By Christopher Guadagnino, Ph.D..

Published July 2000

• React to this article in the Discussion Forum.

George D. Lundberg, M.D., is executive vice president and editor-in-chief of Medicalogic/ Medscape and former editor-in-chief of the Journal of the American Medical Association. He is scheduled to deliver a keynote address in September at an Orthopedics conference in Philadelphia on the topic of the future of medicine on the Internet.

PND: What role can the Internet play in health care?

GDL: One still to be defined but potentially huge role. Most of medical practice involves simply communication of information: gathering, assessing, distributing and acting upon the information, and then monitoring and getting feedback with information. In short, that part of medicine which is not surgery specifically, radiology specifically or chemical treatments for things is simply information. The Internet can play an extremely important role in conveying such information from anywhere to anywhere quickly, at very low cost and, if done right, with great security. I see the Internet as one of the three biggest advances in science in the last 500 years as it applies to medical care.

The Internet will be conveyor of medical information that’s gathered at the doctor-patient interface in office practice and probably in hospital practice by the online medical record replacing the electronic medical record. The creation and keeping of medical records, including physician observations, patient observations, physical exams, lab tests, progress notes, pharmacy orders, will all be electronic fairly soon. And in the very near future, in order to have accurate information transmitted quickly and kept flawlessly, as well as the ability to guide physicians to make the right decisions at the point of care, electronic record keeping will become the usual instead of rare, and probably mandatory in most areas. The ability for Internet-based decision support systems to prevent error in medicine and get the right thing done for patients will be seen as overwhelmingly necessary in the near future. The Internet will be the method for conveying and capturing and keeping the information that matters on essentially all doctor-patient interactions.

PND: How, in your view, has proliferation of medical information on the Internet changed the physician-patient relationship?

GDL: It is changing very rapidly. The era of paternalism by physicians was not ended by the Internet. That era ended in the middle to late 1980’s as patient autonomy began to become the principal ethic about the relationship between doctors and patients in this country. All of a sudden in a system in which patients are already clamoring to take charge of their own health, here plops the medical Internet with the ability for patients to do the same kind of research a doctor would do, and maybe with even more time and incentive, free of charge. The Internet has played a great role in empowering patients to develop information about their own conditions so that they could take charge of their health in a more sensible way and can ask their doctor really pertinent and telling questions and, frankly, put the doctor a little on edge in terms of whether the doctor knows as much about a given disease as the patient does. So, there’s a stressful situation created by this, but I find that very healthy. I think it’s wonderful for patients to be able to take charge of their own health and do the best they can about learning, which they’ve always been able to do through a library or through books they might buy, but the Internet is the world’s easiest and least expensive to use library.

PND: What do physicians need to do differently to handle this new challenge?

GDL: They need to welcome the idea of patients being interested in their own health. There are over 20,000 health websites—nobody knows exactly how many. A lot of them are complete junk, but some of them are very good. Some are tailored specifically to patients. I think physicians should become thoroughly aware of what’s available to patients on the Internet and develop a list of the best sites to go to for specific types of questions. An Internet site can be used by a physician to prescribe information or even make printouts for patients. By being assertive, the doctor can take control back by guiding the patient where to go to supplement the patient’s knowledge with information from the Internet. It’s important for doctors to be very knowledgeable about where patients are likely to go and then guide them to the best places so they don’t waste their time.

PND: What is an efficient way for physicians to develop a list of the best medical websites for patients?

GDL: In a given field there would be maybe five or ten sites that would be most helpful to the patient and the physician could easily hand out such a list to patients. The physician could say to the patient, "Go anywhere you like for fun, but these places will probably give you trustworthy information."

PND: Many physicians have been slow to adopt the Internet for patient care uses. What obstacles exist to medical use of the Internet?

GDL: Obstacles are basically doing things the old way and needing to learn the reasons to do them the new way and then be rewarded by incentives of one kind or another. These could be sugar- or club-type incentives. The sugar would be that you can do your work faster and cheaper if you use the Internet, such as transcription services. When the quality agencies and regulators start saying, "In order to enhance patients safety it’s necessary to do your drug ordering with a computer," then doctors will do it.

PND: What is the rationale for online-only medical publications?

GDL: People who access our journals and information on Medscape have a right to print out anything they want, and they often do. We just don’t want to have to send it through the mail. The rationale for on-line publication is speed, quality and economy. The biggest expenses of most publications are paper, postage costs and some production costs. If you get rid of that you can do publications very well at very low cost.

PND: What proportion of physicians use online medical publications?

GDL: The data are not clear. Medscape, my company, has registered 2.5 million users in 230 countries and we currently have 400,000 physician users, about half in North America and half in the rest of the world. We’re adding four registereds a minute. The frequency with which physicians and others are coming to this form of information is extreme and the growth slope is very steep.

PND: How do you go about getting more physicians to use on-line publications?

GDL: You give them the best information. Refer them to it so they know where to go. Reward them when they show up by giving them speed, utility, trustworthy information and they come back.

PND: How do you insure that medical information on the Internet is reputable?

GDL: How do you insure information on paper is reputable? You don’t. It’s total censorship if you try to do that. All you can do is guide people to the best sites and tell them they could go to the bad ones for fun if they want, but they better not follow what’s on there because it might hurt them. You set up ways to teach people how to figure out the best ones. Tell people when they go on a medical Internet site that they ought to be able to quickly answer these five questions. First, "Who wrote what they’re reading?" A lot of sites don’t even have the names of who wrote it. Second, you ought to be able to tell where that person works so you can find them if you need them. Third, if information has come from somewhere else, it should be attributed as to what its origin was. Fourth, you need to be able to tell quickly who owns the site and where the money comes from to keep it going. And fifth, the timing of material that’s put there and if it’s been updated should be clearly stated. So these five questions—authorship, institution, attribution, financing and timing—are the key points to look at on a medical Internet site. I think for consumers it’s best to go with name brand identification. If you can trust The National Institutes of Health and the National Cancer Institute in general, you can trust their web site.

PND: How is publishing a medical journal on the Internet different from doing so in print?

GDL: It’s faster and it’s cheaper. Other than that, it’s the same. Information is information no matter where. Process is process no matter where. Ethics are ethics no matter where. Trustworthy people are trustworthy people no matter what medium they’re in. Most of what is on the Internet is the same as it would be in person or in print form, it’s just that the Internet is a different medium. So I like to say that the Internet is the medium; it is not the message.

PND: Doesn’t that medium have an aura of being less reliable than print?

GDL: There should be healthy skepticism. If you look up shark cartilage, you find 275 sites on shark cartilage and they’re all complete tripe. But that’s the topic. None of those, to my knowledge, pass my five questions. But if you’re going to read JAMA on the Internet or you’re going to read JAMA in print it’s the same thing.

PND: How does an Internet-only medical journal establish its credibility?

GDL: By deserving it. By being around a while. There aren’t many Internet-only medical journals. You start something fresh and do the best you can. You get people who are known to be trustworthy to work with you and you put in the same methodologies of peer review and proper ethical behavior that you would for a print journal—at least as good and in some instances better. You try to attract good authors to write good articles, go through peer review, then publish the best ones. People come and see them, they like them, they respond to them and they come back. I guess that’s the way you establish trust with anything: you deserve it.

PND: The integrity of print medical journals has been mired recently by issues of researchers’ financial interests, editorial independence, commercialism, autonomy and integrity of editorial process. What needs to be done to bolster that integrity?

GDL: It starts with competence of editors and editorial independence in which owners and editors have agreed on a set of goals for a given publication and have agreed on a budget. From that point forward neither influences the other. There can be many forms of, or efforts to influence an editorial product: financial, political or personal. All of those are risks and pressures at pretty much all times. It’s up to the governing body of the owner to believe that integrity matters and then to put into place methods of assuring that the integrity is sustained. There must be a set of rules established between the owner and editor that should set up the working relationship and then be followed in order to do the very best job, even if that job might result in at least temporary harm to the owner for political or financial reasons, but nonetheless, the greater public good is what matters. You try to hire an editor who has enough courage and stamina to stand up against the kinds of pressures that are inevitably there from advertisers, from authors, from politicians, from various political constituencies within medicine, as well as from the owners. It is not easy because the stakes are very high and there are many highly different publics that an editor has to serve in good faith all at the same time.

PND: What should the threshold of the editor’s autonomy be?

GDL: One hundred percent. The editor must have autonomy within a job description and an agreed to mission statement to determine what goes in the journal. No one else should be able to determine what goes in the medical journal except the editor. The owner has the right to get a new editor anytime the owner feels like it. But one would hope that that wouldn’t simply be because the editor published the right thing which, however, may have not made the owner feel good at that moment.