Abstract
The search engine is one of the greatest inventions in human history.
‘Doc . . .
. . . could the white spots in my mouth be due to commencing epilim?’
. . . could lithium have caused my atrial fibrillation?’
. . . could ritalin have caused my penis to have become smaller?’
Such seemingly false speculations from a patient to a psychiatrist might elicit a kneejerk dismissive response, evoke a wary equivocal reply (‘I think that is unlikely’) or generate a call on clinical experience (e.g. ‘I’ve never come across such a side-effect’) – with all such options communicating rejection of the postulates. In instances where some improbable side-effects might just be plausible, the psychiatrist might in the past have offered a temporizing response allowing time to consult with a colleague or a reference book from the hospital library (for younger readers, this was a purpose-designed room containing collections of books and medical journals).
In the last few years, Dr Google has become my clinical wingman, generally providing rapid clarification in response to many such recherché and quirky queries and seemingly far-fetched hypotheses. This partnership was not anticipated and is contrary to the views by patients about doctors’ views about Google and other search engines, as evidenced by their invariable hesitant framing of their questions. (‘My apologies doc, but I was looking on Google and . . .’).
Following such ‘could’ questions, I now await the predicate with interest and with a finger hovering over the keyboard. Not only do I have an immediate resource strategy but there is a strong chance that I will learn something. In a face-to-face consultation, I might offer ‘Let me run a check on that’ and turn my attention briefly to the computer, seemingly evidencing an open mind. In a telepsychiatry consultation, I can often (undeclared) initiate the reference check on the search engine while maintaining a steady stream of seemingly undistracted conversation.
For any clinical question, there are generally multiple search engine sites offering a specific or definitive response. Other sites are essentially chat rooms or channels that simply report anecdotal information. It’s a wheat versus chaff world.
Thus, let us pursue the exemplar questions (which were all put to me in a single week). The first patient’s description of white spots suggested mouth ulcers. I turned to my computer and punched in ‘Can epilim/valproate cause mouth ulcers’ while maintaining a temporizing parley. In 0.52 seconds, I was informed that 43,600 results were on offer. Such a side-effect was affirmed by numerous respected medical bodies (e.g. the Mayo Clinic) and medical organizations (e.g. the UK’s National Health Service, New Zealand’s Medsafe). In addition, in the first two ‘pages’, I found two journal articles reporting on the phenomenon and providing quantitative data. Gold. An unequivocal response was able to be offered to the patient (‘Yes, it’s a well-recognized phenomenon’) with a level of urbane authority.
In some instances, the available data will not simply affirm a query but provide clarifying contingency data. For example, when I punched in ‘Can lithium cause atrial fibrillation’, not only was the (albeit weak) possibility detailed but several sources offered clarifying information (e.g. that such a risk is increased if the serum lithium level is at toxic levels or that the phenomenon can occur as a consequence of the lithium inducing a Brugada syndrome). The latter also initiated a search for information.
While the first two exemplars support the claim that search engine sites can provide definitive and enlightening knowledge, the third provides a good example of dubious or problematic information that search engines can generate. In response to ‘Can Ritalin affect penis size’, and where there were only a disappointing 190,000 results in 0.44 seconds, site information was weighted to opinion rather than to any authoritative data – other than the opposite side-effect (of priapism) being occasionally reported. Speculation abounded. One named doctor affirmed such a phenomenon and stated that it is the result of the drug causing constriction of the arteries to the penis. Another site stated that shrinkage was a consequence of the amount of elastin in the body being decreased by the drug. Another postulated testosterone-blocking effects. However, the sites were more dominated by those with secondary agendas (e.g. one US medical centre affirming the phenomenon and recommending penis enlargement surgery) or those that appeared to embrace tittle-tattle. The lead pages were weighted with chat sites such as Reddit (Reddit being an American discussion website allowing anyone to discuss anything), generating anecdotal information, speculation and, at times, rhetorical hyperbole (‘Are these drugs creating generations of men with smaller penises?’).
While I now view such technology as offering a highly useful (albeit niched) informational tool, this appears anti-zeitgeist. Accessing views about ‘Dr Google’ itself (or should it be himself/herself/itself?) is readily achieved by consulting Google directly and examining the listed memes. Most memes weight a high risk of inaccurate or alarmist information. For example, (1) ‘Panic wildly after googling your health issue’; (2) ‘I googled your symptoms. You have one week to live’; and (3) ‘I thought I had an ulcer. But after reading it online I am 100% sure it’s cancer’. A lead quote captured a common response by doctors to web-based information (i.e. ‘As a medical professional, sometimes you have to just put your face in your palm and sigh when you realize that most people will search the web before consulting their doctor when they have a health issue’). If not portrayed as dismissive, doctors are portrayed as defensive (e.g. ‘To keep my practice going, I changed my name to Dr Google’) or marginalized (Patient to doctor: ‘I already diagnosed myself on the Internet. I’m only here for a second opinion’).
For those patients who have accessed a dubious site (perhaps one with a strong anti-medication stance) and appear to have more belief in that site than in the clinician’s opinion, the task then is not dissimilar in negotiating with a patient who has an intrinsic bias against the clinician’s suggested management option. Any number of strategies can be employed. I like Desmond Tutu’s suggestion: ‘Don’t raise your voice, improve your argument’.
One of the most notable changes in medical practice over recent decades has been a move away from a hierarchical doctor–patient model, where the doctor automatically knows best (if not everything), and the patient is a passive receiver of information and advice, and a change to be applauded. Given such a context and our reliance on digital technologies, why should a patient offer a defensive apology when they inform us about consulting ‘Dr Google’? Inventor James Dyson observed that search engines are the new equivalent of publishing in being an enabler of information.
The clinician’s task – as it is generally in making diagnostic and management evaluations – is often to use their skills to sift kernels from the dross in their interactions with patients. That task has now widened to interpreting search engine information. To repeat myself, Dr Google has become my clinical wingman, offering more positives to clinical management than concerns, potentially offering access to swathes of information and doing so rapidly.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship and/or publication of this article.
