Wednesday, July 23, 2008

Open Source Medicine and the Doctor-Patient relationship

A recent post by Dan Schultz on PBS' MediaShift Idea Lab blog discusses the pros and cons of comments. Schultz mostly sticks to practical tips on how to beef up the comments on your publication, but a belief in the benefits of crowdsourcing seem to underly his advice.

It seems everyone is talking about crowdsourcing in terms of politics and in terms of going hyperlocal. Power to the people via the vast amounts of information available on the internet and the vast sea of experts we can access in only an instant.

I don't see many media people talking about crowdsourcing and data in terms of health. But the medical profession has noticed, and boy are they talking about it.

Let's stop there for a moment for some disclosure. I'm a pushy, inquisitive patient, the kind older doctors hate and young doctors love. I'm pushy and demanding, but that seems to have been effective. Since I started down this path, researching my own health problems and taking a hand in the decision process, my health has improved a great deal. In each case I eventually found a specialist who I trusted - usually because the information that specialist was giving me made sense in the context of the research studies I was reading online. I still try to do some of my own research, but I'm more likely to go with my doctor's advice now that I feel I'm with someone competent.

So what are the doctors saying?

Health providers must avoid frustration about having their role as the sole source of information challenged, or possibly risk losing patients. In one survey of different specialty and general medicine practices, one third of the patients who felt their relationship with their physicians was low in participatory decision-making changed providers within a year.
The Patient-Physician Relationship in the Internet Age: Future Prospects and the Research Agenda, from the Journal of Medical Internet Research
Earlier in the same paper, after observing that patients who have done their own research may be able to get more out of their appointments by skipping the basics and spending more time on the pros and cons of treatment options, the authors write:

"...physicians must be prepared to address alternative possibilities that the patient has learned about from external sources. Instead of saving time, this scenario may require extra discussion when untested approaches need to be debunked (as in the case of some complementary and holistic medicine practices). ... Still, it is yet uncertain whether efficiency improves or declines when patient-acquired Internet information is brought into the decision-making process. This subject warrants further investigation."
A lot of the discussions I'm reading are about the doctor-patient relationship, or impacts on visit duration or visit frequency. This study's results suggests that these fears are unfounded, while this one concludes that "Hype around Internet use by patients appears to exceed the reality of Internet use."

Sure, these results are preliminary, and as internet adoption grows, the way patients use the internet will almost certainly evolve.

But the thing is that the internet doesn't pick and choose what to democratize. In science and medicine there has always been a great divide between the layperson and the expert. Now, as more and more research journals go open source, average people are feeling increasingly confident in their own ability to make judgments about science and medicine. Thanks to the democratizing force of the internet, the chasm between people and scientists appears to be narrowing.

Appearances can be deceiving.

When it comes to science, the learning curve to equal or even approach the expertise of a biologist or physicist (for example) is far too steep for most of us to achieve. The necessary math skills alone present a formidable barrier. But doctors are not necessarily scientists. What does their education consist of, and to what extent can new media equip your average person to fruitfully discuss their health with a doctor?

My own experiences suggest that the ability and inclination to search the internet, decipher article abstracts, assess the quality of evidence, and then weigh that against other evidence, is enough. In fact, more than enough - I often end up teaching doctors (especially general practitioners) new things about my illnesses, although pride may prevent them from learning from it.

When I tell people about this, I'm often told that I'm "different." Because I have a background in science (physics/astrophysics, which has nothing to do with medicine, I should point out), I understand the scientific process and scientific jargon, and I'm not intimidated by it. My friends will even sometimes argue that I'm smarter than your average patient, and that it isn't reasonable to base my assessments of what people can do with the internet's vast sea of data on what I can do.

Mmm, maybe. I certainly think a lot of people (including some doctors) need a crash course in how science works, and in particular, on evidence-based medicine. (by the way, the entire concept of evidence-based medicine originated in Canada at McMaster University in 1992). I'm not sure how smart you need to be, once you have that basic knowledge, to get involved. And hell, who knows: maybe I'm not smart enough. Maybe with all of the pushing I've done to get better healthcare, I've shot myself in the foot and don't know it. I don't think that's the case, but sometimes I entertain the possibility with some degree of horror.

Lately, I've begun to suspect that the general practitioner is essentially a walking talking database of often-obsolete medical information. If that's true, then a skilled internet researcher who understands how to assess medical evidence could potentially provide better medical advice than the general practitioner. I certainly feel like I've done that on occasion.

To get to the bottom of this all, there need to be more studies on the reading comprehension of patients who are familiar with the scientific process. To what extent does their perceived comprehension match their actual comprehension?

I also need to learn more about how general practitioners are educated, and how they continue to educate themselves throughout their careers. Do they learn how to interpret statistics, or how to avoid being influenced by medical literature or drug advertisements? Are they taught about evidence-based medicine these days, and when did that find its way into the curriculum? For those doctors who graduated before EBM, how many of them have learned about it nonetheless? And, as medical information is updated through research, how are general practitioners updated on that information - or are they?

I have a lot more to say about this, but I think it's time to close this post down. I'd love to hear your thoughts on all this, though. Do you use the internet to research health problems? Do you think you can learn as much as some general practitioners? Talk to me.

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