Personal Narrative
Mar 2001
"Hey doc, my son got this stuff off the Internet. I was looking at it and wondering, how come I'm not taking this medicine?"
I smile, taking the printed pages from Mr. S, then look down to see what he's found. Quickly scanning this printout from an arthritis support group Web site, I see a discussion of chondroitin and glucosamine for osteoarthritis. My mind races; do these substances work? I recall a recent Grand Rounds on osteoarthritis, the speaker mentioning the data suggesting a possible benefit, and breathe a mental sigh of relief. "Mr. S," I say, "there have been some studies on these two supplements for patients like you, and some show that they do help. But not all experts agree, and we don't know some of the possible harms. "Also," I continue, "it's hard to know if the stuff you buy is the right potency, since these are not regulated by the Food and Drug Administration."
Another crisis averted. With each passing day, my anxiety about the next Internet printout rises. Next time, it may be a treatment that I know nothing about. How soon will my patients know more than I do? What will they think if I don't know the latest development? Is the information they read even accurate?
As the number of Internet-based resources for medical information rises, more patients enter the clinical encounter with unprecedented amounts of information. Ranging from diagnoses of illnesses to new and untested treatments, this information challenges the physicians' traditional role of holder of all medical knowledge, and thereby potentially undermines an age-old source of medical authority. At the same time, when patients do obtain, read, and process accurate medical information in advance of the clinical encounter, it can enhance their ability to understand the clinical decisions that lie ahead, potentially solidifying their role in medical decision making and strengthening the patient-physician relationship.
Physicians can easily feel threatened by these developments. Our own medical knowledge and judgment are called into question. We may feel defensive, needing to justify our reliance on more accepted approaches to diagnosis and treatment. Our skepticism about new and untested clinical developments is questioned. Yet this need not be so. Physicians can and should use their patients' interest in medical information as an asset, allowing discussion of the sources of this information to increase the patient's knowledge and forging a stronger therapeutic alliance.
How can physicians encourage the positive side of increased patient access to information? It is important to see patient interest in learning as an invitation to discuss their conditions. Try to find parallels in the medical diagnosis that mirror the patient's own interpretation of his or her illness. It is important to make the distinction between the patient's interpretation of the illness and our diagnosis of disease and, at the same time, to understand the relationship between them. Our clinical diagnoses are translations of the patient's real-life experience, and in respecting the patient's version as legitimate, we foster the therapeutic relationship.
Similarly, by demonstrating a respectful rather than scoffing attitude toward the patient's sources, one can convert a potentially adversarial discussion into a more collegial one. When patients share their sources of information, they are also demonstrating trust in us and giving us insight into their thinking. What do they really think of our diagnoses and treatment recommendations? These are questions for which we need answers; they hold the key to fostering patient adherence to treatment regimens. We can make the patient feel comfortable by acknowledging that they are not taking their medications, or that they are taking alternative treatments outside of our prescribed plan. These situations also offer an opportunity to give patients advice about finding reputable sources of medical information. We can ask them about their sources, and along the way suggest sources we know to be providers of good quality information.
What should we do if the patient challenges our advice? Occasionally, patients will hold strong views on medical diagnosis or treatment that are diametrically opposed to the physicians. This can create conflict and tension. The ethical dilemma for the physician intensifies when the basis for the patient's views seems to be inaccurate information from outside sources. Such situations are not really new, but because the Internet makes such information sources increasingly ubiquitous - not to mention unregulated and potentially misleading - the physician may see strong disagreement as a way of meeting an ethical obligation to prevent harm. These situations underscore the importance of maintaining trust and open communication, even in the face of disagreement. Any chance that we might have to help patients see that their strong views could turn out to be harmful rests on our ability to foster trust. Patients must feel confident that we know what we're talking about, can acknowledge our own uncertainty, and are acting in their interest rather than merely upholding medical authority.
Furthermore, as patients become more knowledgeable, it becomes ever important for physicians to remain up-to-date on medical developments. Critically reading the biomedical literature, attending continuing medical education conferences, and conferring with colleagues are all parts of the life-long learning, a core part of our obligation to maintain professional excellence.
Overall, then, Mr. S.'s question had a positive effect. It caused me to think more carefully about how he processes medical information, and to understand the influences, including, very obviously, the opinions of his son, on his views about his illness. I also was reminded of the importance of keeping myself up-to-date (boy, was I glad I had attended Grand Rounds that week). Finally, I was grateful that Mr. S. thought enough of our relationship that he was willing to call me "on the carpet" for what he thought might be an omission in his medical treatment, for this afforded me the opportunity to address his concern, and in so doing lay another brick in the foundation of our therapeutic alliance.
