Dr Google - a patient opinion (revisited)

Why do patients consult Dr Google?  It may be that they simply want to check out (self-perceived) minor symptoms so as not to bother their GP - or conversely checking those same minor symptoms as they misinterpret same as the first sign of a major illness; they may be in the midst of investigations and feel left out of the information loop, vulnerable and frightened; they may have a diagnosed condition and wish to educate themselves in and understand how their illness will impact on their lives and thereby develop coping strategies.

Disregarding the 'worried well' and those who seek antibiotic therapy for the slightest sniffle - patients (I am thinking of me here) seek GP advice in an effort to provide an answer to their presenting symptoms.  Often doctors are able to diagnose immediately, prescribe medication if required and the patient, reassured, will go on their way.

Sometimes a diagnosis may take a little longer and the patient will receive the full input of their doctors skills and appropriate care during and up to the time the diagnosis is finally made

At times, the illness may not have evolved into something recognisable and a 'wait and see' period may be necessary and perhaps following this, the patient will be referred to a specialist - at times the referral may be immediate if red flag signs/symptoms are apparent..  This is the time when patients feel most vulnerable as they lack an answer, at times, they are fed little information as it would be inappropriate for a GP to state positively "I think you have this" without medical evidence; whatever reassurance is given at this time is meaningless (to them).

Patients need a name to give to their illness - whatever it might be - as they need an end to uncertainty; I quote Balint here:  "Perhaps this case may also help us to understand why patients have a great need to be told what their illness is, what fears may be rampant in them if no name is given, and, last but not least, what the inevitable implications of any diagnosis, however innocent-looking, may be."

Patients who are referred to secondary care, that of a consultant specialist, often find themselves going to and fro between specialist and specialist and their GP.  Speaking from experience this is a terrible time where the patient receives very little information and in a sense, is on the outside looking in.  I think that doctors tend to forget that patients exist (and think) outside of the time of the consultation and feel abandoned by the profession whose help they are seeking.

This is The Collusion of Anonymity where no physician has full responsibility for the patients as he sees doctor after doctor (all offering their own differing opinions) and the patient is left in a no-mans land; respectfully I quote Balint again:  "Nobody mentioned, and perhaps nobody was even interested in, what happened inside the patient while he was being whisked from doctor to doctor....."

What ever the original driver, however simple or complicated the presenting diagnosed or undiagnosed illness, patients consult Dr. Google purely and simply because they need an answer.

Doctors and Dr Google

As I am not a doctor, I am not qualified to offer a doctors point of view and therefore what follows is based on information gleaned from research or personal observations.  Please, if I am totally wrong docs - tell me as I live to learn.

The doctor-patient relationship is an unequal one and must always be so.  Doctors  have a vast knowledge base regarding medicine and we patients have very little.  A patient arrives voluntary and submits to medical attention.  There has to be an element of trust in our doctors' skills and ability to provide the answer we are seeking.  The relationship is not always therapeutic in that both doctors and patients personalities are sometimes opposed.  However, even in this case, we attend our doctor and provide him with clues in the expectation that he can provide us with a name for our illness.  At times we may not accept a given diagnosis for a variety of reasons.

Doctors at times feel threatened and insulted by the arrival of Dr Google - the unwanted and uninvited interloper who upsets the dynamics of the doctor-patient relationship.  The doctor may also be fearful for the mental health of his patient who might have read something on the Internet that is pure nonsense - and there is a lot of it out there - that might instill in them fear or provide them with false hope.

Some doctors welcome their patients interest in their condition - whether diagnosed or not - and see it as a positive step in the doctor-patient relationship.

Doctors visit Dr Google - but very differently from the average patient - recognising where quality lies in peer reviewed articles, professional medical sites and a multitude of other sources.  It is estimated that there are 3 billion Internet medical articles.

It is true that Dr Google is not going to go away and doctors will have to accept this.  It is also true that patients remember perhaps a half of what doctors tell them, so will seek information elsewhere.

Is Dr Google a friend or foe?

He can be either.  A recent survey by BUPA covering 12,000 people around the world found that globally, 47% of respondents used the net to self-diagnose and 68% sought information on a medicine.

The problem lies with the quality of information looked at and its potential to make a person imagine the worst for minor symptoms or ignore symptoms that would indicate a serious condition.  The term cyberchondria was coined in the year 2000 to describe how patients' symptoms escalate as they self-diagnose.  It has to be remembered that a search engine cannot diagnose - it needs a person, or more accurately a doctor to make the final diagnosis.

Nevertheless, Dr Google can provide a wealth of quality information for a patient if they know where to look, and can also 'talk and give time' to patients about their presenting illness in a way that doctors cannot do because of time constraints.  Doctors and patients must reach a happy medium.  Perhaps doctors could prescribe helpful sites?

Dr Googles BIG limitations

Dr Google can only offer what has been fed to him and as said, the potential to mis-inform and instill fear in the heart of the reader is dependent on the quality of the information provided, and the readers ability to interpret what is said and to sift out the dross.

I decided to 'consult' Dr Google myself as an exercise to discover possible pitfalls.  I keyed in just two words (the site on the body and the presenting symptom) of a benign condition and visited the first two pages.   I did not enter the 'question' sites - just those that appeared to be true medical sites - just three in total.  The first offered a doctor to patient differential diagnosis and I was able to locate my 'problem.'  The remaining two offered doctor to doctor differential diagnosis and these confirmed my 'problem.'

I then transposed the two words and inserted 'on' in the middle and was met with totally different results.  Of the three quality sites (including Medline) I visited, two suggested quite strongly that I had cancer and Medline inferred in the first sentence that I had.   I don't!

I then visited http://ffff.at/dr-google/ (this will not provide a direct link so you must google it and click on) - which I presume is an official google site?  I keyed in the same three words and clicked 'I'm Feeling Icky' and the one result was cancer - no ifs or buts!   I then clicked 'Second Opinions' and was then redirected to the pages I had originally consulted.

I then read this article on Cyberchondria: The perils of Internet self-diagnosis (interesting read) and then visited the 'trusted' medical sites listed at the end keying in the same three words.  Medhunt had the dross Wrongdiagnosis as the first entry, followed by three identical entries of the first site I had visited on my search - the doctor to patient differential diagnosis - and the rest were related to plastic surgery; NHS Direct, although offering the body site did not offer the symptom and was therefore useless;  Patient Line gave the best results and was quite informative and finally WebMD offered a mish-mash of irrelevant and unrelated results to the question posed.

So beware patients - Dr Google, if you look in the right places might be helpful if you understand and are able to discriminate in what you are reading - or he may scare the hell out of you.  That said - I have used him and not found him wanting - but it is about recognising quality sites.

If you should find something out there, don't take the printouts to the doctor - but inform him what you have found.  If he is a good doctor he will ask you to bring them to the next appointment.  Respect him (or her) and he will respect you.

Michael Balint: 'The Doctor, His Patient and the Illness'  (Churchill Livingstone)

Anna :o]

Heartsink Doctors and Dr Google - a Patient Opinion

I am grateful to Dr Philyerboots for his post on "Heartsink" patients, for it opened my eyes.  I think most patients - if they know the term exists - regard heartsinks as the moaning hypochondriacs who plague a GP practice on a regular basis - I did, that is, think that, not plague a doctor!

But this is not only the case; a heartsink is also "...the most common one is of patients under my care who steadily deteriorate despite all that I and modern medicine can do", it is the "very few I object to on a personal level", it is "the patient that has consulted Dr Google before coming", it is "those who ask the same question, again and again an again.  It is as if they ask the question often enough that I will tell them that I have a miracle cure", it is "the insane", it is those "who seemingly just want a chat" or those "who have complaints about BGH, or about my colleagues or their GP..."

I think that most of us, as patients, regard doctors as super-human who are void of negative emotions.  If they are cool/cold with us - it offends us - it certainly offends me!  We are the patient - they are the doctor.  Forget the heartsink patient who is the eternal hypochondriac and let us think of ordinary Joe who visits the surgery with perhaps, a minor complaint.  He has a minor problem which he wants nipped in the bud.

Say Joe has not visited the surgery for three years - he is a seldom attendee - and he has a wart on the end of his nose and wants it removed.  Request over - he is met with a barrage of questions required to meet the QOF.  He is asked if he smokes - yes he does - but he thinks what the hell has this to do with the wart on my nose? and internally, becomes angry.  He then has his BP taken and it shows he is hypertensive (white coat and anger) and he is asked to return and have his BP rechecked and his bloods ta\ken.  He leaves the surgery in a state of angst.

After three visits to check his (white coat) hypertension he is commenced on meds and also meds for high (who says - Big Pharma?) cholesterol, and suffers side effects which are viewed as another problem and he is prescribed meds for this and that, and this no meds man suddenly takes home a carrier bag full of drugs from the chemist all due to the wart on the end of his nose.

But this entire aside, what if the patient is Jessie who has multiple comorbidities?  She likes Dr Smith for he is kind to her and treats her with compassion.  She needs to see a doctor, but the only doctor available is Dr Jones.  Nobody, but nobody wants to see Dr Jones, for he makes a patients heart sink.  Dr Jones meets the definition of a total w*nker!

Yes!  There are doctors that make a patients heart sink!  Whether in a GP or hospital setting,  patients leave thinking what the hell did I do to deserve to be treated like that!?

Then there is Janet who is also a seldom attendee who visits her doctor as she knows that something is not right.  She doesn't know what it is as she is not a doctor.  She has all the usual investigations and nil is found.  She is told she is anxious - for after all she is a woman - and is left on the outside looking in.  But she knows that something is wrong and consults Dr Google - for that is all she has left.  He does not listen - but he talks to her in the written word.  She is not stupid and discounts all that does not apply to her.  But then, she finds her illusive dx and consults her GP with a printout - bad move - for a sure sign of hypochondria!  She also takes a list of symptoms as NHS sites suggest that she should - but GPs and hospital docs hate lists and must take control of same and a list is another sure sign of hypochondria!  But months down the line - after much professional abuse (?) by doctors - she is proved right.

I need two pairs of hands to count the number of close family or friends who after routine investigations have been told there is nothing wrong with them, only to discover later down the line that there is - at times with terminal consequences!

Doctors are not perfect and neither are patients.  We need to meet in the middle!

Rant over!   I love doctors really!

Anna o]