What are the biggest reasons doctors are usually reluctant to give medical advice online?

July 29, 2011 12:11 AM

What are the biggest reasons doctors are usually reluctant to give medical advice online?

Doctors & medical researchers of MeFi: say an unknown person emails you with a question about their personal medical condition that is:

- Concise (e.g. 1 paragraph)
- Relevant to your unique area of expertise (e.g. you've published research articles on this subject, and they are clearly emailing you because you have unique knowledge on this topic)
- Well-researched & intelligent
- Respectful
- Doesn't ask for a recommendation, but is more of a factual request, like "do you know of any effective treatments for this symptom"?

I have been trying to get a response to a specialized question that has stumped my doctors, so I found a couple of journal articles on the subject and emailed their authors as described above. However, I didn't get responses. I can see several reasons why:

(1) It's hard to give quality medical advice outside a face-to-face visit
(2) Legal/contractual issues
(3) Patients expecting you to provide your services for free cheapen/devalue your profession
(4) Don't want to set a precedent that results in a flood of random people emailing you.
(5) Too little free time to answer unsolicited emails

Out of curiosity, which of these are the main reasons, which ones are secondary/non-issues, and which ones have I missed?

posted by wireless to Health & Fitness (18 answers total)

I have a lot of doctors in my family, and it can take some of them ages to respond to an email from *me*, a person related to them. I'd say time is a huge factor. Lots of doctors work well over 40 hours a week and have families and hobbies too. I suspect a lot of them filter their emails very aggressively to protect their non-copious free time - and the older ones might even have a secretary who does it for them. However, all your other reasons are good reasons too. Medical advice isn't something you just throw out there. Frankly, I would be VERY surprised to get a response from a practicing MD who wasn't your doctor on a medical question in an email.

I know you didn't ask this, but I have to say that I would recommend that if your doctors are stumped and this symptom is really something that's impacting your quality of life, you should ask for them to refer you to other, more expert doctors. Doctors are vastly more willing to take on a referral from another doctor because it's vastly less likely to be a waste of their time than responding to a random email from a stranger.
posted by troublesome at 12:29 AM on July 29, 2011

The first three issues are valid problems with giving advice in the online environment.
The fourth issue is unlikely to be the case, because the general public is unlikely to be aware that a doctor answered your e-mail and thus all start e-mailing. It would be more of a problem if the doctor was posting publicly to a message board using their real identity.

I suspect either 5, or that the email addresses you used were invalid/old or had very active spam filters. Otherwise I would expect they would send you a response saying something like "sorry, but I don't feel I can comment on your case/question because of X", out of courtesy. I'm a doctor and that's probably what I would do, although personalities as always, may vary.
posted by treehorn+bunny at 12:30 AM on July 29, 2011

I think the biggest issue is "an unknown person emails ... with a question about their personal medical condition." The policy of the American Medical Association is that doctors must take a medical history and perform a physical examination when establishing a doctor-patient relationship. I can't imagine any AMA licensed doctor would be able to respond to that kind of e-mail without violating AMA policy. Even if they could, are you even certain that the doctors in question are licensed to practice medicine in your jurisdiction?

In theory, you might be able to send an e-mail to doctor in which you: a) make it clear that you are not seeking medical advice, b) propose a hypothetical proposition, and c) then ask a question about that hypothetical. Under such circumstances you might get answers to your questions. A couple of doctors who answer medical related questions on Ask Metafilter essentially take that approach: i.e. make it clear that they don't have a doctor-patient relationship with the questioner, restate the question as a hypothetical, and then answer with regards to that hypothetical.
posted by RichardP at 12:34 AM on July 29, 2011 [6 favorites]

Well, I can't speak for physicians, but as a (currently non-practicing) registered nurse I don't do it because giving professional advice introduces an expectation of care that I know I can't meet online.

"Please tell me the effective treatments for this symptom if you know any" is actually a medical advice question, because effectiveness is contingent on the physiological reason for the symptom and the rest of what's going on with you medically. Partly because I'm NOT a physician, I would refer you right back to your doctor or EMS.

Even if you asked me a nursing question, I can't gather physical or lab data, I can't collect a proper history from you, I can't document our visit, I can't perform any urgently needed interventions, and I can't follow up with you. Moreover, my license is constrained to a specific geographical region, and I'm limited to practice there. Online, you might be in Switzerland or Ohio or France, and clients in each region expect that region's standard of care, which may be quite different from my region's scope of practice.

When I'm asked for information only - "Hi you wrote this paper on the geographic colocation of yoyos and tinkertoys - has there been any more recent work on this?" - I will usually answer either directly or with some relevant resources.

None of this stops me from explaining facts about anatomy and physiology and epidemiology and microbiology.

But I'm not going to enter an untenable professional relationship over e-mail with a total stranger, no matter how respectful, well-crafted and knowledgeable the request, and a research physician is probably going to be just as reluctant. It's unethical, it might be illegal, and it's certainly a bad idea. (I suspect that it's such a bad idea that some people pretend they never saw your e-mail.)
posted by gingerest at 12:50 AM on July 29, 2011 [7 favorites]

I should clarify - because my post wasn't long enough, ha - that the resources I mean when I'm asked for information only are things like patient advocacy groups. If you say, "I have a tinkertoy collection and I'm interested in your work etc." I will probably give you not only the new reference but I will try to hunt you up the name of a tinkertoy aficionado or tinkertoy aficionado family support group in your area. Because if you have a deep, personally-motivated interest in tinkertoys, you might want more, and maybe they can help.
posted by gingerest at 12:54 AM on July 29, 2011

Giving medical advice without performing a physical exam, or at least lab data/films, is asking for a malpractice lawsuit.

Also, doctors currently don't get paid for that kind of thing. You want to benefit from your physicians' expertise? Make an appointment.
posted by valkyryn at 3:50 AM on July 29, 2011 [2 favorites]

Someone who publishes and is an acknowledged leader in a particular field, enough so that a member of the general public gets to know the name will often have so many hats it would be impossible to address your query, even to give you a polite kiss-off.

I've worked in the field of surgical training for 11 years and off the top of my head if I took one of my key stakeholders Prof XYZ who is a leading Spine surgeon:

Roles: Departmental lead, clinical lead, lead for Medical Students in his Hospital, sub-Dean at the Medical School, Programme Director for Trauma and Orthopedics for the region, Specialty advisor for same, person who approves all the Job descriptions of this specialty in this region & others, sits on interview panels all over the country for new consultants, advisor to a variety of MScs theses in Orthopedics, inventor of a piece of surgical kit that requires him to travel to demonstrate, contributor to international conferences, national conferences, regional training days, member of the national Specialty Advisory Committee for the UK in Trauma & Orthopaedics, visiting inspector to other regions/nations programmes,................... (this list is not comprehensive)

I haven't yet gotten to his Day Job as a surgeon...
He will do at least 48 hours a week for his public patients and possibly a further 10 for private patients, add to this his on-call in the evenings/nights, weekends, (I generally see his e-mails time-stamped 5am-7am as the morning Trauma meeting is 8-9am every day)and I haven't described all the e-mails he gets from Medical Students, trainees & researchers from all over the world. Besides all of the things you list above, the most important being that he would be breaching ethical & professional guidelines,

the fact that this man has time to pee is of enormous surprise to me..... Notice I haven't even begun to mention family, friends, his small farm, his classic car that he lavishes love & attention on, his wooden sailing boat, his elderly mother....
posted by Wilder at 4:44 AM on July 29, 2011 [1 favorite]

The problem with the question: "do you know of any effective treatments for this symptom", that the answers are already likely published. And if they aren't, and you had some knowledge of how to solve this problem that no one else knows about, you would want to publish it - not tell Mr. Anonymous.
posted by Drama Penguin at 5:42 AM on July 29, 2011 [1 favorite]

Mostly 1,2,3. Non-researchers who email me about an article overwhelmingly don't understand what they're asking.
posted by a robot made out of meat at 5:49 AM on July 29, 2011 [3 favorites]

It's been my experience that there are a handful of doctors/nurses/researchers in a (rare-ish) specialty that like to interact with the public and do a limited amount of advice-giving online. Two of them, for instance, are listed here, for specialties related to my own condition. A bunch more are here. Look for a community like that.
posted by SMPA at 6:39 AM on July 29, 2011

For a while I think it was because older doctors didn't like to change the way they did things, but now that's changing as more and more people grow up on the internet.
posted by Melismata at 7:48 AM on July 29, 2011

All of your reasons on that list, which stems from something that's not--you're asking them to do their job, poorly and in a more time consuming way (because they don't have your medical records), but without pay. Who would do that?

Also, I'm not a medical doctor but I do work in a field that leads to occasional topical-but-unsolicited contacts of a similar nature. And I have always--ALWAYS-- regretted writing back. This is partly because, as a robot made out of meat said above, the people asking the question don't actually understand the question much less the answer. Sometimes a short response from me leads to multi-page responses that get longer and more frequent when I don't respond. Sometimes they're selling something. Sometimes they think my job is something it's not. I still answer questions when I can because I'm apparently a glutton for punishment, but not everyone is.

You do have an option, though. Get a referral to a specialist from the doctors that don't have a good answer. Then they know you're for real, and they get paid, too.
posted by tchemgrrl at 7:51 AM on July 29, 2011

You may want to ask one of your current physicians to e-mail the uberspecialist you are interested in. A question from a physician about a patient is very likely to get a useful, friendly, informative response from the uberspecialist. This happens a lot in my office.
posted by SLC Mom at 7:52 AM on July 29, 2011

If I don't know you, I will probably not reply. If I do know you, we'll do it face-to-face.

Like what others said upthread, it's best to get a referral.
posted by onegoodthing at 7:57 AM on July 29, 2011

gramcracker, a Metafilter user and ER physician, recently had this to say:

Let me just say this upfront: I've dramatically reduced the number of responses I write on Ask Metafilter (I lurk on the health and fitness category daily) because I don't want to be construed as providing medical advice to anyone (only general education) because of malpractice issues or I have no idea the health education of the person I'm responding to. I frequently have a full response typed in, and then I close the tab because it's just not worth the possible liability. I have seen my colleagues sued for the most bogus of bogusness, and sorry, I'm already in over $100k of debt, thankyouverymuch.

I don't answer questions over the phone. My ED's phone number is publicly available, and calls frequently get routed to me, but I don't care how simple the question is: I don't. Give information. Over the phone. I'm happy to see anyone for any reason at any hour. That's one of the reasons I chose to specialize in emergency care. But I can't hear part of your story, without getting your vital signs and doing a focused physical exam and occasionally some routine testing to give my opinion and recommendations. Should a car mechanic be able to figure out your problem by only your layman description?

I get that people just want to be reassured that "it's nothing," and go on their way, but so far, medicine doesn't work that way. I can give you some numbers (evidence-based medicine self-link), but can I say that you're not the 1 in 250? Or 1 in 2500, or 1 in 25000? Nope.

#3: One of the other reasons I've stopped posting to these threads is the amount of incorrect information and noise in the threads with people's N = 1 experience. It's seriously frightening. "My boss had that" is not accurate or relevant information to the poster, at all. Similarly, "the same thing happened to me and it was nothing" is not relevant, either. Both answers are wrong. There is no way to know what is wrong without evaluating the patient. There are literally 50 different reasons someone may pass out.
posted by HotPatatta at 9:44 AM on July 29, 2011 [2 favorites]

1 and 2. (Honored to be quoted, HotPatatta!)

1: Like HotPatatta said -- I'm an emergency physician. I see anyone, for anything, at any hour, but I have no continuity of care with my patients (besides the chronic alcoholics, homeless folks, and chronically ill that I get to know over time). Answering questions, or evaluating someone online is like being an emergency physician: we know nothing about you, we have no prior relationship with you, and we're working with very limited information. If you develop a relationship with your primary physician, they get to know you and your quirks. If you know John never complains, and now John is saying "I'm coughing a lot, and having some trouble breathing," then the doctor knows John really needs to be seen. If John was just seen last week for the exact same thing, it's maybe less urgent. You don't get any of that history online. That's why a primary care doctor feels more comfortable calling in a prescription over the phone for patient X -- she knows that the patient is reliable, will fill the prescription, and will call her if the patient gets worse. If the patient's not "reliable," as we say, then in order to make sure the patient is okay and going to get better, it's better for the patient* to be seen in the office for the same exact prescription, have the doctor face-to-face reinforce the importance of taking the medicine, etc. (*Value judgment, paternalism, yeah yeah, I know.)

Online, you also don't get to "eyeball" a patient. You don't get any of the non-verbal stuff that you get when you physically see a patient. (Even over the phone, you can tell a lot -- are they having trouble breathing, are they too weak to talk, does their voice sound funny, are they in a lot of pain, does their mouth sound dry, etc.) A picture tells a thousand words. This is something that we try to make a main goal of internship: telling "sick" from "not sick."

The word "sick" to a doctor (mostly when communicating to other health care folks, not patients) is code for "crap, there's something really wrong with this person". This is almost exclusively due to what the patient looks like, and has very little to do with what the patient is telling you, but possibly how they're telling you. It's a gestalt thing you develop over time, but don't really realize each part of it that you're putting into the mix. It's if they make eye contact. Or if their eyes are open when you enter the room. It's how they're sitting in the stretcher. It's how they're talking to their family member in the room. How they're breathing. How they're talking. What their face looks like. The "sick" spectrum runs from "Totally fine" to "looks a little sick" to "doesn't look so good" to "sick" to "sick as shit."

For example: Patient A comes in, 40 years old, with a cough for the past week. You walk in the room, he's texting on his cellphone, eating a bag of Fritos, and laughing with you during your exam. He has his legs crossed, and his arms bent behind his head. He occasionally coughs.

Patient B is also 40 years old, with a cough for the past week. He's got his eyes closed when you enter the room, he's breathing about twice normal, and you have to wake him up several times while you're talking to him. Or he's turned away from you and won't sit up to talk to you. He looks a little pale.

Those are two completely different patients, both with the exact same complaint: "cough x1 week." One will almost assuredly go home and may not even need anything but reassurance; the other may be headed toward the ICU and could have a good 5-10% mortality during this hospital stay, depending on his course, your treatment, and his labs.

Part of the reason vital signs are "vital" is that they don't lie as often as patients (being facetious), and they can help to objectify and standardize "sick/not sick" -- they help nudge your gut feeling in the right direction.

So, getting back to the original question, that's the main reason I don't like answering medical questions online -- I don't know you, and I can't see you, and can't easily ask you more questions or examine you. And because I don't know you and can't see you, I would be ab. solutely. Devastated. If I said the wrong thing and it harmed someone. I'm in the business of trying to do more good than harm, so I'd hate to falsely reassure someone they're fine and then have them have a more serious problem later because they waited, for example.

(1 has nothing to do with the AMA, btw -- the AMA only counts something like 30% of doctors as members -- I'm not a member for many reasons, not limited to the fact that the AMA has been and is still incredibly obstructionist in its policies toward health care reform and universal coverage.)

2 is out there, too. You may be a normal person out there just wanting an answer to a question, but god forbid something goes wrong, or you're not a normal person, or your family are not normal people, or your family is grieving, or you want to make a buck saying that X was inappropriate or wrong, God Bless America, you can sue anyone for any reason. Malpractice requires a doctor-patient relationship, a duty that was breached, and a harm to the patient. Many people are worried that by answering a question online, you've now established a doctor-patient relationship. (That's why if/when I reply, I try to make it explicitly clear that we have no doctor-patient relationship, and that I'm not providing specific medical advice to anyone, just medical information about a disease or symptom.)

Example: A MeFite posts that they have right lower quadrant pain. A surgeon replies, "Could be appendicitis, but if you've had it for two weeks, it's unlikely." Said MeFite then ruptures his appendix, has to get a big invasive surgery with a big scar, gets a post-operative wound infection, and is bankrupted because he loses his job. The surgeon was trying to be reasonable and help -- it actually is unlikely that it's an appendicitis if it's been two weeks -- but now some lawyer can try to argue that that was inappropriate medical advice, and that the surgeon is responsible for all the problems caused. It's honestly easier and safer to say nothing or say something vague (but probably worse for the patient, if you believe like I do that in cases like this, a more-educated patient is better than a less-educated one).
posted by gramcracker at 11:27 AM on July 29, 2011 [6 favorites]

You might be interested in this article from JAMA talking about responses to unsolicited patient email requests for advice. It's from 1998, so I suspect things have changed dramatically, but it's interesting to look at what the lay of the land was at the time

The study found a striking lack of consensus among medical information providers on the theoretical and practical handling of unsolicited patient e-mail messages and their judgment of this topic. About one third of those who replied explicitly refused to answer patient requests individually, arguing that it would be impossible to make a diagnosis via e-mail without an examination, as well as arguing that they lacked the resources and/or mandate to reply to these kinds of inquiries. The remaining two thirds attempted to help individually, 5 of whom gave detailed treatment advice.

posted by jessamyn at 11:39 AM on July 30, 2011 [1 favorite]

I agree with a lot of what's posted upstream - I'd say legal is the biggest reason. Next, you're probably not as knowledgeable about whatever topic as you think you are. That ties in nicely with the next point, time. The amount of time I'd need to spend (uncompensated) to explain something to a layman on a topic within my scope of practice and/or research would be too great. And in a nod to a previous post in this thread, here's my n=1 as to why I wouldn't answer your email:

A layman emailed my boss about receiving an experimental treatment for his condition. This treatment was not approved at the time and is not widely available, so he was hoping to be included in the clinical trial. My boss passed him off on me. This person had not been diagnosed with a condition that would even make him eligible for the treatment, in fact such a diagnosis had been ruled out several times, however he remained convinced that he did have such a condition. I tried to help him - I offered to review his case and told him what type of specialist he should actually be in touch with, but he never took advantage of that offer and remained insistent on receiving the treatment, which is invasive and was obviously inappropriate. Finally, he went away.
posted by sero_venientibus_ossa at 3:33 PM on July 30, 2011