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An Apple a Day Doesn’t Have to Keep the Doctor Away

Medical professionals are bracing themselves for what some consider a major threat to public health. No, it’s not a pandemic infectious disease such as SARS or MERS. Nor is it the threat of bioterrorism, global warming or nutrient deficient school lunches. The major threat to public health is the online diagnoser.

The online diagnoser uses the Internet to diagnose a condition for himself or herself and others. According to a recent Pew Research study, there are about 1.7 million online diagnosers in the United States alone.1 Online diagnosers include people who have conducted online searches to answer questions about dietary, pharmaceutical, medical and alternative treatment for self-diagnosed conditions. I suspect more than a few doctors, nurses and allied healthcare professionals are online diagnosers – which may explain the sudden disappearance of your chiropodist in the middle of an examination. In fact, "Isabel, the Symptom Checker” advertises itself as "The one doctors use.”2

Online diagnostic tools are meant to improve communication between patients and their caregivers by providing a starting point for dialog – sort of like direct to consumer (DTC) pharmaceutical ads on the television. Well, maybe not entirely like DTC advertising, which has been banned in every country in the world except the U.S. and New Zealand for fear these ads may coerce rather than inform consumers.3 If the ethical approach requires a process of medical decision-making that is shared by practitioners and patients, why is the online diagnoser so feared?

Perhaps, some practitioners are apprehensive about the Internet because they fear patients might read or contribute to negative reviews when they’re online. Doctors are suing patients for negative online criticism.4,5 Reputation-management companies guarantee to remove or bury bad reviews, and some doctors even require their patients sign documentation, promising not to post online reviews in exchange for "additional privacy protections.” 6

Perhaps, clinics, hospitals and medical facilities are apprehensive about the Internet because the healthcare system fears it may lose revenue from direct competition with online diagnostic tools. Reportedly, one-third of online diagnosers do not follow up with medical professionals, with about half of all online health inquiries done on behalf of someone else.7 Some may call it "responsible parenting” when Internet research is done on behalf of a sick child; but, most will agree that it could be interpreted as practicing medicine without a license.

In principle, the threat is that online diagnosers will receive false or misleading information. The health and ethical repercussions of potentially harmful medical advice merit warning online diagnosers. That’s precisely what the Australian Medical Association (the other AMA) did by publicizing a double-suicide committed subsequent to an online diagnosis of cancer.8

Despite ethical apprehensions about Internet savvy patients, there are also ethical problems associated an outright exhortations against the Internet as a medical resource – chiefly, the assumption that patients always get complete and correct information from flesh-and-blood health providers. The results of the Pew study suggest it is easier for many patients to obtain and appraise online information than it is to get information from some doctors, even in those rare instances when doctors have time for conversation.

An recent article in JAMA Internal Medicine reported that less than 10 percent of patients are informed of the possibility of over diagnosis and overtreatment from cancer screening.9 Excluding those who read JAMA (or this IJAHSP commentary), patients might not discover this kind of information unless they are encouraged to use the Internet and become an online diagnoser. Ideally, the Internet can help explain a procedure, provide patient narratives of the experience, and help corroborate (or refute) the information and diagnosis provided by flesh-and-blood medical practitioners. At the very least, the Internet may raise concerns that help the patient articulate questions about symptoms, treatment options, rehabilitation and follow up.

Ethical medical practitioners should be concerned about the potential harm that online misinformation may cause their patients; but patients should also be concerned about the potential harm caused by misread tests, medical errors, misdiagnosis, miscommunications, malpractice, and negligence. Doctors, nurses and allied health professionals blame medical error and oversight on increased patient-loads, limited time to conduct complete history and exams, and not enough time to discuss all the risks and treatment options. From the patient’s perspective, mistrust is born from participating in what seems more and more like assembly-line healthcare. It is understandable why some patients fear that the odds of getting complete information or a correct diagnosis from their doctors is dubious, at best.

Enter the online diagnoser - no longer a boon or threat to public health, but a potential ally to the health professional. Instead of discounting and feeling threatened by the patient who arrives at her appointment with printouts from online sources, ethical practitioners can encourage their patients to conduct valid online research by recommending reputable Websites and online resources, urging them to use the information to help express their questions or concerns. Only a narcissist like television’s Dr. House would refuse to listen to information that conflicts with his own diagnosis or treatment plan. Open-mindedness to Internet savvy patients builds trust, improves compliance and strengthens provider-online diagnoser relationships.


  1. Health online 2013. Pew Research Center. Available from http://www.pewinternet.org/files/oldmedia//Files/Reports/PIP_HealthOnline.pdf
  2. Isabel: the symptom checker. Available from http://symptomchecker.isabelhealthcare.com/
  3. Burton, B. Drug industry to fight New Zealand’s move to ban direct to consumer advertising. BMJ 2004;328:1036.5. Available from http://www.bmj.com/content/328/7447/1036.5
  4. Thompson, P. Cosmetic surgeon sues woman who claimed his botched surgery left her with ‘Frankenstein’ breasts. Available from http://www.dailymail.co.uk/news/article-1331775/Cosmetic-surgeon-Jay-Pensler-sues-woman-botched-Frankenstein-boob-job.html
  5. Klein, G. Greenbrae plastic surgeon sues online critics. Marin News. Available from http://www.marinij.com/marinnews/ci_15444079
  6. Lieber, R. The web is awash with reviews. New York Times. Available from http://www.nytimes.com/2012/03/10/your-money/why-the-web-lacks-authoritative-reviews-of-doctors.html?pagewanted=all&_r=0
  7. Health online 2013. Pew Research Center. Available from http://www.pewinternet.org/files/oldmedia//Files/Reports/PIP_HealthOnline.pdf
  8. Hasty, R.T. Wikipedia vs peer-reviewed medical literature for information about the 10 most costly medical conditions. J Am Osteopath Assoc 2014;114(5):368-373. Available from http://www.jaoa.org/content/114/5/368.full#ref-1


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