Clinical pearls to manage cyberchondriacs.

Sir: “Doctor, I saw on the Internet that drug X works well for people with diagnosis Y. I think I have Y; can you try X for me? ” This has become almost a daily statement in most physicians' offices today. The number of people searching for medical information online in the United States increased from 54 million in 1998 to 97 million in 2001 and 110 million in 2002.1 A study of U.S. physicians in 2003 indicted that 85% of 1050 physicians polled had experienced patients' bringing Internet information to a visit.2 This can place a lot of extra responsibility and pressure on a physician to change a treatment regimen. It may also create a “digital divide” in the patient-physician relationship3 or make a stronger alliance for therapy. A few physicians may even take a defensive role and see Internet-obtained patient information as a challenge to their therapy. This phenomenon poses a unique problem in psychiatry due to the nature of mental illnesses. With paranoia, suspiciousness, grandiosity, and formal thought disorders already in place, how does one convince a patient that we still have his or her best interest at heart? Patients who are searching the Internet for answers are very likely already sensitive to their symptoms and somatic sensations, as in the case of hypochondriacs. The information revolution is changing the old notion of a hypochondriac into a “cyberchondriac. ” With the Internet revolution, input from patients is becoming imminent in daily practice. How does one handle the information our patients provide to us? What does one do when a patient insists on changing treatment based on something he or she found on the Internet? Can one use these opportunities to further strengthen the therapeutic alliance? Here is a 4-step approach that may be helpful to sort through the perils of information overload. Assess the competency of the patient. This is relevant in all practices, but has a unique importance in psychiatry. Does the patient have psychosis, is she or he disorganized, is she or he grandiose? Does the patient have borderline intellectual function? Is there a dementia or cognitive impairment present? Does the patient have a guardian? Assess quality of the material presented. Does the material reflect on evidenced-based medicine? Is this a case report, or is it a double-blind, placebo-controlled study? How many patients failed with the treatment? Was any bias or conflict of interest involved in obtaining the study results? Is this a commercial advertisement by a pharmaceutical company? Discuss risk/benefits/alternatives to treatment. If the information looks credible, can the treatment be implemented? Are there formulary issues? Are there more side effects than with the patient's current treatment? Can the patient afford it? Is there anything bothersome with the patient's current treatment? Is there another possibility to the proposed treatment and the current treatment? Could the proposed change be used as augmentation? Make a clinical decision with the patient. Ultimately, it is your decision. You have to write the prescription and be comfortable with the choice. The rapport that you have with the patient will best determine what happens next. But, if you have taken the steps above with the patient, chances are it will be a mutual decision upon which both can agree. Tips for managing the Internet-informed patient are listed in Table 1. Table 1. Tips for Managing the Internet-Informed Patient