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Patient with bundle of printouts from internet

You're the expert, don't be fazed ­

see it as a learning opportunity, says

Dr Harry Brown

As a GP registrar many of the scenarios you face are run of the mill to an established GP like your trainer. But being faced with a wad of printouts from the internet can often be a challenge for the established GP principal, never mind a GP registrar new to the sometimes bewildering world of primary care.

Okay, so a patient comes through the door of the consulting room, sits down and produces a thick pile of paper containing printouts from a number of websites and puts them on the desk and says: 'What do you think doctor?' Well, rule number one is keep cool and don't show your discomfort, even if you feel it. Though easier said than done, don't feel challenged, insulted or threatened, look upon this as an educational experience: the patient has kindly organised the tutorial.

Like any other standard consultation, try to determine the patient's agenda:

 · Why did they do this and what specific questions or problems did they have?

 · Are they unhappy with your or other doctors' management (approach this tactfully in a non-judgmental way)?

 · Did they find this exercise useful? If so why?

 · Have they done this online searching before?

Remember they have brought the printouts to you, so they are probably asking your advice and opinion and it is likely they are going to value it. So don't feel threatened, look on this as a positive educational experience you are likely to benefit from.

Ask the patient what information they have found out and ask them to summarise it. In particular clarify areas of disagreement but avoid confrontation or criticism ­ look upon this section of the consultation as a fact-finding mission. They may offer you a bundle of printouts to look at and, if there are too many, you may offer to read them at your leisure.

This may eat up some of your personal time so you could ask the patient to summarise the main points for you.

Once you have elucidated the patient's concerns, questions and anxieties, then start to appraise the information they have gleaned. Remember, the patient is likely to accept that all that is written and said on the internet is not always true. Equally the patient may not understand some of the technical data they have acquired.

Your job is to grade the quality of material the patient has downloaded and printed out before embarking on reading their contents.

Obviously material downloaded from quality sites that are freely available to the public as well as the medical profession is likely to be correct. If the article came from the website of the BMJ (www.bmj.com) or BNF (www.bnf.org) then it is highly probable that the source is unquestionable. But if the data came from less credible sources such as a mailing list, chat room and so on, though the information may still be valid, it needs to be cross-checked. If you want to put this exercise on a more formal level, there are websites that assist appraising online medical information. Look at:

lwww.discern.org.uk/discern__instrument.htm

(two underscores is correct)

lwww.hiquality.org.uk/guide/default.htm

lwww.judgehealth.org.uk

lwww.quick.org.uk

lwww.hon.ch/HONcode/Conduct.html

Glancing through, you can see there is a common theme on how to address the quality of information on websites. That theme can also extend to offline publications such as magazines and newspaper cuttings that patients also bring to consultations.

If the patient has produced information that is credible and cross-checks with reference sources such as textbooks and your advice or information is wrong, then don't be afraid to admit that. Be grateful the patient has made the efforts to correct you. But if you disagree with what the patient has found, explain carefully the reasons and try and not sound triumphant.

During this or a future consultation you may be asked to interpret technical information that the patient has acquired but does not fully understand. This is fine and helps to build mutual trust and understanding. Also bear in mind that this whole process will probably not be managed within the time constraints of one consultation and follow-up may be needed. This also gives you breathing space to do your own research if you need to clarify some points raised during the initial consultation.

You could suggest quality resources for the patient to look at, to confirm what you have said, These could include:

lwww.nhsdirect.nhs.uk (the online version of NHS Direct ­ an excellent site)

lwww.patient.co.uk (a super portal leading to a whole raft of patient information)

lwww.nelh.nhs.uk (more geared to the health professional rather than the consumer but contains links to a great number of useful information sources)

lwww.doh.gov.uk (Department of Health site)

lwww.vh.org/navigation/vh/topics/adult_

patient_index.html (although American, this is part of the amazing virtual hospital site and contains a large number of links to patient-orientated resources)

Reference

Brown H. Internet Printout Syndrome Health Information.

February 2000 Health Information on The Internet. Royal Society of Medicine www.rsm.ac.uk/hii/issue13.pdf

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