- Email: [email protected]
ONLINE CONSULTATION
Editorial How does online consultation fit into this picture, whether as part of a professional relationship that is already established, or as an unsolicited request for information and advice from patients? Sands has pointed out that direct email communication from known patients offers many of the advantages of the telephone, with one major additional one, that the communication is not limited in time to when both have telephone access.7 Patients may regard online consultations as less intimidating than physical consultations, and may describe them as providing ‘quality time with their own practitioner’. One potentially serious disadvantage is security. Secure sites are becoming increasingly available and The American Medical Association (AMA) will soon offer a secure communications system for its members and their patients.8 There is still the risk of human error, and accidental copying to third parties is quite common. Other disadvantages are that an email message could lie unopened for ever (whereas with the telephone you know you are being heard), and that the patient might not know who else in the practice has access to the emailed letter. Clearly, this is not a trivial business and anyone contemplating online consultations should apply the guidelines carefully.9 Unsolicited email letters are a completely different matter. They can never contain enough information for a practitioner to make a diagnoses or suggest a treatment—both rely on information gained from face-to-face interaction, from the physical examination, and often from previous knowledge of the patient. The ethical principles and legal liability for such advice have not been clearly established. Nevertheless, doctors in the US are making a business out of providing an Internet advice service.10 They argue that they are only giving a range of possible diagnoses, and only generalised advice. However, there is a grey area between general information and tailored advice which has yet to be tested in the courts. Providing disclaimers is probably no protection. The AMA is against it, and in the UK the General Medical Council website11 warns physicians contemplating providing this service to be extremely careful. The same cautions must apply to complementary medicine. Unsolicited emails carry another risk: they may be bogus! Sandvik posed as the patient ‘Molly Jones’ to judge the quality of information provided by specialists in urinary incontinence and relevant websites that offered an interactive service.12 Half responded, only one in five noting that a drug that Molly was ‘using’ could be causing her symptoms. Eysenbach posed as a patient requesting information from 58 dermatology consultants and webmasters.13 Again half responded, and 10 gave detailed treatment advice. In a repeat of this experiment, published in this issue, we sent unsolicited emails to reflexologists
ONLINE CONSULTATION Telecommunications can offer huge benefits for patients and their health care providers, and naturally a few risks. The telephone line has long been a useful tool for improving access and saving time—except in Germany, where telephone advice is outlawed by the doctors’ professional body on the grounds that it is too risky. However, there is evidence from the UK that it can improve asthma care.1 Video-consultations with a patient might be the next step (even from mobile phones, where the words ‘I’m on the train’ could have interesting implications!) and are already being used to diagnose dermatological conditions in patients who live a long way from the specialist centre.2 The World Wide Web has multiplied the opportunities. Forty-eight percent of adults in the UK have access to the web at work or home.3 Patients can now gain information from a large range of websites, of varying quality. The image of the patient confronting the primary care physician with armfuls of printouts might be a caricature, but in reality presents professionals with some major challenges—such as how to keep up to date with all this literature, how to evaluate what the patient has read, how to maintain the relationship of trust. The problems become most acutely focused when patients diagnose themselves over the Internet and medicate themselves with pharmaceuticals purchased the same way. But that is only part of the story: patient discussion groups lead to increased patient self-efficacy, and practitioner discussion groups and Internet courses provide continuing education. Further, practitioners can set up personal websites for patients, with background information about the practice and frequently asked questions. The safety of a website is an obvious worry, in terms of its accuracy, balance and completeness of information.4 It is worth remembering that this is equally true of other sources of health information. Moreover, surfers are unlikely to rely on a single site and are likely to have some common sense. Doctors report that, on balance, websites probably produce greater benefit than harm.5 Rating instruments for websites exist, and have been reviewed.6 A few problems remain unsolved, such as cross-border supply of drugs by Internet pharmacies to avoid local regulations. Additionally, excessive Internet use risks addiction, feelings of unreality and isolation. But the safety of websites is not their only concern in terms of delivering health services. The Internet is likely to increase inequality of health care since the elderly and the poor are less likely to have access to computers and the Internet. In the UK, access to the Internet in the home falls from the average of 43% to only 21% of those homes in high deprivation areas.3 Complementary Therapies in Medicine (2003), 11, 62–63 doi:10.1016/S0965-2299(03)00066-9
© 2003 Elsevier Science Ltd. All rights reserved.
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whose email addresses were available on an association website. We obtained ethics committee approval prior to this survey. Earlier studies had not done so, and in fact Eysenbach reported that the local committee stated that they did not need to consider the study since it did not involve patients. But surveys can sometimes cause harm to their subjects—and even to the researchers.14 We did gain ethics approval for our study, as it involved individuals with feelings. Some of those are professional colleagues. We are glad we did: for, like Eysenbach (but not Sandvik, apparently), we told the participants afterwards that they had received a bogus letter, and some were quite distressed. This is deeply regretted. In planning the study, we had judged that any risk of harm to the reflexologists was very slight and was outweighed by the potential benefits to society. This might not have been the correct judgement, and the lesson is to assess those risks and benefits more explicitly when planning this kind of research. In mitigation, it should also be stated that several of the reflexologists were grateful that the potential risks in dealing with unsolicited emails had been brought to their attention. Chatting to friends by email is a pleasant, informal pastime: emailing in reply to patients, particularly unknown ones, can be fraught with liability. But the solution to the problem is not in simply pressing the ‘Delete’ button: practitioners have an ethical duty to respond to a call for help, even if only by suggesting other more appropriate resources. Adrian White Editor
REFERENCES 1. Pinnock H, Bawden R, Proctor S, Wolfe S, Scullion J, Price D et al. Accessibility, acceptability, and effectiveness in primary care of routine telephone review of asthma: pragmatic, randomised controlled trial. BMJ 2003; 326: 477–479. 2. Wootton R. Recent advances: telemedicine. BMJ 2001; 323: 557–560. 3. http://www.oftel.gov.uk/publications/research/2002/ trenr0702.htm#4. 4. Eysenbach G, Powell J, Kuss O, Sa ER. Empirical studies assessing the quality of health information for consumers on the world wide web: a systematic review. JAMA 2002; 287: 2691–2700. 5. Potts HW, Wyatt JC. Survey of doctors’ experience of patients using the Internet. J Med Internet Res 2002; 4: e5. 6. Jadad AR, Gagliardi A. Rating health information on the Internet: navigating to knowledge or to Babel? JAMA 1998; 279: 611–614. 7. http://www.ajmc.com/sands editorial.html. 8. http://www.ama-assn.org/ama/pub/category/2386.html. 9. Kane B, Sands DZ. Guidelines for the clinical use of electronic mail with patients. The AMIA Internet Working Group, Task Force on Guidelines for the Use of Clinic-Patient Electronic Mail. J Am Med Inform Assoc 1998; 5: 104–111. 10. http://www.ama-assn.org/sci-pubs/amnews/pick 02/ bisa0610.htm. 11. http://www.gmc-uk.org/standards/default.htm. 12. Sandvik H. Health information and interaction on the internet: a survey of female urinary incontinence. BMJ 1999; 319: 29–32. 13. Eysenbach G, Diepgen TL. Responses to unsolicited patient e-mail requests for medical advice on the World Wide Web. JAMA 1998; 280: 1333–1335. 14. Evans M, Robling M, Maggs RF, Houston H, Kinnersley P, Wilkinson C. It doesn’t cost anything just to ask, does it? The ethics of questionnaire-based research. J Med Ethics 2002; 28: 41–44.
ONLINE CONSULTATION Telecommunications can offer huge benefits for patients and their health care providers, and naturally a few risks. The telephone line has long been a useful tool for improving access and saving time—except in Germany, where telephone advice is outlawed by the doctors’ professional body on the grounds that it is too risky. However, there is evidence from the UK that it can improve asthma care.1 Video-consultations with a patient might be the next step (even from mobile phones, where the words ‘I’m on the train’ could have interesting implications!) and are already being used to diagnose dermatological conditions in patients who live a long way from the specialist centre.2 The World Wide Web has multiplied the opportunities. Forty-eight percent of adults in the UK have access to the web at work or home.3 Patients can now gain information from a large range of websites, of varying quality. The image of the patient confronting the primary care physician with armfuls of printouts might be a caricature, but in reality presents professionals with some major challenges—such as how to keep up to date with all this literature, how to evaluate what the patient has read, how to maintain the relationship of trust. The problems become most acutely focused when patients diagnose themselves over the Internet and medicate themselves with pharmaceuticals purchased the same way. But that is only part of the story: patient discussion groups lead to increased patient self-efficacy, and practitioner discussion groups and Internet courses provide continuing education. Further, practitioners can set up personal websites for patients, with background information about the practice and frequently asked questions. The safety of a website is an obvious worry, in terms of its accuracy, balance and completeness of information.4 It is worth remembering that this is equally true of other sources of health information. Moreover, surfers are unlikely to rely on a single site and are likely to have some common sense. Doctors report that, on balance, websites probably produce greater benefit than harm.5 Rating instruments for websites exist, and have been reviewed.6 A few problems remain unsolved, such as cross-border supply of drugs by Internet pharmacies to avoid local regulations. Additionally, excessive Internet use risks addiction, feelings of unreality and isolation. But the safety of websites is not their only concern in terms of delivering health services. The Internet is likely to increase inequality of health care since the elderly and the poor are less likely to have access to computers and the Internet. In the UK, access to the Internet in the home falls from the average of 43% to only 21% of those homes in high deprivation areas.3 Complementary Therapies in Medicine (2003), 11, 62–63 doi:10.1016/S0965-2299(03)00066-9
© 2003 Elsevier Science Ltd. All rights reserved.
62
Online Consultation
63
whose email addresses were available on an association website. We obtained ethics committee approval prior to this survey. Earlier studies had not done so, and in fact Eysenbach reported that the local committee stated that they did not need to consider the study since it did not involve patients. But surveys can sometimes cause harm to their subjects—and even to the researchers.14 We did gain ethics approval for our study, as it involved individuals with feelings. Some of those are professional colleagues. We are glad we did: for, like Eysenbach (but not Sandvik, apparently), we told the participants afterwards that they had received a bogus letter, and some were quite distressed. This is deeply regretted. In planning the study, we had judged that any risk of harm to the reflexologists was very slight and was outweighed by the potential benefits to society. This might not have been the correct judgement, and the lesson is to assess those risks and benefits more explicitly when planning this kind of research. In mitigation, it should also be stated that several of the reflexologists were grateful that the potential risks in dealing with unsolicited emails had been brought to their attention. Chatting to friends by email is a pleasant, informal pastime: emailing in reply to patients, particularly unknown ones, can be fraught with liability. But the solution to the problem is not in simply pressing the ‘Delete’ button: practitioners have an ethical duty to respond to a call for help, even if only by suggesting other more appropriate resources. Adrian White Editor
REFERENCES 1. Pinnock H, Bawden R, Proctor S, Wolfe S, Scullion J, Price D et al. Accessibility, acceptability, and effectiveness in primary care of routine telephone review of asthma: pragmatic, randomised controlled trial. BMJ 2003; 326: 477–479. 2. Wootton R. Recent advances: telemedicine. BMJ 2001; 323: 557–560. 3. http://www.oftel.gov.uk/publications/research/2002/ trenr0702.htm#4. 4. Eysenbach G, Powell J, Kuss O, Sa ER. Empirical studies assessing the quality of health information for consumers on the world wide web: a systematic review. JAMA 2002; 287: 2691–2700. 5. Potts HW, Wyatt JC. Survey of doctors’ experience of patients using the Internet. J Med Internet Res 2002; 4: e5. 6. Jadad AR, Gagliardi A. Rating health information on the Internet: navigating to knowledge or to Babel? JAMA 1998; 279: 611–614. 7. http://www.ajmc.com/sands editorial.html. 8. http://www.ama-assn.org/ama/pub/category/2386.html. 9. Kane B, Sands DZ. Guidelines for the clinical use of electronic mail with patients. The AMIA Internet Working Group, Task Force on Guidelines for the Use of Clinic-Patient Electronic Mail. J Am Med Inform Assoc 1998; 5: 104–111. 10. http://www.ama-assn.org/sci-pubs/amnews/pick 02/ bisa0610.htm. 11. http://www.gmc-uk.org/standards/default.htm. 12. Sandvik H. Health information and interaction on the internet: a survey of female urinary incontinence. BMJ 1999; 319: 29–32. 13. Eysenbach G, Diepgen TL. Responses to unsolicited patient e-mail requests for medical advice on the World Wide Web. JAMA 1998; 280: 1333–1335. 14. Evans M, Robling M, Maggs RF, Houston H, Kinnersley P, Wilkinson C. It doesn’t cost anything just to ask, does it? The ethics of questionnaire-based research. J Med Ethics 2002; 28: 41–44.