The Internet and the Evolving Patient-Clinician Relationship

Leanna M.W. Lui


May 11, 2023

As health information becomes increasingly accessible through the internet, the dynamics of the patient-clinician relationship are changing. Traditionally, this relationship is utilitarian: A patient sees a clinician due to a medical condition, and the clinician identifies the root cause and delivers treatment.

However, with the explosion of online health information, patients are now empowered to take an active role in their own care in an equal partnership with their healthcare providers.

Medscape spoke with Roger McIntyre, MD, professor of psychiatry and pharmacology at the University of Toronto, and Joshua Rosenblat, MD, MSc, assistant professor of psychiatry at the University of Toronto, to discuss the evolving patient-clinician relationship and the role of social media in these interactions.

How do you see your relationships with your patients?

Roger McIntyre, MD: I see my role as an advocate. I also see my role as a person who can help with knowledge exchange and knowledge transfer as well as a person who can help patients choreograph their own self-management of their illness with the available resources that we have in the community.

How has your practice/interaction with patients changed over time?

McIntyre: The biggest change I've seen with respect to the impact on practice is moving from a more traditional medical model where I provide consultation on diagnosis and treatment and provide conventional treatment approaches to a newer model that includes all of that but is supplemented with advocacy. I've tried to augment patient self-management, shared decision-making, and serve as a resource of information to boost illness- and treatment-related literacy. In other words, I increasingly see myself as a partner with my patients who are managing their own health.

What are some key differences you've noticed in your clinical approach when you were younger vs now?

McIntyre: Most things have not fundamentally changed. I would say most people are looking for empathy, competency, and respect. They're looking to meet a healthcare provider who will work with them in a way that exhibits perseverance and dedication, and all of that has stayed the same throughout my career. I think we are seeing some differences in the use of more technology as well as much more dialogue and shared decision-making.

What are some key differences you've noticed between your generation vs psychiatrists in-training or new psychiatrists?

McIntyre: It's my perception that new graduates are not as familiar with the history, culture, or the multimodalities of treatment in psychiatry. Psychiatry has been focused more on transactional assessments in consultation, which I believe should continue, but that can be enriched by taking a historical cultural psychodynamic approach which gives a great deal of consideration to personal history, family history, economics, cultural and racial backgrounds, and exposures to trauma. A lot of these factors are not emphasized as much in current psychiatry training. The emphasis is more on a transactional diagnosis and treatment.

Joshua Rosenblat, MD, MSc: Younger psychiatrists and trainees are probably more flexible and adapt better to the virtual milieu. I anticipate that a physician's ability to provide virtual care will get better over time as the new generations of physicians who have grown up with a virtual care model. Over the past 2 years, I've supervised a ton of residents virtually. I'm supervising virtually, and they're seeing patients virtually and were just all used to it. It has gone smoothly, and I haven't run into any issues with the residents. But in practice, a lot of physicians have had trouble because they're not used to the technology.

What role has virtual medicine played in clinical practice?

McIntyre: Psychiatry has had a longstanding problem with timely access to affordable and scalable evidence-based care. I don't think virtual healthcare will solve all of these problems, but I do think the implementation of virtual healthcare can really help us narrow the implementation gap and can be more cost-effective in helping people in underserved areas. It can also help reduce the perceived stigma of seeking mental health care. However, many people who need and stand to benefit from virtual care don't have access to it because of the high cost of Wi-Fi and cell phones, and unless the government is a partner in reducing this inequity, these problems will persist.

Is there a role for social media in clinical practice?

McIntyre: Currently, I don't see any evidence-based role for social media in clinical practice. I see plenty of risks with social media with respect to boundaries, misunderstanding information, and miscommunication. I do, however, think the future of social media might play a role in helping us track diagnosis, illnesses, perhaps even suicidality, and maybe even treatment outcomes. So I do think it could play a future role in clinical practice, but like everything else, it has potential adverse effects.

Do you find that there are pros and cons with the integration of social media and expression of vulnerability as a clinician (eg, willing to share personal aspects of your lives)?

McIntyre: I don't believe it's appropriate for healthcare providers to disclose their personal matters. The patient is not there to serve the clinician; the clinician is there to serve the patient. Disclosing personal information is not helpful and runs the risk for boundary violations in confusing therapeutic objectives. In short, I don't think clinicians sharing information about themselves on social media helps the clinical encounter and is a highly risky behavior.

Rosenblat: I started getting into social media a couple of years ago on the advice of older colleagues. They told me to get on Twitter to help my career and boost research connections. I used hashtags and provided psychopharmacology tips on medication recommendations, geared toward clinicians. I was very clear and explicit that this was not medical advice. Rather, it was for educational purposes aimed at the community psychiatrists and primary care providers and included, for example, tips and tricks on how to start medication, etc.

Certainly, there were a lot of patients and individuals with lived experiences commenting on them, some positively and some negatively, which gave me something new to learn from in terms of how to carefully interact. I'd have patients on social media asking me directly for advice, but I would tell them kindly and compassionately that I can't give them medical advice over social media, which is partly why I pulled back on these tips.

I also separate my social media accounts: My Twitter account is professional, whereas Facebook is purely personal. A lot of academics' Twitter accounts are a mix of personal and professional content, but that's not something I found helpful.

One of the other aspects that has been interesting, and I'm not sure how I feel about it yet, is the personal disclosure of mental illness on social media. I think it would be rare for a physician to disclose to their patient that they are struggling with bipolar disorder or depression/anxiety. But now, there are a lot of physicians, residents, and medical students that are disclosing their mental health status on social media, and it's kind of empowering. It's not something we should be ashamed of, and I think this a good thing, but we should keep in mind that patients could Google you and they could potentially ask you about it. It's an interesting evolution where I think it would be very rare for a senior physician to post such information online.

Leanna M.W. Lui completed an HBSc global health specialist degree at the University of Toronto, where she is now an MSc candidate. Her interests include mood disorders, health economics, public health, and applications of artificial intelligence. In her spare time, she is a fencer with the University of Toronto Varsity Fencing team and the Canadian Fencing Federation.

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