AMA Journal of Ethics®

Illuminating the art of medicine

Journal of Ethics Header

AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. November 2002, Volume 4, Number 11.

Medical Professionalism

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Medical Professionalism in the Digital Age

The Internet has changed the patient-physician relationship but may actually help that relationship become more equally balanced in terms of information flow.

Jeremy Spevick

The information revolution of the last decade has transformed many aspects of our lives. The Internet, e-mail, and a host of other technologies spew volumes of information with just a click of the mouse or a peek at a personal organizer. Buried in the millions upon millions of Web sites are, according to 1 search engine, approximately 19,000 sites dedicated to the dissemination of health knowledge. With so much health information so readily available, one has to wonder: How reliable is the data? Will the information exchanged by e-mail remain confidential? What policies are needed to ensure user safety?

The information revolution has not only offered us a wealth of medical information, but it has also initiated changes in the patient-physician relationship and in the notion of what it means to be a medical professional. Today, many physicians are reluctant about introducing new forms of connection into medicine. Of particular concern is many patients' desires to contact their doctors by e-mail. While this would be a great convenience to patients seeking routine requests such as appointments or test results, many doctors worry that they will be bombarded by patients around the clock with incessant and often unreasonable requests. Other doctors fear that patients may rely on e-mail in situations that warrant an immediate response or even a visit to the ER or doctor's office. Some have begun to add disclaimers to their own emails, informing patients not to rely on e-mail communications if their message is urgent or sensitive.

Ironically, similar reservations were expressed upon the introduction of the telephone in the late 19th century. Many doctors, "believed that practicing medicine over the telephone compromised the moral integrity of the profession" [1]. Doctors were able to adjust to the telephone by using answering machines and hiring secretaries. In the recent issue of the Milbank Quarterly, physician David Blumenthal argues that doctors will be able to make the necessary changes to adapt to e-mail. He goes on to say that, "if physicians are willing to accept some basic changes in their training, attitudes, and practices," then the information revolution will create opportunities to not only preserve professionalism, but "enhance it" [2].

The concept of professionalism is something that most people are aware of, but it is difficult to define. Paul Starr identifies 3 attributes of professionalism in The Social Transformation of American Medicine [3]. The first is cognitive knowledge, the scientific knowledge and technical dexterity doctors possess that enables them to diagnose and treat patients. Secondly, there is a moral component of professionalism, which requires that the needs of patients come before the needs of the doctor. Finally there is a collegial responsibility for doctors to monitor one another and to ensure competence in the profession. Collegial monitoring is peer-review and is necessary because the layperson does not know enough to evaluate the medical profession accurately.

Traditionally, the relationship between the physician and the patient was asymmetrical; that is to say, doctors had significantly more information about medical conditions than their patients. This unequal distribution of knowledge makes trust an integral part of a successful patient-doctor relationship. Blumenthal notes that the medical profession's claim has been to offer "something that society cannot find elsewhere" [4]. The availability of health information on the Internet severely weakens this claim by giving patients alternative sources for health advice. The question now is whether the information revolution will provide the layperson with enough knowledge to make decisions that were previously reserved for doctors.

Blumenthal talks about the information revolution as a series of possibilities for increased connectivity between members of the health care system. The various connections could include superior communication between individual patients, between patients and their doctors, and among doctors, patients, and health care organizations. This increased connectivity in the health care system will affect each of the 3 attributes that define professionalism.

Patients with access to the Internet can search the Web for vast amounts of information on a particular condition, whether it be through Web sites, or chatrooms with other patients. Before visiting the doctor, a patient may have looked up possible diagnoses for his or her symptoms and may be aware of different treatment options. By assuming part of the physician's role, the patient effectively reduces the knowledge asymmetry in the patient-doctor relationship.

The multi-way communications may strengthen patient appreciation for the physician's moral commitment to putting patients first. Among the welter of patient-to-patient communication and of advertising on the Web and elsewhere, patients will find that it is only in the personal relation with their own physicians that the information becomes specific to them and their needs. This can occur only within the patient-physician relationship.

With increased connectivity, patients will likely enter into the current system of self-governance that ensures competence in the medical profession. They will be able to contact one another more easily to compare and evaluate their visits to a particular doctor. Perhaps more significantly, Web sites already exist which focus on evaluating specific hospitals on specific procedures, such as coronary bypass surgery, or back and neck surgery. See for example http://www.Healthgrades.com.

Blumenthal contends that in the new information age physicians must recognize a new role, that of a consultant. Patients will still need doctors to prescribe medications and to perform physical exams and diagnostic and therapeutic procedures. Patients, bombarded by the media with health information, will depend on doctors, with years of rigorous training, to transform health data into medical knowledge and appropriate treatment decisions. Patients will begin to look at doctors more as partners with whom they can consult to make informed decisions under uncertain circumstances. As a physician who uses the Internet, Blumenthal believes that patients will not doubt their doctor's knowledge if the doctor consults the Web during a visit; in fact he believes that most patients will expect this from their doctors. And there are still millions in the country who do not have access to the Internet. For these people, the doctor's role will remain unchanged.

If history is any indication, a doctor's professional status is rooted in something deeper than knowledge itself. In the 14th century doctors had little valid knowledge, yet they were still highly regarded and "compensated generously" [5]. Blumenthal discusses the possibility of humans having a "primal urge to project onto some group the power to heal" [6]. The argument is that people desire a healing class that can offer hope in times of suffering. This desire goes beyond the knowledge-based asymmetry that distinguishes medicine today.

There is no way to predict the precise way that the information revolution will continue to unfold. More knowledgeable patients should not decrease the importance of the medical profession, but rather force the profession to adapt to a new role. Doctors will still be needed to perform medical procedures, but now patients will ask medical professionals to help them sort through the vast amount of data available on the Internet. Perhaps the information revolution will bring us closer to Robert Veatch's collegial model of the patient-physician relationship, wherein doctors and patients work together to reach a common goal in a relationship that seeks input from both the doctor and the patient [7]. With the Internet's help, patients may become more equal partners with their physicians in caring for their health.



References

  1. Spielberg AR. On call and online. JAMA. 1998;280:1354.
  2. Blumenthal D. Doctors in a wired world. The Milbank Quarterly. 2002;80:527.
  3. Starr P. The Social Transformation of American Medicine. New York: Basic Books;1982.
  4. Blumenthal D. Doctors in a wired world. The Milbank Quarterly. 2002;80:527.
  5. Blumenthal. ,528.
  6. Blumenthal., 529.
  7. Veatch RM. The patient-physician relation: The patient as partner, part 2. In: Smith DH, Veatch RM, eds. Medical Ethics Series. Bloomington, IN: Indiana University Press; 1991.

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