Third of a series, from my lecture “Dealing with Patients Who Surf the Net” at the 2011 Philippine College of Physicians Annual Convention last May. Available at Slideshare.net.

In my last post, I talked about how access to health information online is transforming the physician-patient relationship. Apparently, the impact of online health information is determined by the severity of the patient’s medical condition and the patient’s attitude towards his physician. This is according to a Vital Signs report (E-Health in the United States, Boston Consulting Group, 2003) by Carina Von Knoop, Deborah Lovich, Martin B. Silverstein MD and Michael Tutty from which I got this figure below:

The Vital Signs report categorizes the online patient population into the following segments:

1. The Accepting (“doctor-dependent and uninformed”) – These patients rarely go online to seek health information even if they have Internet access, as they are comfortable with a paternalistic relationship with their doctor. Most of my patients fall in this group, though I often wish that they become more involved in decision-making. It can become quite frustrating when after I patiently explain all the options, the patient says, “Kung ano po ang sa tingin ninyo ang mabuti Dok.” Translated, “Whatever you think will be best, Doctor.”
2. The Informed (“doctor-dependent but informed”) – This group still depends on the doctor to make decisions but they are likely to seek more information online before or after a clinic visit. I encourage this by giving “Internet prescriptions” – a list of websites that patients can visit. My dream is for the Philippine Society of Endocrinology & Metabolism (PSEM) website (www.endo-society.org.ph) to be the leading resource for Filipino endocrine patients. Malayo pa
3. The Involved (“junior medical partners”) – These patients are fairly well-informed and somewhat involved. They visit websites and discuss these actively with their physician. While they prefer to make joint decisions, they usually defer to the doctor. These patients respond well to Internet prescriptions.
4. The In-Control (“autonomous patients”) – These patients seek online information to be able to diagnose their condition and decide the treatment for themselves. They may even attempt to update their doctors on the latest treatments or studies. They may be active members of online patient communities and contribute to blogs.

As can be seen from the figure, the more severe the medical condition is, the more involved the patient becomes in his care and the doctor’s role is lessened from being Godlike to becoming merely a supplier of information and/or treatment. I know this from my experience when I diagnosed myself as having a prolactin-secreting pituitary adenoma last 2000. The prevailing treatment then was surgery but I reviewed all the literature (did an extensive MEDLINE search) and decided on medical therapy, despite the advice of consultants in both endocrinology and neurosurgery (I was only a medical resident then).

I must confess I feel more comfortable with The Involved. I’ve met a few of The In-Control and the encounters have been particularly stressful. I guess it’s because these autonomous patients most often show their distrust (often a result of previous encounters with other physicians before they come to see me ). I then have to demonstrate to these patients that they can trust me, more than or maybe just as much as what they read online.

Second of a series, from my lecture “Dealing with Patients Who Surf the Net” at the 2011 Philippine College of Physicians Annual Convention last May. Available at Slideshare.net. 

The physician-patient relationship in the Philippines remains mostly paternalistic but I think that the time will come when more patients will become empowered by the health information available online and become active partners in medical decision making. Gerber BS and Eiser AR (The Patient-Physician Relationship in the Internet Age: Future Prospects and the Research Agenda J Med Internet Res 2001;3(2):e15) describe this change in the physician-patient relationship:

“Until recently, in the clinical visit the physician had the sole responsibility for medical knowledge, whereas the patient was only accountable for his or her own preferences. Now, by more easily obtaining medical information prior to seeing their doctors, patients potentially have a different position in the decision-making process; possessing both preferences and knowledge prior to any physician contact.”

And so I ask, are doctors threatened by the Internet savvy patient? Certainly, there is a “leveling effect” since patients can now have access to health information previously made available only as their doctors saw fit to disclose to them. Interestingly,  Geiber & Eiser had this to say in their paper -

“Paradoxically, a patient’s interest in knowledge may not always accompany an interest in the medical decision-making process.“

Aha!

Geiber and Eiser then go on to discuss two kinds of patient-physician encounters:

1. The Physician & the Informed Decision Maker – The patient has done a Web search prior to the clinic visit and is equipped to weigh the alternatives the doctor offers and decide on treatment. Pros: There is truly an informed consent. Time can be wisely spent on an in-depth discussion during the clinic visit since the basics have already been researched and understood by the patient. Cons: Physician may need to spend more time with the patient debunking alternative or complementary treatments and/or correcting wrong information.
2. The Physician & the Knowledge Acquirer – The patient discusses his values and beliefs with the physician who then is able to decide more ably for the patient. The patient may then browse the Web after the clinic visit, which serves to reinforce the medical decision that has been made by his physician. In this situation, Geiber & Eiser describe the physician-patient encounter as having a “priming effect” on the patient’s behavioral response to subsequent information provided by the Internet.

In my endocrine practice, I find that for the less common hormonal disorders such as those involving the adrenal or pituitary glands, patients need to read up after the clinic visit to fully understand the concepts I’ve explained during the encounter. I then find myself recommending websites to the patients or their more internet savvy relatives. This is what is called an Internet prescription. More about this in a future post.

Photo credit: http://www.flickr.com/photos/dannysullivan/273838692/

First of a series, from my lecture “Dealing with Patients Who Surf the Net” at the 2011 Philippine College of Physicians Annual Convention last May. Available at Slideshare.net.

Before the Internet, physicians served as the main source of health information for patients. NOT anymore! In the clinic encounter, it has become more and more common to see patients bringing information gathered from the Internet. Gunther Eysenbach in Medicine 2.0: Social Networking, Collaboration, Participation, Apomediation, and Openness (J Med Internet Res 2008;10(3):e22), describes this shift:

The first possible approach is to use intermediaries (ie, middlemen or “gatekeepers”), for example health professionals giving “relevant” information to a patient. Trusted Web portals containing only information vetted by experts can also be seen as an intermediary. The second possibility is to bypass “middlemen” completely, which is commonly referred to as disintermediation. Examples are patients searching for information on the web, or travelers booking their flights directly on the booking system of an airline, bypassing travel agents. The third way, prevalent in the age of Web 2.0, is a special form of disintermediation: an information seeking strategy where people rely less on traditional experts and authorities as gatekeepers, but instead receive “guidance” from apomediaries, ie, networked collaborative filtering processes.

 

I worry about disintermediation – patients directly accessing information on the Web! It is possible for patients to get lost in the sea of information the Internet provides. I also worry about apomediation – crowdsourcing health information! Eysenbach’s examples of apomediation (where agents “stand by” rather than “in between” as in intermediaries) include ratings on Digg, amazon.com or epinion.com.  Can we apply the same strategy for finding information about good deals, the best hotels or destinations to health care?

Mary Cain et al. in their report Health e-People: The Online Consumer Experience (written for the California HealthCare Foundation Aug 2000) classifies online health information consumers into 3 groups:

1. The Well – around 60% of online health consumers who occasionally browse for general health and wellness information
2. The Newly Diagnosed – a small group (~5%) that understandably searches widely for information following their diagnosis
3. The Chronically Ill and Their Caregivers – actively manage their illness daily and seek information regarding management online (~35%). The report identifies this group as having the most potential to be affected by health information on the Internet.

Which of these three groups have you met in your practice? I’ve met some of the newly-diagnosed clutching their web print-outs and have patiently answered queries regarding the veracity of online health information from a few caregivers of the chronically ill. What to do? More in my next post.

 Photo credit: Person: question http://www.sxc.hu/photo/1124847