Public use of the Internet for health information is increasing but its effect on health care is unclear. We studied physicians' experience of patients looking for health information on the Internet and their perceptions of the impact of this information on the physician-patient relationship, health care, and workload.
Cross-sectional survey of a nationally-representative sample of United States physicians (1050 respondents; response rate 53%).
Eighty-five percent of respondents had experienced a patient bringing Internet information to a visit. The quality of information was important: accurate, relevant information benefited, while inaccurate or irrelevant information harmed health care, health outcomes, and the physician-patient relationship. However, the physician's feeling that the patient was challenging his or her authority was the most consistent predictor of a perceived deterioration in the physician-patient relationship (OR = 14.9; 95% CI, 5.5-40.5), in the quality of health care (OR = 3.4; 95% CI, 1.1-10.9), or health outcomes (OR = 5.6; 95% CI, 1.7-18.7). Thirty-eight percent of physicians believed that the patient bringing in information made the visit less time efficient, particularly if the patient wanted something inappropriate (OR = 2.5; 95% CI, 1.5-4.4), or the physician felt challenged (OR = 3.6; 95% CI, 1.8-7.2).
The quality of information on the Internet is paramount: accurate relevant information is beneficial, while inaccurate information is harmful. Physicians appear to acquiesce to clinically-inappropriate requests generated by information from the Internet, either for fear of damaging the physician-patient relationship or because of the negative effect on time efficiency of not doing so. A minority of physicians feels challenged by patients bringing health information to the visit; reasons for this require further research.
An increasing proportion of the public is using the Internet for health information [
We surveyed a nationally-representative sample of physicians about their experience with patients bringing health information from the Internet to office visits. Our aims were to determine physicians' perceptions of the effects of patients bringing health information from the Internet on the physician-patient relationship; time efficiency of the visit; quality of care received by the patient; and patient's health outcomes.
Two thousand physicians were randomly selected from the national list of physicians provided by the Medical Marketing Service, Inc (MMS). The Medical Marketing Service list is based on the national database of the American Medical Association (AMA) which includes both members and nonmembers of the American Medical Association, and is updated weekly. The American Medical Association database contains over 650000 physicians, and is the most-complete list of physicians available in the United States. Physicians who currently spent over 20 hours a week on direct patient care were included in the survey. The sample was stratified by specialty: primary care, medical specialty, or surgical specialty. Primary care included family practice, general practice, internal medicine, and pediatrics. Ob-Gyn was classified as a surgical specialty.
The questionnaire was developed following literature review and focus-group discussions. It was pretested to ensure that the instrument was easy to complete, all areas of interest were covered, and no questions were ambiguous. It consisted of closed-end questions, took approximately 12 minutes to complete, and was in 3 parts. The entire sample received Part 1 of the questionnaire, which elicited general information about views on health information on the Internet and direct-to-consumer advertising (DTCA). Questions included general views on accuracy and effects of such information, and personal use of the Internet at work. Part 2 was sent to a random 50% of the sample, and requested information about the last time a patient brought in information from the Internet. "Last-time" methodology was used to minimize recall bias. Areas explored were the relevance and accuracy of the information, physicians' perceptions of why the patient had brought the information, physicians' responses to the patient, and their views about the impact on health care, health outcomes, and the physician-patient relationship. The other 50% of the sample received a different Part 2, which explored these same areas but with regard to the last time a patient brought in information from direct-to-consumer advertising. The direct-to-consumer advertising data are presented elsewhere [
Data collection was undertaken between November 2000 and February 2001. The questionnaire was mailed to the selected physicians with a check for US $35 as a token of appreciation for completing the questionnaire. Up to 3 reminders were sent and additional telephone contact made with nonresponders. Of the original 2000 physicians sent the survey, 38 were ineligible because they were deceased, retired, or no longer in practice; and 1050 physicians completed the questionnaire (response rate 53%). Of these, 515 received the Internet version of the questionnaire, and 535 the direct-to-consumer advertising version.
Data were weighted to represent the national population of physicians in the Medical Marketing Service database who spend 20 or more hours per week on direct patient care, using the Medical Marketing Service variables mentioned above. As can be seen in
Demographic, workload, and practice characteristics of respondents
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Age | ||||||
<39 | 222 (22) | 198 (20) | ||||
40-49 | 360 (36) | 363 (36) | ||||
50-59 | 248 (25) | 248 (25) | ||||
60+ | 169 (17) | 188 (19) | ||||
Gender | ||||||
Female | 228 (22) | 223 (22) | ||||
Male | 808 (78) | 812 (78) | ||||
1999 Income from practice | ||||||
$100000 or less | 177 (19) | 179 (19) | ||||
$100001-$150000 | 298 (31) | 297 (31) | ||||
$151001-$200000 | 194 (20) | 195 (20) | ||||
$200001-$250000 | 128 (13) | 126 (13) | ||||
$250001+ | 162 (17) | 160 (17) | ||||
Geographic setting | ||||||
Urban | 342 (34) | 346 (34) | ||||
Suburban | 334 (33) | 333 (33) | ||||
Small town | 275 (27) | 273 (27) | ||||
Rural | 67 (7) | 66 (7) | ||||
Geographic region | ||||||
East | 288 (27) | 298 (28) | ||||
South | 316 (30) | 310 (30) | ||||
Midwest | 231 (22) | 230 (22) | ||||
West | 215 (21) | 213 (20) | ||||
Type of medical specialty | ||||||
Primary care | 404 (39) | 406 (39) | ||||
Medical specialty | 350 (33) | 355 (34) | ||||
Surgical specialty | 296 (28) | 289 (28) | ||||
Office-based or Hospital-based | ||||||
Office-based | 942 (90) | 937 (89) | ||||
Hospital-based | 108 (10) | 113 (11) | ||||
Country of training | ||||||
United States | 946 (90) | 937 (89) | ||||
Foreign | 104 (10) | 113 (11) | ||||
Respondents best estimate of the percentage of their patients who were |
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Uninsured | 3 | 5 | 13 | 3 | 5 | 13 |
On Medicaid | 5 | 10 | 25 | 5 | 10 | 25 |
From a minority group | 10 | 20 | 40 | 10 | 20 | 40 |
Had an annual household income of $20000 or less | 10 | 15 | 30 | 9 | 15 | 30 |
Respondents best estimate of: | ||||||
Number of hours spent per week in face-to-face contact with patients | 24 | 32 | 40 | 24 | 32 | 40 |
Number of patients seen per week | 50 | 80 | 105 | 50 | 80 | 104 |
The analytic approach focused on evaluating univariate and multivariate relationships with 4 clinically-important outcomes — change in physician-patient relationship; time efficiency; quality of care; and patient health outcome — each of which was assessed on a 3-point scale (improved vs no difference vs worsened). All the demographic, workload, and practice variables listed in
Although several of the workload and practice characteristics were assessed as continuous variables (eg, percentage of patients who were uninsured, average number of patients seen per week), most were highly skewed, so medians and interquartile ranges are reported for these data. These variables were split at the 75th percentile for analysis of univariate relationships to test for the influence of these factors. This split was chosen over a median split to maximize the opportunity for an effect to be visible.
Separately for each outcome variable, correlates with chi-square statistics achieving
As all data were weighted (except where specified), the appropriate procedures to correct
The characteristics of the respondents before and after weighting are presented in
Sixty-one percent (n = 639; 95% CI, 58%-64%) of all respondents used the Internet in their own practice. In this group, the most-frequent uses were to obtain scientific information such as articles or guidelines (88%; 95% CI, 86%-91%) or to e-mail colleagues (63%; 95% CI, 59%-67%). Obtaining clinical information about patients, such as lab results (28%; 95% CI, 25%-32%), and e-mailing patients (16%; 95% CI, 13%-18%) were much less common uses of the Internet by physicians.
Overall, respondents were positive about the recent increase in health information on the Internet, with 75% (95% CI, 72%-77%) of the total sample thinking that it was a good or very-good thing. Only 15% (95% CI, 13%-17%) believed that it was a bad thing, and the remainder were neutral. Similarly, most physicians (77%; 95% CI, 74%-79%) stated that they had encouraged patients to look for information, although only 35% (95% CI, 32%-38%) had referred patients to Web sites.
Eighty-five percent (95% CI, 82%-87%) of all respondents had experienced an occasion when a patient brought information from the Internet to a visit. For most physicians this is still a relatively-rare event; 59% (95% CI, 56%-62%) of respondents stated that less than one fifth of their patients had done this. 87% (95% CI, 85%-89%) of physicians perceived their patients as being concerned about the quality of information on the Internet, and 84% (95% CI, 82%-86%) of respondents rated their patients as only fair or poor (rather than good, very good, or excellent) at appraising the quality of information on a Web site
A random subsample (n = 519) was asked about the last time a patient had brought in health information on the Internet to a consultation and 430 reported that a patient had done so. The remaining data are from these 430 respondents.
Most respondents believed that the last time a patient had brought in health information from the Internet, the information had been very (18%; 95% CI, 15%-22%) or somewhat (64%; 95% CI, 59%-68%) relevant to that patient's problems and very (8%; 95% CI, 5%-11%) or somewhat (66%; 95% CI, 61%-71%) accurate.
Respondents perceived that the majority of these patients (90%; 95% CI, 87%-93%) had brought them the information because they wanted the physician's opinion on it. Physicians reported that patients sometimes also wanted a change in medication (31%; 95% CI, 27%-36%), a test (26%; 95% CI, 22%-31%), or a referral to a specialist (13%; 95% CI, 10%-17%).
Physicians usually did what the patient wanted, either completely (23%; 95% CI, 19%-28%) or partially (59%; 95% CI, 54%-63%). Univariate associations are shown in
Did you do what the patient wanted?
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Total | 400 | 23 | 59 | 18 | |
Medical specialty | .004 | ||||
Surgical specialty | 112 | 29 | 59 | 13 | |
Primary care | 152 | 21 | 66 | 14 | |
Medical specialty | 136 | 22 | 50 | 28 | |
How relevant did you feel the information was to the patient? | .002 | ||||
Very / somewhat relevant | 327 | 24 | 61 | 15 | |
Not very / not at all relevant | 73 | 19 | 48 | 33 | |
How accurate was the information? | .001<.001 | ||||
Very / Somewhat | 291 | 27 | 62 | 11 | |
Not very / Not at all | 107 | 14 | 48 | 38 | |
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.001<.001 | ||||
Test / Referral / Medication change | 184 | 9 | 69 | 22 | |
Your opinion only | 206 | 37 | 50 | 13 | |
Did you think that the patient's request was not appropriate for their health? | .001<.001 | ||||
Yes | 128 | 4 | 59 | 37 | |
No | 273 | 32 | 59 | 9 | |
Did you have enough time to discuss the information? | .001<.001 | ||||
Yes | 253 | 29 | 53 | 17 | |
No | 147 | 13 | 68 | 19 | |
Did you feel the patient was taking responsibility for their health? | .121 | ||||
Yes | 308 | 25 | 59 | 16 | |
No | 89 | 18 | 57 | 24 | |
Did you feel the patient was challenging your authority? | .001<.001 | ||||
Yes | 69 | 6 | 60 | 34 | |
No | 329 | 27 | 58 | 15 |
On multivariate analysis, only 3 factors independently predicted not doing what the patient wanted. Thinking that the patient's request was not appropriate for their health was the most important factor (OR = 4.4; 95% CI, 2.4-8.0), followed by thinking the information that the patient brought in was not accurate (OR = 3.0; 95% CI, 1.6-5.5) and the type of specialty the physician was in. Medical specialists were more likely than primary care physicians and surgical specialists not to do what the patient wanted (for medical specialist compared to primary care physician OR = 2.8; 95% CI, 1.4-5.5, and for medical specialist compared to surgical specialist OR = 2.0; 95% CI, 1.02-4.1).
Most physicians believed that the patient bringing information to the visit had had a beneficial (38%; 95% CI, 33%-43%) or neutral (54%; 95% CI, 49%-59%) effect on the physician-patient relationship. Univariate associations are shown in
Effect on the physician-patient relationship of the patient bringing information from the Internet
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Total | 406 | 38 | 54 | 8 | |
How relevant did you feel the information was to the patient? | .001<.001 | ||||
Very / somewhat relevant | 331 | 44 | 51 | 5 | |
Not very / not at all relevant | 74 | 11 | 66 | 23 | |
How accurate was the information? | .001<.001 | ||||
Very / Somewhat | 298 | 44 | 52 | 5 | |
Not very / Not at all | 106 | 22 | 59 | 19 | |
Did the patient want: | .001<.001 | ||||
Test / Referral / Medication change | 183 | 36 | 50 | 14 | |
Your opinion only | 212 | 42 | 55 | 3 | |
Did you do what the patient wanted? | .001<.001 | ||||
Yes, completely | 94 | 53 | 47 | 0 | |
Yes, partially | 234 | 39 | 55 | 6 | |
No | 71 | 15 | 57 | 27 | |
Did you think that the patient request was not appropriate for their health? | .001<.001 | ||||
Yes | 126 | 27 | 48 | 25 | |
No | 280 | 43 | 56 | 1 | |
Did you have enough time to discuss the information? | .010 | ||||
Yes | 257 | 40 | 55 | 5 | |
No | 148 | 34 | 52 | 14 | |
Did you feel the patient was taking responsibility for their health? | .001<.001 | ||||
Yes | 313 | 43 | 51 | 6 | |
No | 89 | 23 | 62 | 15 | |
Did you feel the patient was challenging your authority? | .001<.001 | ||||
Yes | 68 | 24 | 40 | 35 | |
No | 337 | 41 | 56 | 3 |
Multivariate analysis yielded 4 factors that were independently associated with a worsening of the physician-patient relationship. The physician feeling that the patient was challenging their authority was the strongest predictor (OR = 14.9; 95% CI, 5.5-40.5) followed by the physician believing that the patient's request was not appropriate for their health (OR = 9.9; 95% CI, 2.7-36.4). Not feeling that the patient was taking responsibility for their health was independently associated with a worsening of the physician-patient relationship (OR = 4.6; 95% CI, 1.7-12.5), as was not doing what the patient wanted (OR = 4.0; 95% CI, 1.7-9.7).
Thirty-eight percent (95% CI, 34%-43%) of physicians believed that the effect of the patient bringing information to the consultation harmed their time efficiency while only 16% (95% CI, 13%-20%) believed that it had helped it. Univariate associations are shown in
Effect on time efficiency of the patient bringing information from the Internet to a visit
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Total | 408 | 16 | 45 | 38 | |
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Country of training | .018 | ||||
United States | 376 | 15 | 45 | 40 | |
Overseas | 32 | 33 | 46 | 20 | |
Proportion of patients on Medicaid | .014 | ||||
25% or less | 307 | 14 | 46 | 40 | |
> 25% | 72 | 28 | 44 | 28 | |
Number of patients seen per week | .117 | ||||
100 or fewer | 273 | 18 | 47 | 35 | |
> 100 | 125 | 13 | 41 | 46 | |
Did you have enough time to discuss the information? | <.001 | ||||
Yes | 259 | 19 | 52 | 29 | |
No | 148 | 12 | 33 | 55 | |
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How relevant did you feel the information was to the patient? | <.001 | ||||
Very / Somewhat | 333 | 20 | 47 | 34 | |
Not very / Not at all | 75 | 3 | 40 | 57 | |
How accurate was the information? | <.001 | ||||
Very / Somewhat | 299 | 20 | 49 | 31 | |
Not very / Not at all | 108 | 6 | 35 | 58 | |
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Did the patient want: | .087 | ||||
Test / Referral / Medication change | 183 | 12 | 44 | 44 | |
Your opinion | 212 | 21 | 46 | 33 | |
Did you do what the patient wanted? | <.001 | ||||
Yes, completely | 94 | 24 | 48 | 27 | |
Yes, partially | 233 | 16 | 48 | 36 | |
No | 72 | 8 | 33 | 59 | |
Did you think that the patient's request was not appropriate for their health? | <.001 | ||||
Yes | 127 | 12 | 27 | 61 | |
No | 281 | 18 | 53 | 28 | |
Did you feel the patient was taking responsibility for their health? | .016 | ||||
Yes | 315 | 19 | 46 | 35 | |
No | 89 | 8 | 43 | 49 | |
Did you feel the patient was challenging your authority? | <.001 | ||||
Yes | 69 | 8 | 21 | 71 | |
No | 339 | 18 | 50 | 32 |
Multivariate analysis showed that many of these factors were independently associated. Physicians trained in the United States were more likely than physicians trained overseas to feel that time efficiency was worsened (OR = 5.8; 95% CI, 2.0-17.0). Other independently-associated workload factors were not having enough time to discuss the information (OR = 2.6; 95% CI, 1.6-4.3) and seeing over 100 patients per week (OR = 1.8; 95% CI, 1.1-3.0). The physician thinking that the request was not appropriate for the patients health (OR = 2.5; 95% CI, 1.5-4.4), feeling that the patient was challenging their authority (OR = 3.6; 95% CI, 1.8-7.2), or not thinking that the patient was taking responsibility for their health (OR = 2.2; 95% CI, 1.3-3.8) were also independently associated with worsened time efficiency.
Most physicians believed that the information made no difference to the quality of care the patient received (70%; 95% CI, 66%-74%). More physicians believed that it had been beneficial (25%; 95% CI, 21%-29%) than deleterious (5%; 95% CI, 3%-8%) (
Effect of the patient bringing information from the Internet to a visit on quality of care
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Total | 408 | 25 | 70 | 5 | |
How relevant did you feel the information was to the patient? | <<.001 | ||||
Very / somewhat relevant | 331 | 29 | 68 | 3 | |
Not very / not at all relevant | 75 | 4 | 82 | 14 | |
How accurate was the information? | <<.001 | ||||
Very / somewhat accurate | 298 | 29 | 67 | 3 | |
Not very / not at all accurate | 108 | 11 | 78 | 11 | |
Did the patient want: | <<.001 | ||||
Test / Referral / Medication change | 182 | 22 | 69 | 9 | |
Your opinion | 212 | 28 | 71 | 1 | |
Did you do what the patient wanted? | <<.001 | ||||
Yes, completely | 94 | 31 | 68 | 1 | |
Yes, partially | 232 | 26 | 70 | 4 | |
No | 73 | 14 | 72 | 15 | |
Did you think that the patient's request was not appropriate for their health? | <<.001 | ||||
Yes | 126 | 15 | 71 | 14 | |
No | 280 | 29 | 70 | 1 | |
Did you have enough time to discuss the information? | .138 | ||||
Yes | 258 | 27 | 69 | 4 | |
No | 147 | 20 | 73 | 7 | |
Did you feel the patient was taking responsibility for their health? | .006 | ||||
Yes | 315 | 28 | 67 | 4 | |
No | 89 | 12 | 80 | 8 | |
Did you feel the patient was challenging your authority? | <<.001 | ||||
Yes | 68 | 15 | 68 | 17 | |
No | 338 | 26 | 71 | 3 |
Seventy-five percent (95% CI, 71%-79%) of physicians believed that the information had made no difference to the patient's health outcome, 21% (95% CI, 17%-25%) believed that it had improved the health outcome, and only 4% (95% CI, 2%-6%) believed that it had been deleterious (
Effect of the patient bringing information from the Internet to a visit on health outcomes
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Total | 406 | 21 | 75 | 4 | |
How relevant did you feel the information was to the patient? | <<.001 | ||||
Very / somewhat relevant | 330 | 25 | 73 | 2 | |
Not very / not at all relevant | 75 | 5 | 85 | 10 | |
How accurate was the information? | <<.001 | ||||
Very / somewhat accurate | 296 | 26 | 73 | 1 | |
Not very / not at all accurate | 107 | 7 | 83 | 10 | |
Did patient want: | .002 | ||||
Test / Referral / Medication change | 180 | 20 | 74 | 6 | |
Your opinion | 212 | 23 | 76 | 1 | |
Did you do what the patient wanted? | <<.001 | ||||
Yes, completely | 92 | 26 | 72 | 1 | |
Yes, partially | 232 | 23 | 75 | 2 | |
No | 73 | 7 | 80 | 13 | |
Did you think that the patient's request was not appropriate for their health? | <<.001 | ||||
Yes | 126 | 16 | 74 | 10 | |
No | 278 | 23 | 76 | 1 | |
Did you feel the patient was taking responsibility for their health? | .001 | ||||
Yes | 313 | 24 | 74 | 2 | |
No | 89 | 10 | 82 | 8 | |
Did you feel the patient was challenging your authority? | <<.001 | ||||
Yes | 69 | 13 | 74 | 13 | |
No | 336 | 22 | 76 | 2 |
This is the first large nationally-representative sample of physicians to study physician perceptions of the impact of health information on the Internet on quality of health care, health outcomes, health service utilization, and the physician-patient relationship that we could find by searching MEDLINE. We found evidence of both good and bad effects. Our findings have implications for practicing clinicians, policy makers, and researchers.
Physicians believed that patients bringing in accurate, relevant online information is beneficial and welcomed it. Conversely, physicians believed that inaccurate or irrelevant information harms the quality of care, health outcomes, time efficiency, and the physician-patient relationship. Thus improving the accuracy and relevance of online information available to patients may improve outcomes of interest to health care providers, payers, and consumers. The policy challenge is how to improve the quality of online health information, given the large number of health-related Web sites and the ease with which sites can be updated. Suggestions include "kitemarks" (seals of approval) for quality Web sites, codes of conduct for development and content of Web sites, market forces, directing users to trusted Web sites, filters, rating instruments for users, and public education in evaluating the quality of online information [
US physicians may feel in a quandary when patients request an inappropriate clinical intervention that they learned about online. Ethically, physicians should refuse inappropriate requests in order to avoid harming the patient and to use health service resources prudently. However, previous studies have suggested that refusing patient requests will reduce patient satisfaction [
Seventeen percent of physicians felt that patients were challenging their authority during the visit. This reaction was strongly associated with harms to the physician-patient relationship, quality of care, health outcomes, and time efficiency. Our study cannot determine why physicians feel challenged. Some physicians may be having difficulty adjusting to a more-equal relationship, where the patient has greater access to medical information [
Although our response rate is only moderate at 53%, it compares well to other surveys of Internet use by physicians. Because our sample was representative of all US physicians in terms of age, gender, specialty, location of practice, and practice income our results are likely to generalize to all US physicians. In contrast, previous surveys have examined specific branches of medicine [
As with all cross-sectional studies, we cannot determine causality, nor do we have objective data on whether patient requests were truly inappropriate or on quality of care or health outcomes. However, our measures are plausible because physicians address the appropriateness of care and outcomes daily on a professional basis. Patient perceptions of these consultations may have been different, but our results from a population survey of public perceptions of the effects of health information on the Internet are not dissimilar [
Health care organizations, payers, and providers have a strong interest in ensuring both that health information on the Internet is accurate and that physicians have the necessary skills to respond to patients who bring in such information. Vigorous leadership in these areas will be needed if the effect of the Internet on medicine is to be truly beneficial.
We are grateful to the Robert Wood Johnson Foundation for funding the study and to the Commonwealth Fund for awarding a Harkness Fellowship in Health Care Policy 2001-2002 to Elizabeth Murray, enabling her to work on this study.
Karen Donelan was Medical Vice-Director of a company providing health information and advice through the Internet. She took up this post after completing the protocol for the study and design of the survey instruments, and had no further input into the fieldwork or analysis of the data.
United States