Medicine and the Internet

A healthy relationship?
General Practitioner, Paris*

Online consultation: This Berlin-designed pacemaker relays cardiological data on a daily basis to doctors monitoring the patient via the Internet and can send an SMS text warning when a patient’s heart is in critical condition. ©Reuters/Arnd Wiegmann

The advent of the Internet has revolutionised the compilation, assessment and distribution of information relating to healthcare. This has modified the traditional doctor-patient relationship in a number of significant ways.

Fifty years ago, knowledge relating to matters of health and disease was largely the “intellectual property” of the medical profession. During consultation, doctors divulged little information to their patients and patients rarely questioned their doctors’ decisions. Doctors were supposed to “know what was best” for their patients.

Patients consulted when they were ill and doctors did not necessarily see themselves in the role of educators in health matters. This has changed, though not just because of the Internet.

The Internet appeared at a time when people were already showing a lot more interest in health matters and taking a more active role in decisions regarding their personal health. Public interest in health grew with increased general and scientific education, the advent of television and live debates on health issues, and with “doctor” columns in newspapers and magazines. Indeed, magazines appeared that were entirely devoted to health. Certain taboos fell and people felt more comfortable discussing their health with friends and acquaintances.

These days many people consult the Internet prior to visiting their doctor and often come to a consultation armed with their own putative diagnosis. Others consult the Internet after seeing their doctor to find out more about their particular problem or about the medication they have been prescribed.

Seeking information online is not an unhealthy practice, but it can result in misunderstanding and confusion, not to mention anxiety. A significant portion of medical information on the Internet is produced by universities and teaching hospitals and can be assumed to be highly reliable. However, even if the information is of high quality, it is often difficult for non-medics to distinguish likely from unlikely causes for their symptoms. Many people suspect the most serious possible disease listed as the likeliest explanation, though luckily for them they are most often mistaken.

Fortunately, most people still prefer to trust their doctor’s advice and see the Internet as more of an accessory to enrich their understanding of their condition. The traditional medical consultation provides a sense of professionalism and confidentiality, and a personal dimension that is not found by consulting the Internet.

However, there are many simple ailments that have simple solutions. For instance, urinary tract infections in women can be treated with a single dose of an antibiotic, and patients who are familiar with the symptoms of this or other benign conditions may prefer to buy their prescription medicine online without having to consult a doctor in person.

Internet sites now exist that sell medication directly to the patient without a doctor’s prescription. Responsible sites tend to cover themselves by warning their clients not to use any medicine without the prior approval of their doctor. They also state that they cannot be held responsible for deliveries being confiscated by customs if the product is being sent across borders.

Nevertheless, the sale of medication over the Internet raises many issues concerning product control and safety. It also challenges the contractual nature and legal responsibilities of the traditional doctor-patient relationship. In most countries drug companies are required to have an official product licence which determines the conditions of sale–such as prescription only versus over the counter. Government drug regulation and safety control bodies alert health authorities and doctors if a drug is found to have dangerous side effects. Doctors are also professionally and legally responsible for informing their patients on the potential adverse effects of a given treatment. Although the prescription of a drug may often seem banal or even redundant, every act of prescription engages the legal responsibility of many players.

The sale of medication over the Internet bypasses much of this control. Patients who purchase medication on the Internet may not know where or by which firm the drugs are manufactured and may lack access to legal recourse if something goes wrong.

Of course, in many countries with socialised medicine, it is not in a patient’s financial interest to buy drugs on the Internet since prescribed medicines are paid for or subsidised by the state. In the US, however, where medication costs can be very high and where many people have limited insurance, there is a real incentive to buying prescription drugs on the Internet if the price seems right.

Another complication relates to advertising. Health websites are hugely popular, and drug companies use the Internet to advertise directly to potential customers/patients. This practice has become very popular in the US but is illegal in countries such as France. Yet the global Internet escapes these national restrictions.

Internet medicine clearly appeals to particular groups of people. Many young people, particularly mobile urban professionals, are not “signed up” with a doctor and tend to use walk-in clinics or emergency services in the event of illness. Telemedicine or online consultation also attracts such people as they already spend much of their time online. Furthermore, as a result of the global nature of the Internet, people can, for a fee, consult a doctor online who is based in another country.

In this virtual world the traditional physical examination is not possible and the normal legal and professional constraints regarding confidentiality and responsibility are less readily defined. Healthcare websites are unlikely to replace the traditional office consultation, but they will draw patients who feel their doctors don’t spend enough time explaining things or who would like a second opinion. In fact, the Internet can enable patients to make more informed decisions with their doctors. In addition, patient interaction sites allow individuals to discuss their illnesses with others and to share personal experiences relating to different treatment approaches. There are even sites which allow patients to compare their experiences with different doctors in a given town or city.

Nowadays, patients are sometimes asked to choose between a number of treatment options for a given condition. The days of patients replying “you’re the doctor, I’m in your hands” are gone. The Internet can be particularly helpful in providing extensive information regarding treatment options. This in turn may help patients to feel more confident in their decisions. For example, a man with prostate cancer can be asked to choose from the following list of treatment possibilities–watchful waiting, radical surgery, external beam or internal pellet radiation, high-frequency focal ultrasound ablation therapy, proton therapy or hormone therapy–on the basis of the advantages and disadvantages of each treatment and without a most appropriate treatment being apparent at the outset.

Online consultation services have also developed for doctors. For example a general practitioner faced with interpreting a difficult electrocardiogram can now obtain an instant diagnosis from a cardiology online service by emailing a copy of the electrocardiogram. The same is true for the evaluation of X-rays, CT scans and MRIs. These types of service are particularly attractive to doctors working in remote areas.

Doctors also rely more and more on the Internet for researching topics and for personal continuing education, as well as for sharing information with each other.

All leading medical journals are now available online. Full journal access usually requires a fee which is generally lower than for a regular (hard copy) subscription, with the additional advantage of giving access to back issues.

In the “age of information” it is only natural that the Internet will play an ever more significant role in the sharing of knowledge on health issues. Doctors are realising that their patients are demanding more and more information and that they have a legal duty to inform them of the potential benefits, risks and alternatives of any given treatment. The traditional consultation provides a human dimension not available on the Internet. The more complex the problem, the greater the need for this kind of interaction becomes. While cyber-medicine has much to contribute to the development of how medicine is practised, it ought not to replace the personal dimension of the traditional consultation in which the doctor provides not only a listening ear, but also words of comfort, reassurance and hope.

*Dr Slattery’s practice is based in Paris. He has also worked as a medical doctor at the OECD. The views in this article are the author’s alone.

©OECD Observer No 268 June 2008

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