The Cancer site at The Mining Company is an excellent source of information on cancer and related subjects.

Not On The Net - Know Your (Web) Doctor!

With the growing interest in health care content on the Web, more and more physicians and other health care professionals are setting up shop on the Net. In most cases, they've mounted marketing sites for their own practices and facilities, detailing personal qualifications and office referral information. Occasionally they offer some practical information about the diseases they treat and the procedures they perform - but designed toward attracting referrals to their own practices. Most stop with this minimal presence, which they're offered in template form at minimum expense by the hospitals, health plans, or professional societies with which they work.

Beyond this level, there are growing numbers of doctors and health care professionals on the Web - like your Guide - with the expressed intention of offering patient counseling and support, and pointing toward available and objective scientific information to clarify issues. Most have a realistic understanding that within the remote communication medium that is the Net, it's not possible or appropriate to offer specific, direct, personal medical advice.

However, a few maintain that the Internet allows them to offer consultative services and opinions, prepare reports and write prescriptions, on request for patients they'll never meet and examine in person. There are ALSO those who present themselves to the Internet world as health care professionals, holding forth on the Web, in newsgroups and mailing lists, but who have no acceptable credentials... those whose true profession is fraud. The Web is sometimes very good at debunking these charlatans (look at "Quackwatch" , and the Health on the Net Foundation )... but their presence raises a serious question for the vulnerable consumer.

An Internet personality is fingers on a distant keyboard somewhere down the pipe. Unless they proffer verifiable details of who they are, you have no way of confirming their identity or intentions except through repeated encounters, history, and trust. If someone portrays himself as a health care professional and offers information, you may be tempted to take serious actions based on his recommendations.

How to know who's reliable? This is a typical Internet issue. The thought needn't cross your mind in other settings (although educated consumers do their own verification). The qualifications of the doctor you see in a private office have been judged and found acceptable by a state or provincial licensing body. The credentials and experience of the medical staff members of a hospital or health plan have already been reviewed and found adequate beyond licensure by other members of the medical staff and the administrative leadership. These processes are designed to protect your interests and function transparently, without any specific action on your part.

As with many other quality issues influencing Internet activities, on the Net you have to think for yourself because the Net spans jurisdictional boundaries and has no central review of its own. Protecting your interests becomes a matter of your own due diligence. It's also not a small issue. Apart from influencing substantive decisions about your health, remember that information exchanged in an open Internet setting is inherently not confidential, and may be downloaded, archived, and searched by others who may not have your best interests at heart. A major concern expressed by physicians about the Internet's potential in health care is the fact that discussion of your health in a newsgroup, chat room, or mailing list can't be held confidential and legally protected in the same way as a conventional medical record. That's one reason why physicians have not embraced these media more actively. In an era of credit reporting services and national health insurance data banks, many Americans feel that their privacy is already tenuous enough, and do not take lightly the thought of another possible problem of diversion and unauthorized use of their medical information.

Assuming you've decided that - on balance - your need for information and support outweighs these risks as you enter into an on-line discussion of your health needs and concerns, you need to be sure that the quality of the answers you get justify that risk. The first step is to examine the Web site for identification and qualifications of the professionals involved. Some "ask the doctor" sites don't identify the doctor, or offer a name with a claim of credentials, but don't support those claims with specific information about training and qualifications. Anyone on the 'Net can claim to be anything - but if you can verify licensure and training, you can understand that the person on the other side of the information exchange works and speaks from an appropriate knowledge base and in an environment with appropriate peer and regulatory scrutiny. Just "talking to someone" isn't enough - charlatans make their livings being persuasive and plausible. The optimal site of demonstrable quality publishes the credentials and qualifications openly, with verifiable and relevant details (as mine does - http://cancer.miningco.com/mbiopage.htm ). That means that you should be able to satisfy yourself that the professional's qualifications include the correct education, training and professional expertise and an underlying health care discipline relevant to the questions you need to ask. If not, before you use or link to the site, you need to ask directly: -- who's on the other end of the interchange; - - what his qualifications are; ... and get answers you can verify before you rely on his information.

Remember as well that "doctor" and "physician" are now variable terms whose use is established by local law and custom. In Florida (my geographic base), by action of the state Legislature conventional medical doctors of the allopathic (MD) and osteopathic (DO) variety, chiropractors, podiatrists, and optometrists are all licensed and legally designated as "physicians". The term certainly does not represent a uniform scientific discipline or comparable scope of practice. Don't rely on the title... you need to know what's behind it. Be aware that the only meaningful qualifications are the ones earned by examination after completing prescribed training. Membership in an impressive-sounding professional organization may mean little more than ability to fill out a form and write a check, and should not be relied on as confirming either knowledge or ethics.

The Physician Masterfile of the American Medical Association is accepted internationally as primary source verification for credentialing medical practitioners (MDs and DOs). For purposes of assessing a doctor's training and qualifications, if it's listed there it's considered as good as going back and getting confirmatory documentation from training institutions, universities, and medical schools. However, it does not list physicians outside the US. Excerpts of the Masterfile are publicly available on the AMA Web site (http://www.ama-assn.org ) in the AMA Physician Select service. If you can identify a location for the Net doc's primary practice, you should be able to verify their standing with the local Board of Medicine or equivalent licensing body. Boards of Medicine in both Massachusetts and Florida have placed physician profiling databanks on professional liability (malpractice) and disciplinary actions onto the Web for public access. More are coming.

For MDs claiming Board certification in a specialty, a listing in the American Board of Medical Specialties directory (not available online) or fellowship in the Royal College of Physicians and Surgeons of Canada serve the same purpose with the same reliability. For osteopathic physicians (DOs), comparable primary sources are available from the American Osteopathic Association and the osteopathic specialty boards. Canadian and American (MD) medical schools and specialty training programs all comply with similar standards and are accredited and reviewed by the same organization - so they're accepted as being equivalent on quality of training. American osteopathic medical schools (DO) have separate review and accreditation mechanisms but are accepted as equivalent.

Further afield, there are no uniform standards. Medical professionals trained in other countries can practice in the US only by passing a specific examination (ECFMG - Enabling Certificate for Foreign Medical Graduates) plus a state or national licensure exam (old - NBME or FLEX; current USMLE) as a minimum to ensure that their knowledge and expertise is comparable. (Licensure is a state-by-state prerogative; some states make special exemptions, but those are unusual.) If your Net doc has practiced in the United States, you should be able to verify this information from the data sources already mentioned. Verifying the qualifications and activities of doctors trained or practicing abroad is a much more difficult issue. I don't believe there's any way of knowing with certainty - and certainly no international verification process or consistent data base of qualifications, because there's no way to crosswalk the quality of medical education from country to country. Medical training in major developed countries is generally considered close enough to what's offered here that American institutions accept their graduates as qualified for further training and to sit the ECFMG examinations, and their publications as worthy of consideration for inclusion in peer-reviewed scientific and medical journals. Medical curricula differ somewhat, and specialty training and certification processes significantly, from country to country. You can check the status of foreign medical schools through the World Health Organization's master directory for information about conformance to minimal standards (faculty : student ratios, hospital beds serviced, and equipment available for students).

You should certainly check Medline by author to determine whether the Net doctor of interest to you has been able to publish peer-reviewed articles of topic, timeliness, and scope that suggest current knowledge of the areas you need. You need to use your best judgment understanding what the useful proxies for quality may be, given that better verifications aren't available. An oncologist in active practice at the Institut Curie in Paris is probably as reliable a resource as a verifiable American specialist; someone trained in the Caribbean practicing in a private clinic in South America whose last MEDLINE-acceptable publication was 15 years ago (or never) may not be.

This is not just an Internet issue. A major battle about licensure is developing within telemedicine - the use of long-distance digital resources for formal consultations and case management with a doctor who is physically at a distance. Some managed care plans already digitize their imaging studies to have them read by radiologists abroad because it's economically advantageous to do so. If a physician located offshore is directing or significantly influencing the medical care of an American patient, that patient may have no right of recourse in case of problems. At this time there is no consensus about whether a physician practicing telemedicine should be licensed in the state of his own location or the state where his patient is located. With telemedicine, if licensure and regulation cannot be assured, electronics and economics make it possible for someone to have a major part of their medical care performed by someone who holds him/herself out to be a physician - but whose qualifications may have no comparability or validity to what's expected. This side of the issue is much larger, and involves many more economically powerful players, than the Internet issues. The likely resolution of the online doctor certification process may come as a side issue when we understand how we may want to regulate telemedicine.

To summarize - look for full disclosure of the credentials and qualifications of any healthcare professional offering information online. The credentials should be verifiable, meaningful, and relevant. In general, sources for verification will be easier to find, and standards of qualification more uniform, for professionals trained and located in the United States and Canada. If you're searching the Net for information and support for medical questions of major magnitude, you can't afford to take this on trust!!

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