Recently, my neighbour Maria shared a story with me about her experience with “Dr. Google.” She’d discovered a red splotch on her left forearm. She didn’t know where it had come from but decided to dismiss it. It didn’t hurt. A day later, the discolouration was worse. Plus there was some itching and some pain. She wore a long-sleeved shirt to cover it up. On day three, however, the pain intensified. She knew she needed to take some action. And so she started Googling symptoms and diagnoses for “red skin discolouration” and other permutations of that phrase. She found some images. And some advice. And she also found some ads for creams and lotions.
Chances are you’ve also used Dr. Google. In fact, 70 percent of Canadians go online to search for medical or health-related information—accounting for 4.5 percent of all internet searches. In the US alone, 6 million people search for health-related information on a daily basis, which exceeds the combined number of daily outpatient visits to emergency departments and physician offices. Health policy and public health folk call this group “health seekers,” and a majority of them go online at least once a month for health information.
And while our gut instinct is to roll our eyes at this type of behaviour, let me be clear: online health information seeking can benefit us. It can, for instance, potentially increase health literacy and can also lead to greater engagement in disease management, which, in turn, may be associated with better compliance and better outcomes. It also helps counteract the lingering effects of an (overly) paternalistic approach to health care, back when many doctors were apt to give their patients a figurative pat on the head. There, there now. Let the doctor make all the decisions for you.
Using search engines to get more information about our health, in other words, is upending the traditional doctor-patient relationship—but it’s not all bad. Rather, health-seeking behaviour has given rise to a shared decision-making model. Ideally, this is one in which doctor and patient work together to achieve disease management that fits the patient’s needs. Of course, there are challenges in this new system, many of which will be familiar to those who have consulted Dr. Google: possible delayed diagnosis, convincing yourself you have something you don’t, wasted trips to the doctor, trying your own home remedy, and so on. Yet, in all these potential pitfalls, we rarely consider a more troubling question: What role does Google itself play in all this?
The vast majority of health seekers use online search engines as a starting point to gain information on a disease or to seek information on the treatment options for a particular disease. Unsurprisingly, Google is by far the most popular search engine and accounts for over 85 percent of health-related searches. We also know that almost four out of five health seekers start an online health information search by accessing sites such as Google, Bing, and Yahoo. With the recent news that Google has been fined an incredible 2.4 billion euros in the EU for skewing its search results, however, it’s worth considering the corresponding implications for online health information seeking.
According to the EU regulator’s investigation into Google’s practices, the company’s search algorithm systematically, consistently gave prominent placement to its own services to the detriment of rival services. This “skew” is critical in the context of health care as, even on a desktop, the ten highest-ranking generic search results on page one receive approximately 95 percent of all clicks. In a health care search scenario, this means that when Maria is looking up her symptoms, the search results that she’s viewing might potentially be showing skewed information—such as an “amazing” cream or ointment.
Those results could be entirely based on the advertising dollars a company has spent as well as the corresponding search engine optimization used to vault it to page one. And it doesn’t help that health seekers are, by and large, incapable of distinguishing between high-value (i.e. correct) and low-value (i.e. incorrect) health care information. This has huge implications when it comes to how we certify, adjudicate, and validate online health information. There are approximately 70,000 websites and online platforms that purport to provide health information. And studies consistently show that a significant proportion of these portals report grossly inaccurate or misleading information.
In other words, while searching the web for health information can bring benefit it can also bring harm. Yet, instead of writing it off entirely, I’d argue that what we really need is regulation and oversight. This is a bold approach for an industry that is already drowning in regulation. Health information is not the same as celebrity gossip. But it is information. It should be readily accessible online, provided it is also reliable—the big caveat. So far, no tangible solutions have emerged, despite best efforts. One fairly obvious reason is that it’s really hard to govern information on the web where anyone with a credit card and a GoDaddy account can set up shop.
But we also don’t have good “quality” signals to send to consumers who are looking for health information. This may be an easier fix: if we assigned a top level domain, like “.health,” people could use it as a signal that a website has been reviewed and adjudicated for accuracy and completeness. Until then, everyone is left to their own interpretation. And while it’s sometimes easy to tell when a web page is from a reputable clinical institution (e.g. Mayo Clinic) other times, it isn’t.
And then there’s the issue of consensus. Suppose there was some person or group regulating online health information. Where would that person or group gain consensus on what information should be shared online and not shared online? In medicine, the heterogeneity of disease combined with a patient’s own underlying comorbidities makes it nearly impossible to suggest a specific treatment approach for every single patient.
While the downsides of online health-information-seeking behaviour may overwhelm the upsides, it’s clear that people aren’t about to stop using Dr. Google. If we ignore the trend, things will get worse, as they usually do. Individuals will continue to make decisions about their own health care, even though they might be grossly incapable of making such decisions. The unchecked growth of inaccurate, bogus sites could also nurture a nation of vigilant, search-engine-using hypochondriacs. It’s what I think of as a “palindromic” hitch. It is a problem both frontwards and backwards. Without intervention, we might drive people to seek care when none is required, or we might drive them to avoid care when care is required. Either way, doing nothing is also a less-than-optimal outcome. And the last thing we need in health care is another less-than-optimal outcome.