Family Practice Vol. 21, No. 2, 189-191
Family Practice Vol. 21, No. 2 © Oxford University Press 2004, all rights reserved.
Article |
Health and the Internet—changing boundaries in primary care
Florence Nightingale School of Nursing, King's College, London, a Holland Park Surgery, 73 Holland Park, London W11, b Law Medical Practice, Wrottesley Road, Kensal Rise, London, c Menopause Clinic, North West London Hospitals NHS Trust, Middlesex and d Kensington Park Medical Centre, London W14, UK
E-mail: mary.malone{at}kcl.ac.uk
Received 3 December 2002; Revised 8 August 2003; Accepted 3 November 2004.
Malone M, Harris R, Hooker R, Tucker T, Tanna N and Honnor S. Health and the Internet—changing boundaries in primary care. Family Practice 2004; 21: 189–191.
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Abstract |
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 Top Abstract IntroductionMethodsResults and discussionReferences |
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Background. Little is known about the frequency with which information from the Internet is presented by patients within primary care consultations or the subsequent impact that it may have on those consultations.
Objectives. The aims of this study were to describe the frequency with which Internet information was presented within primary care consultations in one inner-city health authority and to describe the characteristics of the subsequent consultation from the perspective of the health professionals involved.
Methods. A postal survey was used to estimate the frequency of Internet information presentation and eight in-depth interviews were used to obtain health professionals' perceptions of the consultations that followed.
Results. Presentation of information from the Internet was relatively infrequent within primary care at the time of the survey (November 2000 to March 2001), but frequencies of presentation were higher for GPs than for any other health professional group. Health professionals have stereotypical views of Internet users and fear for their own professional status in relation to the Internet-informed patient or client.
Conclusions. Although presentation of information from the Internet to date remains relatively infrequent, health professionals appear to feel threatened by it and adopt strategies that minimize its impact on the subsequent consultation.
Keywords. Communication, Internet, patient empowerment, primary care, professional boundaries, professionalism and professional insecurity.
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Introduction |
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TopAbstractIntroductionMethodsResults and discussionReferences |
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The Internet is a major new source of health information with the potential to enhance the patient agenda in health care provision.1,2 It has the potential to alter the nature of some service delivery and to create a generation of informed service users who may challenge traditional doctor–patient relationships.2 Primary care, with its essentially ‘generalist’ focus, may be at the forefront of such alterations.3–7 Little is known, however, about the frequency with which information from the Internet is actually presented within consultations in primary care or, indeed, about the impact this information has on the interaction which ensues. This short report describes a two phase multi-method study that examined both of these important issues.
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Methods |
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TopAbstractIntroductionMethodsResults and discussionReferences |
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In the first phase (November 2000 to March 2001), a brief postal questionnaire was sent to all 272 health professionals within a random stratified sample (by practice patient list size) of one-third of all general practices within a UK inner-city Health Authority. In phase two of the study (June–August 2001), in-depth interviews, incorporating critical incident analysis, were conducted with eight health care professionals purposively selected from within the initial sample. Descriptive statistics were used to analyse survey data, while qualitative data were analysed using the constant comparative technique.8 Disaggregation of qualitative data was followed by identification of key issues, categories and themes.8
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Results and discussion |
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TopAbstractIntroductionMethodsResults and discussionReferences |
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Almost three-quarters of respondents (n = 134, 74%) had indeed been presented with information retrieved from the Internet during a consultation at some point in time. However, only 5% of respondents were presented with information retrieved from the Internet more than six times per month. Frequencies of presentation were higher for GPs than for any other health professional group (see Table 1).
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Data from phase two identified three main cate-gories: ‘legitimacy’ and ‘non-legitimacy’ of presenting information from the Internet, plus ‘handling the situation’. The subcategory ‘anxiety/neutrality–the personal/professional voice’ informed each main category. The theme ‘impact on professional role and function’ united both categories and subcategory. It was seen as ‘legitimate’ to present information on matters of acknowledged controversy (e.g. MMR vaccine), but presentation of information on ‘cosmetic’ or ‘insubstantial’ health concerns was regarded as ‘non-legitimate’. Patients presenting the latter were typified as ‘the worried well’, those whom the Internet served merely to enhance ‘unfounded’ health anxieties. Internet users were seen as ‘demanding’.
Patients using information from the Internet to self-diagnose and to identify appropriate treatments in advance of consultations were viewed particularly unfavourably by all health professionals. Those patients with an already established diagnosis using Internet information to improve their management of conditions or symptoms were, however, viewed much more favourably. In these cases, information from the Internet was seen as both complementary to professionally led clinical decisions, and potentially enhancing patient well-being as well as the doctor–patient relationship. When information from the Internet was presented prior to diagnosis, it was seen by the health professional as potentially misleading for the patient and time-consuming for them as clinicians.
Health professionals described admitting their relative ignorance to Internet-informed patients and offering them a follow-up consultation at a later date. Additional consultations, however, led to an inevitably increased workload while admissions of ignorance in the consultation itself contributed to a professional ‘loss of face’. There were obvious difficulties and frustrations in offering a ‘generalist’ service when the Internet potentially makes everyone, but most importantly makes the patient, a potential ‘specialist’. In the face of this, many health professionals described feeling ‘dis-empowered’ and even at times ‘professionally insecure’.
Positive statements about the potential for health gain were mixed with ambiguity about what future use of the Internet might hold. In some cases, positive and negative feelings were juxtaposed even within one sentence of a response. Concerns were also expressed not only about the sheer volume of information available on the Internet but also the variation in its quality over different sites and its usefulness to either or both parties.
Conclusion and recommendation
In conclusion, the impact of the Internet on consultations in primary care can only be expected to increase. This will necessarily have implications for all clinical roles.9 ‘Generalists’, such as health professionals in primary care, may feel particularly vulnerable when faced with patients who have ‘specialist information’ that they (the patients) have retrieved from the Internet. This study identified a variety of strategies, some helpful and others less so, used by health professionals within such consultations. More guidance and clearer protocols are needed in order to encourage flexibility and responsiveness to such new challenges.10 In this way, the potential which the Internet holds for supporting evidence-based practice and optimizing client-centred care can be realized more effectively.
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Acknowledgments |
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We thank Professor Sarah Cowley for comments on an early draft of the paper and The West London Research Network (WeLReN) for support funding. The views expressed in the paper are those of the authors and not necessarily those of WeLReN.
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References |
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1 Jellinik D, Lambden P, Lilley R. Your Health and The Internet. Norwich (UK): Stationery Office; 2000.
2 Hardy M. Doctor in the House: the Internet as a source of lay health knowledge and the challenge to expertise. Sociol Health Illness 1999; 21: 820–835.[CrossRef]
3 Florin D, Coulter A. A partnership in primary care consultation. In: Gillam S. (ed.) New Beginnings: Towards Patient and Public Involvement in Primary Care. London: King's Fund; 2001.
4 Guadagnoli E, Ward P. Patient participation in decision making. Soc Sci Med 1998; 47: 329–339.[CrossRef][Web of Science][Medline]
5 Department of Health. The New NHS Modern, Dependable. London: Department of Health; 1997.
6 Department of Health. The NHS Plan: A Plan for Investment a Plan for Reform. London: Department of Health; 2000.
7 Department of Health. The Expert Patient: A New Approach to Chronic Disease Management for the 21st Century. London: Department of Health; 2001.
8 Glaser B. Emergence vs Forcing: Basics of Grounded Theory Analysis. Mill Valley (CA): Sociological Press; 1992.
9 Coeira E. The Internet's challenge to health care provision. Br Med J 1996; 312: 3–4.
10 Hurwitz B. Clinical guidelines and the law. Br Med J 1995; 311: 1517–1518.
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