I’ll often use “pimp” in a sentence, and non-medical folks give me a strange look. So, to set the record straight:

pimp, verb. To question a medical person lower than oneself on the spot about a medical fact or truism to see if said person knows the answer show how smart or dumb the person is in front of a group.

Examples:

• “Man, my attending pimped me mercilously about acid-base disorders in my patient, when I’d only seen her for 20 minutes!”
• I cannot believe my intern started pimping me about physiology in front of the attending. He’s supposed to be on my side!
• It was great. My resident was pimping me about medication dosages and I got them all right.

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Running was, apparently, Sam’s thing. I don’t know exactly why he runs–he’s a a friend from the neighborhood where I grew up, and we haven’t kept in touch–but he runs, and he loves it. So it was a huge, huge loss when he developed pretty severe pelvic pains every time he tried to run. Specialists one through four recommended rest, but Sam knew there had to be something better. So he turned to Google.

It turns out Sam had bilaternal sports hernias, also known as athletic pubalgia. (I had never heard of it, and most doctors haven’t, either.) He typed in his symptoms, queried away, and found news articles, papers, and PDFs on the condition and its treatment–surgery, performed by one lone sports medicine surgeon in Pennsylvania. (Apparently the intake form has a box, “Check here if you’re a professional athlete,” reassuring Sam that the condition exists in the world outside of textbooks and medical journals.) Sam underwent the surgery, the surgeon repaired the hernias, and he’s now recovering and excited to hit the ground running. Pun intended.

That’s the good–no, the great–side of Google Medicine. Enter symptoms in one end, spit out a diagnosis on the other. In no way is this a new idea: Meg Hourihan’s mom starting Googlecooking in 2002 –you just enter what ingredients you have at home into Google, and the search engine spits out a list of recipes. If I’m trying to find the name of a song on the radio, and I only know bits and pieces of the lyrics, I’ll type them in, add the word “lyrics,” and I’m almost certain to find my match. Googlediagnosing isn’t that far behind. The BMJ recently had an article indicating that more medical journals are getting hits from Google Scholar than they are from PubMed.

In some cases–like Sam’s–this is great. Fantastic. Revolutionary. If I have a very specific set of symptoms–tooth itch, purple-hazed vision, and new-car-smell breath (the classic triad for the Grahamazon syndrome, of course), I can probably figure out a likely diagnosis, see my doctor, and get a treatment (dihydrogen oxide as needed). Hooray. In the most common of syndromes, this also works well. Runny or stuffy nose, fatigue, muscle aches can be a pretty common presentation of the common cold, and we see that this works pretty well –most of the top links have to do with the common cold or the flu. Common things being common, there are probably more webpages out there about common colds than say, dengue fever, and since Google results are essentially a web popularity contest, the common things rise to the top.

Again, this is great. Patients can get information about their possible diagnosis, read about over-the-counter treatments, when to seek medical attention, etc. But there are chasms of caveats to Googlediagnosing. In a world wide web of blogs and forums and comments, anyone can be anyone, and everyone can have an answer. And if Google ranks its information by popularity and not by accuracy , you can end up with some pretty mixed results. Let’s say I have fevers, chills, and muscle aches –holy shit! I have babesiosis? Or Rocky Mountain Spotted Fever? Or leptospirosis? No, I probably have the flu–but not according to Google.

When everyone’s an expert, no one is. I used to frequently respond to Ask Metafilter’s health section (it’s a website where members can post health-related questions), but I’ve stopped outright because there’s just so much bad advice from everyone and their mother. I’ve seen so many users give anecdotal evidence (“my great aunt had the same symptoms you’re describing and ended up having a pheochromocytoma–you should get an MRI before it spreads!”) that’s so scary and harmful and wrong that they must not even know what they’re doing. In other categories of questions–science, travel, computers, etc–I give my anecdotal advice or opinions as well, but I’m not potentially screwing with their mental or physical health.

And there’s potential for great anxiety when Googlediagnoses are incorrect–enlarged lymph nodes and a fever may net a person a diagnosis of lymphoma or HIV, instead of sore throat. The two diagnoses are pretty damn different. (HIV is the latest in a long line of “great imitators” like syphilis and TB that can present in many, many ways.)

Most diseases also present with a specific time course and other symptoms–that physicians are trained to recognize because of their experience seeing diseases so many times–and so often a patient may come in with a diagnosis that, while symptomatically correct, doesn’t fit the way the disease works, the age group, the time course, etc.

Add to this the fact that most patients don’t understand the concept of a differential diagnosis (I didn’t until I entered medical school), and you can get people posting that someone with syptom X definitely has disease Y, or you can get a patient who has done some self-Googlediagnosing, and is adamant that the disease they read about is the one they have. (Or even the disease Y they think they have is treated with drug Z, so they want a prescription for it.)

Another barrier exists between doctor and patient: medicalese. This is the ever-popular “diaphoresis” instead of “sweating,” “erythema” instead of “redness,” “edema” instead of “swelling.” If a patient doesn’t know the lingo, he or she may have the signs and symptoms right, but may lack the ability to learn about his or her condition. How many patients of yours would call a low platelet count a thrombocytopenia? Or how many refer to their diuretics as water pills? If you’re using the wrong keyword, you’ll get the wrong diagnosis–or miss the right one–every time.

Now, there are websites and companies and organizations that try to provide some sort of standard for health information on the web. And there are symptom to disease tools like Dxplain and Gideon that allow people to enter symptoms (both medicalese and non-medical) and, using algorithms and data, generate a list of possible diagnoses. But all of these are still far from perfect.

If we continue to move toward more and more Googlediagnosing (and it certainly looks that way) these tools and standards will be vital. Like the safer-sex mantra, if you’re going to do it (uh, Googlediagnose), do it safely.

Update: My wish at their command. Healthline is a search engine that tries to filter out the bad health info on the net.

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So I’m reading through this Wikipedia list of cognitive biases , and it’s pretty apparent that almost all of these factor in to our discussions of patient care. A sample, with the definitions provided by the Wikipedia:

• belief bias – the tendency to base assessments on personal beliefs (see also belief perseverance and Experimenter’s regress) All the time. We assume things about patients–what they do, how they act–based on our own understanding of “normal.”
• bias blind spot – the tendency not to compensate for one’s own cognitive biases. We don’t have to compensate. We’re the doctors; we’re right, duh.
• confirmation bias – the tendency to search for or interpret information in a way that confirms one’s preconceptions. Uh, pertinent positives and negatives? If I suspect cirrhosis, I’ll ask you about alcohol. And if you tell me you have 1-2 drinks a night, someone will say the “rule of doubling” so that you actually drink 2-4 drinks a night.
• disconfirmation bias – the tendency for people to extend critical scrutiny to information which contradicts their prior beliefs and accept uncritically information that is congruent with their prior beliefs. If I suggest someone might have HIV, someone usually says he or she “doesn’t have any HIV risk factors.” Translation: I think he or she is married or heterosexual, so they can’t possibly have HIV.
• endowment effect – the tendency for people to value something more as soon as they own it. If it’s lymphadenopathy, I don’t brag about my patient. But when it turns out to be fetus in fetu, I talk all about him.
• hyperbolic discounting – the tendency for people to have a stronger preference for more immediate payoffs relative to later payoffs, the closer to the present both payoffs are. Should we keep a patient or discharge her tonight? Discharge; it’s one less note to write in the morning.
• illusion of control – the tendency for human beings to believe they can control or at least influence outcomes which they clearly cannot. Oh boy. This just about sums up the physician mind.
• mere exposure effect – the tendency to express undue liking for things merely because they are familiar with them. “She’s just another CHF/COPD exacerbation.”
• planning fallacy – the tendency to underestimate task-completion times. “I’ll be right up to see the patient;” “He’ll be getting his CT at 2:30;” “The dictation should be online by tomorrow.”
• rosy retrospection – the tendency to rate past events more positively than they had actually rated them when the event occurred. “No, really, internship’s not that bad.” “This won’t hurt a bit, I had it done when I was your age.”
• selective perception – the tendency for expectations to affect perception. You label a person as “really nice,” and your team will probably think they’re nice. Label them as cranky or grouchy, and they’ll expect someone to be grouchy.
• status quo bias – the tendency for people to like things to stay relatively the same. We’re happy when the creatinine stays at baseline. We like uneventful hospital stays.
• Von Restorff effect – the tendency for an item that “stands out like a sore thumb” to be more likely to be remembered than other items. Attendings give anecdotal evidence: “During my residency I saw an Asian person with sarcoid, so it happens more often than you’d think!”
• Zeigarnik effect – the tendency for people to remember uncompleted or interrupted tasks better than completed ones. This is the intern’s defense mechanism. Everything gets done because you know you haven’t completed it yet, and no one else is going to do it for you.
• fundamental attribution error – the tendency for people to over-emphasize personality-based explanations for behaviors observed in others while under-emphasizing the role and power of situational influences on the same behavior. A person is over-emotional if they cry.
• ingroup bias – preferential treatment people give to whom they perceive to be members of their own groups. Hell yeah. If you say you’re Dr. So-And-So, you have a lot more clout that if you say, “I’m the medical student taking care of Ms. Jones.”
• self-serving bias – the tendency to claim more responsibility for successes than failures. It may also manifest itself as a tendency for people to evaluate ambiguous information in a way beneficial to their interests. “We really got her through that acute renal failure well” versus “She was really sick when she came in.”

Note: I’m not saying these happen all the time. Just that they can, and we’ve got to be on the lookout for them.

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