AN AUG. 22 ARTICLE INCORRECTLY SAID THE BOOK "HEALTH ONLINE," WRITTEN BY TOM FERGUSON AND PUBLISHED IN 1996, WAS THE FIRST GUIDE TO MEDICAL SITES ON THE WORLD WIDE WEB. IN FACT, "DOCTOR TOM LINDEN'S GUIDE TO ONLINE MEDICINE," BY TOM LINDEN AND MICHELLE KIENHOLZ, WAS PUBLISHED IN 1995. (PUBLISHED 09/04/99)
Terry Fitzgerald's "guest" -- don't ever call them patients -- is sitting in front of a computer screen somewhere near Houston with fluttering in the chest.
Fitzgerald doesn't know the person's sex. Nor age. He has no EKG to consult and, it hardly needs to be said, can't look the person in the eye. That's because the emergency medicine physician is sitting in front of a computer screen in a building in Calvert County.
Although these are not ideal conditions in which to provide "medical information" -- don't ever call it advice -- Fitzgerald would like to get clear on one thing.
Does the fluttering start suddenly and end suddenly, or does it sort of creep up on you? the doctor types into the computer.
Kind of creeps up, comes the answer from Houston. Like now it started again.
Back and forth go the questions and answers, in clipped, sparsely punctuated sentences reminiscent of telegraph communication. But by six minutes later, Fitzgerald has learned enough to say this:
We cannot know for sure, but this kind of picture sounds like the type that is not in itself dangerous. But it would be appropriate to have it checked out in the office.
In the brave new world of Internet communication, almost anything that can be reduced to words is possible. For the last few months, that has included free online visits to the doctor.
Fitzgerald is one of about a hundred medical professionals contracting with AmericasDoctor.com, a World Wide Web company headquartered in Owings Mills. Opened just under a year ago, the Web site now attracts about 3,000 people a day to its round-the-clock "Ask-the-Doc" feature (and many more to the other offerings on its site.) At the busiest hours, as many as 20 physicians, at two call centers, may be talking one-on-one to "guests," as these visitors are called.
Dozens of sites on the Web let computer users anonymously pose questions to physicians and get answers, usually posted publicly, within a few days. At a handful, a consumer can transmit medical history, laboratory data and specific questions to a specialist, who analyzes the information and renders a "second opinion" (often including treatment options), for a fee.
The Maryland company, however, may be the only one to simulate the back-and-forth that occurs in the consultation room, online and in real time.
In one sense, the service is a marketing gimmick, a hook to attract visitors in the fierce competition for attention among the estimated 10,000 Web sites dealing with health and medicine. According to executives at AmericasDoctor.com, more than 80 percent of first-time visitors use the free service, but by the second visit, fewer than half do. The company gets its revenue from hospital systems that pay to have their services displayed exclusively when a visitor registers and provides a zip code. There are now 94 "sponsors" of the site.
In another sense, however, "Ask-the-Doc" represents a new and largely unexplored form of communication between physicians and the people who seek their expertise.
AmericasDoctor.com emphatically says its service is not an online medical practice. This is stated several times on the site, and a standing message saying "we do NOT provide medical diagnosis or treatment advice" comes up before each "Ask-the-Doc" talk begins. The people answering the questions -- board-certified or board-eligible physicians -- reiterate it during their online conversations.
Such disclaimers are virtually universal on Web sites linking "health care providers" and "health care consumers." Even Mediconsult.com, when it outlines the kind of report a customer will get from the specialist for $195, announces, "This service is provided for educational purposes only and is not intended to substitute for informed medical advice."
The definition of what constitutes the practice of medicine is largely based on what courts have ruled it is, rather than in legal definitions enacted by governments. It involves the intent and expectation of both the parties, the advice-giver and the advice-taker. It usually involves rendering a diagnosis and prescribing a treatment. Almost always, there is a record of the encounter. Most of the time there is also the expectation of "follow-up."
AmericasDoctor.com steers clear of all those features of the "doctor-patient relationship." It sees itself as a new answer to the explosive growth of people's quest for health information. Also, an updated version of long-established communication through other media.
"This is the old ask-a-nurse service," said Scott M. Rifkin, the 39-year-old Baltimore internist who founded the company two years ago and is its chief executive officer. "I also like to think of it as a consumer's `personalized medical librarian.' "
There have been no malpractice suits arising from online medical advice, and no laws have been enacted to define what can and cannot be done by physicians over the Internet. (Some states and medical societies, however, are looking into online prescribing of drugs.)
If such claims arise, courts will have to decide whether doctor-consumer conversations on the Web are akin to casual discussions at a cocktail party, or if they're more like traditional telephone consultations. There are lots of cases in which the latter have been found to constitute the "practice of medicine," said Alissa R. Spielberg, a lawyer who teaches at Harvard and Tufts medical schools.
"There may be some skepticism when [Web sites] say, `This is not the practice of medicine, but please give your Visa card number to us here,' " she said. "I think those disclaimers would be rendered useless pretty quick."
Interaction between physicians and consumers is so new -- and concrete evidence of any problems it may have caused so lacking -- that most authorities at this point speak of its hazards in hypothetical terms.
In April, a 14-person panel of experts appointed by the Department of Health and Human Services issued a 190-page report, "Wired for Health and Well-Being," which looked at the myriad computer-based activities falling under what it termed "interactive health communication."
While outlining the Internet's immense potential for benefit, the authors of the report noted, among other things, that "inaccurate or inappropriate health information and support could result in inappropriate treatment or cause delays . . . [and] can also lead to unnecessary conflicts and confrontations between consumers and health care providers."
The American Telemedicine Association, composed mainly of physicians and computer experts, issued an "advisory" last month on the use of medical Web sites that included the observation that "at this time consumers should exercise caution in using Web sites that offer online diagnosis of an individual's medical condition and prescribe treatment and medication for the diagnosed condition. There are currently no recognized accreditation or regulatory authorities overseeing the operation of these sites."
Nevertheless, it seems certain that much -- if not all -- of this dialogue will remain. It cannot be suppressed, even if someone wanted to.
An entirely new role for physicians is emerging, believes Tom Ferguson, a 56-year-old Texas physician who wrote the first book about Internet medical sites, "Health Online," in 1996.
When doctors talk to non-doctors these days, Ferguson says, they no longer have to be both the source of medical information and the party responsible (implicitly or otherwise) for the application of that knowledge. He calls it the "unbundling" of the doctor role.
This is most evident in Internet chat groups, where people with a common medical problem, such as breast cancer or multiple sclerosis, often engage a physician "consultant" to answer questions they can't.
"I think there's all kinds of reasons to encourage this instead of discourage it," said Ferguson, who founded the journal Medical Self-Care, now defunct, at the dawn of the "patient empowerment" movement in the 1970s.
"There is a much higher degree of patient autonomy and decision-making than there used to be. Patients are much less likely to unquestioningly accept the first treatment suggestion their local doctor offers. Five or 10 years ago, I don't think most patients knew they had a choice not to accept it.
"We're not only seeing more of these Net-savvy patients getting second opinions, we are seeing patients who get fifth and sixth and ninth and 10th opinions. And I think that's a good thing."
CAPTION: On the America's Doctor Web Site (This graphic was not available)