long-term psychosocial, physiological, and existential consequences of highly stressful (traumatic) events. Although this is one of the most widely subscribed lists in the InterPsych collections, the mailing load is not sufficiently high to make it burdensome for most. The average number of messages per week is generally about 20. One of the ongoing topics of discussion of particular interest on this Forum is the continuing efforts to identify a cure of PTSD (Figley, 1995). To subscribe to Traumatic-Stress, send a message to <Traumatic-Stress@listp.apa.org> with SUBSCRIBE Traumatic-Stress in the body
InterPsych: Rural-Care
Rural Care addresses Self-Care needs and encourages an exchange of ideas, opinions, and information among persons concerned with the delivery of health services to individuals in rural and bush areas. Rural-Care tries to reduce feelings of isolation which rural- and bush-based professionals may feel by providing a professional community at their fingertips. Through Rural Care, workers in the field can find support from and connections with those professionals who may be located in more urban areas. Some of the issues discussed on Rural-Care are telemedicine; appropriateness of treatment; access to referral sources; evaluation of patients and/or service delivery; the unique difficulties in service delivery brought about by geography, weather, local customs, etc.; and the application or misapplication of urban or Western health techniques and ideology in rural/bush settings (Stamm, 1995,c). To subscribe to Rural-Care, send a message to <Rural-Care@listp.apa.org> with SUBSCRIBE RURAL-CARE in the body
References
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