Navigating internet-based misinformation with patients in the clinic

Abstract

Dear Dr Dermatoethicist: I recently saw an unvaccinated patient with active COVID-19 at a telemedicine clinic. He had pustular rosacea worsened from masking. After doing online research, he requested oral ivermectin, believing that it would be effective for rosacea and COVID-19. I expressed concerns about his treatment request. Despite my urgings, he refused to consider alternative, evidence-based treatments. Ultimately, he became frustrated and ended the appointment after raising doubts about my expertise and sources of information.How should I confront medical misinformation while still respecting patient treatment preferences?—Dr Conscientious Dear Dr Dermatoethicist: I recently saw an unvaccinated patient with active COVID-19 at a telemedicine clinic. He had pustular rosacea worsened from masking. After doing online research, he requested oral ivermectin, believing that it would be effective for rosacea and COVID-19. I expressed concerns about his treatment request. Despite my urgings, he refused to consider alternative, evidence-based treatments. Ultimately, he became frustrated and ended the appointment after raising doubts about my expertise and sources of information. How should I confront medical misinformation while still respecting patient treatment preferences? —Dr Conscientious Dear Dr Conscientious: Medical misinformation often generates more interest among patients than researched information and is amplified on social media and search engines.1Iglesias-Puzas Á. Conde-Taboada A. Aranegui-Arteaga B. López-Bran E. “Fake news” in dermatology. Results from an observational, cross-sectional study.Int J Dermatol. 2021; 60: 358-362https://doi.org/10.1111/ijd.15254Google Scholar Dermatology is particularly susceptible to misinformation: long wait times can lead patients to scour the internet for remedies, and the lack of treatment guidelines for many conditions has led to nontraditional therapies. Sometimes, medical misinformation can influence patient preferences for treatment, as in the vignette. Indeed, exposure to medical misinformation can, often subconsciously, change patient behavior significantly.2Truglio-Londrigan M. Slyer J.T. Singleton J.K. Worral P. A qualitative systematic review of internal and external influences on shared decision-making in all health care settings.JBI Libr Syst Rev. 2012; 10: 4633-4646https://doi.org/10.11124/jbisrir-2012-432Google Scholar In such scenarios, dermatologists must balance recommending a treatment plan that is evidence based and respecting the patient’s autonomy in the choice of treatment. Not all patient preferences are autonomous, even among those with decisional capacity. It is important to note that patient preferences must be informed and reasonably rational to be autonomous.3Bastick Z. Would you notice if fake news changed your behavior? An experiment on the unconscious effects of disinformation.Comput Hum Behav. 2021; 116: 106633https://doi.org/10.1016/j.chb.2020.106633Google Scholar Informed decision making requires patients to be substantially aware of acceptable treatment options before making decisions. If patients’ expressed preferences are based on misinformation, then we argue that they are not truly acting autonomously. As a result, dermatologists must address medical misinformation to be sure that their patients are informed of reasonable, evidence-based treatments. Further, dermatologists are not required to offer treatments that they believe are not effective. However, after clarifying the acceptable treatment options, patients should be allowed to make medical decisions that align with their values. Other principles of medical ethics (beneficence, nonmaleficence, and justice) also support confronting medical misinformation. A patient would benefit both from learning why such medical misinformation is unfounded and from hearing evidence-based clinical recommendations for their skin disease (beneficence). Moreover, not confronting such medical misinformation can result in patient harm (maleficence). Misinformation can convince patients to try dangerous treatments, reduce adherence to clinically recommended treatments, result in a delay in seeking care, and begin to be accepted as truth after widespread dissemination.1Iglesias-Puzas Á. Conde-Taboada A. Aranegui-Arteaga B. López-Bran E. “Fake news” in dermatology. Results from an observational, cross-sectional study.Int J Dermatol. 2021; 60: 358-362https://doi.org/10.1111/ijd.15254Google Scholar Finally, misinformation can have unintended consequences for limited health care resources, such as increasing demand for medications, thereby reducing their availability for other patients for whom the medication is medically indicated (justice). Furthermore, individuals of a lower socioeconomic status are more likely to believe medical misinformation and have less equitable care.4Pan W. Liu D. Fang J. An examination of factors contributing to the acceptance of online health misinformation.Front Psychol. 2021; 12: 524https://doi.org/10.3389/fpsyg.2021.630268Google Scholar Supported by principles of medical ethics, dermatologists should confront misinformation by employing strategies that extend beyond the identification and correction of misinformation. These include listening to patients’ concerns, questions, and preferences with empathy through open-ended conversations, providing accurate and educational medical resources to patients, promoting information and news literacy both inside and outside the clinic, and earning patients’ trust for successful shared decision making.5Southwell B.G. Wood J.L. Navar A.M. Roles for health care professionals in addressing patient-held misinformation beyond fact correction.Am J Public Health. 2020; 110: S288-S289https://doi.org/10.2105/AJPH.2020.305729Google Scholar — Dr Dermatoethicist None disclosed.