Wall Street Journal - December 8, 1997
Ron Winslow

"The Internet is really a lot of hype," she says. As a doctor in solo practice who is also a member of the Maryland State Board of Physician Quality Assurance, a director of a local hospital system and an active member of the county medical society, she has enough to keep her occupied without getting sucked into the time sink that surfing the Web can amount to.

Nevertheless, on many days when she gets home from treating patients, Dr. Winchell pours herself a glass of wine and logs on to a doctors-only cyber service provided by Physicians Online Inc., a closely held Tarrytown, N. Y., company. She checks her e-mail, especially for messages from her three adult sons, and downloads the crossword puzzle from the New York Times. Then she often clicks her way into one of dozens of discussion groups to monitor or join fellow doctors in a lively give-and-take on anything from how to treat a chronic earache to how to handle the headaches of managed care.

Reluctant or not, Dr. Winchell is among a surging number of the nation's doctors who are shedding their image as technophobes and joining the on-line revolution. Michael Brown, president of MSB Associates, a Needham, Mass., consulting firm, estimates that 25% to 30% of the nation's 700,000 physicians use the Internet themselves in their practices, and that about 43% either use it themselves or have a staff member who goes on-line on their behalf. Both numbers are expected to jump more than 40% by the end of next year, according to a survey Mr. Brown conducted for Find/SVP Inc., a market-research firm in New York.

That reflects a potential fundamental shift in attitudes toward personal computing technology and the Internet among a profession that has long held on to its fountain pens as the rest of the world went digital.

Of course, some doctors, especially those affiliated with medical schools, have long used Internet services to access Medline, the National Library of Medicine's database of abstracts of thousands of scientific articles, or to stay in touch with fellow researchers at medical centers around the globe.

But now more than 10,000 sites on health and medical topics exist on the Web on subjects ranging from heart disease to impotence to aromatherapy -- and they are actively used by an army of sophisticated and demanding consumers. Hundreds of sites, many sponsored by professional medical societies, drug makers and device companies, cater specifically, though not always exclusively, to physicians. All of this is helping to inspire -- or prod -- more doctors to log on.

Physicians Online (www.po.com), which bills itself as a doctors-only service, and New York-based Medscape Inc. (www.medscape.com), which says it serves a total of 400,000 doctors, health-care professionals and patients, are among services that offer both their own medical content as well as wider Internet access to their members. Physicians Online, which has grown to 150,000 members in about two years, gets most of its revenue by selling advertising space on its Web site to drug, financial services, automobile and travel companies eager for access to a physician audience. The company gives the passwords required for entry only to physicians, for whom membership is free.

"I'm a big fan of the Internet," says Hannah Brooks, a New York internist with a special interest in breast cancer, and an avid user of Physicians Online. "I love the whole aspect of being able to communicate at any time with anyone anywhere."

Ms. Brooks often spends hours at a time at a computer in her apartment adding her views to cases that are posted on the service. "You can get addicted to this," she concedes. But she has no doubts about its value.

As just one example, Dr. Brooks helped a desperately ill patient get into a federally sponsored clinical trial of a new breast-cancer treatment via the Internet. The patient is now doing well. "Because of the Internet, a patient can have access to other treatments, other doctors and other ideas across the country," she says. "The whole thing is a miracle. I think it saves lives."

The Web offers less dramatic possibilities as well. Amy J. Byer, an obstetrician-gynecologist in Rockville, Md., saved the cost and time away from her office of a business trip by taking a continuing-medical-education course on-line via Medscape. She also consults with some patients by e-mail, though many other doctors who frequently go on-line shun e-mail relationships with their patients.

Michael Ruggerio, an osteopathic doctor in Bryan, Texas, sometimes goes directly into a Physicians Online chat room between patient visits to query colleagues about symptoms that puzzle him. "Most of my patients are thrilled if I ask to put their case on-line," he says.

For all their enthusiasm, however, the doctors acknowledge that use of the Internet -- especially as a resource in the care of patients -- poses a raft of thorny ethical concerns around issues such as patient confidentiality. The Find/SVP survey found doctors highly skeptical of the quality of information available to patients on the Internet. And even in a doctors-only service such as Physicians Online, there is little formal peer review of the opinions and advice that clinicians post.

"It's definitely buyer beware in terms of a doctor who posts a case and gets advice," acknowledges Steve Zatz, president and chief executive of Physicians Online. "It does require the physician to synthesize the opinions of others, just as they do with advice {from traditional encounters with colleagues}, and come to a conclusion." But he says that participants in the discussions quickly develop reputations based on the reliability of their advice.

Other experts worry about whether doctors who provide medical advice or services to patients in other states violate laws prohibiting the practice of medicine across state lines. Another concern: Would a series of postings about a patient's case constitute a paper trail that would provide ammunition to a savvy malpractice lawyer?

Dr. Winchell, who spends part of her professional time evaluating the conduct of other doctors, wrestles with such issues even as she uses the Internet. In many ways, her slow and still-skeptical adoption of the technology reflects the approach many doctors have taken to personal computing in general and the Web in particular.

As recently as three years ago, she typically wrote professional articles out in longhand and had an assistant type them into a computer. When she finally bought a PC, she had so much trouble getting it to work that people staffing customer-support telephone banks would ask to speak to her son when she called. (In her defense, she says that when a techie finally made a house call, it took him eight hours to fix the computer, and even then he wasn't convinced he had cured the problem.)

Nowadays, though, Dr. Winchell is as skillful with a mouse and keyboard as any dedicated Web surfer. One recent night, she clicked and scrolled through a sampling of "threads," as the individual case and topic discussions are known. What is revealed is frank and vigorous discussion that reflects many of the clinical debates and economic tensions that are present in medicine today.

She clicks on to a case involving a doctor who has discovered a venereal wart on a 15-month old baby, a classic symptom of child sexual abuse. But the doctor tells his on-line colleagues that when he poses general questions to the parents, "they don't get defensive. What do you do now?"

Dr. Winchell, who considers child abuse a special interest of hers, had posted a reply. "Children can be infected with venereal warts at birth and not express symptoms of the infection for up to three years," she writes. It could be that the mother had been infected and transmitted the problem to her infant during the journey down the birth canal, she explains. She recommends that he refer the mother for a test.

Other doctors had offered similar advice. The outcome wasn't known, but Dr. Winchell expects that the inquiring doctor avoided an ugly confrontation with the parents, or perhaps worse, a premature referral of the case to authorities that could devastate the family.

She then calls up a discussion about remedies for enuresis, medicalese for bed-wetting among children who are well past the age of potty training. The postings concern a debate over whether bed alarms or a prescription nasal spray are the best remedy. But one doctor, a frequent participant in these discussions, suggests that the patient should have a base-line electrocardiogram.

"This is stupid advice," Dr. Winchell says (to a visitor -- not on-line). "I enjoy his postings but sometimes he's completely off the mark." Generally, she adds, bed-wetting is a hereditary problem. "I think it should be added to the list of questions you ask the people you date," she says.

Portions of a thread on an 18-month-old child with a chronic earache also raise her eyebrows. The child hasn't responded to antibiotics, and tubes inserted in the ear to relieve the symptoms keep falling out. The doctor who posts the case is looking for help.

As she clicks through the postings, one pops up where an anonymous doctor suggests a CT scan to check for possible bone inflammation, a special lab culture and an AIDS test. Dr. Winchell is astonished. "This is a guy who is going to flunk managed care," she says. "He's just ordered a $1,000 work-up for a problem that is as common as brown eyes."

Dr. Winchell admits to conflicting feelings about some of the exchanges, which point out a shortcoming of the Internet. "Everybody's input is equal," she says. "You don't know what their credentials are. Some have good judgment. Some have judgment that is abysmal."

Yet as a solo practitioner, she, like many of her colleagues, finds the discussions offer an intellectually exciting exchange of ideas. They also provide a respite from the daily hassles of dealing with insurance companies and other economic battles that many doctors say take the enjoyment out of their jobs. "I get a sense of camaraderie on-line," she says.

And despite her worries about wasting time, she taps into cyberspace often enough that Iris and Bandit, her two bearded collies, are well-tuned to the sounds of her computer. They can detect the telltale clicks that indicate she is about to end her on-line session. They start barking. It is time for their walk.

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Mr. Winslow is a staff reporter in The Wall Street Journal's New York bureau.

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