Dot-Com Doctors Are In
Blame managed care; blame the Internet. But by now most of us are aware that medicine is an imperfect science. Lab tests can be misread, X-rays botched and even our own favorite doctor is human.
That’s why many consumers are beginning to demand--and some doctors to offer--second opinions online, based not on general health histories but on lab results, X-rays, diagnostic tests and detailed medical records.
In effect, these sites provide the latest and clearest step toward a phenomenon experts have anticipated and many health professionals still don’t trust: doctors practicing medicine over the Internet on people they’ve never examined.
Though major teaching hospitals such as the Johns Hopkins School of Medicine in Baltimore have offered patients and their doctors remote access to Hopkins specialists for some time, there are now at least a half-dozen free-standing sites with second-opinion features that are not backed by major institutions. And they are sprouting up in precisely those fields of medicine in which doctors can strongly disagree about lab results and what they mean for patients. For example:
* A Los Angeles-based site called eSpine.com charges $75 for a review of spinal X-rays, CT scans and other diagnostic tests, plus a phone consultation with an orthopedic surgeon who specializes in spine operations. Spine specialists often don’t agree on how best to treat disc problems or whether to treat them at all, researchers say.
* FindCancerExperts.com in Bethesda, Md., connects people worried about a cancer diagnosis to pathologists who review tissue biopsy slides to make sure the tests have been interpreted correctly. Several large-scale studies have shown that biopsies taken to check for cancers are misread 1% to 10% of the time. FindCancerExperts refers visitors to three leading experts for free; the patient is then billed a consultation fee, usually by the hospital where the doctor is practicing.
* For $450 to $800, MDExpert.com in Palo Alto, Calif., will have your medical records reviewed by a cancer specialist who provides a thorough explanation of treatment options, medications and follow-up tests, if necessary. This is then sent back to the treating doctor for discussion with the patient. Even with some common cancers--prostate tumors, for example--doctors have honest disagreements about treatment, and patients are left to sort through conflicting advice.
Although these electronic consultations are generally not covered by insurers, those who run second-opinion sites say the service can provide a lifeline for people in remote areas, or who are confused by advice they’re getting from their own doctors.
“Most people with a cancer diagnosis want a second opinion, but they wonder, ‘Where should I go, whom should I ask?’ ” says Rachel Pomerantz, president of MD-Expert, which has enlisted some 200 cancer specialists from teaching hospitals such as Memorial Sloan-Kettering Cancer Center in New York and UCLA. “These are people who don’t have access to the best medical experts, they don’t have the kind of connections they need, and that’s what we’re providing.”
Among the site’s first clients was Joan Tersol, a 74-year-old retiree living in Carmel, Calif., whose doctors disagreed about how to treat her breast cancer. “You have to understand that I was absolutely coming apart when I contacted MDExpert,” says Tersol. “I had no idea what to do. But I felt much more confident when I learned that experts on either side of the country agreed” with one of her doctors on the treatment. She followed their advice and now has no detectable cancer.
Despite such stories, however, most practicing doctors continue to draw a very clear line between what can be handled well online and what is best handled in person. For instance, interpreting the results of many tests, such as X-rays and biopsies, often can be done perfectly well without an exam.
“In practice we rarely see patients anyway, we don’t examine patients, we simply look at the clinical information,” says pathologist Dr. Barry Shmookler, founder of FindCancerExperts, which provides access to 70 specialists across the country chosen on the basis of their affiliations, reputations and contributions to medical literature. “I’d say that 80% to 85% of cancer diagnoses are straightforward for a trained pathologist, but the other 15% or so are borderline, and this is where experience helps. When you’re talking about a cancer diagnosis, you want to be absolutely sure.”
At the same time, doctors caution against following specific online advice about treatment without talking to a physician in person. “Any evaluation of a patient still begins with history and physical, and review of lab work,” says Dr. Richard Corlin, a gastroenterologist in Santa Monica and president-elect of the American Medical Assn., “and the ability to get history is somewhat limited online, and the ability to get an exam is obviously not there at all.”
Dr. Patrick Sheehy, a medical oncologist in Newport Beach who operates a Web site for his own patients explaining cancer treatment and diagnosis, agrees. “I feel strongly that medicine is as much an art as a science, that there’s a lot of intuition and heuristic thinking going on, you’re looking at the patient, taking in the signals, the breathing, the eyes, looking at the way the patient is responding. I think a patient presenting over the Internet may exaggerate symptoms, for example.”
Corlin says that a larger concern, especially if second-opinion sites proliferate, is quality control. The specialists available through MDExpert and FindCancerExperts are not anonymous, for example; they’re named, along with their affiliations. And Dr. Robert Pashman, who consults on eSpine.com, is an accomplished surgeon with an established reputation. But there is no guarantee that less experienced practitioners won’t jump into the second-opinion game. “The question becomes are you certain you’re speaking to who you think you’re speaking to, and the qualifications are what they say?” Corlin says. “You may not be talking to a 15-year-old boy in Montana, but the principle is the same--how do you know?”
Nick Augustinos, an e-health consultant based in San Francisco who has long experience as a health-care analyst, says that, ideally, a firm will emerge that specializes in quality evaluations of such Internet sites. “An independent company with expertise that would assess these places, that’s what’s needed,” he says. “But so far there’s no one out there doing it, as far as I know.”
And for now, the demand for online second opinions seems only to be increasing. Shmookler says he has had 600 to 700 requests for second opinions, many of them in the last several months. Pomerantz estimates that MDExpert has handled about 100 cases since last fall. And Pashman, the orthopedic surgeon who runs eSpine.com, says he handles three to five consultations a week, in addition to his own patients.
“I absolutely agree that if you are going to diagnose or treat somebody, you have to meet them first,” says Pashman. “But the fact is that we have such sophisticated imaging techniques and information-gathering techniques now that the physical exam is becoming less important. Anyone who thinks medical consulting is not going to be done from remote locations is in denial. It’s being done now.”
