The real danger is not that computers will begin to think like men, but that men will begin to think like computers.
—Sydney Harris (1917–1986), American journalist
In today’s ever-changing technological environment, we are seeing unprecedented disruptions in medicine—both positive and negative. We expected that the information and technological revolution would have an impact on the way medicine is practiced, but many did not predict that the advances in and emergence of new technologies would change the very nature of the doctor-patient relationship itself. Today, we find ourselves in the midst of a technology-fueled shift in how doctors and plastic surgeons are scrutinized, trusted, and discovered.
The culprit at the core of this revolutionary landscape is the modern search engine: limitless universes of information are at our fingertips, allowing for new and unprecedented connections and interactions. I could pick up my phone right now and find hundreds of people to copyedit, translate, illustrate, digitize, narrate, or rewrite this editorial if desired. Insofar as the search-engine culture has affected modern medicine, physicians have affectionately dubbed the mechanism and phenomenon “Dr. Google.” As a side note, that particular search engine is not solely responsible for the revolution, but it is taken to represent the “search engine” culture as a whole. (Plus, “Dr. Yahoo” and “Dr. Bing” are probably real practitioners somewhere in Texas.) Simply put, the Internet’s Dr. Google has transformed some of the universal key roles of the doctor-patient relationship, such as informing and educating patients; unfortunately, Dr. Google is also prone to misinforming patients. Search-engine culture has also revolutionized how patients find physicians—especially plastic surgeons—across a digital landscape without borders.
HOW TO BE FOUND
Powerful search engines have led to major investments in search engine optimization and social media. The need to be listed on the first page has truly transformed medicine in not only highly visible specialties such as plastic surgery, but also others, including ophthalmology and dermatology. Furthermore, the need to be the number one search result is truly affecting medicine as we know it in every specialty, including primary care, family medicine, pediatrics, and internal medicine. Building and maintaining a private practice often requires traditional advertising and marketing, but also—and increasingly more important—a digital presence and a strategy, including a Web site; digital marketing; a presence on YouTube and key social networks such as Facebook, Twitter, Instagram and LinkedIn; community networks such as RealSelf; online listings in society Web sites; and key word and search optimization.
PAGING DR. GOOGLE
In line with those practice-management efforts, the search-engine culture has transformed the referral system. This is shaping and reshaping the system as the doctor on the first page of search results may not necessarily be the best or most qualified in his or her field, but simply the one with the best search engine optimization. Referrals are no longer reliant on a specific medical society, best friend, or even family doctor. Today, when patients are trying to navigate our ever-perplexing and complicated health care system, most go online to consult Dr. Google.
Search engines have been transformative to my practice, even as an established plastic surgeon in Dallas. Based on recent intake forms and conversations, it seems that up to 60 percent of my new patients currently find me through a search engine result as a referral from my new colleague, Dr. Google.
However, this new digitized referral standard comes with a fresh set of challenges for the plastic surgeon. For example, I recently welcomed a patient from India who was distraught with her previous rhinoplasty procedures. It took several preoperative consultations to help her understand what we can and cannot do in revision surgery. I am confident that if she had been referred to me by a human doctor rather than through artificial intelligence, she would have had more realistic expectations ahead of our consultations. It goes to show that even in a digital age where patients may be delivered to your doorstep by a search engine, the doctor-patient relationship becomes even more important to creating a holistic patient experience and realistic outcomes.
A word of caution: Dr. Google may be an efficient referral service, but we cannot allow efficiency to breed complacency. If a patient is coming to see you from far away—the other side of your country or even from across the world—the appropriate criteria for accepting her or him as a patient remain the same: Are the patient’s expectations realistic, not only for what can be done, but what cannot be accomplished? Is the patient healthy? Even if Dr. Google referred someone to you, it is your responsibility to do the right thing by the patient.
HOW TO BE A PATIENT
Although Dr. Google may be a great source of referrals, his help in other areas can be as frustrating as it is amazing. First of all, people are naturally using the power of the Web to investigate their health concerns and to navigate to their pediatricians, oncologists, and other specialists such as plastic surgeons. You research and order meals, books, computers, music, plane tickets, hotel rooms, and even your socks online—so why not medical care too? Today’s patients are more empowered to be “medicine consumers,” which in and of itself is a positive. We have always promoted education among our patients, and we encourage them to do their homework in more ways than one.
I am sure other specialists agree that knowledge is power, and a well-informed patient leads to the best possible outcomes. However, when a super-powerful online search delivers reams of information on any subject and patients begin to feel more informed or better-educated than their physicians, that is a problem. The customer is always right in any good business, but medical consumers are—for the most part—not doctors, and neither is the search engine that educated them. Dr. Google does not have a medical degree. He has never seen a patient die; nor has he ever helped one be born. Nevertheless, Dr. Google has the public’s trust and wields great influence in guiding them to a local, corporeal doctor, potentially armed with as much misinformation as information.
I do not mean to sound negative toward this practice—yes, I am a doctor, but I have been a patient too. I am as guilty as I am sure you are of consulting the Internet for medical advice. If I am unwell or facing some new virus or flu or ailment, I have opened the Web browser and typed in my medical question: “Why is my left eye twitching?” or “How can I keep from catching the stomach bug my kids brought home from school?” And I know I am not alone as “the rush to define ailments online makes up a significant portion of Internet searches, with Google reporting that one in 20 of its 100 billion searches a month was for health-related information. Previous research found 35 per cent of US adults had gone online to self-diagnose a medical condition.”1 Dr. Google’s practice is convenient, it is open 24/7 every day, and it is instantaneous and free.
However, I must ask, was Dr. Google right? Did he assess your individual case and provide you with the correct diagnosis and treatment? Studies have shown that a Google search will give you the right answer to your medical questions only 40 to 60 percent of the time; one study showed that only 43.5 percent of 1300 Google results for “proper infant sleep positions” contained recommendations in line with the American Academy of Pediatricians2; another study compared Google searches to 26 cases from the New England Journal of Medicine and found that the search engine revealed the correct diagnosis 58 percent of the time.1 If I was only correct that frequently, I would no longer be a plastic surgeon or a physician! Patient education and research can be hugely beneficial for patients and their doctors, but self-diagnosis can be harmful or even dangerous—especially if it leads to ignoring or avoiding trained medical professionals.
HOW TO LIVE WITH DR. GOOGLE: GOOD, BAD, AND UGLY
So how do we move forward from here with this powerful tool that can be so useful in leading patients to find doctors, but that can also mislead patients into doubting their doctors? The key is to directly educate patients to become smarter and more savvy about their own medical problems or symptoms. Today, you must be able to truly navigate and understand your own health or you will not get great care in most cases. As powerful as the search engine is, doctors must be even stronger—educate your patients about evidence-based medicine and trustworthy sources including plasticsurgery.org, Plastic and Reconstructive Surgery, and PRS Global Open. Dr. Google is not going anywhere, so we must learn to work with him and embrace the good, change the bad, and avoid the ugly.
It is wonderful that people can access information 24/7 to find helpful tips and (sometimes) useful advice relating to general health and wellness. This encourages individuals to take an active role in improving their health. There are many credible sites related to physiotherapy, for example, that provide information regarding common types of injuries, simple stretches, or when to see a doctor or physiotherapist. An appropriate site can also serve as a nice tool for the consumer to obtain a little more background on an injury and what he or she can do to help, once the problem has been diagnosed correctly. The search engines encourage academic doctors to publish more, to educate about their field and their research online by means of social media while interacting with patients—existing and future—more routinely and publicly. This kind of practice could lead to more referrals, but more importantly, it will help inform the public.
The amount of information on the Internet about virtually any subject is amazing, but that is also the problem; the sheer volume of data is overwhelming, to say the least. It is not uncommon to see a patient after she or he has already had an appointment with Dr. Google online, with multitudes of information in hand. More often than not, much of it is either not germane to their condition or completely outdated or wrong. These individuals often sit down and tell you exactly what is wrong with them on the day of their first appointment, but following a thorough history and assessment, I have seen that Dr. Google is most often incorrect (or perhaps the patient’s interpretation of the injury and research conclusions are incorrect).
Nonmedical self-diagnosis can be dangerous in a variety of ways. Everybody is different, and each person experiences pain and injury differently. For example, one person’s “sharp stabbing pain” could be described by another as a “dull ache.” Both could have the same injury, or they could have something completely different. That is where the hands and mind of a thinking physician who can diagnose the problem is still needed—and always will be. When patients self-diagnose and self-treat, they can actually slow their healing process and even extend the length of pain and dysfunction that they experience.
There is a lot of great information on the Internet, but it has no filter—no doctor to say what is right or wrong or what is germane to you and your problem. This is the biggest opportunity presented by Dr. Google—for us living, breathing doctors to be the ultimate search-engine filter for our patients.
Simple misdiagnosis from Dr. Google is bad enough, but it can also get ugly. Patients may search a particular “diagnosis” and find page after page of downward-spiraling negative diagnoses. A common search phrase such as “low back pain” yields more than 92,500,000 results. People can find information ranging from “don’t worry about it; do nothing” to “you’ll need surgery and will likely be permanently in a wheelchair by next week.” The truth could be anywhere along this spectrum and, typically, the more you read, the more terrible the results!
As humorous as this phenomenon may seem at times, it is not too far from the truth to say that no matter what symptom you type into the search field, eventually Dr. Google will diagnose you with cancer. This causes far too much anxiety and worry. People can end up searching for days, convincing themselves of all types of terrible and scary things, when in reality, they would have far less anxiety and stress (and waste less time) if they were to simply seek the advice of a trained professional from the beginning. This is the ugly side of powerful search engines.
Possibly, consumers are becoming savvy enough to avoid this—which has been termed cyberchondria3—but what can we do as doctors to educate those who will not make an appointment to see us? We can educate, promote, publish—scream from the rooftops—but there is not much we can do to alleviate the potential pitfall of search engines. All we can do is see and treat one patient at a time.
If you have not already done so, get yourself online in some fashion or another. Promote evidence-based research and studies. Get in the search engine mix, and when Dr. Google refers someone to your office—which, believe me, he will—do your homework, take your time, and understand that you are not the first doctor your patient has consulted. Dr. Google has likely filled your patient’s head with information—some good, some bad, and some ugly. It is your duty at that point to listen to your patient, diagnose and advise, and nurture an authentic, nondigital doctor-patient relationship. Do not be afraid to learn from Dr. Google yourself, though, as the search engines can lead you, the real physician, to new techniques, evidence-based discoveries, interesting cases, and global scientific communities.
In practice, do not be intimidated by your new colleague in the cloud; after all, the one thing Dr. Google cannot do is actually practice medicine. The treatment, preoperative consultations, diagnosis, operation, follow-up—the actual care—are still your responsibility, and no one—or thing—can do it better.
Technology challenges us to assert our human values, which means that first of all, we have to figure out what they are.
—Sherry Turkle (1948-), founder, Massachusetts Institute of Technology Initiative on Technology and Self