2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

exactly the same treatment, even though her oncologist has
assessed her performance status and associated problems
and found her not to be a candidate for intensive therapy. At
each clinical encounter, she raises the same questions over
and over, driven by continued Internet searches and interactions
with other patients online.
In many ways, the archetype that Mrs. D represents is the
most challenging of the four oversimplified patient types
presented. She is challenging because such patients appear
to place more credence in information they find online than
they do in their oncologist, even if they feel they have a good
relationship with him or her. This is plausibly driven by
psychological distress and the need to be reassured by
seeking out positive information preferentially in the face of
such a devastating diagnosis.
Several important issues should shape the approach to
such a patient. The first is to recognize that the primary
driver of this patient’s reaction to information (much of
which she may not fully understand or accept) is distress
about her illness. In this respect, it would be valuable to
pursue efforts at helping to alleviate her psychological
distress (e.g., counseling, cognitive behavior therapy, medication,
supportive interventions). The second is to take into
account that such patients’ apparent lack of understanding
or acceptance of information from the physician that contradicts
online information is most likely due to distress and
not to cognitive impairment, low health literacy, or low level
of education (although all of these issues could also have a
role). Thus, as a management strategy, continued explanations
and attempts to correct misunderstandings are likely
not to be productive in the long term. Stated differently,
after an initial attempt to correct misinformation or misunderstandings,
further long, cognitive explanations are not
likely to change the patient’s mind and, indeed, might even
appear adversarial. A different strategy I would recommend
is to implement a supportive listening approach, in which
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the physician listens supportively and actively to the patient’s
stories about information acquired on the Internet
and acknowledges the patient’s efforts but does not attempt
to correct the perceptions on a repeated basis, except when
specifically asked to render an opinion. This approach recognizes
the “cognitive block” that may be affecting the
patient’s perceptions and the fact that further logic-driven
discussion is not likely to lead to greater understanding. At
the same time, this approach allows the physician to engage
in relationship-building behavior (active listening). This
issue is difficult, however, driven as we are to logic and
explanation as a means of effective communication and so
requires some “letting go” of those goals of communication.
In my own experience with patients who do not appear
emotionally prepared to have their misunderstandings and
misperceptions corrected. I have found that shifting the
focus of our interactions to supportive listening and abandoning
attempts at contradictory argument is a reasonably
productive approach.
Conclusion
The Internet has changed all of our lives forever and has
certainly changed the way in which patients acquire information,
share their stories, find others in similar circumstances,
and analyze their medical situations. It is clear that
patients have widely adopted the use of online resources in
the face of illness. Access to unfiltered information online
clearly has positive and negative potential effects, and the
introduction of Internet information into the physicianpatient
encounter may be managed in more or less productive
ways. The means of managing such introductions of
information should vary based on the physician’s analysis of
a patient’s information preferences and styles and his or her
apparent reactions to the information. Managed well,
knowledegable patients can offer important opportunities of
informed and shared decision making.
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Ownership Honoraria
Paul R. Helft Genentech; Lilly-
Amylin (I);
Merck (I)
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