Everyday physicians come in contact with patients who need to be educated about their disease or injury. In order to perform an invasive or surgical procedure, the patient must sign a written statement signifying that they have been informed about their condition, alternatives to treatment and consent to the proposed operation. In the 1990's, patients are constantly obtaining second and third opinions prior to undergoing medical or surgical treatment. Frequently, patients seeking second and third opinions in my office simply want me to explain their condition better to them and to their families. A physician often does not have enough time to completely teach as well as perform the necessary clinical evaluation of an individual coming to their office for help with their health care. In 1977, the A.H.A. published "Eye on Patients" and reported that their healthcare providers did not provide them with enough information or with answers to important questions. In the information age, patients are still searching for more information, but expect to find specific data related to their health or disease state.
The Internet represents a communication tool as well as a huge supply of medical information. Often elderly individuals more than 60 years of age have either more time or through their peer organizations better knowledge of where to surf on the Internet in order to obtain answers to their health-related questions. The Internet may represent an enhancement of our ability as physicians to inform patients. However the Internet contains an unedited grouping of medical data, often in a poorly organized system. More recently university programs and corporations have created dedicated medical web sites specifically aimed at providing health care information for people. Such efforts have significantly changed the way that medical information is distributed throughout the world. Because of these web sites, surfing is less necessary and excellent patient education data now exists on specific web sites.
Will the Internet, with improved access to healthcare information, affect the patient-physician relationship? If the patient is more knowledgeable about their disease of illness then they can better follow the advice of their doctor and participate directly in their treatment. By actively involving a patient in their own medical care, then they should have an improved outcome or shorter time interval to completion of treatment. Improved communication between the physician and the patient is always a desirable goal. However patients must be able to speak and use the same medical vocabulary as their physician. If a patient at least partially understands their medical condition then the physician can spend more time counseling and directing their patient's care.
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Over the past three years, my web site has emphasized the need for the physician to interpret patient education information located on the Internet. I enjoy the challenge of dealing with patient expectations after they have read about new surgical operations or medication. This trend of bringing printed articles into the physicians' office will continue into the next century. Physicians will have to be aware of the new journal articles and keep abreast of new trends in disease management.
Patients expect consumer product information related to medications. This information will be given to them from physicians' office computer files when the prescription is written and then from their pharmacists and even later off the Internet. They will expect detailed information on diseases and will use this information to manage their own disease. In my own practice I have identified a slow evolution toward a surgical neurology practice. Often multiple individuals are better informed with Internet information and come into the office with stacks of paper and huge numbers of x-rays. The time required to effectively treat these patients has increased substantially. Often one hour of time has become a minimum in order to perform a history, physical, review of records, review of x-rays and then discussion of treatment alternatives with the patient.
The patient-physician relationship may be enhanced if along with this newly found knowledge , the physician is willing to interpret and then counsel these information age patients. Certainly time constraints and economic factors may affect the doctors' ability to present recommendations during a single office visit.
Reassessment and revisits are becoming more frequent when alternative treatments are tried. . When using the Internet for communication purposes, many physicians have found that E-mail communication can be valuable. Voice communication requires a synchronous action between the patient and the physician. With E-mail communication methods, the physician or the patient can respond when they have time to sit down and log on to their Internet Service Provider. I currently discourage E-mail communication in my own practice. I prefer eye-to-eye contact for counseling or, minimally, voice communication between myself and my patient. I cannot fully understand the patients' needs and emotional response by E-mail. Motivational and emotional issues coexist when dealing with many health-related problems. In answering E-mail, I find that I have additional questions that have to be answered in order to properly respond or recommend treatment. Pertinent negatives and positives as normally obtained while taking a history or the patient and medication effects and current use, etc. which I normally would ask when they are in my office or on the phone is not possible. I do not find that E-mail communication enhances my patient-physician relationship.
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However Cyberdocs can receive E-mail or web site directed patient information and their questions can be answered for a fee. This patient-physician interaction does constitute a true patient-physician relationship. Major medical malpractice insurance companies may not cover these patient encounters. Also, the doctor may be practicing medicine outside of their licensed state. However there are many healthcare related questionnaires that can be answered on the Internet giving the patient information about their condition through relative value scoring of the test results. Also, Internet chat rooms with support groups of patients with similar diseases or illness have been growing in size and number. There will be a continuation of this trend into the 21st century.
E-mail communication between physicians, however, is becoming more common especially when questions related to an unusual clinical condition arises. With an Intranet or Wide Area Network, an E-mail system could be useful. Even direct eye-to-eye contact using video cameras or review by exchange of radiographs or test results between physicians can be done today. However be aware of the implications and possible criminal or civil prosecution if confidential patient medical data is transmitted over insecure Internet communication lines. HCFA may soon rescind the Internet-based medical information ban with a new set of guidelines and security requirements. Last year the New York based HCFA office had determined that no medical records should be sent over the Internet. " Any activities using the Internet or an unsecured internal network ( to transfer individual health information) must cease immediately." The policy ban was based on the Federal Privacy Act of 1974. HCFA will most likely recommend specific encryption and authentication methods. Encryption uses complex scrambling formulas and long strings of digits, called keys, to allow access only by authorized people. The length of formula and the encryption framework and algorithm will be changed as new weaknesses are discovered protect the data from hackers trying to break the encryption code. The issue of confidentiality of medical records will not be discussed in detail today.
However, overall, over the past five years, the Internet now has several excellent medical web sites available for both physician and patient use. In the past editorial staffs would review an article or information prior to publication. Medical text books and scholarly articles often required intense peer review by experts in the speciality field prior to publication. At this time no such editorial or publication policy exists on the Internet. Simply stated, our national organizations and individual practitioners need to provide editorial review of Internet data. Internet articles should contain data on the background of the author and the supporting articles for their ideas as well as the time of modification or update of the specific information on the web site.
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INFORMED CONSENT IN THE INFORMATION AGE
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Another spinoff of the information age and Internet is the use of computers in patient education. Physicians use handouts, pamphlets and personal physician web sites to help educate their patients. A patient cannot remember all the information presented to them during an office visit. Each person will have a differing ability to recall information when presented verbally or in a written fashion. Perhaps one of the best methods currently to help inform patients is interactive computer education. The patient takes a quiz after they read text on their specific disease. Afterwards the physician or staffs can score the tests and identify if they understand specific topics adequately which may imply that they are indeed well informed patients. Certainly this could be useful if any legal questions arise related to informed consent in the future. Video recordings and computers in doctors' waiting rooms are still unusual but would offer the individual who is waiting, access to health related data.
Because of the time constraints currently identified on all physicians' practices, their valuable time could be more effectively used if the patient has been educated during or ahead of their visit. Also family members, or children of elderly patients, who may have a better education or a better ability to understand this information, could view educational materials when bringing their parents or their children to the doctors' office.
The question remains, has the patient been well informed? Using the Internet may be one way to enhance the patient- physician relationship.
ELECTRONICALLY READ and SIGNED BY JERRY V. MARLIN M.D.