eMJA: Yellowlees, Healthcare on the Internet

Medicine and the Community

Healthcare on the Internet
Buyers beware

Peter M Yellowlees
MJA 2000; 173: 629-630

The World Wide Web is becoming a new medium of medical practice.

Access to misinformation - Internet addiction - The practice of skullduggery - References - Authors' details
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Around the world books and other media are focusing increasingly on aspects of healthcare on the Internet.¹ A whole series of new jargon terms are evolving, such as "B2B" (Business to Business), "B2C" (Business to Consumer), "D2D" (Doctor to Doctor) and "D2C" (Doctor to Consumer/Patient). While these terms seems to derive more from the business world than the medical, the two worlds are becoming increasingly intertwined. Doctors are more familiar, through their training, with the derivation of other new terms such as "cyberchondria", "cybersex", "technophobia" and "Internet addiction disorders".

As a clinician and researcher who is interested in the exciting possibilities of Internet healthcare, I have been encouraging patients to use the Internet to access health information for some years, and also to communicate with me, if they wish, by email. Several patients have effectively self-referred themselves to me, via their general practitioners, after reading my curriculum vitae, which is posted on a website at the University of Queensland (www.coh.uq.edu.au). I also encourage patients to download information about their disorders from the Internet to discuss with me or other doctors or healthcare professionals who might be treating them. I keep a list of what I consider to be good sites on the Web that I can hand out to patients who wish to do research themselves, and who at least want a reasonable start in finding good-quality information from reliable sites. In future, with the increasing prevalence of published e-books in particular, patients will be able to learn how to do structured searches that make it more likely that they will get good-quality health information from the Internet.²

I am confident that the Internet, and in particular the much faster Internet2 that will be with us within two or three years,³ will have a positive overall effect on the way we treat our patients and the way they manage themselves. It is, however, crucial to retain a critical view of any new approaches in healthcare, and to evaluate them carefully, as it is becoming clear that there are some quite marked "side effects" to the Internet.

Access to misinformation

Patients do need to understand the importance of finding both reliable and valid information,⁴ and I believe that doctors will increasingly need high level skills in information analysis as a core medical competence. Unfortunately, at present, patients too often gain health information from chat rooms and discussion groups, and this is frequently either wrong or inappropriate. Just as there have been well publicised cases of individuals altering stock market values on the NASDAQ (the American National Association of Security Dealers Automated Quotation system) by aggressively presenting themselves in discussion groups, so cases are arising of cults, religious or otherwise, and other unusual organisations, trying to influence people through misinformation. Patients may heed this information and buy the wrong products or services.

Similarly, many health sites promote the sales of unproven treatments, or may in fact be entirely bogus, intended as satire or designed to steer people towards pornographic sales and marketing situations, or the like.

Patients are increasingly sending emails to sites that offer medical advice, purported to be from licensed medical practitioners, or seeking consultations by email. It is obviously vitally important that patients know who exactly is the doctor that they are emailing, and I would personally strongly advise against any patients receiving information from an anonymous doctor.

As a brief test of potential quality of health "advice" on the Internet, I recently asked a question at a major commercial American health site about the ideal treatment for depression. I received three single-sentence replies from an individual identified only by a number and which were completely contradictory, informing me I should (a) see a psychiatrist, (b) always engage in psychotherapy, and (c) consider medications, without any further details. I believe I would have received a better reply from a women's magazine agony aunt.

Some clinically sensible and ethically focused Internet healthcare sites are beginning to emerge. Perhaps the most well known is NHS Direct,⁵ in the United Kingdom, where symptom-driven decision trees (effectively patient decision-support systems) are backed up by a nursing telephone service which allows symptomatic patients to be triaged and to select either self-care, general practice or hospital treatment options. In Australasia the most comprehensive email consultation site is doctorglobal.com,⁶ with which I am commercially involved. Patients who access Doctor Global consult a named doctor, whose photograph and biography appear on the site, whose work is audited by a clinical advisory board and who has gone through a formal accreditation process before being allowed to practise through the site. At the moment, mainly because of medicolegal fears and a more restrictive clinical culture, there is no equivalent broad healthcare website in the United States providing real electronic clinical consultations.

Internet addiction

The concept of Internet addiction disorder^7,8 has been around for some years, but cases of patients so affected are becoming increasingly prevalent, and I have treated several (Case 1).

Internet addiction disorder is so well described on the Internet that it is even possible to receive treatment online.⁹ This seems a bit like going to the pub for a few drinks to try to cure one's alcohol dependence, and isn't something that I would instantaneously recommend.

Cyberchondria is a syndrome closely related to Internet addiction disorder that is also becoming increasingly common, and which occurs in anxious or hypochondriacal patients who start spending too much time chasing around the Web searching for information which may make them more anxious (Case 2).¹⁰ I can see no reason to define cyberchondria as a new form of psychiatric disorder, as it is simply a modern-day approach taken by those hypochondriacal patients who in the past have tended to read too many medical dictionaries.

The practice of skullduggery

Like it or not, our world will always contain some dreadful people who prey on others, and who will now use the Internet as their chosen access route to victims.¹¹ At least one man has already been imprisoned for "stalking" his ex-girlfriend on the Internet by publicising her name and contact details as someone who prostituted herself for clients wishing to have sadomasochistic sex. There are examples of men who cross-dress on the Internet pretending to be women, and then having steamy cyber-relationships with other men (a seemingly fairly common danger of Internet love affairs), and many instances of paedophiles joining chat rooms to try to meet adolescents.

As long as we are aware of these sorts of side effects, or dangers, we can make sure that patients are appropriately warned. Whatever we may think personally of the Internet -- and I am an obvious enthusiast -- it is inevitable that patients will increasingly use it both to find information about their disorders, and to communicate with doctors. There are now several publications that promote the sensible use of the Internet in healthcare and which propose guidelines for medical activities, in particular email use, on the Web.^12,13 These should certainly be reviewed by all doctors who intend now, or in the future, to practise, at least in part, in this manner.

References

Slack W. Cybermedicine. San Francisco: Jossey-Bass; 1997.
Yellowlees P. Your guide to e-health. Third millennium medicine on the Internet. Brisbane: University of Queensland Press, 2000 [eBook available from http://www.uqp.uq.edu.au]. Accessed 27 October 2000.
About Internet2. <http://www.internet2.edu/html/about.html> Accessed 27 October 2000.
Yellowlees PM, Brooks P. Health online: the future isn't what it used to be. Med J Aust 1999; 171: 522-525.
NHS Direct. <http://www.nhsdirect.nhs.uk> Accessed 27 October 2000.
Doctor Global. <http://www.doctorglobal.com> Accessed 27 October 2000.
Young K. Caught in the net: how to recognise the signs of Internet addiction. New York: J Wiley & Sons; 1998.
Yellowlees PM. E-therapy: a guide to mental health in cyberspace. [eBook available from http://www.mightywords.com]. Accessed 27 October 2000.
Center for On-line Addiction. <http://www.netaddiction.com> Accessed 27 October 2000.
Brosnan M. Technophobia: the psychological impact of information technology. London: Routledge, 1998.
Gwinnell G. Online seductions: Falling in love with strangers on the Internet. New York: Kodansha Press; 1998.
Kane B, Sands DZ. Guidelines for the clinical use of electronic mail with patients. J Am Med Inform Assoc 1998; 5: 104-111.
Spielberg AR. On call and online: sociocultural, legal and ethical implications of email for the patient-physician relationship. JAMA 1998; 280: 1353-1359.

Authors' details

Department of Psychiatry, Faculty of Health Sciences, University of Queensland, Brisbane, QLD.
Peter M Yellowlees, MD, FRANZCP, Head, and Director, Centre for Online Health.

Reprints will not be available from the author.
Correspondence: Professor P M Yellowlees, Department of Psychiatry, University of Queensland, K Floor, Mental Health Centre, Royal Brisbane Hospital, Herston, QLD 4029.
P.YellowleesATmailbox.uq.edu.au

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Case 1: Internet addiction disorder

Mr A was a 25-year-old, highly intelligent university student undertaking a health sciences course. At the age of 22 he had his first bout of severe depression, and was soon diagnosed with a bipolar disorder after a manic episode. This young man also had a very obsessional personality style and started spending many hours every day searching the Internet for information about the biology and treatment of bipolar disorder, sitting up all night and sometimes spending as much as 16 to 18 hours a day on his searches. His inappropriate use of the Internet took over his life and made it impossible for him to continue with his studies, and eventually became a greater cause of disability than his original bipolar disorder. He was successfully "withdrawn" from the Internet by agreeing to move back home to live with his parents, who did not have an Internet connection, and discontinued his university studies for some months while he received treatment for his primary psychiatric disorder.

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Case 2: Cyberchondria

Mr B was a 28-year-old single man with a five-year history of somatisation disorder. He became fascinated by the Internet, particularly by support groups for people with his type of disorder, and started to spend large amounts of time communicating with other sufferers on the Web. He became obsessed with the need to find a "biological cure" for his disorder and communicated regularly with researchers around the world involved in this area. Treatment consisted of the conventional treatment for his psychiatric disorder, particularly encouragement to use non-biological approaches, as well as reducing the amount of time he spent on the Internet. He was able to do this and, in a very positive postscript to his treatment, while on holiday overseas he organised to see one of the psychiatric researchers he had come to know on the Internet for a second opinion. I organised this appointment for him and he was pleased with the outcome.

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