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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

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

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

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

1. Slack W. Cybermedicine. San Francisco: Jossey-Bass; 1997.
2. 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.
3. About Internet2. <http://www.internet2.edu/html/about.html> Accessed 27 October 2000.
4. Yellowlees PM, Brooks P. Health online: the future isn't what it used to be. Med J Aust 1999; 171: 522-525.
5. NHS Direct. <http://www.nhsdirect.nhs.uk> Accessed 27 October 2000.
6. Doctor Global. <http://www.doctorglobal.com> Accessed 27 October 2000.
7. Young K. Caught in the net: how to recognise the signs of Internet addiction. New York: J Wiley & Sons; 1998.
8. Yellowlees PM. E-therapy: a guide to mental health in cyberspace. [eBook available from http://www.mightywords.com]. Accessed 27 October 2000.
9. Center for On-line Addiction. <http://www.netaddiction.com> Accessed 27 October 2000.
10. Brosnan M. Technophobia: the psychological impact of information technology. London: Routledge, 1998.
11. Gwinnell G. Online seductions: Falling in love with strangers on the Internet. New York: Kodansha Press; 1998.
12. Kane B, Sands DZ. Guidelines for the clinical use of electronic mail with patients. J Am Med Inform Assoc 1998; 5: 104-111.
13. 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

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

©MJA 2000
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