Dr Anthea Martin from the MDDUS writes nicely in BBC Health today about “cyberchondria”, or the phenomenon of internet self-diagnosis. All working GPs will recognise this; it happens to me very frequently. The patient comes in bearing a printout from a website, with a list of symptoms underlined, and says, “I want to get tested for mercury poisoning/ candida/ Lyme disease – I have all the symptoms.” According to this article, many doctors will find their heart sinking as they square up for a discussion about why it’s not what the patient thinks it is.
The thing is, I don’t believe that’s the case any more. It certainly isn’t with me. One of the core skills we learn as GP trainees is to “explore the patient’s health beliefs”. In other words, the consultation is much more likely to be mutually beneficial if the GP can extract from the patient what they believe about what’s wrong with them, and what they believe to be true about the condition. We use the acronym ICE – what are the patient’s Ideas about what is wrong with them?; what are their Concerns about the diagnosis, and what are their Expectations of what will happen next (will she examine me, do I need a test, am I going to die?).
This might be relatively straightforward:
- Patient: “I have a pain in my breast; I’m really worried.”
- Doctor: “Yes I can see you’re very anxious. Was there something in particular that you were worried about?”
- Patient: “Well my mum has just been diagnosed with breast cancer, so….”
Cancer is a huge worry for most people, and many people have quite complex beliefs about it, often erroneous. They might think that breast cancer is a common condition amongst young women (this is particularly true when high profile celebrities develop a disease), when actually it is far more common in women over 50. Sometimes it’s much more complicated, and it takes a bit of luck or some serious “digging” before you reach that point of shared understanding, like my patient Mrs V who believed that an x ray she had had during pregnancy had harmed her child.
When patients arrive having diagnosed themselves over the internet, I feel as though I have been given a gift. Immediately I know what the patient is worrying about – I don’t have to go digging quite as deeply to find out why the patient is here. I usually begin by thanking the patient for bringing it in, I have a quick read (and at this point it really doesn’t matter whether the printout is from somewhere bona fide like the excellent www.patient.co.uk or whether it’s somewhere much less reliable). I clarify the history, exam as I need to, organise investigations if appropriate, but crucially, I incorporate the patient’s health belief into my explanations about what will happen next. Kindness and respect are key here: even if I think the self-diagnosis is very unlikely, if you ignore it, you will get nowhere. So I might say: “Mr Smith; this has been really interesting for me. I can see why you thought it might be Lyme Disease, but I’m not sure it is, because [x,y,z]. I would have thought glandular fever was much more likely because [a,b,c]. But if things aren’t getting any better, we should probably revisit this in a couple of weeks/ once we have the blood results back and we can look a little more closely at things.” This patient is far more likely to believe that I have taken him seriously (because I have), than one whose doctor doesn’t address those concerns.
The corollary, too, is that for every patient who is worrying about a rare illness that he’s discovered on the internet, there might be a dozen who’ve been given valuable information about how to manage a fever in an infant, or what to do about a verruca, who then won’t feel they have to take themselves to the GP about it. As long as I can encourage my patients to use reputable sources, the internet has a huge power to educate and inform about health issues, and reduce demand to boot. So-called “cyberchondria” is such a small issue in comparison.