Towards ethical guidelines for dealing with unsolicited patient emails and giving teleadvice in the absence of a pre-existing patient-physician relationship — systematic review and expert survey

Abstract

BackgroundMany health information providers on the Internet and doctors with email accounts are confronted with the phenomenon of receiving unsolicited emails from patients asking for medical advice. Also, a growing number of websites offer "ask-the-doctor" services, where patients can ask questions to health professionals via email or other means of telecommunication. It is unclear whether these types of interactions constitute medical practice, and whether physicians have the ethical obligation to respond to unsolicited patient emails.ObjectiveTo improve the quality of online communication between patients and health professionals (physicians, experts) in the absence of a pre-existing patient-physician relationship or face-to-face communication, by preparing a set of guiding ethical principles applicable to this kind of interaction.MethodsSystematic review of the literature, professional, and ethical codes; and consultation with experts.ResultsTwo different types of patient-physician encounters have to be distinguished. "Traditional" clinical encounters or telemedicine applications are called "Type B" interactions here (Bona fide relationship). In comparison, online interactions lack many of the characteristics of bona fide interactions; most notably there is no pre-existing relationship and the information available to the physician is limited if, for example, a physician responds to the email of a patient who he has never seen before. I call these "Type A" consultations (Absence of pre-existing patient-physician relationship). While guidelines for Type B interactions on the Internet exist (Kane, 1998), this is not the case for Type A interactions. The following principles are suggested: Physicians responding to patients' requests on the Internet should act within the limitations of telecommunication services and keep the global nature of the Internet in mind; not every aspect of medicine requires face-to-face communication; requests for help, including unsolicited patient questions, should not be ignored, but dealt with in some appropriate manner; informed consent requires fair and honest labeling; health professionals and information providers must maintain confidentiality; health professionals should define internal procedures and perform quality control measures.ConclusionsDifferent media are appropriate at each point on the continuum between dispensing general health information and handling patient problems that would require the practice of medicine to solve. For example, email is a sufficiently capable medium for giving out general health information, while diagnosis and treatment usually requires at least advanced telemedical technology. Patients have to be educated that it is unethical to diagnose and treat over the Internet in the absence of a pre-existing patient-physician relationship, and if the interaction is limited to a single email. More research is needed to establish more evidence regarding situations in which teleadvice is beneficial and efficient.

The Impact of the Internet on Cancer Outcomes

“…46 In one study, 50% of physicians were in fact tempted to respond to such an e-mail inquiry from an unknown patient, 47 despite possible liability consequences. 48,49 Guidelines for this so-called "type A" communication (in the absence of a preexisting patient-physician relationship) have been proposed, 50,51 but this kind of "cybermedicine" remains a gray area. Recently, a woman filed a lawsuit against a radiologist, whose e-mail address she found on a hospital Web site and whom she asked a seemingly casual question via e-mail.…”

Primary care physicians' experiences of carrying out consultations on the internet

“…Such an education should not only include general rules on how to provide textbased answers, but also techniques on how to carry out literature searches on the internet, the clinical application of evidence-based medicine, and legal and ethical aspects of internet-based consultations, as part of the subject of medical informatics. [9][10][11] …”

How Should Orthopaedic Surgeons Respond to Unsolicited E-Mail?

“…Many practitioners do not respond at all and in one study assessing the response to e-mail regarding infection by herpes zoster in a fictitious patient on immunosuppressive therapy, 50% of practitioners acted in this way. 16 Of those who did respond, 93% recommended that the patient should see a medical practitioner. Failure to answer (47%) was demonstrated in a more recent study evaluating the response of anaesthetists to e-mails from a fictitious patient.…”

“…It could be suggested that by entering into such an exchange, the doctor is undertaking to provide care to the patient. 18 This has been further emphasised by Eysenbach 16 who highlighted the difficulties associated with defining the boundaries of telemedicine and differentiating health information from treatment. "The more health information is personalised and tailored to the individual, and the more it encourages the receiver to act upon the advice, the more we are moving within the continuum from giving health advice towards attempting to treat, and thereby practising medicine."…”

“…Others, however, believe that this approach while "doing no harm" is also "doing no good" and do not advocate it. 19 Eysenbach 16 has recently outlined the view of medical associations in Europe and the USA regarding the management of unsolicited e-mails requesting advice or treatment. How doctors utilise the guidelines and the effects on various outcome measures, such as patient and doctor satisfaction, demands on time and the legal implication, has yet to be evaluated.…”