When Do Patients With Hand Illness Seek Online Health Consultations and What Do They Ask?

Abstract

Background

Several websites allow people to post health questions and get answers from doctors. Knowing more about what patients seek from these websites might help in-office educational efforts, but little is known about what occurs on these sites.

Questions/purposes

This study addressed whether patients seeking advice online already have seen a physician, the type of questions asked, if they are dissatisfied with their doctor, the characteristics of the physicians who respond, and the content of their answers. This study documents the circumstances and content of questions asked about hand illness, the characteristics of the physician responders, and their responses.

Methods

One hundred thirty-one hand surgery-related questions from an online health consultation website were reviewed retrospectively. The timing of and reason for the consultation, the content of the questions, the specialty of physician responder, and the content of the responses were recorded.

Results

Sixty patients (46%) were seeking information before seeing a doctor, 21 (16%) after a medical encounter, and 19 (15%) after hand surgery. With increasing contact with providers, patient queries transitioned from diagnosis, to treatment, to prognosis, and potential complications. Patients who had seen a doctor often expressed dissatisfaction (16 of 37 patients [43%]) as did those who had hand surgery (seven of 26 patients [27%]). Between one and eight doctors (average, two) answered each query. Most of the answering physicians were hand surgeons. The information they provided predominantly addressed diagnosis.

Conclusions

Online consultations are most common among patients who have not seen a doctor, but also reflect uncertainty and dissatisfaction after seeing a doctor. Although online health consultations might support patients’ quest for information and understanding, and the potential for multiple answers from different doctors creates the possibility for increased balance and breadth of opinions, the quality of the information and cost-effectiveness of this approach are uncertain and need to be evaluated carefully in future studies.

Introduction

The availability of online medical advice is expanding [3, 20]. In the United States, people are as likely to use the Internet for health consultations as they are to go to a physician in person [1, 6]. There are several websites where patients can pose questions and doctors provide answers. One of the larger online health consultation websites is HealthTap, with 7.5 million unique questions per month [5].

However, little is known about the content, advantages, and disadvantages of online health consultation. A prior study in sports medicine found that online inquiries most often requested information about diagnosis, treatment, and symptoms [14]. One advantage of online consultation is anonymity—delicate issues can be addressed more comfortably [14, 19]. It is not clear whether online medical advice can substitute for or just complement in-person medical consultation [10, 21].

We were interested in the type of advice that patients with hand problems seek from online consultation. First, is online advice sought more often before or after in-person medical evaluation? Second, what kind of information is sought? Third, are patients that already have seen a doctor dissatisfied with that doctor? Finally, what are the characteristics of the physicians who respond and what information do they provide?

Patients and Methods

We reviewed questions related to hand illness posted to a then-free health consultation website (http://www.avvo.com/health, now HealthTap [https://www.healthtap.com/]) between January 2010 and November 2012. The website was managed by a company that profited from advertisements on the site. Patients posted their queries without registering. Doctors were registered and identified. Doctors received email notifications inviting them to respond to new posts in their field. The website emphasized that the advice given by the doctors could not substitute for an in-person evaluation and did not constitute a doctor-patient relationship. Orthopaedic hand-related terminology was used as search terms: hand, hand surgery, wrist, and carpal tunnel. Inclusion criteria were: (1) the patient posted a question regarding a hand problem; and (2) a reply by a physician registered with the website was received.

One hundred thirty-one online consultations satisfied the inclusion criteria. The patients’ questions and physicians’ answers were analyzed according to categories that we developed. We recorded the patients’ demographic information (age, sex) if available, the content of the patient’s questions (diagnosis, treatment options, and prognosis/complications) (Table 1), the timing of the consultation (before or after a patient has seen a doctor and before or after surgical treatment), the specialty of the physician, and the content of the physicians’ answers (diagnosis, treatment options, and prognosis/complications)(Table 2), and the reason for consultation (dissatisfaction with current doctor, insurance issues, or request for information) (Table 3). We also recorded how often in-person evaluation by a hand surgeon was recommended.

Table 1.

Characteristics of patient queries

Content of query†	Before seeing a doctor (n = 63 patients)	After seeing a doctor (n = 39 patients)	After surgery (n = 27 patients)	p value§	Phi
Request for information regarding:
Diagnosis (number of queries)	49	20	4	0.001	0.51
Treatment options (number of queries)	12	15	5	0.042	0.25
Prognosis/complications (number of queries)	4	8	19	0.001	0.57

Timing of consultation was unknown for two of the 129 patients; ^†sometimes there was more than one query per post; ^§assessed with chi-square; effect size measured with Phi.

Table 2.

Characteristics of physician advice

Query	Before consulting a doctor		After consulting a doctor		After surgery
	Number of queries	Percent	Number of queries	Percent	Number of queries	Percent
Answered by*
General orthopaedic surgeon	9	7	5	4%	3	2.3%
Hand surgeon	48	37	33	25%	25	19%
Plastic surgeon	1	1	2	1.5%	1	0.8%
Neurosurgeon	2	2	0	0%	0	0%
Neurologist	4	3	0	0%	0	0%
Psychiatrist	6	5	2	1.5%	0	0%
Primary care physician	3	2	1	0.8%	1	0.8%
Trauma surgeon	0	0	1	0.8%	0	0%
Other	3	2	2	1.5%	0	0%
Content of answers
Diagnosis	54	42	28	23%	12	9%
Treatment	25	19	23	18%	22	17%
Prognosis	23	18	16	12%	16	12%
Referral	47	36	29	22%	15	11%
Complications	1	1	5	4%	11	9%

* Some questions were answered by multiple physicians, so the total number of physicians exceeds the number of posts.

Table 3.

Bivariate analysis

Type of post*	Timing*
	Before seeing a doctor	After seeing a doctor	After surgery	Total	p value§	Phi¶
Dissatisfaction	0 (0%)	16 (13%)	7 (6%)	23 (19%)	0.001	0.49
Additional information	60 (49%)	21 (17%)	19 (15%)	100 (81%)	0.001	0.45
Total	60 (49%)	37 (30%)	26 (21%)	123 (100%)

* n =123 patients, excluding four with insurance issues and two with unknown timing of the consultation; §assessed with chi-square; effect size measured with Phi.

Statistical Analysis

A descriptive analysis of patient inquiries and physician responses was performed. Contingency tables were analyzed using the chi-square test to compare categorical variables. Effect size was measured by calculating Cramer’s V, with V ≥ 0.10 meaning a small effect size, V ≥ 0.3 a medium effect size, and V ≥ 0.50 a large effect size.

Results

Sixty-three (48%) patients were seeking information before seeing a doctor, 39 (3%) were seeking advice after seeing a doctor, and 27 (21%) were seeking advice after surgery (Table 1). Before and just after seeing a doctor, patient queries predominantly address diagnostic information (Table 1; V = 0.51, p < 0.001). After surgery, patients were more interested in prognosis and complications than before or after seeing a doctor but before surgery (Table 1; respectively V = 0.57, p < 0.001; and V = 0.25, p = 0.042).

Patients who already had seen a doctor or had surgery were more likely to express dissatisfaction (Table 3; V = 0.49, p < 0.001). Among the 37 patients (30%) who posted a query after a medical encounter but before surgical treatment, 16 (43%) were dissatisfied with their current treatment, and 21 (57%) requested additional information (Tables 1, 3). Among the 26 patients who posted a query after hand surgery, seven (27%) were dissatisfied and 19 (73%) were asking for more information regarding their diagnosis or treatment (Table 3).

Patient queries regarding hand illness were answered primarily by hand surgeons (n = 107 [69%]) and general orthopaedic surgeons (n = 17 [11%]) (Table 2). The content of the responses given by the doctors consisted mainly of diagnostic information (n = 94 [73%]). For 70% of the queries (92 queries), the online health providers suggested that the patient should see a hand specialist in person (Table 2). On average a question was answered by two physicians (SD, 1.2; range, 1–8). For the majority of the questions with multiple doctors responding, the doctors generally agreed (92%).

Discussion

Online medical advice is rapidly increasing, but little is known about the reasons why patients make inquiries online. We wished to determine the content of questions asked about hand illness, the motivation of the patients, the characteristics of the physician responders, and their responses. We found that the consultations are most common among patients who have not seen a doctor, but also reflect uncertainty and dissatisfaction after seeing a doctor.

There are many limitations to this study. First, basic demographic information and history remain unknown to the answering physicians and researchers. Second, we do not know if patients were satisfied with the information received. Third, we have limited information regarding why patients were dissatisfied or seeking more information. Finally, we have no way to measure the relative harms and benefits of receiving online information.

Online consultation for hand problems seems related primarily to diagnostic questions before seeing a doctor, but also to dissatisfaction with or uncertainty about the information received from an in-person visit to a hand surgeon. These results are in line with previous studies that suggest online health advice might be helpful for nonurgent problems [8, 19]. Protectiveness and preparation for the worst (catastrophic thinking/low self-efficacy) are strong determinants of symptom intensity and magnitude of disability [12, 15, 17, 18, 22, 23, 25] and it is possible that these factors also lead patients to seek online advice, particularly when they already have a hand specialist treating them. Patients often find it difficult to trust health providers when the advice received is unexpected or counterintuitive [11]. We speculate that online consultation with the input of multiple surgeons at once might be an efficient and cost-effective way to help patients more rapidly assimilate the facts about their illness—including the range of debate and uncertainty in hand surgery. It also might help patients come to terms with any counterintuitive aspects, which might facilitate recovery and limit the use of resources (urgent or emergency medical services in particular) by people with nonurgent hand and upper extremity disorders. However, one could argue that receiving multiple different diagnoses and opinions might be confusing and unsettling to patients. Furthermore, not all information provided on the Internet is equally trustworthy [13].

There is an increasing focus on patient satisfaction and the doctor-patient relationship [7, 24]. Prior research suggests that increased patient satisfaction is associated with increased compliance and subsequently improved treatment outcomes [9, 26]. There is evidence that dissatisfaction correlates with certain psychologic factors such as depression [2]. When expert advice clashes with first impressions or gut feelings, the relationship may become somewhat adversarial (eg, “my doctor doesn’t listen,” “my doctor was dismissive of my concerns,” “my doctor didn’t even examine me,” “I don’t know why my doctor didn’t get an MRI”). Examples that we encountered on the online consultation site included when the recovery process seemed to take longer or be more uncomfortable than expected, or a clear diagnosis with an easy solution was not forthcoming. In this regard, the growing popularity of online consultation sites may emphasize the value of facilitating communication with our patients. If we make it easy to communicate directly with us after the visit or surgery and acknowledge that our expert advice often is unexpected and counterintuitive, patients may feel more connected and direct their queries to us. The ability to promptly address any uneasy feelings or uncertainty might help with recovery. Patients with painful hand and upper extremity conditions sometimes feel that their condition is urgent, but a timely explanation of what makes a condition truly urgent might put patients at ease and limit the use of emergency services.

Only 69% of the responses were from a hand surgeon. The answers generally were cautious and the majority of patients were advised to see a hand specialist in person, which is in line with prior research in maxillofacial surgery [4]. Currently, doctors are not reimbursed for most online consultations. In a prior study, approximately 1/3of the patients posting online questions indicated that they would be willing to pay for advice (33% of the people in the lowest income bracket versus 48% for people in the highest bracket) [16].

Online health consultations are becoming commonplace [1, 6] and might help inform patients and increase their participation in decision-making [4]. The ability to read multiple opinions and to see how and why caregivers disagree might be informative and empowering. Multiple answers should provide greater balance and breadth of opinion. However, it could be confusing and patients may receive misinformation. Future studies should address factors associated with patient satisfaction and the accuracy of the information provided by online health consultations.