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Exam Room

Use the Internet, but include your doctor in the mix

By Dr. Victoria McEvoy
December 15, 2008
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Ask a group of physicians whether they appreciate their patients' use of the Internet to figure out what ails them, and you may be greeted by communal eye rolling. They quickly conjure up images of article-clutching, hypochondriacal, worry warts who take up precious office time with this newfound information.

From a pediatrician's point of view, a perfect example of an emotional misuse of the Internet is some parents' belief that immunizations cause autism. These parents hold that view despite good studies, accepted by most doctors, that disprove any connection. Pediatricians spend an inordinate amount of time trying to reassure parents about the advantages of immunizations, but it is almost impossible to refute the continual stream of online invective that counters sound evidence-based data.

The Internet can also cause an undue amount of anxiety. Dr.Yehoshua Levine, a first-year resident in internal medicine at Massachusetts General Hospital, recalls a patient who was convinced of the need for a CT scan to rule out a blood clot in her leg. The patient had read that sitting for long periods could cause such a clot, or pulmonary embolus, and after sitting for several hours was convinced a test was needed, even with no symptoms whatsoever. (The test was neither needed or done.)

Even a savvy health information consumer can go astray. A physician who is the mother of one of my young patients unsettled me when she informed me that her baby had a rare sweating disease. The baby tended to sweat a lot, as many babies do, but I had never heard of such a condition. It quickly became apparent that this was a case of "Internetitis." The baby was perfectly healthy.

So, given such tales, why am I not bothered by seeing a worried parent clutching a sheaf of online printouts headed my way? Why - even on days I see 14 patients in three hours - am I not bothered by diagnosis-by-Internet?

Because, on balance, I think the Internet has helped, not hurt, the practice of medicine. Thirty years ago, medical paternalism ruled; doctor knew all. Today, my patients serve as an unofficial news service, a medical Bloomberg wire of sorts. "Dr. McEvoy, I read today that they have found traces of melamine in American-made formula. What should we do?" Or, "Our baby bottles contain Biphenol A; should we discard them?" Often these questions not only educate me, but send me scurrying to the Internet to learn more.

And the Internet offers shared resources. Recently, I was recommending the use of an inhaled steroid for a child with asthma. The mother was concerned about the potential effects of steroids on growth. I was able to quickly go to my office computer and pull up a reliable medical source about the side effects of inhaled steroids. We were then able to view and discuss the issue together.

There are times an Internet diagnosis is what brings in a patient who might have otherwise avoided the doctor's office. Indeed, sometimes it sends them flying in, says Margot Holman, a nurse practitioner at Mass General West in Waltham. The downside, of course, is that time must then be spent allaying an unnecessary worry, she says.

To the extent that there is a problem with patients using the Internet, it is what they chose to view there. Finding reliable Internet sites is the most important part of the risk/benefit equation. Their doctor can help.

There are many valuable resources to be found - for example, smoking cessation plans or good hamstring exercises for an injury. My colleague, Dr. Levine, thinks the Internet has tremendous potential in managing chronic diseases such as diabetes or congestive heart failure. There are reputable online guides for diabetics on "how to use your insulin pump" or, for asthma patients, action plans that can advise how much to boost their medication under particular circumstances.

Add to that the online conversations on blogs that speak to a defined interest group - mothers, for example - and the live chats with doctors that are linked to such sites. Such expanded conversations lead to more informed health choices - and a lessened sense of isolation for patients needing group support.

Dr. Christina Gelev, an internist at Mass General West, prefers to be the gatekeeper for online information, and directs her patients to respected sites such as the Centers for Disease Control and Prevention. Partners Healthcare purchases certain reliable Internet sites such as Up To Date for its providers, and Mass. General has developed its own website called Primary Care Operations Improvement. That site thoroughly vets all recommendations through primary care leaders, specialists, and national advisory panels, providing evidence-based guidelines for its providers.

While it was easier in some ways to dictate care to a somewhat less informed patient population, the shared decision making model that defines care today allows for information to go both ways between providers and patients. Discussions in the exam rooms need to assess the information in a way that allows an optimal outcome. A medical professional's experience and wisdom need to be added to the mix. Once it is, we all come out ahead.

Dr. Victoria Rogers McEvoy, a pediatrician, is medical director of Mass General West Medical Group and an assistant professor at Harvard Medical School.

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