Each day pediatrician Deanna Aftab-Guy quickly shuffles through her medical texts to counsel worried parents who inquire about their children's fevers, ear aches, and rashes.
Then she logs on to an America Online health site called Thrive, where she becomes "The Kid Doc." Aftab-Guy posts answers to selected medical questions, chats with surfers, and assists Netizens a long way from her hometown in Ohio.
Aftab-Guy's online persona bears a dual responsibility: Not only does the Kid Doc dispense appropriate medical advice, but she also spends much of her time countering misinformation that people have gotten on other parts of the Internet.
"The hard part for me is seeing inaccurate advice from people who aren't physicians," she said.
That is the paradox facing physicians on the Internet, which is stretching the boundaries of doctor-patient relationships in myriad directions. In addition to giving them millions of established medical resources, it gives online consumers access to a lot of information that may not be reliable.
Many patients say they are willing to take the risk, preferring to have unrestricted access to as much health-related information as possible from the vast number of medical journals, non-profits, consumer groups, and holistic health advocates online. At the same time, a rush of pharmaceutical companies and personal home pages have also found their way to the Net, offering everything from home remedies to marketing pitches for products with little or no regulation. And it may be only a matter of time before a malicious hacker preys on a legitimate site.
Ironically, the issue has also raised liability questions for doctors like Aftab-Guy. Most medical sites carry disclaimers, but it is unclear whether that would absolve them of responsibility in a malpractice case resulting from online advice.
"Courts have ruled in the past that disclaimers don't always protect from liability because people may not see them. Courts have also said, 'Why did you give out the information unless you thought people would use it?'" said Dr. Richard Anderson, chairman of board for The Doctors' Company, a firm owned and operated by physicians that provides medical liability insurance to 18,000 doctors nationwide. "There is no easy way a doctor will be protected from liability on the Internet."
Attributed medical information, however, is not what's generating the most concern.
According a recent study by research consultancy FIND/SVP, more than half of the health sites on the Web are owned by individuals or organizations who want to sell products or services. The report, based on 1,000 adult Internet users, also stated that the material is often inaccurate.
"The most creditable information will be put together by a team of people, under peer-review system," said Dr. Robert Johnson, associate medical editor for Mayo Clinic's Health O@sis information site which targets lay audiences. "Also, people should look at the focus of the Web site. A lot of sites are really marketing a product, and the health information is secondary."
Other sites are set up in public newsgroups where non-doctors and others exchange ideas anonymously or on home pages claiming to belong to doctor, but contain no credentials or hospital affiliations.
A method used by physicians and researchers to deliver medical information via electronic systems. This transfer of medical data, which allows immediate access to shared patient records and diagnostic images, may use the Net, intranets, PCs, satellites, and videoconferencing.
Drawing particular concern are sites that provide off-the-shelf advice to anyone who requests it, such as online medical advice forums and search engines that associate symptoms with a partial diagnosis. For example, surfers can punch in symptoms and get possible causes at such sites as House Call, Medical Matrix, Pareras Online, Pharmaceutical Request, and Telemedical.
The medical establishment, as well as the Food and Drug Administration and state regulators, are trying to get hold of the situation, but the issue has proved elusive.
Last summer, the American Medical Association passed a resolution recommending that doctors who give advice online be licensed in the states where their patients live. However, the AMA said this week that it has yet to form a policy on Net-advice liability issues for physicians.
"We rate the sites listed with the AMA on whether they're overly commercial and other criteria," said Nancy Vlasak, the AMA site business manager. "With the Net being the wild, wild West where anyone can publish, we want to bring people creditable, reliable sites reviewed by the AMA."
And not everyone sees danger in the proliferation of such Web sites, saying that it has democratized health care for patients.
"The days of doctor knows best are over. Patients are taking a more active role in their treatment using the Internet and other resources," said Dr. Howard Bleich, co-president of the Center for Clinical Computing at Harvard Medical School and Beth Israel Deaconess Medical Center.
Bleich helps run Paper Chase, a search index of 10 million resources from repositories such as the National Library of Medicine and the National Cancer Institute. The service is used by doctors, nurses, and many non-medical people.
"I think it's to be encouraged," he said. "Medicine is trying to defy nature's decree. The more brains, the better."
Doctors themselves need such online resources to save time and stay current. "They have very little time to read," said Bob Ubell, president of BioMedNet, a Web site for the biological and medical community. "With the Net they can search articles and abstracts from their desktop."
For consumers, sponsored advice sites like the "The Kid Doc" are the online equivalent of radio call-in shows or newspaper Q&A columns. They often provide generalized advice, not to specific patients, and remind people to seek their personal physician's advice.
"It's really an educational service more than anything else. I don't answer personal condition or specific drug prescription questions," said another health expert on Thrive, Dr. William Lloyd (a.k.a. "Dr. Bill").
Lloyd said he did not worry about malpractice lawsuits when he signed on with Thrive. "It is written in my contract that Thrive will compensate me for any legal fees and judgments arising from cases concerning my work with them," he said.
Aside from unknown liability issues, doctors also fear that Net consulting leaves out the important physical examinations and personal interaction doctors rely on to diagnose patients.
"The hardest part is not being able to see the patient," Aftab-Guy said. "If I could just look into their ears or see the rash it would be easier. No matter how great the Net gets, even with video, it won't replace face-to-face contact."
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