A thoughtful friend recently pointed me to this New York Times essay by a physician-in-training, Dr. Warraich. She discusses the ethical ramifications of Googling her patients for information beyond what she could obtain through a traditional face-to-face history and physical examination. The author believes doctors should resort to such third-party sources of information only when there is a “safety issue”. Well, yes. But.
Leave aside for now that “safety issue” is a pretext that could be stretched like a latex exam glove to cover a meaty fistful of iniquity. Dr. Warraich and I both stipulate good intentions; for considerations of ethics, intentions matter more than results. But after years of making critical decisions, too often with incomplete information, I’d never want to arbitrarily exclude Google, or any other potentially useful source, out of an erroneous sense of ethical unease. The ethical conundrum arises not in obtaining information, but in deciding how that information will be used to further the therapeutic goals of the doctor-patient relationship. The issue is power and its exercise, not the information per se, or how it’s obtained.
While Dr. Warraich and I agree that Google shouldn’t replace an actual face-to-face history and physical exam, there are circumstances in which your clinical “Spidey sense” — refined over decades of training and practice, and ignored at your peril — tells you that something is just not right. With the patient unwilling or unable to cooperate, and family members unavailable or clueless, supplementing the “H & P” with further information, however you can get it, is the right thing to do.
Dr. Warraich cites two such cases. In the first, a patient tried to talk her way into a double mastectomy for a nonexistent illness. In the other, a surprise laboratory test result pointed to an undiscovered history of substance abuse. In both patients, clinical impressions did not jibe with hard data; information gleaned from web searches enabled the medical teams to do the right thing for the patients. The first patient’s caregivers thereby avoided unnecessarily operating on her; one hopes that they were able to get her the psychiatric care she obviously needed. In the second case, Dr. Warraich’s recounting leaves me uncertain whether the substance abuse was directly related, or merely incidental, to the patient’s current illness. Regardless, she recovered uneventfully.
Dr. Warraich chose not to confront the second patient with her internet findings, when the confrontation wouldn’t have advanced the therapeutic cause. She need not feel she “violated [the] patient’s privacy” in resorting to Google, through the purest of intentions, to obtain those findings. Once in possession of the information, she declined to exercise simply for its own sake the unequal power it gave her over her patient. That sounds like ethical doctoring, not cause for hand-wringing.