The Internet, Dr Google and now Chat-GPT And The Top 5 Ways They Have Changed My Medical Practice

Every generation, I suppose, considers the world as it was when they were young to be a unique situation that has shaped them in ways no other generation has been, ever.

And they would be right.

I hail from a year right at the end of the Gen-X and beginning of the Millennial Generation. Cell phones were not in existence. Rotary phones were everywhere. Credit cards were the exception and not the rule when paying. TVs weighed 500 lbs and probably didn't have a remote control. This was the world when I was born.

By the time I graduated high school many people had cell phones and the internet, while in its infancy, was a well known thing. Having actual computers in the home, even our home, was not uncommon -- I remember getting our first PC compatible 386x computer with, I believe Windows 3.1 and a version of DOS that still had to be dealt with -- that blinking cursor at the DOS prompt was always fascinating to me. I could have easily ended up in the computer sciences had my childhood bounced in a different way.

I am of the generation which knew a world before cell phones and TikTok trends all about how your doctor and their gaslighting ways (I kid, I kid.) We knew a world where being a doctor meant a little more, from societal status to perceived trustworthiness -- and there are many reasons for this, but access to information is the biggest, in my opinion. Of course, the quality and motivation behind any given data vector is very important and generally, TikTok is not the place to get medical advice.

When I was in medial school, it soon became apparent that it was actually, memory school and if you "could not retain, you would not remain." It did not take long for me to realize that thoughtful and critical learning would be the exception and the rule was having to retain large amounts of archaic and abstract data and terms long enough to regurgitate on the frequent testing we underwent.

Many professors would emphasize that understanding concepts and not detail in minutia would allow for success in testing and long term competency as a physician. Of course, to score high on the tests that these same professors wrote, knowing the minutia was key for top performance. Medical students are nothing if not motivated creatures and my 30 something brain was battling early 20s brains. I did well, for the most part, but was not in the top cohort for medical school grades.

I very much agree with the idea that understanding the concepts is key, and even now, in any given day in the clinic, I think back to a lesson taught in medical school and it informs me in what the next step in diagnosis or treatment may be. Many patients may be a little surprised to learn that just about daily, patients present with issues that no medical school lecture or residency rotation addressed or provided me with the easily accessible knowledge of how to treat that patient. Well, maybe not daily, but on a regular basis. I must point out that I don't see this as a deficiency in my education, instead this is a hallmark of primary care -- anything and everything is waiting for me in the exam room.

In all the medical school tests I took, all of the board tests, USMLE, COMLEX and medical specialty exams I believe that having a resource that mimics real clinical settings would be appropriate. Just yesterday I was reviewing a medical issue on UpToDate with a patient as we were discussing an issue I did not know much about. A board exam question may ask me to know this specific issue off of the top of my head, and be able to answer a 3rd or 4th level question. In this case it was an issue of an antibiotic causing a specific side effect -- I know the basics behind this, but I was looking for more detailed information -- information that doesn't need to be stored in my head (it does stay there after a clinical encounter like this) as accessing resources, in real time, while sitting next to a patient, is what my day consists of.

Of course I know how the body works in a somewhat comprehensive fashion, and of course I know about disease processes and the treatments thereof but as above, many times there are issues that demand that I seek additional information. My base knowledge of all things medical plus online resources is the basis of how I treat patients. If a doctor in this day and age claims to have all the answers in their noggin -- don't go-a-knock'n on their clinic door.

I think there is value in the memory school model of medical education. It sharpened my brain. It taught me to "drink from the firehose" of information that blasted my face off and keep going. But, as the medical educational process continues, that model breaks down and in my opinion, board exams and licensure exams should mimic the clinical setting much more than they do now.

It also became apparent that my ability to find information swiftly and from reliable sources would be key in my clinical success -- this has proven to be much true beyond my pre-clinical imagination. I've had to figure this out for myself, for the most part. Medical school taught me how to organize and access large quantities of information in my noggin, but not how to access information outside my noggin.

Patients will sometimes come armed with details concerning their suspected ailment or issue that either I'm not aware of or involve details that have me digging in the recesses of my brain. Some doctors become frustrated and agitated when patients consult "Dr Google" before coming to see them. I can, at times, feel this as well. I try to remind myself that if roles were reversed and I was still installing floors for a living, I know I'd be consulting Dr Google on a regular basis.

The most frequent office visit that has this, is a patient worried that they have diabetes.

A patient with a transient numbness and tingling in a few fingers who frames houses for a living, and is 24, and is otherwise healthy, will google his symptoms and in that list of possibilities of causes is, of course, diabetes. Yes, uncontrolled diabetes for years, if not decades, can cause nerve damage. But, without knowing anything else -- no tests, no physical exam, no family history -- I can confidently say this transient neuropathy is not because of diabetes (brief side not: elevated blood sugars for long periods of time will damage the tiny nerves and blood vessels first -- meaning the eyes, kidneys take a beating first, but can also affect the penis and erectile dysfunction often comes in these situations. I've had patients who don't seem to care about their A1c of 11.5% and their elevated risk of stroke, heart attack, blindness, kidney failure, and losing their toes and feet but when I mention their penis not working any more we can start talking about what medications need to be started.) The patient will then tell me that they use a hammer 8 hours per day and they numbness is worse after work. They will still want to do diabetes testing though.

So I try to be understanding when a patient has a concern and has already looked up symptoms online, and has requests for testing related to what they found. Sometimes it is reasonable, sometimes not. I try to talk this through with patients as time allows

Another brief side note: the time crunch in modern medical practice is a problem not often addressed and is due to the Wolves who hold the purse strings -- primarily commercial insurance companies. By keeping reimbursement rates low, and denying claims in an egregious fashion, we have been forced, over the years to move to shorter and shorter appointment times. Yes, some visits definitely should be 15 minutes, providing the patient shows up on time, but many require some discussion and evaluation, and on my part, critical thinking that is tough to do in the time frame provided. Verily, I say unto thee, some industries should not be profit driven and mainstream healthcare is at the top of this list -- we will drive the Bulls of Bashan over the cliff and into the driving surf at the bottom of the cliff.

Here are the top 5 ways The Internet, Dr Google and now Chat-GPT has changed my medical practice.

• Number 5

In the mid-2000's I got my first job in the medical world and this was as a registrar in a Denver emergency department. I remember watching the docs google stuff -- back then, somewhat feeling unsure about the appropriateness of this -- now, realizing the huge benefit, I understand it completely. It's not as if we doctors are looking up core medical training tenets online, but everything from dosage to where the closest 24 hour pharmacy is all available online, and it could be argued that not taking advantage of information available it tantamount to malpractice.

As I alluded to above, I remember visiting the doctor before the internet as a child. And, likewise, I don't know what it's like to be a doctor without the internet.

Again, as above, I am of a certain age that allows me to straddle the pre and post internet dominated world. I think this allows me to have some understanding and empathy that doctors of other ages may not so easily have; not that that gap can't be bridges, but it comes naturally to me and people of my age. I understand my older patients and their frustration with the move to all communication being moved to an app or "portal" and phone calls being the exception, not the rule. When I have a request specifically for a phone call for results, I always worry that this will be forgotten and they will get a MyChart message instead of a phone call, as this is overwhelmingly the most efficient way for me and the clinic to communicate.

The 5th most impactful way The Internet (and with lesser effect, Dr Google and Chat-GPT) has impacted my medical practice is allowing me to easily bridge generational differences by the virtual of knowing a world pre and post internet dominance.

• Number 4

My time spent on TikTok, Instagram, to a much lesser extent, Facebook fluctuates with business and downtime on any given day. I do find it somewhat valuable to know what the trending medical topics are -- things like POTS, ADHD, obscure vitamin deficiencies, and perhaps the most difficult point of view to encounter is the idea that of "medical gaslighting."

This has, does and will happen in the doctor's office. I don't pretend to speak for other doctors but at this point I have a pretty good idea of how many doctor-patient interactions go down. A common scenario is a patient comes in complaining of knee pain and the patient is obese (quick side note -- BMI >29.99, and BMI is just a person's weight divided by the square of their height and this is a poor determination of an individual's health by itself) and depending on the etiology of pain, the extra weight may be playing a larger or smaller role. Osteoarthritis is of course driven by extra weight on the body. An MCL strain from a slide tackle while playing soccer, less so, but of course, healing can be impaired when carrying more than an ideal amount of weight.

During these conversations it would be bad medical care to not discuss the role obesity plays in knee dysfunction. Just as it would be bad care to explore other options of diagnosis and treatment other than weight loss -- and as we all know, weight loss is difficult (as I say, simple does not mean easy, and in many ways, weight loss is just that -- simple but not easy) and is time consuming. I weave this together -- in this very simplified scenario of a doctor visit to emphasize the type of communication that is needed to continue to earn the trust of any and all patients.

Of course, the wolves with the purse strings of American health care push for shorter and shorter visit times by way of diminishing reimbursement for services rendered and proper communication takes time.

The 4th most impactful way that the internet, Dr Google and Chat-GPT has changed my medical practice is by having me monitor social media to see what the trending medical topics are and perhaps more importantly, discuss treatment options in a way that actively avoids gaslighting, or the perception of gaslighting.

• Number 3

Combining the internet, which lead to Dr Google, and now, ChatGPT at the dawn of the age of AI seems more like a black and white approach coming from a Boomer and not the nuanced, thoughtful approach that you have undoubtedly come to expect from yours truly but again, I think this stems from my age and the things I dun seened. I dun seened a lot.

Precisely because I have seen a lot, can I approach this next phase of how technology shapes our lives, and for the purposes of this exposition, my medical practice, with confidence that I can adapt. It is an adapt or die scenario, after all.

I see many advertisements for AI in healthcare -- and most, as best I can tell, involve 2 main premises -- help with writing notes and help with diagnostics. Both of these are day to day challenges and if there were actual help in the horizon, I would heartily welcome it. Writing notes is basically for insurance companies and less for documentation of the patient's actual well-being, and as far as making diagnoses -- I'm always worried I missed something important.

But there is so much more -- things that I've yet to dream of. The medical space is good at nothing if not gathering data.

The 3rd most impactful way that the internet, Dr Google and Chat-GPT has changed my medical practice is by providing me motivation to anticipate and hopefully, help mold, how AI will be used in the medical care space.

• Number 2

In some ways the proliferation of information has degraded the social standing that a physician holds. This is understandable, if not fraught with potential.

I remember when I was a newly minted physician and having people call me "doctor" was almost embarrassing, as if I was better than them. I've long gotten over this, but there is an element there, not an element of me being better than any given person, but the element of my standing through training has provided. In the medical setting, it also is important to know the credentials of the clinician -- in the hospital, emergency department this is imperative, as a patient generally doesn't choose who their provider is. This is not the place to have a discussion of the mid-level vs physician dynamic (well, maybe the right place, but different post) but people should know.

The 2nd most impactful way that the internet, Dr Google and Chat-GPT has changed my medical practice is by reducing the incidence physicians "put on airs" and while I hope this wouldn't have been me regardless, it is a social construct that has seen the degradation of a patina once brightly shining now turned dull.

• Number 1

Instant access to information, instant access to those in our contact list. Why would one not have instant access to their doctor?

The burden of managing an inbox as a primary care physician is just that -- truly burdensome. I spend just about every minute, outside of lunch (but often includes large parts of lunch) in exam rooms with patients. 18 to 22 meetings per day, with agendas that can change and be added to at any time, usually last minute and these meetings need actionable items addressed and executed. Oh, and the dozens of messages that come every day from patients -- some simple, like clarifications or simple questions, many requiring medical decision making in my reply.

Patients don't want to make an appointment to address, what may be in their mind, a simple medical question. As my panel has swelled to over 2500 patients, I've had to take a much harder line in terms of issues I'll address over messaging and what needs to be an appointment. Generally, I try to be as helpful as possible, but the hours per day that this inbox could extract would be life draining if I let it. Verily, verily, verily, I say unto you: feel free to message your doctor but be happy (or willing, at least, I do understand the hassle) to make an appointment to discuss any medical issues.

The most impactful way the that the internet, Dr Google and Chat-GPT has changed my medical practice is that I can get palpitations when opening my inbox to address the dozens of requests for medical advice. I understand why this is happening, but the model I work in, that is the only way I can bring money in is by billing the insurance companies has me in a rock and a hard place, in that I am pressured to provide free care on a daily basis with my patients. The heart of a primary care doctor, however, is to do the right thing for the patient not for the CPT codes. The gears of our system are greased with the tears of the doctor and patient alike.