Sunday, January 17, 2016

Should Patients Consult Dr. Google?

You see your gastroenterologist with long standing stomach pain.  You have undergone a reasonable evaluation and all the endoscopic bodily invasions and imaging studies of your abdomen have been normal.  Repeated lab work provides no clue explaining your distress.   You have been twice to the emergency room and were sent home with  prescriptions that didn’t work.  You are frustrated and so is your gastro guy.  You are convinced that there is a diagnosis that has been missed and you have the Google search to prove it.

Every physician has had patients who come into the office with reams of paper from an internet search.  Usually, this approach uses a net that is just slightly over-sized for the task at hand.  It would be like using a butterfly net to catch a paramecium.

Paramecia - Use a Small Net to Catch these Critters!

Plug a few symptoms into a search engine, and then be prepared to take a year or so to review the results.  Pick a symptom, any symptom.

Whistleblower Search Suggestions
  • Causes of stomach pain
  • Causes of fatigue
  • Causes of fever
  • Causes of joint pains
  • Causes of dizziness
The above searches might crash your computer and I hope I will not be legally vulnerable should this occur.  

The internet is a powerful medical tool.  Most physicians, including me, rely upon it.  It contains an encyclopedic reference on all knowledge, but hasn’t yet been able to rival living, breathing human healers with respect to medical judgment.  Of course, artificial intelligence will surely enter the medical arena in our own lifetimes.  Technology will continue to byte into the medical profession bringing great rewards and many costs to society.  While we can argue over technology's merits and drawbacks, its victory is inevitable. 

I counsel patients daily that we physicians cannot eliminate all diagnostic doubt.  There is no CAT scan, laboratory study, physical exam or professional opinion that is 100% certain of anything.  All of us want reassurance that we are well.  Every physician has been asked throughout his career by worried patients, “are you sure I don’t have cancer?”  Seasoned physicians are very careful with our speech and choose words carefully.  We rarely speak in absolute terms.

We can’t exclude every diagnosis, but like lawyers, we strive to surpass a reasonable doubt threshold.   How much uncertainty are you willing to accept?  How much doubt will your doctor tolerate?

Of course, this varies with the circumstance.  We are likely to push harder to explain rectal bleeding and weight loss in a 60-year-old man than we would in an 18-year-old college freshman with stomach aches. 

The hypothetical patient at the beginning of this post wants more work done.  Assume the physician has already excluded 85% of the common causes of stomach pain.   How much more medical work and money is worth reach the 90% level?  95%?  If we use the patient’s Google search as a road map, then the diagnostic journey is likely to be an endless excursion into the abyss. 

When we  search Google to find a restaurant, a vacation site, a plumber or a movie review, most of us well click on a few hits, even though there may be hundreds or thousands of search results.  We can’t spend our lives swirling and spinning in a search engine, even if it means we did not hire the best plumber.  We make a reasonable effort and then we make a decision.

While I admit that the stakes are higher with one’s health than with a clogged toilet, patients need to be wary of an avalanche of medical information that spews forth unfiltered noise and static. 

I’m not suggesting that if you have an unexplained symptom that you simply accept it.  Of course, one reason your symptom might be unexplained is because a diagnosis has been missed. There is a role for a second opinion or pursuing additional medical studies.  But, not every symptom can or should be explained.  Every case is different.  Knowing when to pull the trigger or to hold your fire – the essence of medical judgment– is not something I would consult Dr. Google on.  I'd talk to a real doctor instead.

If you feel I've missed the mark on this post, go for a second opinion.  Google is just a click away.


Anonymous said...

(I haven't figured out how to post yet under my google account but name at bottom)

This is an important post. Patients have developed a desperation and a need to be one's own advocate & they do indeed turn to google for answers. I personally like it...

To start with:
1) It tells something about pts prior experience w/physicians. We can be annoyed OR choose to feel empathy. The vast majority of patients that bring in google searches are telling us that they have been let down before & that it's made them feel helpless. Part of gathering information is a means to contain anxiety & try to make THIS appt different. You can gain great trust by commenting on them bringing in info & ask them if they've had bad experience.
2) The majority of patients are nervous, dont organize records to get rid of nonsense & most are horrid historians unsure if what's important to say. So LOOK AT WHAT THEY SEARCHED FOR at home & WHY. It's critical information easily missed in a quick assessment.
3) Recognize physicians trained to know all of medicine & practice daily with an extremely wide variety of anatomy & disease. The patient whose coming into see you? especially if in pain or dealing w/chronic condition has been immersed in an intense course of their issues. *They actually may have caught something you weren't thinking of.
4) Put aside ego. Medicine is book smarts, good diagnostic work is a knowledge & ability to understand algorithms. But BEST medicine involves noticing seemingly small insignificant details & choosing to investigate. This means that even though you may have done what you feel is 85% of an evaluation, you could have chosen to place your attention in the wrong direction & you most certainly haven't considered that all the people performing those tests may have made errors.

My rule of this is:
When you know....
Let it go.
When you're not sure...
You must do more.

If you feel 100% confident that you have enough data to make a decision of no findings, let go of the search. Don't waste patients time. Give your opinion & encourage patient to consult elsewhere. Why? Because if you've not identified the problem you've already developed a bias that will prevent you from seeing one. If you have some data suggesting "something" but "not enough" Do more. You've likely missed something or someone else gave you a report with an error for which you relied.

Lastly, know your patient as a person. If they seem reasonable, intelligent & generally happy but suffering, something IS wrong, even if you stop looking, they won't. Let it go or do more.

Cheryl Prevor Psy.D

Hanna George said...
This comment has been removed by a blog administrator.
Michael Kirsch, M.D. said...

Cheryl, thank you for your thoughtful comments. I agree. Of course, the patient may have important relevant medical information that the physician was not aware of. This can never be excluded. When a patient brings internet stuff to me, I use this as a starting point of a conversation, to better understand the patient's concerns and expectations. I always respect a patient who is advocating for himself and is aiming to become more informed.

Anonymous said...

Terrific. Glad to hear although please know that I do understand & respect the frustrations that arise when patients bring in Internet data. This is where we are. Might as well figure out a way to make it constructive.


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