Case Scenario

A 48-year-old patient with a family history of early colon cancer came to my office complaining of fatigue. He also said he felt “feverish” and had chest pressure. A physical examination and echocardiogram were normal. He returned to my office several more times complaining of chest pressure. I performed a work-up for cardiac disease and, because a complete blood cell count showed that he was anemic, I referred him for a colonoscopy.

The patient's wife accompanied him to his fourth office visit. She said, “Doctor, could this be NHL?” After thinking for a few minutes, I realized that she meant non-Hodgkin's lymphoma. She said that she found this diagnosis after doing Internet searches on her husband's symptoms. Follow-up computed tomography showed mediastinal lymph nodes, confirming that non-Hodgkin's lymphoma indeed was the diagnosis. Are patients becoming better at determining diagnoses than physicians? Should patients be diagnosing themselves? I often refer to the Internet myself when I have a specific inquiry, but I am mostly too busy to do this when I am in the middle of delivering patient care. When is it appropriate for physicians to conduct Internet searches to find diagnostic information?

Commentary

Patients are not trained to diagnose illnesses across a wide spectrum of diseases and are not familiar with presentations that physicians are trained to detect. However, patients are highly motivated to determine their diagnoses, are more intimately familiar with their own symptoms, and may have more time to investigate potential diagnoses than physicians.

Internet tools that are available directly to patients have become more sophisticated. Search engines provide quick access to large volumes of information on common and obscure topics. Often this information is easy to access without knowledge of search technique. For example, I entered the words fever, night sweats, chest pressure, anemia, and diagnosis into a search engine and the first result was an entry on tuberculosis from a free online encyclopedia (http://en.wikipedia.org/wiki/Tuberculosis_diagnosis). The second result was a description of chest pain from a sickle cell information center (http://www.scinfo.org/chest.htm). The wife of the patient in the scenario could have quickly found these Web sites and determined that they were not relevant to the patient's condition. However, the third result from my search was a summary on Hodgkin's lymphoma from an informational oncology Web site (http://www.oncologychannel.com/hodgkins/symptoms.shtml). The Web site included sufficient information within the available links to lead the patient's wife to the non-Hodgkin's lymphoma diagnosis.

After entering “diagnose yourself” into the search engine, I found several advertiser-sponsored Web sites that assist patients with self-diagnosis. Using one of these Web sites (http://myelectronicmd.com/) and focusing on night sweats, I was able to reach the non-Hodgkin's lymphoma diagnosis in five clicks. Although I do not advocate these specific searches as ideal methods for determining a diagnosis, they show how untrained persons can quickly find diagnostic information.

Establishing a diagnosis, whether it is specific (e.g., celiac disease) or general (e.g., dyspepsia), facilitates communication and selection of further evaluation and treatment. Sometimes the diagnostic process seems definitive; at other times, physicians make assumptions regarding the most likely diagnosis without formally establishing an illness. Making a diagnosis can be a cognitive exercise or may require additional testing, which can be costly or potentially harmful to the patient. However, applying diagnostic labels without testing also can be harmful because the diagnosis affects decision making. For example, a fibromyalgia diagnosis might lead to a less-thorough evaluation (e.g., history taking, physical examination, testing) when the patient presents to his or her physician with pain.

Ideally, patients and physicians work together to determine the best course of action. The Internet provides patients with opportunities to become more self-informed and may help promote this shared decision-making approach. A Health On the Net Foundation survey¹ of Internet users showed that the Internet helped 91 percent of survey participants become better “partners” with their physicians. However, the Internet also may provide patients with advice that is inaccurate, misleading, and counterproductive. Physicians may suggest professional Web sites or offer guidance on information seeking.

Physicians themselves sometimes use the Internet to search for diagnostic information, although they have traditionally been taught facts and how to use algorithms rather than information-seeking behaviors and tools for keeping current. There are many barriers to searching for information in a busy practice.² These barriers include time constraints, lack of awareness of sources that can be accessed quickly, reimbursement concerns, reluctance to adapt to changing technology, distrust of available information, and disruption of established work-flow patterns. There is no absolute guide to determine when Internet searching should be used. In general, physicians are expected to use resources that fulfill information needs. Internet searching is one strategy for fulfilling these needs and may be preferred because of its speed and comprehensiveness.

The most useful resources for meeting information needs balance validity, relevance, ease and speed of use, and afford-ability. Validity can be evaluated by looking for explicit descriptions of how evidence is selected and evaluated, statements deter-mining whether the process is systematic or author-dependent, and information about the frequency and timeliness of updating. The other factors are based on personal preference and are best determined by com-paring available online resources. Trying and comparing resources before they are needed in practice can help physicians fulfill information needs more efficiently during practice. Some resources are more intuitive than others, so trying multiple methods of navigation may be needed to determine whether or not a resource is relevant and quick and easy to use. Also, physicians can conduct searches when they are not immediately busy with patients.

A randomized trial³ showed that using an online database of synthesized evidence helps primary care physicians answer clinical questions during practice and find answers that change clinical decisions. A free Internet portal designed for physicians that includes more than 100 Web sites for finding medical information is available athttp://www.myhq.com/public/a/l/alper.