Patients would at times come for consultations insisting that we manage their ailments based on what they had learnt from the Internet. The stories of two such cases are as told. One patient was enamoured with the authority of Dr Oz who hosts a popular health website and talk show. The other cited an even greater authority, namely himself, after he was beguiled by information gleaned from the Internet. The challenge to ensure that these consultations remain therapeutic took different courses for the two patients.
Is it leukaemia?
The sixty-year-old man's chief complaint was that he could have leukaemia as he had a recent rash on his right shoulder with loss of weight and fatigue for some months. When I clarified the symptoms and the basis of his assumption, he cited Dr Oz, host of a popular US talk show.
Abdominal examination was normal. A monomorphic non-vesicular eczematous rash was evident around his right shoulder. What was significant though was that he was a diabetic who had defaulted treatment for months!
Surprisingly, the patient was only on acarbose before he defaulted. He said that he did not attend as he could not afford the drug. I assured him that there was no physical evidence of leukaemia and his ailments were due to uncontrolled diabetes. However, we would still do a full blood count when his blood was taken to check on his diabetes.
I delved into his records and learnt that he was first started on metformin. However, one doctor flagged that he was "allergic" to metformin and so replaced it with acarbose after the patient reported "stomach irritation". The patient had gone after reading on the Internet that gastric irritation was a common side-effect. Clinical notes of that encounter were scanty. However, I verified with him that there was no other reaction.
I was not surprised that his diabetes was poorly controlled even when he was taking acarbose regularly, as acarbose was never considered an efficacious drug. I considered replacing the acarbose with a gliptin but found that the latter was even more expensive!
The man listened respectfully to my counsel that the drug alert of gastric irritation was not indicative of an allergy. He agreed to be put back on metformin and to come back in a week, or earlier if he experienced any untoward symptoms. I also prescribed topical corticosteroid cream for irritant contact eczema resulting from an over-the-counter cream he applied for neck pain.
When reviewed one week later, the fasting glucose and full blood counts were normal. He felt better. The patient was happy that Dr Oz was wrong and his diabetes could now be controlled with an affordable drug. I assured him that his diabetes control would continue to improve with metformin. I have replaced Dr Oz as his expert!
I later learnt from Wikipedia1 that Dr Oz is a "cardiothoracic surgeon" who was exposed by the New Yorker and other institutions as a "pseudoscience promoter" on his popular Internet website. A US Senate investigation chided his weight loss miracle products as "scams", while an investigation by the British Medical Journal found that 46% of his claims were misleading or incorrect. Dr Oz's daily talk show continues to be very popular.
"I" am the expert
A 50-year-old man came for his third consultation because of high levels of low density lipoprotein (LDL) cholesterol. He first came eight months before when the problem was detected during screening. He elected to adopt lifestyle modifications and dietary control. I agreed as he did not have other comorbidities.
Repeated lipid panel done four months later was still high at 4.22 mmol/L. I counselled anti-lipid medications then but he refused. In this consultation, the LDL-cholesterol was even higher at 4.39 mmol/L. I clarified his understanding of the adverse sequelae of high lipids and he gave eloquent, erudite but derisive answers. I then told him about the benefits of lowering LDL cholesterol by using statin and assured him that he would be monitored carefully. The patient refused, citing the "many side effects of statins". In response, I quoted evidences from the scientific literature.
Sensing his "expert" role now challenged, he turned the table and haughtily insisted, saying: "I know my body. I can lower the cholesterol by changing my lifestyle. I do not want to be addicted to your medicine." He was thus enacting a role reversal to assert that "I am the expert. Who are you to tell me what is good for me!"
On hearing that, I documented the conversation and enquired: "What would you like me to do?" He ironically replied: "You should tell me. You are the doctor!" I booked an appointment for a repeat of the lipid profile in four months.
Interactive roles in consultations
"History taking is extended when we explore our own ideas, concerns and expectations (ICE) of the consultation – and not just the patient's – and reflect on how these impact the conduct of the consultation. This allows us to choose more effective therapeutic roles in managing our patient."2
The first patient came with the idea that his symptoms were due to "leukaemia", citing Dr Oz. His concern was that we do the blood tests that Dr Oz counselled and his expectation was that we comply. Our idea, however, was that he had uncontrolled diabetes; our concern was that he should take the appropriate anti-diabetic medication, and our expectation was that he should comply. But then there was the stumbling issue of cost.
We thus went out of the box to confirm that the allergy to metformin was not valid. The outcome was therapeutic as the patient accepted the challenging, engaged and expert roles we (the doctors) assumed. The previous doctor who replaced metformin with acarbose had assumed a comforting stance to assuage the patient's downloaded fears but that proved counter-therapeutic.
The second patient was obviously full of himself and the knowledge he gleaned from the Internet. He clearly knew the long term sequelae of high LDL cholesterol but chose to focus on the side effects of statins instead. He had this magical belief that the LDL cholesterol would be lowered if he continued to modify his lifestyle. His idea was that we should just do the blood tests.
There are obvious conflicts in the ICE interaction in this second consultation. We are expected to play a professional role of providing counsel. However, if we had continued to challenge and engage him on his reasoning, the consultation may have turned ugly.
We have all heard of patients making complaints that the doctors were rude and overbearing. In an "I say, you say" scenario, the doctor would often be the loser. Such patients may later become belligerent when complications of diseases ensue, and allege that the doctor did not provide due care. Should we routinely insist on signed informed refusal?
Attention to the interactive roles in this consultation and strategically switching our roles from challenging to comforting and from engaged to detached, was needed to avoid confrontation in this consultation. With the therapeutic relationship still intact, we can then broach the importance of statins again in the next visit.
Many patients search the Internet for expert advice and we need to accept that their ICE can differ from ours at times. Conflicts in consultation can happen when patients insist on their views against counsel. Extending the consultation to understand the interactive roles we play is one strategy to navigate this new disease called "internet-ism".
Author's Note:
The above narratives were based on patients seen by National University Health System family medicine (FM) residents, Drs Kristel Low, Audrey Han and Jean Tan. The two illustrations used were drawn by phase 3 medical students of National University of Singapore’s Yong Loo Lin School of Medicine based on salient cases encountered during their 2017 FM posting. To understand more about ICE, the cited 120-page book, The Extended Consultation – Talk Matters! is now available for interested readers.