Wednesday, May 26, 2010

Internet Doctorin'

I used to think it was hard to get into medical school. I’ll never know if it really is, because I got in as an accident of fate. (More on that another day…if I’m going to be blogging every day, I can’t blow all my stories at once. Got to have a few for backup on those days when writing takes a back seat to…well, almost anything.) But I bring this up because it turns out that it’s a lot easier to get into medical school now than it ever was before. It’s not the need to turn out more primary care physicians that have led academia to swing open their gates, nor a sudden demand on the part of college students to enter a career where you can work harder and make less money than ever before while always at risk of being sued. (Who wouldn’t find that attractive?) It’s because the internet now allows everyone to go to medical school. Armed with a fresh diploma from the Wikipedia College of Doctorin’, patients are now just as qualified as physicians to tell us what’s wrong with them, what tests we need to get, and how they should be treated.

Let me say up front that I really have no problem with informed patients. They actually make life easier, especially when they understand their own disease process and recognize what we can and can’t do for them. They make better decisions regarding their care, and it’s truly more fun to work with a partner in the process. But I’ve come to believe that the internet is often a rotten source of health care information because it’s voluminous, unfiltered, and unchecked.

I’ll give you an example of what I mean from within the House of Medicine itself. Many hospitals have protocols that require nursing staff to contact the Regional Poison Control Center to notify them of any overdose patients you’ve received. There are a couple of reasons for doing so. One is medicolegal, to say that we called if something goes wrong. The second (and I suspect most valid) reason is that the more calls the Poison Control Center receives, the more they can justify their continued funding. Enhancing clinical care is not really one of the reasons to call, because what most often happens is you get a nurse or a trained technician who simply reads off or faxes you a list of every single adverse effect that has ever been reported to occur with that drug, in no particular order, and suggests a plan of care that is often impractical at best. You get too much unsorted information that may or may not actually be relevant to the case at hand.

So here’s what really happens with most overdoses. It’s surprisingly easy, and surprisingly generic. You support the patient’s vital signs by managing their respirations and blood pressure. If they have ingested any one of the handful of medications that has a specific antidote (there are less than ten you actually use) and their condition is life-threatening, you give it. You have them drink a solution of activated charcoal to bind up any spare medications floating around the gastrointestinal tract. And then you wait four to six hours, until the peak effect of the medication has likely passed by, and if they’re doing fine you send them wherever they need to go. If not, they’re admitted. Pretty easy, which is why I never really mind taking care of them. It’s a lot more straightforward than people who claim to be “weak and dizzy” (the two words we hate more than anything in the ED, even more than the phrase “accreditation site visit”). Plus, there’s usually a pretty good story that goes along with that, and if Lady Luck is on your side you can keep a bed occupied for up to eight hours by the time the psychiatric staff gets a chance to look at the patient, insuring that you won’t have to see an extra patient any time soon.

Looking for health care information on the internet is like getting it from Poison Control. There are huge volumes of information, all of it unfiltered and unweighted, and most of it without oversight. (This is why I have less of a problem with pharmaceutical ads on television than I do the internet. At least the FDA tries to regulate the content of the former, while anyone can say anything in cyberspace.) And if you look at the distribution of the information out there, it’s slanted away from science-based knowledge and much more towards hype.

Let me give you two examples of what I mean. The first is from an article entitled “UK Bans Doctor Who Linked Autism to MMR Vaccine” by Marrecca Fiore (AOL Health, May 24, 2010). It concerns Dr. Richard Wakefield, an English physician who described an association between vaccines and autism, and whose work has now been considered as invalid and unethical. (I’ve addressed this issue in a previous blog; in brief, I don’t think a firm link between the two has been established, and the risks to the population as a whole of withholding vaccination clearly outweighs any unproven ideas.) As you’d surmise from the title of the article, Dr. Wakefield has now lost his medical license in his home country. But to read the article, there are 7 paragraphs of quotes from Wakefield and his supporters, and one from an actual scientist. There is also a video clip of Dr. Wakefield defending himself, but none of anyone representing the scientific community. The comments that follow the article are bitter, vituperative, and focused on destroying vaccination programming; woe to the one or two brave souls who comment that Dr. Wakefield is in the wrong (as he clearly is…yep, I’m taking sides.) This is supposedly an impartial “news” source. So what’s the message here?

It’s even worse if you do an internet search. There is an alleged condition called Morgellon’s Disease, in which people claim to have crawling and burning sensations in the skin, persistent sores that don’t heal, and small fibers emerging from some of these lesions. I say ‘alleged” condition because nobody’s sure if it exists. Promoted by media coverage, the CDC is investigating the problem, but most dermatologists think this “disease” is really a type of delusional parasitosis (a mistaken thought that there are parasites within the skin). But if you look at the web, there is no question that this is a horrible, debilitating, epidemic disease. Of the first ten hits that came up when I did a web search, one was a Wikipedia article (which was actually reasonable) and one was a microbiology site. The other eight were all sites convinced that the syndrome exits, with quotations such as:

“Morgellons is an unexplained and debilitating condition that has emerged as a public health concern…”

“Morgellons Syndrome. A Horrifying and Fascinating Skin Disease is affecting thousands of people in the Bay Area, along the Gulf Coast, Florida…”

“Morgellons disease, or Morgellons syndrome, is a new and frightening disease that is yet to be recognised by medical science…”

“For years, doctors denied the suffering of skin parasite victims. The days of Morgellon's Syndrome denial are over. Join us and learn more.”

There’s no reason to assume the other web pages (there are 86,900 results) are any different. So what’s a patient to believe, and how does a doctor explain, let alone fight, that number?

When patients bring up information they’ve read on the internet, I can sometimes defuse the issue. I can explain that while it’s good to use the internet as a resource, you’ve got to keep in mind that it doesn’t reflect the real world or their case in particular. I’m often able to correlate their information with my clinical findings, and to direct them to more appropriate websites. But still, it’s a conversation I wish I didn’t need to have. And it’s very frustrating when the patient says, as they often do, “The website told me you would say that. You doctors are all alike. It’s because you get paid off to say stuff like that.”

Where do you go from there? You want to ask the patient if they knew they were going to get an answer that they didn’t want, why were they here in the first place?

Is it because they couldn’t find a licensed practitioner from the Wikipedia College of Doctorin’?

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