Don't ditch your doc just yet

You've woken up with a tummy ache that could be due to last night's kebab, but you feel sure it's appendicitis. The receptionist at your GP's surgery cheerily offers you the next appointment, which is in two weeks' time. Clutching your side, you sit in front of your computer and find You learn that appendicitis causes right-sided pain and that since you've not felt sick and are now ready for a fry-up you're unlikely to need a surgeon's scalpel.

With medical information available at the click of a mouse, who, you may ask, needs doctors anyway? How many times have you waited for an hour to see the doctor only to get a six-minute consultation and a diagnosis in Latin? Clutching your list of unanswered questions you marvel at how unassertive you are in a GP's surgery. The Internet, on the other hand, is available 24 hours a day, doesn't make you feel it's terribly busy and lets you browse indefinitely. You can download information for reference and visit more than one site for a second opinion.

In the US, patients are increasingly being cheated by hospitals run by managed care organisations, which like to save money by limiting costly treatment. So patients use websites to check they're being given the best and not just the cheapest. Before websites were invented they would have used magazines and encyclopaedias. All are rich sources of health information. My father, for example, diagnosed scoliosis (a curvature of the spine) from reading an article in the New York Times.

Much research has been carried out into what patients want from a consultation with their doctors. Generally it's information. They'd like a cure, but they also want to be listened to and reassured. Some of this they can get from the Internet and even more from e-mail consultations with their doctors. Although these are not in widespread use, they have worked in university health services in the US, where access to the Internet is high. A study of over 100 college students using a health promotion computer network found their visits to doctors fell by nearly a quarter. Studies of patients with diabetes who were given dietary education programmes by computer show control of their illness improved dramatically.

The bare bones of a consultation between doctor and patient can certainly be replicated by a computer. Although the consultation is historically seen as detective work in which the doctor works out what's wrong with you (in at least half of all cases the diagnosis is found by looking to your past health and lifestyle), such history-taking essentially consists of asking a stylised set of questions. Patients can (and in some hospitals already do) easily answer this kind of formulaic list on a computer. In fact, phrasing the questions may be easier than in a human interaction where asking "what seems to be the problem?" can be met with "'You're the doctor." Likewise, "What's brought you to see me today?" can produce "I caught the C12 bus." After the patient has completed the list of questions, the computer or e-mailing doctor may offer some diagnostic suggestions and options for self-treatment. There are obvious limitations to this - resuscitation from a distance doesn't usually work - but there are also less tangible ones. Patients may not know whether facts are relevant, and decide to omit them. Patients also tell half-truths and virtual doctors may be more gullible. When asking about alcohol some doctors mentally double what patients have admitted. Or they'll ask "So how much do you drink a day - a bottle of spirits perhaps?" and see whether the patient looks shocked or is mentally adding up their intake.

And then there's doctors' intuition - more reliable with experience. A computer programme may work rigidly to hospital guidelines, but in a face-to-face interview a doctor may just have a hunch that something's not right. A doctor I know once insisted a child had a skull X-ray even though her head injury fulfilled none of the hospital criteria for the investigation. The little girl hadn't been knocked out, sick or amnesiac. The X-ray showed a large fracture.

Telemedicine consultations may allow doctors to diagnose anaemia by seeing patients looking pale, but they won't be able to feel their sweaty palms and suspect an over-active thyroid. If listening is vital, touching can be even more so. And it's hard for an e-mail to be effectively sympathetic because it can't reach for a patient's hand. A bad prognosis should never be sent by e-mail or read from an impersonal website, which cannot offer hope.

Perhaps it's because doctors are not always effective communicators that the Internet has caught on as a health provider. But the best use of Net information has to be in conjunction with a flesh-and-blood person. Most people will have met a doctor who has magically made them feel better. As Hippocrates said: "Some patients, conscious that their condition is perilous, recover their health simply through their contentment with the goodness of the physician." It's unusual for anyone to say that about their computer.

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