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Internet Medicine
Maxwell J. Mehlman, J.D.

Mr. Mehlman reports no commercial conflict of interest.


Release Date: 03/15/1999
Termination Date: 03/15/2002

Estimated time to complete: 1 hour(s).

Albert Einstein College of Medicine designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Albert Einstein College of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
 
Learning Objectives
Upon completion of this Cyberounds®, you should be able to:
  • Discuss the advantages and disadvantages of medical practice on the Internet
  • Discuss the potential liability for practicing Internet medicine
  • List ways of reducing potential liability for Internet medicine.

 

Introduction

On February 5, 1999, the Wisconsin Medical Examining Board issued a complaint against a Milwaukee physician who prescribed Viagra® via the Internet. Among other things, the board complains that the physician did not conduct face-to-face meetings with patients and, in many cases, didn't even speak with them. Instead, prospective patients spoke with a screening person, who asked what medications they were taking, whether they were allergic to any medications, and what surgeries they had had. The complaint also objected that the doctor could not reasonably ensure that Viagra® was being used for "legitimate medical purposes [rather than for] recreational or experimental or other non-medical uses."(1)

This is the first instance I am aware of in which a state medical board initiated a disciplinary proceeding against a licensed physician for practicing medicine on the Internet. Let's look at its implications.

Advantages of Internet Medicine

Internet medicine presents advantages and risks. To discern the advantages, just ask yourself why anyone would want to get a prescription for Viagra® over the Internet. The answer is that it's convenient and it may be cheaper than going through your regular physician. But added to that is the very facelessness that the Wisconsin medical board complains about, the sense of privacy and relative anonymity. Of course, the Internet communication may not be adequately secured and, if you actually order the drug from the website, you have to pay with a credit card and give some sort of address. But this may be preferable to discussing your sex life in person with someone, even your physician, and enduring the embarrassment of picking up the prescription at the drugstore, particularly when the pharmacist or clerk, in making sure that they are giving you the correct prescription, announces the name of the medication to you and everyone else standing in line.

Risks of Internet Medicine

Yet, the dangers of Internet medicine can not to be ignored: the potential for inaccurate or incomplete information about the patient, particularly information from an actual physical examination; the difficulties of providing adequate warnings to the patient; the lack of follow-up. But how real are these dangers, compared to typical non-Internet prescribing practices, and are there reasonable ways of avoiding them?

Are the Risks Real in Modern Medical Practice?

Internet medicine certainly doesn't comport with the traditional concept of the patient-physician relationship. There is no face-to-face interaction and little or no opportunity for physicians to access and consult patient records. Still less does Internet medicine resemble the image of the small-town, family doctor who knows all of the histories of his/her patients by heart.

Yet, how realistically do these traditional models describe the modern patient-physician relationship? Modern physicians increasingly practice and prescribe by telephone, which is similar in many respects to practice via the Internet. In one two-physician family practice, 31 percent of telephone conversations with patients resulted in prescriptions, more than half of which were not for refills.(2) Many of these interactions took place after hours, when physicians do not have access to patient records. Physicians may be disinclined to prescribe medications for someone they've never met or examined but, practically speaking, without immediate access to the chart, the physician may retain little information from a previous encounter with the patient who is on the other end of the line. Furthermore, in an era of managed care in which patients are cared for increasingly by non-physician health professionals, and rarely if ever see their actual physician and in which patients voluntarily and involuntarily switch physicians frequently as they change residences, jobs and health plans, the likelihood is small that the physician will know or recall enough information about the patient to avoid relying on what the patient tells the physician over the phone.

In short, in its facelessness and need to rely on patient-reported information, Internet medicine may not differ all that much from what transpires in so-called traditional practice settings.

Isn't Sex Always "Recreational?"

As for the Wisconsin medical board's concern over "recreational" and "non-medical uses" of Internet-prescribed Viagra®, how many traditional prescriptions for the drug do you suppose are written for true, frank, erectile dysfunction? Or, to put it another way, whose sexual performance is so optimal that they can't say that they suffer at one time or another from some measure of dysfunction that Viagra® might remedy? The Wisconsin officials would seem hard put to distinguish between prescribing the drug for a non-approved use, which is perfectly legal, and prescribing it for a non-medical purpose. After all, most of us probably regard sex as "recreational" in the first place.

Maybe what's bothering the authorities is that Internet medicine is unseemly, particularly given its commercial overtones. This recalls the hostility of organized medicine (and the bar and other professions, for that matter) to professional advertising. Yet, as the Federal Trade Commission has recognized (and used as the basis for its attacks on advertising restrictions by local medical and legal societies), advertising can perform a valuable function for consumers. In the case of Internet prescribing, these advantages were mentioned above: convenience, cost and relative anonymity.

For Internet Medicine, Avoid the Obvious Pitfalls

This isn't to say that Internet medicine can't be shoddy, even dangerous. There are clearly practices to be avoided. As a general rule, treat Internet medicine like telephone medicine and avoid obvious pitfalls:

  • Don't prescribe narcotics.
  • Have direct interaction with the patient. Don't rely on inadequately trained and certified personnel.
  • Be sure to obtain adequate information from the patient and do not prescribe medications that can only be taken safely after a physical examination.
  • Don't prescribe medications that have a high risk of side effects or adverse drug interactions, either in terms of frequency or severity.

Moreover, recognize the value of the Internet in educating and informing patients.

Conclusion

Someday, Internet medicine most likely will be routine. Patient information will be accessible to physicians online from electronic medical records. Physiologic data will be transmissible telemetrically. Laboratory results will be obtained via in-home testing. The present efforts, while perhaps sometimes reprehensible, are beginning to chart this course. The task is not to try to prevent the growth of Internet medicine but to make sure that it is delivered ethically and responsibly.


Footnotes

1For more information, see the BNA Health Care Policy Report, February 15, 1999.
2Spencer and Daugird, The nature and content of telephone prescribing habits in a community practice. Fam. Med. 22, 205-09 (1990).