The "global community" is a somewhat overworked phrase, but truly applies to the ability of surgeons around the world to pick each others' brains and share thoughts and experiences online.  The "curbside consult" is being replaced by the online consult, using e-mail exchange of clinical photos, x-rays and literature. The surgeon practicing in a remote area can, in fact, solicit and receive valuable feedback from colleagues around the world, in and out of academia, sometimes within a matter of minutes.

Current Reality
What is described above is happening now, and in a very real way in hand surgery.  Several parallel groups exist for in the sole purpose of sharing hand surgery information on a global scale. These services are generally available through e-mail list serves, in which mail from any one subscriber is automatically forwarded to everyone else in the group. This allows very rapid multilevel communication. The American Society for Surgery of the Hand (7) sponsors e-mail forums for its members which allow open discussion of relevant topics, including presentation and discussion of difficult clinical problems. WorldOrtho hosts an On-line Rural Advisory Service (66), and  Orthogate (54) sponsors a number of orthopedic surgery related e-mail forums.  The Orthogate hand list currently includes several hundred members from over 30 countries. Other hand surgery mail lists geared to allow immediate feedback include the list sponsored by the Electronic Journal of Hand Surgery (14), the Hand Surgery Therapy Network (21), Hand Therapy Network (51) and Hand Rehab On Line (19). Paid subscription services offering online specialty support for hand surgery professionals include Hand Surgery Online (20) and MD Consult (39).

List serves are not without quirks and problems.  First, voluntary lists have voluntary participation, and there is no guarantee of helpful feedback in a timely fashion.  Responses may be hindered by lack of time or intermittent mail checking by potential respondents.  Paradoxically, the most interesting problems presented may generate the most unpredictable feedback, for it is easier to compose a simple reply than a considered, researched recommendation for a complex clinical problem.  Most people, physicians included, access their e-mail on an irregular basis, and do not deal with electronic communications with the same level of daily routine as they do for standard mail, the newspaper, and the evening news on television. List members may defer important replies until time permits a considered reply, only to miss the best opportunity to respond.  Second, list servers may generate an overwhelming amount of mail, and the subscriber may either ignore mail or be forced to unsubscribe to regain control of time on their computer. Third, as with all advice, the value of online informal medical consultation is only as good as the adviser, and cannot replace the surgeon's own responsibility and judgment.

Nevertheless, hand surgery mail lists serve a critical function of sharing progress in hand surgery on a global scale.  Subscription is an excellent method to share one's experience, to stay fresh regarding clinical problems uncommon in one's practice, and to benefit from the experience of others, good and bad.  Clearly, many surgeons maintain busy practices and develop enormous personal experience without publishing.  Mail lists are a unique method of coaxing valuable information out of what is otherwise an inaccessible body of knowledge - experience of the the silent (unpublished) majority.