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CORR Insights®: What are the Implications of Excessive Internet Searches for Medical Information by Orthopaedic Patients?

Crijns, Tom J. MD

Clinical Orthopaedics and Related Research: December 2019 - Volume 477 - Issue 12 - p 2674-2676
doi: 10.1097/CORR.0000000000000940
CLINICAL RESEARCH
Free

T. J. Crijns, Dell Medical School, Department of Surgery and Perioperative Care, Austin, TX, USA

T. J. Crijns MD, Dell Medical School, Department of Surgery and Perioperative Care, 1601 Trinity St, Austin, TX 78712 USA, Email: tom.crijns@austin.utexas.edu

This CORR Insights® is a commentary on the article “What are the Implications of Excessive Internet Searches for Medical Information by Orthopaedic Patients?” by Blackburn and colleagues available at: DOI: 10.1097/CORR.0000000000000888.

The author certifies that neither he, nor any members of his immediate family, have any commercial associations (such as consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

The opinions expressed are those of the writer, and do not reflect the opinion or policy of CORR® or The Association of Bone and Joint Surgeons®.

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Where Are We Now?

A large proportion of patients will search for information about their symptoms on the internet prior to seeing an orthopaedic surgeon [5]. In fact, some seem to come to the office mostly to confirm a diagnosis they’ve already made. Indeed, the advent of the internet has had a profound impact on the way we deliver care. But as strange as it sounds, this new dynamic has positive effects. Patients can read about other people’s experiences with treatments and can determine whether a treatment aligns with their values. The fact that patients are better informed also allows them to be more actively involved in their care, which may improve how they fare with treatment [2]. But internet searches for health information can also adversely affect health, as the current study demonstrates. Blackburn and colleagues [3] found that excessive internet searching by patients, defined as “cyberchondria”, explains about one-third of the variance of the relationship between intolerance of uncertainty and health anxiety. Excessive internet searches for health information have the potential to give people false information or information that inspires maladaptive coping strategies [9].

To an extent, every person is somewhat intolerant of uncertainty. Experiencing pain in the absence of a good understanding of what is causing the discomfort can be frightening. Misconceptions that people have about an illness can increase symptom intensity [6, 10]. Following a Google search of his symptoms, one of my patients thought his trapeziometacarpal joint arthritis might be a neurological issue that “will move up the arm,” and might, in turn, influence his elbow and shoulder function. After explaining that the pain was due to age-related changes of the thumb joint, his anxiety diminished, and he left the appointment feeling reassured.

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Where Do We Need To Go?

As Blackburn and colleagues [3] suggest, managing a patient with cyberchondria involves the surgeon building his or her patient’s intolerance of uncertainty and providing reassurance. To do this, surgeons should consider introducing modern communication media in order to better guide patients in the perioperative process. Adopting modern-day technology to provide our patients with access to correct and reassuring medical information through websites, message boards, text chats, and remote video visits with surgeons may enhance physician-patient communication, decrease the number of office visits for orthopaedic illnesses, and decrease the costs associated with care. This is important, since many patients do not have the time nor the financial security to visit the doctor. We must remember that clinic visits carry “hidden” costs for patients—taking time off work, paying for childcare, parking, and travel—and that these represent barriers to receiving care [1].

Technology will likely not completely replace face-to-face interaction, especially since expressing empathy is an important aspect of any treatment, and this is better achieved in person. However, text chats and remote video visits can supplement standard care. In a recent clinical trial [8], researchers observed that patients reported less pain when receiving a structured text message that expressed concern and reassurance. Video communication after surgical treatment is another example of how modern communication technology can potentially improve care. Patients commonly have questions that could be answered easily in a video conversation (“Does my wound look okay?”). Particularly in remote areas, video communication with a surgeon could help improve post-operative care. If proven effective, this can both decrease costs and increase efficiency.

Currently, the concept of introducing technology to supplement care has not yet been well-studied in orthopaedic literature. Although there is a paper that compares telemedicine to office visits [7], this type of study has yet to be validated for an orthopaedic population. Therefore, we should identify whether the present generation is interested in having online communications with their doctor, and which demographic is most interested in this transition. Presumably, as the younger generation is typically more comfortable with technology and use social media and text chat for a large part of their daily communications, they may be more at ease with having such conversations with their doctor. We will need to test whether the use of websites, text chats, and remote video visits provides equal (or increased) patient satisfaction as office visits, and we should identify the most effective medium. This may not be the case of “one size fits all”, and should be catered to specific patients and circumstances. One of the major ethical issues that we need to consider is the risk of data breach and confidentiality, as some patients may not feel comfortable providing privacy-sensitive information over the internet.

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How Do We Get There?

In order to assess whether patients are interested in implementing technology to enhance care, we could distribute cross-sectional surveys among patients visiting the office, rating their interest in different media on a numeric scale and asking when and under which circumstances they would be interested in technology-enhanced care. We can perform multivariable linear regression analyses to identify patient factors associated with patient interest. Such surveys can guide future efforts to make care more patient-centered and can help “tailor” technology-enhanced care.

We should also compare the effectiveness of different media (such as websites, telephone, and remote video) to decrease anxiety and provide reassurance. I am part of a research group that is currently designing a web-based platform to provide patients with information through video and text, allowing them to share experiences, find answers to frequently asked questions, and, if needed, talk to a physician who can answer questions about the operation or recovery process. This platform will be evaluated either through a randomized controlled trial or a stepped-wedge approach. Outcomes of interest will be patient satisfaction, physical function, pain intensity, and anxiety. With this platform we are trying to decrease the risk of data breach by providing patients with unique usernames and passwords in order to set up a secure system. Although comparatively it will be less challenging to assess the effectiveness of such interventions, it will likely take large patient numbers and a long follow-up period to address whether this is a safe approach. Data breach is unlikely to occur with a secure password-protected system, but any loss of confidential data may have a great impact on an individual patient.

After studying whether technology-enhanced care can be a safe and effective tool to provide reassurance and decrease anxiety, we could move towards addressing the costs associated with its implementation. Since not every orthopaedic clinic will have the time nor expertise to develop such platforms, companies may consider designing such websites, offering clinics their services using a subscription-based model. If a web-based platform has the potential to decrease the number of return visits or to decrease the amount of time that it takes to complete a visit, this may be a lucrative tool for such orthopaedic clinics [4]. Another important aspect is the impact that implementing the use of technology would have on out-of-pocket expenses incurred by patients, and future studies should attempt to quantify and compare those costs.

When it comes to patient care, it is tempting to default to the familiar path. The use of technology to expand the way we deliver care may seem exciting to some surgeons, while daunting to others. We should pursue future efforts to test the most effective communication media, the safety of these platforms, and the impact on healthcare costs. Patients have adapted to the modern era with the use of technology, and so should we as doctors.

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References

1. Alokozai A, Crijns TJ, Janssen SJ, Van Der Gronde B, Ring D, Sox-Harris A, Kamal RN. Cost in hand surgery: The patient perspective. J Hand Surg Am. [Published online ahead of print February 20, 2019]. DOI: 10.1016/j.jhsa.2019.01.009.
2. Andrawis J, Akhavan S, Chan V, Lehil M, Pong D, Bozic KJ. Higher preoperative patient activation associated with better patient-reported outcomes after total joint arthroplasty. Clin Orthop Relat Res. 2015;473:2688–2697.
3. Blackburn J, Fischerauer SF, Talaei-Khoei M, Chen NC, Oh LS, Vranceanu A-M. What are the implications of excessive internet searches for medical information by orthopaedic patients? Clin Orthop Relat Res. [Published online ahead of print]. DOI: 10.1097/CORR.0000000000000888.
4. Blackstone EA, Fuhr JP. Redefining health care: Creating value-based competition on results. Atl Econ J. 2007;35:491–501.
5. Dardas AZ, Stockburger C, Boone S, An T, Calfee RP. Preferences for shared decision making in older adult patients with orthopedic hand conditions. J Hand Surg Am. 2016;41:978–987.
6. Hageman MGJS, Anderson J, Blok R, Bossen JKJ, Ring D. Internet self-diagnosis in hand surgery. Hand (N. Y). 2015;10:565–569.
7. Hanson RE, Truesdell M, Stebbins GT, Weathers AL, Goetz CG. Telemedicine vs office visits in a movement disorders clinic: Comparative satisfaction of physicians and patients. Mov Disord Clin Pract. 2019;6:65–69.
8. Keith DJ, Rinchuse DJ, Kennedy M, Zullo T. Effect of text message follow-up on patient’s self-reported level of pain and anxiety. Angle Orthod. 2013;83:605–610.
9. Loeb S, Sengupta S, Butaney M, Macaluso JNJ, Czarniecki SW, Robbins R, Braithwaite RS, Gao L, Byrne N, Walter D, Langford A. Dissemination of misinformative and biased information about prostate cancer on YouTube. Eur Urol. 2019;75:564-567.
10. Vranceanu A-M, Bachoura A, Weening A, Vrahas M, Smith RM, Ring D. Psychological factors predict disability and pain intensity after skeletal trauma. J Bone Joint Surg Am. 2014;96:e20.
© 2019 by the Association of Bone and Joint Surgeons