When patients visit your office, they may already have a diagnosis in mind. Google says that one of every 20 searches on its search engine are conducted to obtain health-related information.
With that in mind, how can a primary care physician (PCP) win a patient’s trust and resolve conflicts if the patient wants tests or treatments that the physician believes are unnecessary?
As patients become more Internet savvy, “we have to evolve with the times as well,” says Jack Chou, MD, a member of the American Academy of Family Physicians’ board of directors and a PCP in Baldwin Park, California.
“I am not afraid of Dr. Google because Google can never come close to a family physician,” he adds. “It’s not about competition with technology. I see Google as a tool. It’s not to supplant what we do as physicians.”
Before attempting to clear up any misconceptions, the best approach would be to acknowledge a patient’s concerns. “We tend to interrupt patients within the first nine seconds,” Chou says. “Take a deep breath and listen to what people have to say.”
The importance of listening
Patients increasingly view communication as essential to the delivery of high-quality healthcare.
In a recent survey by the Associated Press-NORC Center for Public Affairs Research, listening and attentiveness ranked as the top factor in evaluating provider quality. The survey, conducted in 2014, found that 59% of participants referenced patient-clinician relationships and provider personalities as primary elements in assessing high-quality care.
Related: Managing conflict with patients
“While Internet resources may influence patients to enter the exam room with ideas that may or may not prove valid based on their own Internet research, they also bring many emotions and concerns related to their health symptoms, such as fear, uncertainty, sadness and worry,” says Laura Cooley, PhD, director of education and outreach at the American Academy on Communication in Healthcare in Lexington, Kentucky.
“Physicians must remain attentive to these underlying emotions, recognize the patient’s perspective, and allow the patient to feel respected and heard. Physicians with higher levels of communication skill competency are well-equipped to manage the dynamics created by ‘Dr. Google’ as both challenges and opportunities,” Cooley says.
The evolution of the physician-patient partnership
Some practitioners nonetheless admit to feeling at least a little threatened by patients who conduct their own online research.
“Physicians often resist or even resent ‘Dr. Google’ for a variety of reasons,” she says. “Patients may receive misinformation, biased medical suggestions, and may enter the medical appointment with preconceived ideas about their diagnosis or treatment.”
Even Google contends that its search results aren’t intended as medical advice, despite careful verification of the content by medical doctors at the tech giant and at Mayo Clinic, according to Google.
“We know that cases can vary in severity from person to person, and that there are bound to be exceptions,” Google officials said in a February announcement of the launch of a new application about common health conditions. “What we present is intended for informational purposes only—and you should always consult a healthcare professional if you have a medical concern.”
A survey of more than 3,000 participants revealed that one in three U.S. adults (and almost half of college-educated adults) turn to the Internet as a diagnostic tool for themselves or someone else, the Pew Research Center’s Internet & American Life Project reported in 2013. For 46% of those surveyed, what they discovered online led them to believe that they needed the attention of a doctor or other medical professional. Of those who visited a clinician, 41% received confirmation of their suspicions.
The trend toward online research goes hand-in-hand with a growing emphasis on patient engagement. Knowledge can empower patients in shared decision-making. This model of care, proven to foster better outcomes, operates under the premise that well-informed patients can pose enlightened questions and express personal values and opinions about their conditions and treatment options.
“The old view is the paternalistic provider and the compliant patient,” says Anderson Spickard, III, MD, MS, assistant dean of educational informatics and technology at Vanderbilt University School of Medicine in Nashville, Tennessee. “This has changed to more of a partnership involving a concordant patient who shares more of the decision-making with the provider.”
Even after patients have done online research, “the expertise of the provider is called upon,” Spickard says. “It is great that patients have access to a plethora of information, but patients need the expertise and authority of the provider to navigate to valid information.”
Spickard suggests creating an atmosphere in which patients feel comfortable asking questions and seeking answers. No matter what, “avoid being dismissive,” he says. “Rather, be solicitous of their investigations.”
Dr. Google’s advantages
Seeing patients who have consulted with “Dr. Google” does have some advantages. For example, a patient who is more attuned to his or her symptoms can articulate them more easily, Spickard says. When symptoms appear embarrassing, online resources allow a patient to research a condition in privacy at home and to feel more at ease in discussing it with a physician.
Also, “if a patient correctly discerns from Internet sources that his or her symptoms are innocuous, and therefore does not schedule an appointment, this too may save time,” he says. “Patients can find themselves with symptoms consistent with a virus or minor flu bug and decide not to come to the hospital or provider. That’s good because they won’t spread disease.”
On the other hand, it is possible that a patient with a serious condition could be falsely reassured by online sources of information. The patient dismisses the symptoms as minor and doesn’t contact a physician until they become worse and more difficult to treat.
“More communication is best,” Spickard says. “I advise patients to contact their provider with any concerns for guidance on next steps.”
In an effort to prevent a patient from heeding the advice of inappropriate sources, “it’s incumbent upon physicians to make good information available to their patients,” says Richard Wexler, MD, chief clinical integration officer at Healthwise, a Boise, Idaho-based provider of health education materials for consumers distributed in physician practices. “People have a great thirst for information.”
The text should be unbiased, written in plain language, and accessible in print and via an online portal, Wexler says. Some practices have their own websites, while others are affiliated with hospitals or health systems that offer information about specific conditions and tests.
If a patient still insists on a particular screening, “we need to understand better why they want that test—what’s driving that request?” he says. Perhaps “they’re worried about something we don’t know about yet. We might be able to ask them questions like, ‘What haven’t we talked about that’s most on your mind?’ ” It’s important “to bring that to the surface and talk about it,” he adds. “Feelings are not rational. You have to deal with the emotion as well as the thinking brain.”
Active listening and probing to the root of the request can help a provider come to an agreement with a patient.,When that fails, the physician is guided by the basic principle of “first do no harm.” Even what appears to be a simple test may carry risks for the patient.
In the opposite scenario—when a patient objects to a test recommended by the physician—it’s important to respect the patient’s autonomy. Ultimately, Wexler says, the patient is in charge of what happens to his or her body. “Doing nothing may be a reasonable choice,” and if it fits in with the patient’s values and beliefs, “we need to honor that.”
While the healthcare system aims for patient engagement and shared decision-making, “what we have, unfortunately, is patients going to Dr. Google and bringing their assumptions to us,” says Larry Brown, MD, FAAP, medical director of primary care, service excellence and mission at CHI Health Alegent Creighton Clinic in Omaha, Nebraska.
For example, a patient may be convinced that he or she has the flu and request a prescription for Tamiflu. Many ailments can mimic the flu’s symptoms, so “that does not preclude my doing a physical and running lab tests,” says Brown, who serves on the physician advisory board of The Beryl Institute, a Bedford, Texas-based research institute focused on improving patient experience in healthcare.
“My job is actually to start over. I’m taking that as information as I’m doing that differential diagnosis. But I’m looking at the patient in totality, which Dr. Google doesn’t have the ability to do,” he says.
While coaching other providers in how to best handle these types of situations, he encounters those who say, “I’ll just give the patient what they want.” Brown’s response is, “Is that good medicine?” In the end, “you can give them what they’re asking for, but if it’s not appropriate, it’s not the right thing to do.”
Sometimes the patient and provider may have to agree to disagree. “There’s always the possibility that a patient could leave a provider’s office and say, ‘I did not get what I wanted,’ ” Brown explains. “But there should never be a situation where they weren’t listened to and a clear diagnostic process was put in place.”