Welcome to the Ethics Forum! The optometric profession has long recognized its ethical responsibilities to patients, colleagues, other health care professionals and the public. This forum provides an opportunity to review a hypothetical case study containing potential ethical challenges and includes suggestions on how one might handle the situation based upon the American Optometric Association Standards of Professional Conduct and Code of Ethics.

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Dr. Google

By Hilary Hawthorne, O.D., and Morris Berman, O.D., M.S.

Case Study No. 19

A patient had redness/swelling/discharge/blurred vision in one eye, and the patient's family member instructed him or her to follow care steps that involve household plants such as aloe vera, lemon juice and an astringent called witch hazel. Another family member found a webpage that produced a holistic, naturopathic remedy for the symptoms that were typed into an online search engine search. The patient's condition lingered without resolving, so the patient became worried about any damage that could result from the treatments.

The patient decided to see a doctor of optometry for the eye problem and told the doctor about the naturopathic websites. Information was from an unconfirmed source, so the eye doctor felt that the treatment regimen was untrustworthy and not within optometry's scope.

The doctor explained the patient's diagnosis, gave a treatment plan and prescribed ophthalmic medication that contains steroids. Before scheduling the follow-up visit, the doctor gave the patient an opportunity to ask questions about the treatment plan. Hearing none, a prescription was sent electronically to a preferred pharmacy, and the eyedrop was dispensed on the same day. When the patient received the medication, it was packaged with an information pamphlet disclosing potential side effects. The patient read it, and a family member decided to follow up with an online search, again. Some of the detailed testimonials described negative effects of eyedrops that contain steroids. Family members remembered stories they had heard about eyedrops. The patient called to inform the doctor that they would not be using the medication because of the harmful effects that "research" had uncovered.

Discussion

Numerous examples of homeopathic remedies that are potentially harmful and/or not medically sound:

  1. Instilling non-ophthalmic and/or non-pharmaceutical products in the eye (e.g., citrus juice, herbs).
  2. Warm compresses using a hot potato, Epsom salt, essential oils, apple cider vinegar.
  3. Cold compresses using cool cucumbers, cold potato, backside of a chilled spoon.
  4. Vick's Vapor Rub as a cure-all.
  5. My Big Fat Greek Wedding-father sprayed Windex on his body to cure ailments and advised others to follow suit.

Internet browsing

The internet has become an important source of health information for patients. A study indicated that searching for health or medical information is one of the most popular activities online.1 Although many online health searches may be more general, Americans reported looking online specifically to determine what medical condition they might have.2,3 Half of people who had conducted a health-related search recently did it for someone else, typically a spouse, child, friend or loved one.

Although eye health information is available online for free, is all the advice practical-or even accurate? Some patients feel seeing a doctor is often too inconvenient, time-consuming and expensive to justify, unless they truly believe their eye health is in danger. The need for free and reliable health information has become reduced to an ability to "navigate the seemingly endless, often contradictory stream of online health information."4

People may not know to use an exact symptom or keyword for searching online. Vague symptoms such as redness or watery eyes could return a wide range of potential diagnoses and trigger anxiety in patients. Sites or apps that function as a stand-alone symptom checker are not ideal and "may not provide the entire picture or cause of a patient's symptoms."5 Seeking consultation via online search engines (aka "Dr. Google") has been known to lead to patients making frantic calls to doctors' offices, or even motivate people to get treated by the emergency department.6

Cyberchondria, also known as compucondria, is a buildup of irrational concerns about common symptoms based on online searches.7 Cyberchondria is a growing concern among health care practitioners as patients can now research any and all symptoms of a rare disease, illness or condition and manifest a state of medical anxiety.

The web does have good medical information, but it is often hard to distinguish the accurate from the false or misleading. The more you know about a given subject beforehand, the better you are equipped to explore remedies. Eye health is a complicated subject, so it is harder to distinguish trustworthy web results.

What initially appears as the top result for an internet search is not necessarily most relevant. A growing number of websites that purport to provide medical information produce posts written not to inform and guide readers but rather to generate revenue or promote certain causes. Patients must skim through numerous health-care-based websites that attract clicks and then show pop-up ads for medications or supplements. Because these platforms depend on advertising revenue, they've been carefully optimized to obtain high rankings in search engines-but not necessarily to provide good information.

Articles are also hosted by businesses and wellness organizations striving to advance awareness and usage of their own specific treatments. These websites often promote the idea that common symptoms can be traced to nutritional or lifestyle problems that are optimally treated by the supplements, cleansers and other products for sale.

Self-diagnosis

Patients who resist professional medical advice and quote unreliable web sources are increasingly common and can be a frustrating obstacle for doctors striving to provide a professional standard of care. Although self-diagnosis is not a suitable substitute for their professional medical consultation, patients who are in doubt may attempt to get their second opinion by turning to web-based sources.8

Conflict can, however, occur in the event a patient prioritizes online advice over provider knowledge. Patients who are unwilling to consider their providers' opinion can set up a very unhealthy relationship that could potentially hurt themselves and their outcomes.

As in this ethical dilemma case, eye doctors express concern about patients who decline treatment, who self-diagnose based on information they've obtained from the internet, or who demonstrate "an incomplete or distorted understanding of other diagnostic possibilities and medical likelihoods."9

Health care and technology

To arrive at a diagnosis, one needs to have the wisdom to weigh data contextually. Medicalized smartphones "with the ability to perform point-of-care lab tests from body fluids, examine your ear for infection or even check your vision, are indeed revolutionary and may ultimately change the playing field."10 Additionally, "IBM's Watson, a supercomputer delving into the new field of cognitive health-whereby computers can understand, reason and learn-may one day be in your doctor's office or even home-the consummate virtual assistant-helping to make decisions, armed not only with evidence-based data but also the ability to detect genomic clues to optimize outcomes."11 Who knows, that type of artificial intelligence may one day be streamed into your home!12 Such a future is comparable to how service packages from Amazon, Google or Netflix get streamed into your home.13

Type in any symptom or combination of symptoms and see what you get

Independent research is done to assure proper advice is provided, or else people may be prevented from pursuing appropriate medical help.14 There are reliable websites that offer useful, understandable material. If asked, the doctor can recommend excellent resources for information about a variety of topics that involve eye health. Examples of websites that publish high-quality, credible content vetted by clinical experts include:

If the patient wants to limit the search to academic/research-based sites, they can add site:edu in the search box after the search term(s).

Mutual respect

If patients do gather information from the internet, they should be forthright with their doctor and allow them to review the resource at the appointment. It is not advisable for a doctor to automatically disregard information presented by the patient from the internet. Eye doctors can check whether the information is accurate and help patients understand it in the context of their individual situations. The doctor-patient relationship is, after all, a respectful partnership.

Conclusion

The internet is a quick and convenient source of information. If the internet can give a patient reassurance, maybe it can avoid a costly visit to the eye doctor. Significantly, "searching symptomology can also be a great way to get educated on a variety of health issues. Rather than relying on the internet for self-diagnosis, (patients) can use it as a learning tool that can make face-to-face appointments more efficient."15

If a patient is unsatisfied with an eye doctor's diagnosis or plan, or still convinced Dr. Google's assessment is the right one, it's completely appropriate to ask follow-up questions. Patients should never leave a doctor's office with lingering doubts about the plan. Using the internet as a research tool can also help establish a more collaborative relationship between patients and providers.
Be mindful when searching for symptoms or diseases that websites want to attract "clicks," and some of them do this by catering to a patient's worst fears, which can be totally unfounded. Sites can look trustworthy even when they post information not supported by scientific evidence. So, online advice should be taken with a huge grain of salt-it can be both falsely reassuring and inappropriately alarming. Rather than using the internet to self-diagnose, inform patients it's best to think of online information as an educational starting point.

Tips to discuss with patients seeking to get the most out of an internet search and what to do with the information:

  • Eye doctors should recommend specific resources for learning more about health issues.
  • Eye doctors should remind patients prone to fact-checking, they could double-check information with a second reliable source and consult with their eye care provider.
  • Encourage patients to contact their eye care provider via phone, email or schedule an in-person appointment to discuss any concerns.
  • Patients will benefit from their visit if they prioritize their concerns before coming in for an appointment.
  • Be careful when reading nonmedical websites; you don't want to die because of a typo.

Patients shouldn't expect a website to replace their eye doctor. Primary eye care providers work through years of optometry school and residency programs, augmented by experience and continuing education. Furthermore, an eye doctor knows a patient's medical history, family history, risk factors, etc., and performs a comprehensive eye examination. For this reason, the eye doctor has superior knowledge about eye health to Dr. Google. Nothing can replace a well performed history and physical exam in an office setting with access to diagnostic instrumentation. Seeking professional eye health care helps immensely in arriving at a correct diagnosis and treatment plan.

1 https://www.pewinternet.org/2013/01/15/health-online-2013/
2 What Did You Google? Describing Online Health Information Search Patterns of ED patients and Their Relationship with Final Diagnoses; Danielle M. McCarthy, Grant N. Scott, D. Mark Courtney, Alyssa Czerniak, Amer Z. Aldeen, Stephanie Gravenor, Scott M. Dresden West J Emerg Med. 2017 Aug; 18(5): 928-936. Published online 2017 Jul 14. doi: 10.5811/westjem.2017.5.34108
3 Consulting 'Dr. Google': Patients Who Self-Diagnose Often Come to Dire Conclusions About What They Have. David Wolpaw, Op-ED, The Hartford Courant, Jan 07, 2018 https://www.courant.com/opinion/op-ed/hc-insight-wolpaw-consulting-dr-google-0107-20180105-story.html
4 https://www.washingtonpost.com/outlook/2019/02/27/precautions-take-before-you-consult-dr-google/ 
5 https://www.forbes.com/sites/robertglatter/2016/10/13/doctors-beat-online-symptom-checkers-new-study-finds/#763236532d44
6 https://www.forbes.com/sites/robertglatter/2016/10/13/doctors-beat-online-symptom-checkers-new-study-finds/#763236532d44
7 https://en.wikipedia.org/wiki/Cyberchondria
8 https://en.wikipedia.org/wiki/Cyberchondria
9 https://en.wikipedia.org/wiki/Cyberchondria 
10 https://www.forbes.com/sites/robertglatter/2016/10/13/doctors-beat-online-symptom-checkers-new-study-finds/#4dec89772d44
11 https://www.forbes.com/sites/robertglatter/2016/10/13/doctors-beat-online-symptom-checkers-new-study-finds/#4dec89772d44
12 https://www.forbes.com/sites/robertglatter/2016/10/13/doctors-beat-online-symptom-checkers-new-study-finds/#4dec89772d44
13 https://www.forbes.com/sites/robertglatter/2016/10/13/doctors-beat-online-symptom-checkers-new-study-finds/#4dec89772d44 
14 https://www.businesstelegraph.co.uk/marriott-challenges-icos-99-million-fine-over-data-breach-z6mag/
15 https://www.onemedical.com/blog/live-well/googling-symptoms


About the authors

Hilary L. Hawthorne, O.D., private practice in Los Angeles, California. Dr. Hawthorne is a member of the AOA Ethics and Values Committee and works at Community Eye Center Optometry in Los Angeles, California. She is a Diplomate of the American Board of Optometry since 2011. As a past president of the California Optometric Association, Dr. Hawthorne is in the association's Distinguished Member category and has also served as a member of the AOA Board of Trustees. Currently, she is an executive committee member on the Great Western Council of Optometry.

Morris Berman, O.D., M.S. Adjunct Professor, New England College of Optometry. Dr Berman has served on the AOA Ethics and Values Committee since 2002. He also has served as dean, MCPHS School of Optometry, and provost at Ketchum University in Fullerton, California. He received the Lifetime Achievement Award from ASCO in 2016.