Foreword to Jeanne Ryer’s book HealthNet

Timothy B. McCall, M.D.

There’s a sea change underway in the power relationship between doctors and patients. The key to that change is information--or more specifically the public’s access to it--and, increasingly, that access is coming via the computer.

Traditionally doctors, like other professionals, have maintained their authority due to their monopoly on specialized knowledge. To take advantage of this knowledge you had to visit the doctor, who would dole out a small parcel of it in exchange for a fee. Those who didn’t, or couldn’t, consult a doctor usually had very little opportunity to obtain accurate medical information in any other way. In the past several decades, however, the doctors’ lock on information has started to break down.

In the wake of Watergate, the Vietnam War and the Women’s Movement--to name a few--the general public’s faith in authority figures diminished. Doctors weren’t spared. Consumers began to question more and expect a say in the medical decisions whose consequences they would have to live with. In response, an entire industry sprang up to provide them the necessary tools. The on-line world is the latest--and potentially most powerful--medium for providing consumers the kind of information that was once available only to doctors.

Ideally, it wouldn’t be necessary to independently research your medical conditions. In a perfect world you could simply rely on your doctor to be up-to-date with advances in diagnosis and treatment. Physicians would have the time and inclination to teach you about your medical conditions and the side effects of the drugs they prescribe, and to fully inform you of the risks and benefits of various treatment options.

Doctors in a perfect world wouldn’t be swayed by reimbursement mechanisms to order too many tests or perform too many operations--as occurred regularly under the traditional insurance system in this country--or to deny potentially helpful services--as we are starting to see in Health Maintenance Organizations (HMOs). You could count on physicians to be unswayed by the formidable marketing arm of the pharmaceutical industry --to prescribe the best drugs--and not simply the ones with the slickest ad campaigns or whose manufactures lavished the nicest gifts on physicians.

This isn’t an perfect world. Physicians’ recommendations are routinely influenced by a myriad of factors other than just your medical condition. The quality of physicians varies enormously. And even good doctors make mistakes, have gaps in their knowledge or advise treatments that may make sense scientifically but which don’t fit in with their patients’ value systems.

Should, for example, an elderly woman with breast cancer undergo chemotherapy? The “medically correct” answer, as I like to call it, is yes. Chemotherapy increases her odds of being alive in five years by a few percentage points, but there’s a trade off. Cancer drugs cause nasty side effects like hair loss and intractable nausea and, in fact, increase the risk of dying in the short run. In such a case, the decision is not based primarily on science but on values: Reasonable people will consider the same information, weigh the potential risks and benefits and come to different conclusions about the best course of action. Unfortunately, too often it’s the physician’s values, not the patient’s, that determine what happens.

In the past, most people have simply followed their doctor’s advice, and done whatever they recommended. The problem with this strategy is that if, say, a doctor advises you have a test, not because you really need it but because he or she is worried you’ll sue, you’re simply told you should have it. Similarly, if financial incentives are affecting a physician’s advice, that information isn’t shared with you.