Nurses are well adept with dealing with old wives’ tales and medicine folklore being handed down through the generations at the dinner table. But as technology has moved on, dealing with the well-engaged but possibly misinformed patient is a modern-day dilemma.
In the age of the internet, ‘Dr Google’ provides a much bigger platform for so-called ‘experts’ in health information and advice. Rather than health myths being spun by well-meaning family and friends, they can now be beamed all over the world and into the minds of vulnerable people desperately seeking help. While there is no doubt that some ‘experts’ come from reputable clinician-backed evidence-based websites, others are faceless, nameless and can come with an ulterior motive.
There is general agreement among health professionals that there has been a rise in the number of people accessing self-diagnosing and health information websites thanks to increased access to the internet. Such technology advances have also meant it is not just the young and educated that question their care but the old, the less wealthy and the less educated. And this appetite for information shows no signs of slowing.
The Royal College of Nursing’s (RCN) primary care advisor Rebecca Cheatle says anecdotal evidence from the organisation’s practice nurse forum shows online usage is on the rise, with more patients accessing clinical websites such as GP Notebook.
Helen Lewis, practice nurse at the Grange Medical Practice in Cardiff, Wales, believes there is a 50:50 split between the number of reputable and non-reputable health information websites in existence and estimates she sees around one patient every two months who has already been diagnosed by ‘Dr Google’.
Usage figures from medical website WebMD, which is run by pharmaceutical chain Boots, shows it attracts an average of 91,396 visitors a day, which amounts to more than 33 million visitors every year. And health information website NHS Choices has noted a year-on-year rise in usage figures and currently receives an average of 16 million hits every month.
Health information is now readily available at the click of a mouse. While some may argue this will keep health professionals on their toes in ensuring their knowledge is up-to-date, others see the pitfalls of ‘Dr Google’ as a barrier to true face-to-face patient care.
While Lewis says she doesn’t want patients to be observers of their care, she claims self-diagnosing websites “undermine” the work of practice nurses.
“It would make my life a lot easier if patients didn’t go these websites before a consultation,” she says.
“To read something on a website can be daunting as it will list all the side effects of particular treatments – however remote they are. So in order to alleviate a patient’s concerns, you need to give them a licence to use the website with an invitation to come back to the practice should they need to question anything.”
“It is extremely difficult for a doctor or nurse to make a diagnosis even with their years of experience, never mind a lay person,” he says.
Katherine Murphy, chief executive of the Patients Association, is another that is “wary” of ‘Dr Google’ and urges patients to heed her words of caution when accessing the internet for fear the company behind the diagnosis is not as it seems.
“Sometimes you can have information overload, especially if you are being given the wrong information,” she says.
“I am always very wary about people receiving a diagnosis or getting health information via the internet, because it is difficult to know whether people visit accredited and regulated websites or they choose to go to sites whereby the company running the service could turn round and try and sell them the magic cure to the illness they have just diagnosed them with.
“Websites like these can be very dangerous and could take advantage of vulnerable people, especially those with unusual or embarrassing conditions who would rather the privacy of their own home when accessing health information.”
Dr Hicks attributes the rise in people seeking health advice online to the increase in relevant, accessible and supportive information “that is easy to take on board”. He also claims time restraints – possibly born out of squeezed budgets – have led to health professionals increasingly advocating online use.
While Lewis rebuffs the claim that cost cutting in the health service has led to an increase in ‘Dr Google’ usage, she does admit more practice nurses and GPs encourage patients to visit reputable websites to learn more about their condition when newly diagnosed. This, she says, may set the “wheels in motion” for more online patient behaviour. The RCN’s Cheatle also believes patient online usage has become “more prevalent” since the swine flu pandemic in 2009 after people were actively encouraged by healthcare professionals to self-diagnose.
In giving patients the confidence to question and challenge health professionals as well as sometimes promoting the initial conversation in the first place, Dr Hicks claims health information websites offer great benefits to both nurses and patients.
Mandy Williams, head of programme and clinical lead for health information website NHS Choices, cited a recent satisfaction survey of site users, which showed over a third (37%) of 2,000 people agreed that using NHS Choices helped them to feel “more confident” when visiting a healthcare professional.
“This implies those using the site are better informed and more able to talk about their symptoms and treatment options with their GP or practice nurse,” she says.
“In addition, the wealth of tools available on the site can help patients to manage their weight, monitor their alcohol intake and even prevent food poisoning. The site also has a range of videos featuring real life stories from other patients, which can help some patients, especially those that may have been recently diagnosed, to feel they’re not on their own.”
But Dr Hicks is well aware of the dangers of ‘Dr Google’.
“The role of health information websites when they are well produced and the information is well researched and delivered is incredibly helpful,” he says.
“But like anything, when they are not well developed and are inappropriately used, they can cause all kinds of havoc.
“I can understand that health information websites make life difficult for nurses, they are no angels. One of the reasons I am involved is to make sure they are less likely to cause problems.”
Dr Richard Stacey, former GP and mediolegal adviser for the Medical Protection Society (MPS), claims symptom checking and health information websites can be “double edged” in educating patients but potentially also giving rise to a “mismatch” in patient and nurse expectations – the most common reason for legal complaints and claims.
“Legal claims generally arise when a patient’s understanding, concerns and expectations of their condition are not identified or addressed,” he says.
As reported by Nursing in Practice in January 2012, the seriousness of legal claims being brought against practice nurses is on the rise, with the cost of legal action concerning cases involving RCN practice nurse members rising by nearly £2m alone last year to reach around £5m.
Dr Stacey says it would be “difficult” to pin the increase in claims brought against practice nurses solely on the rise of ‘Dr Google’. Instead he blames the current economic climate for the growth in legal claims and estimates patient online usage to be a “small factor, if a factor at all”.
But aside from the legal complaints, what about the sacred patient-nurse relationship?
Lewis played down the impact of self-diagnosing websites on such relationships, claiming it would depend on the state of the pre-exisiting bond.
“If you have got a good relationship with your patient, you will be able to bring up evidence-based practice and discuss within the consultation the shortfalls of the information they have in front of them,” she says.
“Now that the National Institute for Health and Clinical Excellence (NICE) guidelines have become more interactive, I would happily bring them up on the computer and talk a patient through them.”
WebMD’s Dr Hicks also believes the rise of ‘Dr Google’ needn’t be as damaging to relationships as one might think “as long as it is handled properly”. In fact, he claims patient-nurse relationships may be strengthened through a patient’s online use.
“As long as nurses don’t tell the patient that the information they have gathered is nonsense and wrong and listen to what the patient has to say, then they are less likely to risk damaging a relationship and are more likely to build a stronger one as quite rightly, the patient will feel as though they have been taken seriously,” he says.
“Managing ‘Dr Google’ expectations is no different than a patient coming in and saying ‘my friend told me I need this drug’. You need to explore why they think they need this drug, find out what their symptoms are and gently and sensitively advise them why it might not be the right idea without upsetting the patient and without implying the friend is a fool.”
The RCN’s Cheatle also advises against nurses taking it upon themselves to determine whether the information gleaned from health information websites are complimentary or undermining to their work and ensure they do not judge either the website or the patient.
“It is not for nurses to criticise the website, they have to be mindful about why patients have gone to them in the first place,” she says.
“Nurses need to point out what is good clinical evidence not to give an opinion over the validity of a piece of information.”
Dr Hicks says it is important for nurses to look behind why patients turn up to the consultation room armed with bundles of paper they have printed off the internet.
“Could it be their treatment is causing side effects or could it be that the patient hasn’t accepted yet that their condition cannot be cured?”
The MPS’ Dr Stacey says nurses must “harness” the benefits of having well informed patients while also “being aware” of the challenges. In order to do, nurses must first have a clear knowledge of what the patient’s understanding is of their condition, the information they have found and any concerns they have by accessing the website in question or reading through any printed material with the patient in front of them.
In the instance where a patient’s expectation has developed as a consequence of some questionable information and is perhaps unreasonable, Dr Stacey says communication is key.
“Patients must feel as though they have been listened to and been involved in deciding on a shared understanding of what the best way forward is for them,” he says.
The idea that the patient-nurse relationship can be strengthened by health information websites has been backed by a study published in the British Journal of General Practice. Researchers from University College London said health professionals should find it “encouraging” after finding those patients who use the internet to self-diagnose can “gain more” from a consultation in general practice.
While many of the 26 patients studied reported positive experiences of GPs listening and acknowledging their concerns, others felt “worried” that their GP felt “undermined or threatened” by their online usage.
Dr Stacey says nurses must have the confidence and humility to be honest with their patients when presented with those who are more informed than they are about a particular treatment or condition. This could mean choosing to include a doctor in the decision-making process, further research, or arranging to defer the decision and scheduling a review appointment.
“Sometimes as a nurse, it can feel quite challenging when a patient is well informed and nowadays people can get very quickly informed about a subject area,” he says.
“Most patients do understand that not all nurses will have the information at their fingertips and appreciate the kind of honesty and thoroughness that comes with a practitioner going away and coming back with research. It is about a nurse recognising that in some instances a patient may have a better knowledge of a subject area than they do.”
Louise Naughton is a writer and journalist specialising in healthcare.
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