Who Solves Your Most Urgent Medical Questions?

It was late night in the Emergency Department of Delnor Hospital in suburban Chicago. As we triaged another patient, gathering vitals, listening intently to symptoms and trying to have compassion, we were struck that the symptoms and complaints sounded remarkably similar to several other patients we had this evening. With a subtle smirk on her face, the attending physician asked the patient if he had been watching any shows on TV lately. Interestingly or perhaps tellingly, the patient stated that he had been watching a medical documentary. I caught the eye of the physician and we set to treat this disorder: hypochondriasis.

While hypochondria affects only three percent of medical patients, a more rampant problem is showing up in medical clinics around the country: self-proclaimed, internet-trained physician-patients, also known as cyberchondriacs. Do you know the type of person? He has a few symptoms that have been nagging him for a while. He has seen some TV commercials promoting various prescription medications and has heard about several natural treatments from friends. He has visited various webpages including WebMD, Wikipedia, and other pages. He has convinced himself of the correct self-diagnosis. He visits the Emergency Department at the local hospital, emphatically telling his physician what’s wrong with him and demanding a particular test and/or treatment. If we are honest, perhaps we all suffer from cyberchondriasis. We tell ourselves that we want to be an informed patient, so that we can ask good questions of our physicians. There is good information available on the internet. Are we really doing something bad? Aren’t computers going to replace physicians soon anyways? I don’t have a mental disorder, do I?

Probably not, but it may be a symptom of our societal lack of respect for the role of expertise in medicine. What is the role of the physician in medicine? What is the role of the patient in determining and promoting his or her own health? I discussed the importance of these questions with Dr. Paul Patrick, a physician at Rochester Regional Health System, and will summarize our discussions.

The diagnosis of an illness is a team effort. Each member of the team brings a particular expertise and unique perspective, whether that be concerns of the patient, the subtle observations of a triage nurse, the skill of a medical lab technician, the honed interpretations of a radiologist, the nuanced experiences of a primary care physician, the consultation of a specialist, the treatment by a physical therapist or the balanced wisdom of a pharmacist, to name a few. While many of these team members never directly interact with the patient and their participation is often not seen or consider by the patient, without the team work, a correct diagnosis and treatment plan would be impossible. How can our inexperienced use of the internet provide this kind of team effort?

Each of these practitioners brings years of training and experience to bear when they work on helping a patient. Consider the education a physician completes. During the first four years of training as an undergraduate, students learn foundational topics in chemistry, biology, physics, psychology, mathematics, statistics, anthropology and economics, in addition to classes required for a major field of study and experiences related to the medical field. Academic performance, passion for medicine and professional demeanor are used to screen over 50,000 applicants for less than 20,000 seats in 141 U.S. medical schools. Once in medical school, students spend two years learning the fields of biochemistry, genetics, molecular biology, pharmacology, anatomy, physiology, pathology, immunology, microbiology, virology, pathophysiology, and behavioral science. The next two years of medical school are clinical rotations, in which students are introduced to a variety of medical sub disciplines such as internal medicine, OB-GYN, family medicine, neurology, pediatrics, surgery and psychiatry. Even with all of this training, a student who graduates with a four-year medical degree is still not prepared enough or skilled enough to practice medicine. These eight years of training have provided a strong foundation in the science of medicine; however, it isn’t until a student completes a medical residency program, which varies from three to eight years, that a medical student becomes a board certified practicing physician. During the residency, a physician learns how to take knowledge and experiences of the last eight years and apply it to direct patient care, to develop the necessary skills such as precise surgical techniques or correct characterizations of heart palpitations using a stethoscope, and to nurture an instinct for the art of medicine. If such specialized training is necessary to become a physician, why do we think that a 10-minute web search will provide an answer to our medical problems?

Even with all of this training, an expert with experience is needed to differentiate between a vast number of underlying diseases that may cause a readily observable symptom. Take, for example, the symptom of high blood pressure. Many diseases cause high blood pressure, such as obstructive sleep apnea, kidney problems, adrenal gland tumors, thyroid problems, congenital defects, certain medications, illegal drug use and alcohol use and abuse, anxiety and even no identifiable disorder. In addition, we are beginning to understand that our personal genetics impacts how and whether our bodies will respond to specific treatments for certain symptoms. Without a thorough understanding of our age, medical history, genetics, symptomology and the plethora of various treatments, how do we expect the internet to provide an answer to our medical woes?

Beyond the challenges of practicing medicine, physicians have professional and legal responsibilities that their expertise confers. Within the medical field, Morbidity and Mortality conferences (M&Ms) provide a place where the medical community comes together as professionals to evaluate and improve medical care by learning “from medical errors, complications, and unanticipated outcomes.”¹ In addition to M&Ms, medical professionals are examined and licensed by the Federation of State Medical Boards. Finally, Tort law represents a way by which state and federal courts are able “to provide relief to injured parties for harms caused by others, to impose liability on parties responsible for the harm, and to deter others from committing harmful acts.”² The professional and legal responsibilities of a physician and all who work in the medical profession provide protection for the health of patients.

Can we expect the same responsibility from a webpage or computer app? A recent report in the Journal of the American Medical Society stated that “Reliance on these applications, which are not subject to regulatory oversight, in lieu of medical consultation, has the potential to delay the diagnosis of melanoma and to harm users.”³

How important is expertise in medicine? If a physician has spent a bare minimum of 11 years in a formal medical education program, works as a part of highly trained medical team, seeks the expertise of others who have more experience, makes decisions on highly complex information and is held responsible, both legally and professionally, for the life of a patient, then expertise is imperative in the field of medicine.

So where does that leave us as patients? What is our role in our health? Should we use the internet at all? Absolutely, but here are several tips for how to be an active participant in your own health.

• Make an appointment with your doctor. If there are symptoms that are starting to concern you, an appointment with your own physician is the best place to start. The medical team will be able to help you understand your symptoms, identify new ones, diagnose your disorder, explain the prognosis and suggest a treatment plan. If you are uncertain about your doctor’s recommendations, schedule an appointment with another physician to get a second opinion. If you involve your primary care medical team in this process, they will be more than willing to help you find another team with whom you can consult.
• Ask your doctor questions about your diagnosis and prognosis. Become an active participant in your medical treatment. If there are terms you didn’t catch or basic medical topics you didn’t understand, ask your physician for clarification. As an expert in a field, we often get comfortable with our particular way of understanding and communicating information, and this can often mean that our words are not accessible to patients and other lay audiences. By asking questions, you will break down the semantical barrier and begin to establish effective communication with your medical team.
• Learn as much as you can about your disorder. As an active participant in your own treatment, it is imperative that you learn as much as you can about your disorder, your symptoms and your treatment. You should understand your disorder well enough that you can effectively explain it to both a family member and a medical professional. This will take time, the understanding of good information, and the asking of many questions. Perhaps you could ask your physician where you might be able to find additional information about your disorder.
• Find credible information on the internet. The internet can be an excellent source of information, but it is also full of conflicting information. Good sources of information are often hosted on sites ending with .gov or .edu. MedLinePlus (medlineplus.gov) is a reputable and lay-person accessible source of medical information. According to their webpage, MedlinePlus is “produced by the National Library of Medicine, the world’s largest medical library, brings you information about diseases, conditions, and wellness issues in language you can understand. MedlinePlus offers reliable, up-to-date health information, anytime, anywhere, for free.” If you are using google to search for information, a general rule of thumb is to read at least ten different sources of information and using the provided information to construct a summative understanding of the disorder or treatment. For topics that have sources providing conflicting information, compose a series of questions that you can discuss with your physician.
• Avoid information from most webpages and TV commercials. Many webpages, with or without a .com identifier, and most TV commercials are marketing tools for a particular product or company. While some information can be gleaned from these sources, be sure to validate the provided information from other sources. Besides providing biased information, these sources of information are trying to sell you something and, therefore, should probably not be trusted.
• Talk with many people about your situation. Cyberchondria affects us all and to various degrees. The internet and personal isolation exasperates its control on our decisions and thoughts. By talking with friends, colleagues and experts, we, as patients, will be able to determine the correct path to health.

By partnering with an expert medical team, becoming an active participant in our own treatment, learning as much reputable information as possible, and by asking a lot of questions, we can seek to live a healthy life.

1. Morbidity and Mortality Conference, Grand Rounds, and the ACGME’s Core Competencies. J Gen Intern Med. 2006 November; 21(11): 1192–1194. ↩

2. Tort, Legal Information Institute, retrieved at https://www.law.cornell.edu/wex/tort, accessed August 11, 2016 ↩

3. Wolf J, Moreau J, Akilov O, et al. Diagnostic Inaccuracy of Smart Phone Applications for Melanoma Detection. JAMA dermatology. 2013;149(4):422-426. ↩