Mrs S, a 50-year-old receptionist, has had rheumatoid arthritis for 10 years. She visits her GP, Dr F, to obtain a drug that she has read about on the internet. Dr F declines to prescribe the drug because he does not feel it is appropriate for her.
Mrs S becomes angry and blames the cost implications, pressing Dr F to prescribe the drug, but he still refuses and she lodges a complaint.
This scenario reflects a modern phenomenon, the rise of the 'activated patient'. The web contains a broad spectrum of information. At one end, moderated, reputable medical information can be found, while at the other, there are uncontrolled sites of a commercial, personal or ideological disposition. The challenge for doctors is to help patients discriminate between reliable and unreliable sources.
The patient surfer
As the number of people accessing the internet grows, so does the volume of patients accessing health information and medical advice. There are two elements that doctors should be aware of with regard to the patient surfer:
- Increased patient awareness (drawing wrong conclusions, conflicting advice, anxiety).
- Self-diagnosis (drugs bought via the internet, pressure to prescribe, inaccurate information).
Rather than offering patients information, the internet can often create anxiety and unrealistic ideas about treatment, a condition that has been dubbed 'cyberchondria'.
The Medical Protection Society (MPS) has surveyed UK doctors from all specialties to gauge their views about the internet. The survey results showed that most doctors (82 per cent) agreed or strongly agreed that the internet causes patients undue anxiety. More than half (57 per cent) agreed that a patient's research could result in disagreements between doctor and patient.
GPs should not feel pressured by the information brought to them by patients, because much of it has been misinterpreted. GPs can safeguard their practice by accepting the limits of their competence and learning how to manage these expectations.
One of the main dangers of the internet is patients who self-diagnose their ailments incorrectly and who lack awareness of the complications of drugs and their interactions. There is a tendency for patients to speed read articles they find online, which is more likely to result in misunderstandings.
Ask patients if they are taking any medication that you do not know about before prescribing for them. By exploring their concerns, you may prevent a patient from ordering potentially harmful medication via the internet.
The MHRA strongly advises patients to consult a healthcare professional for a face-to-face consultation so that the right diagnosis is made. GPs can monitor conditions and advise on better or new treatments and technologies.
In some circumstances, online advice can be essential for patients, particularly those who live in remote locations.
The GMC's Good Medical Practice in Prescribing Medicines (2008), which is currently under review, states that doctors should only prescribe online if they can do so safely. Appropriate dialogue should:
- Establish the patient's current medical condition and history.
- Identify the cause.
- Justify prescribing.
- Discuss other treatments.
- Ensure medicines are not contraindicated.
- Create an accurate medical note for records.
Doctors who are not providing continuing care, or have no access to patients' records, must:
- Explain the processes involved in remote consultations and provide their name and GMC number.
- Use a questionnaire to obtain sufficient information.
- Monitor the patient's progress and review the diagnosis.
- Inform the patient's GP.
GPs need to make patients aware of the limitations of email consultations. The risk of emailing patients lies in the perception that there is the same doctor/patient relationship as there is in a face-to-face consultation. Email consultations, however, do not occur in real time.
There is potential for medical error because incomplete information may be received and shared.
GPs can avoid this by asking a range of background questions, to make sure they understand the patient's needs.
All information will need to be directly requested from the patient, so GPs will need to be more assiduous than merely asking, 'Are you taking anything else?'. GPs will need to ask specific questions about medication patients are taking and if they have other serious illnesses.
If you cannot make an accurate diagnosis by email, ask the patient to come to see you.
Do not ...
Doctors may wish to opt out of the world of online medicine, but ultimately may not have a choice, as patients bring their internet-sourced demands with them to the consulting room.
The biggest challenge will be teaching people how to be evidence-based patients.
- Dr Clements is the head of medical services in Leeds and a medico-legal adviser; Sara Williams is a senior writer and editor at MPS
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