Clinical knowledge has now become easier to obtain than ever. Open-access medical journals that waive subscription fees for readers, electronic medical record systems such as My e-Health in British Columbia that allow patients access to their own lab results, and full subscription to point-of-care tools such as UpToDate by patients have flattened the information hierarchy enjoyed by care providers over the past centuries. It is also changing the landscape of our health care encounters: close to 1 in 5 adults in a recent survey had spoken to a clinician about a medical condition they read about online.
However, rather than trimming away at the benign paternalism that has reigned over medicine for an age of enhanced physician-patient partnership, the spread of medical knowledge to the public has driven a wedge between many providers and those whom they serve. The notion that medical knowledge is best kept outside the realm of patients, lest it becomes a source of confusion for “cyberchondriacs”, remains entrenched in many providers’ minds. Meanwhile, web-savvy patients, discovering that their physicians were not aware of the latest clinical trial that had been broadcast in the media, become disillusioned and skeptical toward their providers. While a patient’s right to self-determination is taught in medical school, as a society we continue to grapple with where the right balance between patient choice and provider guidance ought to lie.
The role of health care providers as a “gatekeeper” makes sense in many situations, such as protecting the general public from risks of powerful medications like opioid painkillers. As the public, we entrust practitioners with the task of interpreting medical information based on their knowledge and experience. This is the reason that direct to consumer advertising by the pharmaceutical industry is restricted in most countries. On the other hand, as the spread of mobile health technology and data liberation initiative of U.S. Medicare services demonstrate, there is sustained desire for patient and public involvement in health care that go beyond simple reliance for clinicians to make the best decisions for us.
So it is clear that the genie is out of the bottle – and I believe that this new era of the shift in provider-patient relationships calls for renewed expectations on both parties.
The providers in this swiftly changing climate must embrace the new reality that it is virtually impossible to know about every novel development in medicine, even in sub-specialist fields. Accompanying this would be acceptance that patients bringing forth clinical information that was previously unknown to physicians should be appreciated as a valuable contribution rather than a threat to their competence.
As “e-Patient Dave” deBronkart mentioned in a recent episode of CBC’s White Coat Black Art, “the physician whose self-worth is dependent on knowing everything is in big trouble […] there is no shame in someone less trained providing a piece of information that you don’t have, because there is still room for the trained mind to interpret it.”
At the same time, patients should in turn evaluate their own expectation for physicians in light of the rapidly expanding medical literature. Patient engagement arose from the recognition that health care is not perfect, and that to err is human. Amongst patients who see themselves as active participants in their care, a shift of focus is needed to see physician encounters not as an adversarial battle where a provider’s performance is judged against omniscience in every field of medicine. The new physician-patient encounter ought to be a meeting place where patients bring their personal experience, search results and an open mind, and where physicians bring expertise in clinical medicine, knowledge of pathophysiology and skills in critical appraisal to help contextualize them.
Dissemination of medical knowledge to the public may be considered by many as a “disruptive innovation.” It is time to leverage this unique opportunity to improve the quality of care with the aim of providing excellent care for all. It has been said that an average primary care physician needs to read over 7,200 articles per month to keep up with every latest advance in the field, an impossible task. A mix of collaborative spirit and trust, combined with mutual humility and understanding, provides the recipe to ensure that patients and physicians both benefit in this brave new world.