Six focus groups were conducted with 48 family physicians, with an average of 10 participants per group (range 8-12), between April and October 2002. Participants, of whom 54% were male, had been practising for 6 to 27 years, and were encountering approximately 125-149 patients per week on average. All physicians had active practices in the greater Toronto area.
Three overarching and interrelated themes were identified: (1) perceived reactions of patients, (2) physician burden, and (3) physician interpretation and contextualization of information. Within the theme of interpretation and contextualization, the sub-themes of physician roles, resistance, and strategies were identified ().
Physician perspectives on Internet-based health information introduced by patients
Dominant views as well as provocative dissenting views are presented below for each theme. Support for our interpretation is provided by including particular quotations from the data that most clearly illustrated the analytic points. From here onward, we refer to Internet-based health information as “Internet health information.” The abbreviations “FG 1,” “FG 2,” “FG 3,” and “FG 4” refer to the four focus groups, and “pg” indicates the page location of the quotes in the transcribed files.
Perceived Reactions of Patients
Physicians distinguished various patient reactions to the Internet health information brought to medical consultations. Broadly, some patients were perceived to have emotional reactions (confusion or distress) to the Internet health information, while others were perceived to have used the information for self-educationon pre-established medical conditions or for self-diagnoses with or without self-treatment. The latter group was discussed as challenging despite its small size.
Patients with emotional reactions were perceived as being either “confused” or “distressed.” Physicians attributed patient confusion to their limited ability to evaluate, personalize, and interpret abundant Internet health information. Physicians identified these patients as needing clarification of the information brought to the visit:
FG 3, pg 2: Patients who do come with information, I find they are more confused than anything else and they come for clarification.
FG 2, pg 2: They [patients] are getting full of rather stupid facts in many cases, which they do not know how to interpret, which are usually misinformation.
In other instances, Internet health information resulted in patient distress, which was perceived by physicians as patient “anxiety,” “worry,” “nervousness,” panic,” or the patients feeling ‘overwhelmed” or “sicker.” For this cluster of patients, physicians attributed their distress to such factors as the sheer volume of Internet health information, blind faith in or acceptance of Internet data (ie, believing everything one reads), and/or the inability to critically evaluate the personal relevance of the information:
FG 4, pg 3: They are bringing up sort of obscure articles and stuff about different conditions, and some of them are pretty scary.… They think everything is happening.
FG 6, pg 11: It makes them sicker, because they get too worried about what their problems are.
Physicians favorably perceived those patients who used Internet health information for educating themselves about their pre-established medical conditions. The self-educators were perceived to introduce the Internet information into the medical visits for confirmation, without challenging physicians’ expertise.
FG 5, pg 4: I think there’s one situation where the Internet is useful. If the person has the diagnosis, and they want to find out more, educate themselves…, I find that’s actually helpful in cases where…it’s not time-consuming for me.
Patients were perceived as “challenging” when they used Internet information for self-diagnosis or self-treatment or to test the knowledge of physicians. The Internet was deemed simply another potential source of misunderstood health information for the challenging patients who were also described as adversarial, professional, difficult, or neurotic. Some physicians perceived these patients as lacking trust in their provider. Physicians often discussed having to defend their diagnosis or treatment plans, with feelings ranging from anger to frustration (for further details, see Physician Contextualization and Interpretation, below). However, a few physicians discussed how patients felt distressed and needed help after making self-misdiagnoses.
FG5, pg 10: If they’re, however, using it to diagnose, then I think that’s where the problem lies….
FG 4, pg 14: You may disagree with whatever disease that they’ve come in with all this research on.... I think it’s like putting the cart before the horse.... They’re ahead of you and not on the right track.
FG 5, pg 9: I find that they are testing me on how up-to-date I manage to be.
FG 1, pg 5: Part of the therapeutic relationship is the trust and the belief that the doctor will make you better. You don’t have that, you have lost a great portion of your therapy.
Physicians discussed several difficulties arising from the introduction of Internet health information into the medical consultations. Expressions such as “awkward,” “tough spot,” “hard time,” “headache,” “nightmare,” “annoying,” “irritating,” and ‘frustrating” indicate the magnitude and nature of the difficulties and the accompanying sense of burden such information placed on physicians.
Concerns about the quality and quantity of health information on the Internet were common. Physicians linked their uncertainty about websites to their lack of information about recommended health sites andthe instability of websites over time.
FG 1, pg 2: I can’t answer for a lot of their questions about the validity of the sites that they’ve received information from….
FG 1, pg 3: I would like to be able to send them to a site that I know is, has reliable information. And I’m not at a point where I have that yellow page book for sites that are approved or somehow controlled.
Time constraint was a major issue for these physicians. They discussed having limited time to deal with Internet-derived “volumes of pages” or “scrolls” of questions that patients bring to their visits. In only a few instances did physicians think Internet health information could actually be time-saving. “Big lists” of questions were particularly problematic and a cause for cynicism among some physicians:
FG 5, pg 13: As soon as that list comes out I panic…[because of] time constraints and everything else.
FG 1, pg 3: I do not mind patients coming in with information, but it is very hard if they present you with a package of, you know, 60 sheets.... Time is really at a premium, so it makes it very difficult.
Furthermore, some physicians acknowledged their limited Internet skills and attributed this to a lack of time to advance their computer skills. This was predominantly discussed among older physicians who seemed reluctant to spend time on learning this new technology:
FG 5, pg 8: One of the frustrations is, knowledge takes time, and it’s fairly busy, in a busy practice, to just keep up and current in all areas.
FG 3, pg 10: All the graduates [are] now using these technologies. So, it’s not that it’s too expensive for us as physicians. It’s that we are caught in this transition in terms of “I do not feel comfortable, the time to learn it.”
There were, however, a few instances of “rare conditions” and “travel medicine” when physicians thought that Internet information brought by patients into medical consultations had been helpful in making a diagnosis or identifying an appropriate referral.
FG 6, pg 12: We [family physicians] do not know everything. Then, it can’t be challenges, actually “teach me” sometimes.
FG 1, pg 3: I had a patient…I didn’t know the diagnosis, something getting off a ship and having vertigo and some problems that ensued. The ENT doctor did not know…and in her search on the Web she found the diagnosis and found a single physician in Ontario. She ended up getting a referral by me….
Physician Contextualization and Interpretation
Many physicians viewed putting Internet health information in context for patients (ie, providing perspective on information in relation to a patient’s unique history and health status) as part of their responsibility and role. Physicians generally believed they were in the best position to explain, synthesize, and contextualize information because of their training:
FG 6, pg 7: I think for many patients they don’t have the wherewithal to assimilate this sort of information and come up with the appropriate response.... Part of our role is to explain that to them.... They don’t have the background knowledge that we have in order to put it into proper perspective.
The specific roles of physicians in relation to the contextualization and interpretation of Internet health information varied depending on the responses of patients to that information. For those patients perceived by physicians as self-educators, the work of the physicianwas generally limited and sometimes actually reduced.
However, for distressed or confusedpatients who took an uncritical stance toward the information, physicians discussed having the significant task of educating them by putting the information into its proper context. Physicians perceived this task as time-consuming, and, hence, a burden on their routine clinical responsibilities:
FG 5, pg 1: Similar experience where the patients are coming informed with information from the Internet, and sometimes from good sources and sometimes from more anecdotal, personal Web pages where the information may not be entirely correct. Then, you have to do lots of damage control and try to not disinform but try to undo and re-educate.
For patients who used Internet for self-misdiagnosis or self-treatment,physicians described doing substantial work in justifying and, at times, even defending their own diagnosis and treatment recommendations or in “debunking” incorrect information. In having their expertise challenged, some physicians felt they were at risk of “losing face” and/or being “put on the spot”:
FG 4, pg 3: Some of my patients come in with a diagnosis...convinced in their minds that this is what they have. Then you’re almost put on the defensive sometimes as to why you think otherwise, or why maybe they should be looking elsewhere for what are their symptoms. So, it’s more of a challenge.
Importantly, not all physicians embraced the role of interpreter, and there were indications of resistance from some to discussing Internet health information with any patient:
FG 3, pg 1: Most of them [patients] know it’s annoying to me when they do it [bring in Internet downloads], so they don’t.
FG 3, pg 3: I just sort of stick with what I know and what I do and how I practice.
The excerpt above highlights the fact that, in some instances, not only is the physician resistant to Internet health information, but his or her patients are aware of this resistance. Older physicians seemed more resistant:
FG 3, pg 11: A lot of people do not take new patients. So, we are going to grow old with our patients. And they’re gonna get used to our ways and we’re gonna [get] used to theirs.
FG 5, pg 14: I think a lot of it is dependent on the age of the physician…. The older physicians are paternalistic and…do not feel comfortable when a patient comes in with an article….
Physicians discussed various strategies they had adopted in order to cope with Internet health information introduced by patients during medical consultations. These strategies included recommending reliable websites, asking for a follow-up visit, or expressing limited knowledge on specific details:
There is nothing wrong with saying, “You know what? I do not see a lot of this but I am going to find out for you.” (FG 1, pg 15)
They have huge time commitment and an emotional commitment to whatever it is they’ve brought in. So, I’ll say, “Leave it with me for a couple weeks and let me think about it.” And I’ll usually look it over, probably not while they’re there, not that minute. (FG 4, pg 5)
Notably, some physicians discussed strategies of “firing” the patient, referring patients to specialists, or charging for extra time. These strategies have the potential to undermine the physician-patient relationship.
FG 4, pg 9: Well, frankly, we’re paid for [the] visit. So, if your patient [is] having a $15 visit, you’re not going to sit for 15 minutes going through all this, you’re going to get them out of the office.
FG 3, pg 4: If they come in and it’s too much and it’s too specialized…I let them slug it out with the specialist. They’re paid very special money to do this kind of work.
FG 4, pg 13: Maybe we can bill our patients privately for extra time to review research with them, if we can choose to do that or not do that.
FG 5, pg 7: They’re coming back [with Internet information]. It requires a little looking into. If you’re tired, of course, you’ll probably just fire them…if they’re really belligerent.