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Internet Use and the Doctor-Patient Relationship — The Good, the Bad, and the Ugly


doi: 10.1097/01.NT.0000326356.49424.d3

Dr. Castaldo is chief of the division of neurology at Lehigh Valley Hospital in Allentown, PA.

Like it or not, 80 percent of America is now online with the Internet and more than half of the users turn to the Internet first for answers about their health care. How is this affecting the doctor-patient relationship, and in particular, how does this affect you as a physician approaching a patient armed to the teeth with Internet-generated fact-sheets about their symptoms and condition?



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The good news is that patients are taking an interest in their own disorders and becoming more invested in their own care. Although public libraries have been around for a long time, we have never seen patients run to them in droves to get answers about health care the way they are currently doing on the Internet. The reasons are simplicity, convenience, and ease of access. Online information is often free and bountiful with powerful search engines capable of finding enough articles to satisfy the thirst for getting answers in plain language. Most patients realize the limitations of the Internet and want their physicians' advice on what to read and how to use it to their collective advantage. Patients understand that not everything they read on the Internet is reliable and they're willing to accept the physician's guidance about its worth.

For physicians who have access to the Web in their examination rooms, difficult questions can be answered “in real time” with a demonstration. For example, an office patient with severe headaches and an “abnormal MRI” may be incredulous when you explain that white matter abnormalities can be seen with migraine. Having already read the radiologist's differential that includes CNS Lyme disease, multiple sclerosis, and sarcoid, your patient is certain you are missing something.

So simply call up Google Scholar in the exam room, type in migraine and white matter abnormalities on MRI and, “Bam,” as Emeril Lagasse would say, with regard to your patient encounter, you've just “kicked it up a notch.” In a nanosecond, the Internet has just given you 20 articles on the subject to satisfy your patient's doubt that much is known and written about this phenomenon.

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The bad news is that the Internet as a repository for information is both a gold mine and a sewer. Powerful search engines like Yahoo and Google find the words we are looking for but can't sift out the quality of what is written, and neither can most patients who read them. Gems containing NIH guidelines for disease management may be linked to blogs filled with diatribe, personal vendettas, misinformation, and plain lies. Great articles on disease states suddenly end with a promotional attempt to sell something that doesn't work and nobody needs. Hence, a stroll down the Internet highway for information can leave you rich with pearls of wisdom you can take to the bank or with a Hefty sack of refuse you can drop off at the local dump.

The sheer volume of information available often prompts patients to try to self-diagnose by matching up their symptoms with those they've read about. Moreover, for some patients, the Internet seems to generate more questions than it answers. Internet junkies who come to their appointment armed with stacks of Internet searches and loaded for bear are unlikely to have a rewarding visit. The doctor-patient relationship shifts from a focus on what they really have, and how to get better, to what they surely don't have, and need to stop worrying about.

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The ugly news is that we as physicians can help but we generally don't. We are sophisticated enough to use the Internet for our own education but are often uninformed about what are good sites for patients. Neither do we have the time or the patience to go over what our patients have learned on the Net and help them sort out what is good and what is not. Instead, we more often steer our patients away from the Internet rather than show them how to use effective search engines to get quality answers. Sadly, at the same time many of us get poor grades for communication and time with patients, and most of us don't provide answers to questions with good hand-out materials on the disorders we are treating.

What's worse is that many physicians experience indignation over their patients' Internet searches, which they feel are a sign of distrust fracturing their relationship with them. Physicians who feel this way are more likely to become defensive with questions about what's been found on this Internet journey and in the process of losing patience, they lose patients.

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While I don't have the answer for all physicians, there are some simple suggestions on how to preserve the doctor-patient relationship when it comes to Internet-based health care.

First, accept the fact that the Internet is here to stay and that more of your patients will be relying on it for health care information even if you are an excellent doctor and communicator.

Secondly, educate your patients about good vs. poor sources of content. Consider reliable sites such as to get good reviews on many neurological and common disorders.

Finally, take their health care Internet searches seriously and don't deride or denigrate their efforts. Informed patients are better patients. The yearning to know more about their condition is natural. When what is being quoted is clearly wrong, simply point out sound principles of medicine and why what is being said sounds off-base to you.

If you adopt these strategies, you will find your patients sometimes will surprise you with what they know and can in fact teach you a thing or two. This is okay. The doctor-patient relationship includes the teacher learning from the student. Take joy in that! You will simply educate, enlighten, and encourage each other with each visit.

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•The Pew Internet and American Life Project: Reports: 2005, 2006, 2008.
    •Murray E The impact of health information on the Internet on the physician-patient relationship; patient perceptions. Arch Intern Med 2003;163:1727–1734.
      •Diaz JA. What types of Internet guidance do patients want from their physicians? J Gen Intern Med 2005;20(8):683–685.
        ©2008 American Academy of Neurology