The Challenge of Doctor-Patient Relations in the Internet Age By Doris Iarovici, M.D.


The Challenge of Doctor-Patient Relations in the Internet Age By Doris Iarovici, M.D.

The New York Times, March 1, 2018

“Let me do some research, and I’ll get back to you,” my patient said.

My patient, a 19-year-old undergraduate, had already taken time off from school because of her anxiety. I was her psychiatrist, with over two decades of experience treating university students, and had just explained my diagnostic impressions based on a lengthy evaluation. I’d recommended that she try a medicine I expected would help. I’d also laid out the risks and benefits of other treatment options.

“Do you have additional questions I can answer?” I asked. I wanted to let her know that’s why I was there, to cull the research, to help make sense of it.

“No, I like to go online and look for myself,” she said.

More and more, I see students turning away from the expertise that a live person can offer and instead turning to the vast and somehow more objective-seeming “expertise” of the digital world.

In an age when journalism we don’t like can be dismissed as “fake news,” suggesting that the information we do like is most credible, regardless of its source, it’s not hard to understand why young people do this. The medical profession itself, under managed care, has played a role as well, providing less time for doctor-patient interactions and undermining the chances that a personal relationship and trust can develop. Under the guise of efficiency, medical test results are now often released directly to patients, sometimes before or even without the benefit of any interpretation.

But there’s danger in trusting data over people, as there is in thinking the expertise of all people is equivalent. When it comes to health, digital natives may not be learning how to navigate effectively. And the consequences could be harmful.

The availability of health data on the internet has its benefits. Online, for example, we can find explanations and solutions for symptoms we might be too embarrassed, or afraid, to discuss with another person, in person. Or, for life-threatening diseases, we can locate clinical trials our doctors may not be aware of.

However, there’s also a lot of misleading information, and information that’s flat out untrue. The internet is full of people selling things — supplements, treatment regimens that have not been rigorously tested, even prescription medications — and making false promises that have not been scrutinized by regulatory agencies. Sometimes, as in the case of “pro-ana” websites that promote “an anorexic diet” for “aggressive” weight loss, the information can encourage life-threatening behavior.

Many smart, well-educated people think they are immune from the risks of misinformation. But they underestimate how the experience of illness can affect judgment. Emotional suffering, in particular, can be profoundly isolating, shaking our sense of self to its core. Having other human beings to walk the path with us — doctors and other licensed clinicians who relay information in the context of a caring relationship — is part of what leads to better outcomes.

Years ago, when we discussed paternalism versus patient autonomy in my medical school ethics class, I came down strongly in favor of autonomy. Who but the patient could best decide what was right for him or her? But years of clinical — and personal — experience have taught me that information in and of itself is insufficient. Judgment is also indispensable, especially in complex situations, and the capacity for good judgment rests within people, not data sets.

I’ve had patients refuse antidepressants I know would be likely to help, because they’ve read online that they will cause weight gain, even when I explain it’s highly unlikely. I’ve had patients insist they need a stimulant medication because they fit a brief symptom checklist for A.D.H.D., balking at my assessment that their substance use or anxiety may better account for their problems. I had a student forgo psychiatric treatment after

reading online that a gluten allergy accounted for his symptoms — and his negative gluten allergy test results could not be trusted.

I go online for many things: to choose rentals when I travel, or to research consumer goods before I buy them.

When I choose a physician, though, I don’t rely on the popular consensus found online.

Satisfied patients typically don’t bother to post feedback about their doctors online; dissatisfied ones are more motivated to post complaints. But those complaints may or may not accurately reflect whether the patients actually got treatment that was right for them.

Similarly, personal anecdotes of experiences with a particular drug or other form of treatment may have little relevance to whether that treatment fits another person. I want professionals whose education, training and actual experience I can trust. Then, after forcing myself to ask all my questions, even the embarrassing ones, I aim to trust my doctors’ judgment, and their interpretation of the research and data in their field.

My young patient returned two weeks later, having decided to start the medicine I offered. She was reassured that what she’d read online, and heard from friends, confirmed what I’d told her.

In her case, the only cost was that she’d delayed treatment by two weeks, deferring the benefit she might have had in the semester’s crunch moments. Some patients delay for much longer, or opt out of evidence-based treatment in favor of something of dubious benefit that’s hawked online.

When it comes to health, I hope we can help the next generations understand that there isn’t always an app for that.

Doris Iarovici, a psychiatrist at Harvard University’s Counseling and Mental Health Services, is the author of “Mental Health Issues and the University Student.”