More on doctors and email

You made some very good points relative to the patient who has complaints or is sick. In my comments (which I agree were not totally clear on this), I was referring to the person who has no complaints but the doctor is determined to do every test possible on the “sick, until proven healthy” theory. This is the worst part of defensive medicine in my opinion.

I know that not all doctors are like this but there are enough out there that those of us who are healthy and asymptomatic do need to protect ourselves (and find another doc)!

Signing off as just one person who thinks that the medical profession still can turn the corner and again become completely worthy of their patient’s trust.

p.s. It is a common tactic for many physicians to act condescendingly to a patient when questioned about their recommendations or to disparage other information (including leading medical journals) that the patient has researched and brought in to the office. I do not think that this kind of behavior does anything to build the level of trust which is essential to the doctor/patient relationship. It can all be boiled down to the willingness to talk with the patient (not at) and to be open minded about new information. (How many doctors prescribed HRT and Vioxx based on drug company information? I would think that this was embarrassing.) Of course, we are also talking about time spent with the patient and the need to bill accordingly!

Your example of why internet searches won’t help is poor— your call to “imagine the patient who complains of chest pain, nausea, and vomiting” fails to work through the senario. If a patient looks up chest pain, nausea, and vomiting on the internet and the first thing someone would find is a heart attack, it is very clear that the person is most likely to go to the ED claiming to have a heart attack or gets to the ED because he thinks something serious is going on. After getting the history from the patient, the physician is either 1) likely to go along with this initial diagnosis of MI, get the chest x-ray and get the right diagnosis, or the physician 2) get the history right and get to the diagnosis through chest x-ray or CT scan. Either way, it is unlikely that the internet search hinders care. It is not clear how a patient would fail to protect themselves by doing the internet search. They are very likely to go to the ED for nausea, chest pain, and vomiting thinking they have a heart attack rather than an esophageal rupture. I am not sure how your example illustrates a case that the patient’s failure to protect him or herself. Later your argument seems to be that by making a wrong self diagnosis, a patient will “demand unnecessary testing or medications.” This is unlikely unless the physician goes along with the diagnosis without doing his or her job. Patient self diagnosis 1) can be ways to engage in history taking with the patient, 2) existed long before the internet and 3) for most patients provisional (they believe that doctor once a history and physical is taken and the physician advises the patient). If patient self diagnosis is wrong and the patient doesn’t want to believe the true diagnosis or the physician’s advice, it’s not the internet that made then that way. There is nothing wrong with demanding a medication or a test, just giving in to it. That is not the internet’s fault.
Second, most patients don’t use the internet to get to a diagnosis, I would say most use the internet for information about their disease or a medication they are taking, or about a procedure they are about to undergo. They don’t use the internet as “a test” in the medical sense. The commenter did not say that patients were using the internet to diagnose, but rather to become better educated. The internet is a resource, and most patients know that. You challenge the assumption of the commentor, which you characterize as the assumption that “ ‘self education’ has a high specificity and sensitivity.” The self education the commenter describes is not about diagnosis, but about protection, i.e. is what my doctor doing and saying about my conditions right?
One final thing. Counterarguments to (or rather dismissals of) ideas on medical payment reform on your blog seem do revolve around “externalities”—unforeseen consequences. The simple logic and simplicity of charging for time for patient seems to me to promote medical laziness—why not spend a lot of unnecessary time with a patient on a simple complaint, charge them more, and make the patient feel better and the physician with easy money? Most patient visits are bread and butter (not complex diagnostic cases), and this is easy money. I think most are hard pressed to find anyone who would rather pay an attorney by the hour, than by a flat fee for a job. If you want an example of “doc by the hour” check out the VA—clock in and clock out. The VA is not a model of excellence—no one goes to the VA to get excellent care. You go because you don’t have outside insurance, or you don’t have pharmacy coverage. And patients don’t get transferred to the VA for “hard cases”, they get transferred go to the nearest medical center.