In their paper “Clinical Interviewing: An Essential but Neglected Method of Medicine,” Fava et al. [1] argue cogently that the integrity of clinical interviewing – a fundamental skill in medicine – has been jeopardised by technology. This interference is manifested in various ways. For example, there have been concerns about the impact of electronic medical records on communication between patients and clinicians and the outcome of their clinical encounters [2, 3]. Also, people often conduct health searches on the Internet (activity commonly referred to as “Dr. Google”) and bring the results of these searches to their consultations with clinicians, which has had various effects, apparently both positive and negative [4, 5]. The aim of this article is to discuss online health information seeking (OHIS) and some of the ways in which it affects patients, clinicians (both physicians and non-physician clinicians), and patient-clinician relationships.

Gone are the days when most health information was “buried” in medical textbooks, encyclopaedias, scientific and professional papers, and various other hardly accessible publications. Nowadays, the Internet is the largest repository of health information, and most people look for it online, which is usually done via search engines such as Google. An international online survey conducted in 2018 found that 76% of participants engaged in OHIS during the preceding 3 months [6]. Online health searches are popular because they are affordable or cost nothing, and information is provided quickly. Easy accessibility is another major advantage of health information on the Internet, with a conspicuous absence of bureaucratic barriers, referral letters, or waitlists. Anonymity allows people to make any health-related inquiry online without feeling awkward or embarrassed.

People commonly perform online health searches before seeing a physician, when a family member or a close friend develops a symptom or becomes ill, and after experiencing a new symptom or some unusual bodily sensation [6]. People who conduct OHIS are more likely to be women [7], individuals with a university or higher education [6, 8], and those with chronic health conditions [9]. People with higher levels of health anxiety, general anxiety, depression, and intolerance of uncertainty, as well as those with more obsessive-compulsive and somatic symptoms, were also found to be more inclined to engage in OHIS [6]. However, only somatic symptoms independently predicted recent OHIS when other symptom domains were controlled for [6]. This underscores the importance of one’s physical health as a determinant of OHIS.

A revolution in the way health information is accessed has had a significant impact on Internet users. The key benefit of OHIS is reflected in the sense of empowerment derived from obtaining health information of interest [10]. This “freedom from ignorance” has contributed to transforming people who engage in OHIS from passive recipients of healthcare to active participants in actions and decisions related to their health. Successful online health searches also make patients better prepared for consultations with clinicians [11‒13]. This makes it easier for patients to understand clinicians and allows for more effective communication between them during those consultations [13‒15]. Ultimately, OHIS has had a demystifying effect on consultations with clinicians, while consultations themselves have tended to yield better results.

However, OHIS can also have undesirable consequences. For example, some people, especially those with poor online health information literacy, are confused by the plethora of health information on the Internet and do not know how to manage it. Such individuals may also be more likely to misinterpret online health information, which increases their concerns. Other problems include difficulty distinguishing between more and less trustworthy sources of online information and inadequate coping with conflicting or contradictory health information. These factors, along with pre-existing health anxiety, intolerance of uncertainty, proneness to reassurance seeking, unrealistic expectations from the Internet, and/or mistrust of medical authority, can contribute to cyberchondria [16]. This behavioural pattern was defined as excessive and/or repeated online health searches that are associated with increased distress or health anxiety, whereby the searches persist despite interference with functioning and negative consequences [17]. Cyberchondria has been associated with increased healthcare utilisation [18] and problems in patient-clinician relationships, with negative effects on the seeking and receiving of healthcare (e.g., via avoidance of healthcare providers or poor treatment adherence) [19, 20].

How does OHIS affect the relationship between patients and clinicians? Early reports were sceptical, suggesting that OHIS might contribute to difficulties in patient-clinician relationships. For example, there were concerns that patients bringing OHIS-derived information to a clinical consultation might challenge their clinicians’ authority and that this could lead to an argument or conflict with them [4]. Such outcomes might erode patients’ trust in clinicians, amplify their dissatisfaction with the care received or with the healthcare system, and either make patients seek a second opinion, go from one clinician to another and increase healthcare utilisation, or abandon consultations with clinicians and resort to self-diagnosis and self-management [21, 22].

A suggestion that there could be such dire consequences from OHIS almost led to the notion that patients who are better informed might represent a threat to the patient-clinician relationship and perhaps to the whole healthcare system. Although some clinicians may still struggle to accept the reality that health information is no longer the sole prerogative of health experts, they are a minority. Clinicians’ antagonistic attitude towards OHIS and any attempt to ignore or even suppress OHIS are bound to fail because online health searches are here to stay, regardless of what some clinicians think and how they respond to them. Just as the tide of history cannot be turned, the numerous benefits of OHIS cannot be relinquished.

Not surprisingly, and in contrast to some simplistic and alarmist conclusions of early works, recent reviews suggest that OHIS does not necessarily affect the patient-clinician relationship adversely and that it can actually have beneficial effects in this regard [5, 23, 24]. The outcome largely depends on how both patients and clinicians approach the issue of discussing OHIS during consultations.

Many patients feel uncomfortable or anxious about bringing the findings of their OHIS to a consultation with clinicians. One study found that 81% of patients never discussed OHIS with their clinicians [25]. This discomfort and avoidance are likely to be a consequence of the power differential and the traditional model of care in which clinicians are perceived as custodians of all health information and knowledge. Within such a context, clinicians are attributed power, while patients see themselves as vulnerable and subordinate. Given this imbalance, patients may be prone to construing discussion of their OHIS as a challenge or even an insult to clinicians. Indeed, numerous studies have documented patient concerns about clinicians’ potential negative reactions to any mention of OHIS [4, 14, 26‒29].

One factor that may play an important role here is patients’ perception of OHIS. If patients mainly regard OHIS as an activity that is not approved by clinicians and medical establishment, they will avoid discussing it. Likewise, if OHIS is viewed as competing with clinicians’ work and potentially undermining their authority, patients who are keen to have a good rapport with clinicians and avoid any conflict will sidestep mentioning OHIS. Of course, patients do not know whether their perceptions are correct, and they need to be certain both about the “official” attitudes to OHIS and attitudes of the particular clinicians. Patients should not get entangled in a “guessing game” as to how their clinicians feel about OHIS, trying to decipher clinicians’ nonverbal clues regarding this. Endorsement by various medical bodies and healthcare professionals of OHIS as a legitimate, reasonable, and acceptable activity, although with some caveats, would make it easier for patients to discuss OHIS with their clinicians.

Another factor of relevance is the embarrassment that some patients anticipate when bringing OHIS-derived material to a clinical encounter [14, 27, 29, 30]. This may particularly be the case with insecure individuals who think that they might be considered incompetent to conduct OHIS, that they would be judged negatively, and that clinicians would then dismiss them.

Understanding the barriers to patients’ discussion of their OHIS with clinicians and overcoming the attendant hesitation or reluctance are important because research has consistently shown that having such discussions is associated with greater patient satisfaction and better patient-clinician relationship [4, 22, 26, 31‒34]. On the other hand, a lack of opportunity to discuss relevant health information, suppression of these discussions, or their avoidance have been related to less favourable outcomes in terms of patients’ experiences of frustration and adverse mental states, their dissatisfaction, and an impaired patient-clinician relationship [11, 14, 22].

It seems that most clinicians have adjusted to the new reality that, more often than not, people coming to see them are equipped with health information obtained from sources on the Internet. This adjustment has generally not been easy. In fact, it is an ongoing process, given the shifting social status of healthcare practitioners and the constantly changing landscape of online health information.

Clinicians’ first task is acceptance. As already noted, the Internet has changed profoundly the dynamics of patient-clinician communication and relationships, and this is likely to be irreversible. Therefore, any a priori resistance to OHIS would be futile and unproductive. The most fruitful approach for clinicians is to understand and embrace these changes and turn OHIS into an ally in their efforts to ensure the best outcomes for their patients.

Clinicians will be effective in their discussions with patients about OHIS if they are aware of what is “out there” in cyberspace when it comes to health information relevant to their expertise. Considering the vastness of cyberspace and the incessant changes that take place there, this knowledge can never be complete, and it does not need to be so. However, clinicians need to know about the main trends when people make online health searches on certain topics. In other words, what are they likely to find? What kind of information and misinformation is frequently encountered online? Awareness of this will allow clinicians to be better prepared for consultations with patients.

Another important aspect of clinicians’ role is to encourage patients to perform effective online health searches. In fact, clinicians are well placed to provide guidance on this, and patients may expect them to do so. For example, clinicians can direct patients to reputable and reliable websites, explain the limitations of health information and the likelihood of finding conflicting information on the Internet, and help patients interpret the results of OHIS. Not only is this going to be of great assistance to patients as they navigate the Internet, but it will also decrease the risk of cyberchondria and strengthen the patient-clinician relationship.

Occasional disagreements between suggestions and conclusions based on the results of patients’ OHIS and clinicians’ findings and recommendations (including diagnosis and treatment) are inevitable. Such disagreements can be ironed out or lead to a major conflict, depending on how patients and clinicians handle similar situations in general. A satisfactory resolution and strengthening of a therapeutic rapport can occur only if both parties accept the possibility that they are not right and take the other view into serious consideration. This does not necessarily mean that opinions and attitudes have to change to reach a compromise. What matters, though, is that both parties acknowledge and validate each other’s perspective.

Given the benefits of including OHIS in any clinical encounter [4, 22, 26, 31‒34], why are some clinicians still seemingly opposed to it? Both patients and clinicians bring to the consultation their personality characteristics and communication styles, and some of these may lead to misunderstanding and misinterpretation [23]. For example, if a patient discusses OHIS-obtained material in a way that appears confrontational or disrespectful, this will not sit well with a clinician. However, such behaviour may be caused by a patient’s frustration with some vague or contradictory online material and the consequent need for understanding and clarification, whereby there is no intention to challenge, provoke, or berate a clinician. Likewise, if a clinician overly critical of OHIS also seems to encourage a patient to avoid further online health searches, the patient may construe this as a reprimand for performing the searches. But this clinician may in fact be primarily concerned about the quality and credibility of online health information and its potential negative impact on the patient, without questioning the need for patients to be better informed via online sources. Clear communication and efforts to foster a good working relationship should help reduce the risk of these occurrences.

It is somewhat paradoxical that after more than 2 decades of the presence of health information on the Internet, there are ongoing discussions about ways of incorporating OHIS into consultations with clinicians. This is yet another manifestation of how OHIS has shaken the paternalistic and rigidly hierarchical model of care. Although there are still “pockets of resistance” to the full affirmation of OHIS, both clinical practice and research have supported the integration of OHIS with face-to-face encounters between patients and clinicians. The two are not antagonistic to each other, and clinicians’ opinions and expertise are not intrinsically threatened by OHIS and remain highly valued [12, 35, 36]. Online health searches tend to be seen through the lens of patients’ empowerment as complementary to consultations with clinicians [12, 35, 36]. Given this, encounters between patients and clinicians might be enriched by a routine initial inquiry about patients’ OHIS. This may have the effect of “clearing the air” and making it more comfortable for patients to talk about their OHIS from the very start. Within this framework, OHIS can maximise the benefits for both parties in the clinical dialogue.

The author has no conflict of interest to declare.

The writing of this editorial was not supported by any sponsor or funder.

V.S. conceived and wrote the manuscript.

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