The Internet in Medicine

Introduction– How I got involved

Overview– Basic principles– Ideas of ways to use the internet

• Patients and physicians

– Group Discussion- share what you find useful with your colleagues

How I got involved…

Keeping up with the literatureConventional methodMove off campuswww.medjet.net

Keeping Up with the Medical Literature

ScienceDirect - My AlertsGoogle Med

“Google is a good Diagnostician”

BMJ  2006;333 (2 December) Using signs and symptoms as search terms on Google

finds the correct diagnosis 57.7% of the time (95% confidence interval 38.3% to 77.1%) say Tang and Ng.

The authors identified 26 case reports published in a single journal and selected three to five specific symptoms and signs from each to be used as Google search terms. They compared Google results with the original diagnoses. Google searching is less helpful in identifying complex diseases with non-specific symptoms than in diagnosing illnesses with unique symptoms.

Basic Principles

Core standards for the digital world should be similar to the world of print

Physician as Interpreter of medical information (patients have the same information we do)

Evaluating Medical Web Sites

“Assessing, controlling, and assuring the quality of medical information on the Internet: Caveat lector et viewer- let the reader and viewer beware.” – Article from JAMA 1997; 277:1244-5

Core standards for the digital world should be similar to the world of print

Evaluating Medical Web Sites

www.hon.ch

Ideas on Ways to use the Net

Pt usesPhysician usesThe interaction of the two

Patient Uses

Harris Interactive calculated that 111 million adults have looked for health information on the Internet last year.

Most Visited Health and Medical -Information Sites, March 2007, U.S.SiteMarketShare

MyWebMD10.61% WebMD9.84% Yahoo!Health3.68% MSN Health 2.5% Emedicine2.24% Med Help Intl2.00% Medscape1.76%

MayoClinic1.67% Kids Health1.62% RealAge1.43% Source: Hitwise

Patient Uses

Patients have basically the same information we do.

They often use the internet in the same ways we do.

Patient Uses

Disease specific informationOn-line prescription drugs

– Viagra, Narcotics

E-mail

Patient Uses

Scorecards– www.thehealthcarescoop.com– www.healthgrades.com– www.carol.com

Patient Uses

Be aware of its use Be Proactive

– Recommend sites– www.mayoclinic.com

Become an Internet-Informed Physician– It is what patients want

The Internet in Medicine:Physician Uses

How do I best make use of the Internet?

The Internet in Medicine:Questions to Consider

Is your information need immediate or not?

What information do you want pushed to you?

What are you trying to accomplish?What information can you download to

your palm and carry with you?

Physician Uses

I need it now…– www.uptodate.com– www.infopoems.com

Physician Uses

I need it now…– http://hopkins-abxguide.org– http://www.eboncall.org– http://content.nejm.org/misc/videos

Physician Uses

I have more time…– www.guideline.gov– http://acpplus./EBMTools

Physician Uses

What am I trying to accomplish?– I would like to improve…– My clinical exam

• http://www.sgim.org/rationalclinicalexam

Physician Uses

What am I trying to accomplish?– I would like to monitor my improvement…

• BMJ Learning

Physician Uses

I want some information sent to me (in case I forget to go get it)…– acponline journal club plus

Physician Uses

I want to download some info and carry it with me (palm)…– http://www.nhlbi.nih.gov/health/prof

Physician Uses

Medline and Journal Sites– www.bmj.com

Physician supersites– www.medscape.com

CME Online– Cme locators– www.hon.ch

Physician Uses

Subspecialty sites

Physician Uses

Medical Content– http://pier.acponline.org– www.aafp.org– www.eMedicine.com– http://www.merckmedicus.com

Physician Uses

In the clinic– JNC 7

Storing your sites– http://www.blinkpro.com/tab/mysites

The Internet in Medicine

Think of what need you may have (e.g. my need to keep up with the literature) and then go see how this medium can help you.

Physician Uses

Any favorite sites out there people want to share?

Physician/Patient Uses

Interaction of the two…

Prostate Cancer Case

Questions: age, ethnic group, family history, height, vasectomy history (he had one), and dietary habits (<5 servings of tomato based foods a week and <5 servings of food with animal fat a day).

Risk is above averageCalled me

Web Based Risk Calculators

New Information resourceAdvantages:

– Tailored risk info based on personal factors

Disadvantages:– Accuracy?– Balanced?

Clarity about Risk

What risk is under consideration: dying of the disease or getting it?

Probability (a number)?Time period associated with this

probability?The site doesn’t tell Mr. Smith the chance

he will get or die of prostate ca in a defined time frame.

Quantitative Risk Estimate

Breast Ca Risk Assessment Tool– http://bcra.nci.nih.gov/brc/

Lung Ca Risk Assessment– www.mskcc.org/mskcc/html/12463.cfm

MI or death over the next 10 years– http://hin.nhlbi.nih.gov/atpiii/calculator.asp?

usertype=prof

Quantitative Risk Estimate

US govt Surveillance Epidemiology End Result Site– http://seer.cancer.gov/

Advantage: Broad array of cancers, time frameDisadvantages: Tailored only to age, sex, and

raceOver the next 10 years, a 55y.o. white man’s:

– Chance of getting prostate ca is 40 in 1000– Chance of dying of prostate ca is 2 in 1000

Context

How this risk c/w chance of dying of other cancers

Risk Charts: His chance of dying of:– Colon Cancer: 4 in 1000

– Heart Disease: 20 in 1000 (50 if smokes)

– Anything: 93 in 1000 (217 if smokes) in the same time frame.

– Journal of the National Cancer Institute, Vol. 94, No. 11, 799-804, June 5, 2002

Uncertainty

Strength of evidence behind the factors used in generating risk estimates:– Age consistently important for prostate ca– Height, diet, and vasectomies not consistently

important• Yet these were included in his initial risk calculator

Communicating Risk:the main work of doctors

Web based risk calculators demonstrate a paradigm shift in medicine.

Physicians are moving from primary medical information providers to information managers.

Physician Uses

Any favorite sites out there people want to share?

Case

52 y.o. man with multiple myeloma presented to our R4 team with fever last month when I was on wards.– Went over his med list– Day #3 he brought in a bottle of Astragalus

which he was taking “because his brother read about it on the internet and it has been curing people in China with cancer for years”

Case

www.puritan.com

Cancer Treatment Strategies at IEP

The Internet on Wards

alternative therapy disclosure

why pts use alternative medicine

Quantitative Risk Estimate

Breast Ca Risk Assessment Tool– http://bcra.nci.nih.gov/brc/

Lung Ca Risk Assessment– www.mskcc.org/mskcc/html/12463.cfm

MI or death over the next 10 years– http://hin.nhlbi.nih.gov/atpiii/calculator.asp?us

ertype=prof

Communicating Risk:the main work of doctors

Web based risk calculators demonstrate a paradigm shift in medicine brought about by the Internet.

Physicians are moving from primary medical information providers to information managers.