In a piece in the New York Times 7/9/08 (Abuses are Found in Online Sales of Medication) a report (also out Weds) from Columbia University is described. According to the authors, 85% of online sites that sell medications directly to the public do not require a prescription or substitute an online questionnaire for one. This is perceived as a problem, and several states have attempted to pass laws to prevent such activity. In Minnesota, a law requiring doctor patient consultation was enacted, but sites circumvented it with a 30 sec telephone “consultation” with a physician hired by the pharmacy. They are now considering laws that mandate a face to face consultation with a physician as a prerequisite to receiving any prescription.

At the heart of this controversy is the concept of the therapeutic relationship. The traditional therapeutic relationship is based on direct, face to face history taking, examination (“laying on of hands”) and clinical decision making (hopefully, shared clinical decision making). Interestingly, early in the 20th century, the telephone was thought by the AMA to be a major threat to this relationship, since it reduced the need to “see” the doctor. It’s that “seeing” that is thought to be a safeguard against fraud and deception. Still, all of us have been conned during a face to face encounter, whether as clinicians or in the marketplace. I’m not going to argue that deception is no more likely through modern communication media (on the Internet, no one knows you’re a dog) than face to face, but I am worried that an over reaction to this fear will slow our progress toward participatory medicine.

The reasoning could go something like this: practitioners alone must control access to complex and dangerous procedures and drugs since great knowledge is needed to know how to apply them and a single gatekeeper will be less susceptible to fraud and abuse (or, at a minimum, this approach makes someone accountable). The more authority we vest in the patient, especially through nontraditional means like the internet, social networking software and collective wisdom, the greater the risk of deception and misapplication of these interventions. Thus, we need to limit the role of the patient. The opposite extreme is represented by the more libertarian views of folks like Glenn Greenwald, whom I referenced months ago in a “found on the net” entry to this blog. He argues that there is no clear reason to limit access to any medication by requiring a prescription from a medical practitioner.

This problem is the reason I’ve moved away from obsessing too much over the e-Patient revolution and am so much more invested in the concept of participatory medicine. While the electronically empowered e-Patient is very important, there really are potential ways this “power” can be abused. The emphasis on the “e” in engagement as part of participation is more critical. I strongly believe that the risks of deception and abuse of treatments and procedures is far lower when patients participate, especially as a group. On the one hand, the knowledge base is expanded and even the appropriateness of a practitioner-ordered treatment can be questioned in a good participatory relationship (how many patients have I heard wondering why their doc started them on an antibiotic for a clearly a viral illness?). On the other hand, there is no doubt that patient communities have an extraordinary sense of when they are being conned, especially by one of their members.

So, while improved regulation of some online interactions may be warranted, each proposal needs to be closely examined for it’s unanticipated impact on the participatory process.