The Internet has produced a truly phenomenal increase in access to information. This is really only helpful to patients if the information is filtered and appropriate to their specific needs. Too often patients access information about conditions they have self-diagnosed and bring it to the consultation with their physician, who then has to spend time disabusing the patients of the misinformation they have accumulated. Patients also return home from their initial consultation, access the Internet, and come up with all manner of promotional information from companies and even orthopedic practices that they want explained to them by their physician. It is the overwhelming conclusion of orthopedic specialists that this kind of Internet use is actually a burden for them in caring for patients and is not contributing to patient enlightenment. It does not have to be this way, if physicians will do just 2 things: first, create white papers for patients that address common current questions, such as surgical approach or bearing surfaces for implants and why we do what we do. This is a huge time saver and will preempt many questions. Second, develop their own website or select excellent nonprejudicial sites to which they can refer patients. To do less will invite a neverending parade of questions irrelevant to patient welfare.
The Internet is a wonderful thing. Rapid and unlimited access to information is a wonderful thing. Unfortunately, it is creating problems for orthopedic surgeons. I believe a relatively simple solution exists if you are experiencing what I am with my patients.
The quotation, the Internet changes everything, or ICE, is attributed to Bill Gates. I think that is completely true. It is hard to recall the situation 10 or 20 years ago, given the access to information that we have today. Unfortunately, unfettered access to information that patients are unprepared to interpret is producing confusion. Several typical scenarios could occur. Here are some examples: (1) The patient consults a physician, gets a diagnosis, goes home, accesses the Internet, and then returns with several questions that they think have not been answered, or worse, challenges the physician. (2) The patient checks the Internet, makes his or her own diagnosis, comes to the physicians office armed with all kinds of information that may or may not be appropriate, and requires the physician to spend time correcting the misinformation that the patient has brought to the consultation.
Direct-to-consumer advertising in orthopedics began in 2003 with the Jack Nicklaus ceramic total hip replacement advertising campaign. The Internet advertisement that was posted in October 2003 read, Jack Nicklaus Tees up Hip Replacement Awareness. The campaign included print and television advertisements, the result of which led patients to call their doctors and ask, Do you do the Jack Nicklaus hip? This typical scenario has since repeated over and over across the country regarding several procedures or products. At first, my secretary was at a loss on how to answer because she first had to check with me. Finally, we realized that the patients did not have a clue and the answer to all such questions quickly became yes. That may seem somewhat deceptive, but more than 5 years have passed since this has been our routine, and not a single patient has complained! Patients call and ask, Does Dr Hungerford do minimally invasive total knee replacement? We reply, Yes. Patients call and ask, Does Dr Hungerford do ceramic total hip replacements? We reply, Yes. Because the patients do not understand what they are asking, the receptionist always answers, Yes. In the past, patients came to see us and asked us what they needed. Today, they tell us what they want. But they do not know what they need, so why should we be a party to that? Just tell them yes and avoid the problem.
This is the hierarchy of information. It begins with data, ie, factual information. Data, collected and organized, produce knowledge, which is a body of truth. If you have good sense and judgment, the proper application of knowledge produces wisdom. The Internet cannot provide that. Patients present with facts and maybe even a little knowledge, but they do not have wisdom. And they do not know that they do not have wisdom.
PubMed is the abstracted synopsis of peer-reviewed articles published since 1966. Most patients do not know about PubMed, but even if they only accessed PubMed, they are still unable to effectively interpret. Nonetheless, it is peer reviewed, so the quality of the data is there.
Consider the Internet, through which you can access the 17 peer-reviewed articles on minimally invasive total hip replacement, or the 5170 hits on Google. One of the Google hits is titled, Pioneering hip replacement surgery sends patients home the day after the operation, the first minimally invasive hip replacement surgery in the world. There was no data, just a claim, and this is what patients bring to the consultation saying, Well, are you doing minimally invasive hip replacement? To which I answer, Yes, absolutely.
But then I tell them it depends on their definition of the word minimal. Websters Dictionary actually has 2 definitions for minimal. One is the least necessary and the second is barely adequate. So I ask the patients which one they want. The answer is always the least necessary, I say, Good, thats the one we have always done, the least necessary. (If a patient ever says, Barely adequate, I want barely adequate, refer them elsewhere.)
A search for total hip replacement in PubMed, however, returns 6900 peer-reviewed articles. So if the patient is lured by the new, the different, and maybe the untried and the unproven, they get a tremendous number of hits in Google. And that is what produces patient confusion.
These are not just the personal opinions of the author. There are several articles in the peer-reviewed literature on this subject. One article by Murray et al1 surveyed 1050 US physicians. Eighty-five percent had experienced patients bringing information to the consultation. If the information was accurate, it was helpful. If the information was inaccurate, it was harmful. Of the physicians surveyed, 38% said it decreased the efficiency of the consultation because they had to spend time disabusing the patients of misinformation.
Bozic et al2 reported that 98% of responding surgeons had experienced a patient who was exposed to direct-to-consumer advertising. It had a negative impact on the overall practice for 78%, and 77% said that it produced patients who were misinformed and confused.
There is a solution. Produce White Papers for patients to read before entering into any discussions with them explaining what you do and why. My practice deals almost exclusively with patients considering joint replacement. One of the dominant issues concerns the bearing surface. Patients have been bombarded with direct-to-consumer advertising touting the advantages of metal on metal, ceramic on ceramic, and metal on highly cross-linked polyethylene. I have created brief summaries of each of these bearing couples, listing advantages and disadvantages, what I use, and why. This simple tool has saved me hundreds of hours of discussions and even arguments with my patients. The best thing you could do is to put the information on your practices website so that it is available before and after the consultation. This can be done for each of the hot button issues that patients are bringing to consultations.
Danquah et al3 described the value of a proactive approach to using the Internet to educate your patients. The study included patients who were presenting for hernia consultation. Patients were randomized into those who were referred to 3 preselected Internet sites before the first surgical visit, and those who were not. All patients underwent primary hernia repair. Good-to-excellent postoperative patient satisfaction was 79% in the study group compared to 45% in the patients who had not been directed to a preselected site. Seventy-four percent of patients who had been directed to a site said that the operation met their expectations vs 30% who were not directed to a site. So if you use the Internet and prepare for the Internet, it appears that you can actually improve your outcomes.
- Murray E, Lo B, Pollack L, et al. The impact of health information on the Internet on health care and the physician-patient relationship: national U.S. survey among 1050 U.S. physicians. J Med Internet Res. 2003; 5(3):e17. Epub 2003 Aug 29.
- Bozic KJ, Smith AR, Hariri S, et al. The 2007 ABJS Marshall Urist Award: the impact of direct-to-consumer advertising in orthopaedics. Clin Orthop Relat Res. 2007; (458):202-219.
- Danquah G, Mittal V, Solh M, Kolachalam RB. Effect of Internet use on patients surgical outcomes. Int Surg. 2007; 92(6):339-343.
Dr Hungerford is from the Department of Orthopedic Surgery, Good Samaritan Hospital, Baltimore, Maryland.
Dr Hungerford has no relevant financial relationships to disclose.
Presented at Current Concepts in Joint Replacement 2008 Winter Meeting; December 10-13, 2008; Orlando, Florida.
Correspondence should be addressed to: David S. Hungerford, MD, Department of Orthopedic Surgery, 5601 Loch Raven Blvd, Baltimore, MD 21239.