The public is continuously encouraged to take charge of their health by researching their conditions and being as proactive as possible.
This is the term Scott Haig, MD, Assistant Clinical Professor of Orthopedic Surgery at Columbia University College of Physicians and Surgeons, used for patients who walked into his office too well-informed by the Internet. It clearly wasn’t a compliment.
Haig recently highlighted a tension between physicians and tech savvy patients in his Time magazine article, “When the Patient is a Googler.” The patient described was an extreme example of a woman who used the Internet to find every piece of medical information online and then was more interested in giving her own assessment than enlisting the aid of Haig during her appointment. Haig’s response was to give her a brief treatment recommendation and then refer her to a colleague. The article reflected how the Internet has had a see-saw effect on the physician-patient relationship, where the middle ground is still unknown.
Empowering patients is a common theme on Internet sites. The public is continuously encouraged to take charge of their health by researching their conditions and being as proactive as possible. Patients are able to research their symptoms, diagnosis, treatments, and even their doctors before making an appointment. While they are taught how to access this information, unfortunately they are not taught how to manage this information overload.
Patients are encouraged to be empowered and well-informed, but at what point does this get in the way of providing the best medical care? As patients become more tech savvy and medical information becomes more widely accessible online, physicians must determine how the Internet will factor into their own personal practice styles.
Jonathan Bertman, MD, Clinical Assistant Professor of Family Medicine, Brown University School of Medicine, qualifies that his reaction to the tech-savvy depends on the personality of the patient.
“If they are not paranoid about their health, but just come in with information to be well-informed, then I’m always pleased. But unfortunately, these days, my gut reaction when I see someone walk in with printouts of online information is to roll my eyes and think ‘Here we go.’ There are some people who are always worrying about their health, and I cringe when I see them come in with printouts, because they tend not to be the easiest people to work with to begin with, and the printouts just add to that.”
Having found the Internet authority gives patients a means to combat the medical authority. But this is nothing new. Difficult patients have always existed, even before the Internet age.
Brian Cotner, MD, who has his own family practice in Clarksville, Arkansas, is not surprised when he has to work with difficult Googler patients. Before the internet, Cotner had patients that stubbornly disagreed with him because of what they read in cheap newsprint flyers from the local health food store. People have not changed since they went online. “I see the Internet as facilitating people’s natural tendencies. It extends our abilities to do the things we would normally do.”
Extreme cases will always exist, with or without the Internet. But Jim Blaine, MD, Health & Wellness Clinic in Ozarks Technical Community College, Springfield, Missouri, believes uninformed patients can be just as difficult to work with. “In my experience, it is more likely that the uninformed patients will be stubborn. I have had patients argue ‘this is how I think it is, because this is what my mother always taught me,’ and it can be pretty hard to argue with that.”
Good for some things, bad for others
The Internet is an invaluable tool for patients to research information once they have a physician provided diagnosis. This patient initiative can benefit physicians as well. With the rapid and continuous growth of medical knowledge, it is difficult to be fully aware of all new medical developments. Each of the physicians we spoke with has experienced and appreciated when their patients arrived with information they had previously unaware of.
Blaine often finds himself researching information with his patients if they come in with data he is unfamiliar with. He encourages his patients to go online, but stresses the importance of staying on reputable sites. Looking up information is particularly important for complicated diagnosis such as COPD, hypertension, and diabetes. He has often found explained something in the most basic language and asked his patients to repeat what he said, just to find they were unable to. By directing them to particular sites, patients can access important information at any time and study it at their own pace.
The worst-case scenario Internet diagnosis
The Internet may be a great place to research a diagnosis, but not necessarily the best place to find a diagnosis. Sites that provide diagnosis based on patient provided symptoms can often be a source of confusion. Patients type in vague symptoms and receive long lists of frightening illnesses. It is not uncommon for patients to come in with exaggerated data and be more worried than is logical. Rather than encountering the stubborn self-certain patient, Blaine finds his patients are more often relieved to hear his diagnosis, since it is usually less severe than the Internet worst-case scenario they were worrying about.
Bertman practices by the mantra “When you hear hoof beats, think horses, not zebras,” as these are more common in America. But the Internet gives all diseases equal weight, so differentiating between the horses and the zebras without medical experience can be a challenge.
To test this, we tried a small experiment. When asked what he would think if a patient came in with a cough and shortness of breath, Bertman said his gut reaction would be bronchitis. Typing the same symptoms into http://www.healthline.com/symptomsearch gave us 57 results, with the top ten including asthma, bronchitis, atypical pneumonia, heart failure, emphysema, and heart attack.
“If you’re a hypochondriac, you can find the worst possible explanation of your symptoms online. If you’re in denial, you can find the most benign possible explanation of your symptoms online,” laments Cotner.
Blaine suggests that a patient arriving with a false Internet self-diagnosis is not necessarily a negative. “Patients may not know the correct diagnosis, but they know if something is wrong with them and if they come in with a diagnosis, I get the chance to really hear them out, and tell me why they think it is so.” Blaine often uses these details to determine his own diagnosis.
Cotner is not particularly worried by Googlers either. “There’s a reason the patient is in the exam room with a physician instead of pecking at a keyboard at home. They either want some kind of affirmation for their viewpoint, or they want to be absolutely sure their assessment of the situation is correct. The patient in your exam room probably attaches some value to your opinion, or they wouldn’t be there.”
The ticking clock
“I think it’s great when patients come in informed! I adore that! I love working with an active partner. I think patients coming in informed shows that they are invested in their health,” gushes Dr. Lynn Ho, who runs her own practice in North Kingstown, Rhode Island. Her enthusiasm for the Internet-savvy patient is likely due to her heavy dependence on the Internet and healthcare IT to run her practice, as she follows the micropractice model of practice. She has no staff, all billing is electronic, all patients have electronic medical health records, she offers her own online patient education materials, and her patients make their own appointments online. With 775 patients, she is capping her practice at 1,000. In other words, she sees on average 40 patients per week, allowing her to spend 30 minutes to one hour per patient appointment. This allows her ample time to address any concerns or misinformation they bring with them.
“Sometimes what they come in with is quite wacky, so we talk about it. I show them my stuff and they show me theirs. I’m not always right and I’m happy to talk about it. I think patients have the clearest perspective on their body; they bring it to me and I give them the benefit of my experience and knowledge and add that to the mix and then come to a conclusion.”
Often she reviews online information with her patient during the appointment, and if they find some useful sites, she e-mails her patients the link. “I think frustration with Googlers is linked with how much time you have. If you’re in a busy practice, you just don’t want to hear it.”
This does not mean reviewing information has to take a lot of time. Blaine spends about 15 minutes per patient visit, and is able to address whatever concerns patients might have. “It doesn’t take that much time to address whatever printouts people may have,” he explains, “and I’m sure it cuts down time in the long-run.”
Cotner admits a different approach. “I accept Internet print-outs for later review, so I can examine them thoroughly. I may send them a letter about my findings, along with my own print-out on the topic. I don’t really spend a lot of time arguing with people about their Internet data. I don’t have time to look at print-outs and things in the exam room.”
The Big Picture
Practice styles may vary, but in the big picture, does reading medical information online improve patient health outcomes? Cotner does not believe so.
“I personally have never had a patient whose Internet research made them a better patient. However, in my experience, it is rare to find a patient who does any kind of extracurricular reading on their condition that leads to increased compliance with the advice of a physician.”
For better or worse, physicians will have to accept that patients will incorporate technology into their medical health. With Google and Microsoft positioning themselves to incorporate consumer health into their industries, it isn’t too far off to think that patients will one day be able to manage their own health information online, just as we manage our bank information online today. And that will only be the beginning...