"Humanity will surpass the first dirigibles as it has surpassed the first locomotives. It will surpass M. Santo-Dumont as it has surpassed Stephenson. After telephotography it will continually invent graphies and scopes and phones, all of which will be tele and one will able to go around the world in less than no time. But it will always be only the temporal earth. And it will even be possible to burrow inside the earth and pierce through it as I do this ball of clay. But it will always only be the carnal earth" - Charles P�guy, 1907
If there was a media buzz word for the nineteen-nineties, it was the Internet. The transforming effect of the Internet on everything from commerce to romance to literature has become one of the great clich�s of our time. The prefix �e-�, as in e-mail, e-commerce, e-romance, has been the letter that launched a thousand feature articles. A year or so ago, all an entrepreneur had to do to persuade normally sober venture capitalists to hurl money at them was to pepper their presentations with words like �Internet� and �e-commerce� as much as possible. On further examination, most of the alleged revolutionary applications of the World Wide Web aren't quite so radical. Most e-commerce is essentially a glorified version of the mail order company; as hugely overvalued internet stocks continue to fall, consumers are realising that the pleasure and convenience of going to a shop and instantly purchasing an item outweighs the pleasure of going to a website and waiting for the postal service to deliver the item. Where the Internet does have far-reaching implications is the sheer quantity of information that is now available.
It�s no surprise that a popular media for whom the Internet is such a fertile source of copy would turn its attention to medicine and the Internet. A copy of Woman's Way asks "Can the Internet replace your GP?" - increasingly assertive patients are using the Internet as a research tool, supplementing advice from their practitioner with information from websites of varying quality. For a variety of reasons, ranging from the Shipman case to increasing public suspicion of all authority, the medical profession has fallen from its lofty perch; from being an unquestioned font of wisdom the doctor is now seen as a service provider. The information explosion is a challenge for all practitioners.
It could be argued that this phenomenon of the well-informed patient has always existed; what is different now is the extreme ease with which the information can be accessed. Certainly in cases of rare diseases it is quite likely that the patient is better informed than the doctor. The most worrying part of this trend is the variable quality of the information available. The Internet can be seen as an information Wild West; exciting and vibrant largely due to its unregulated, decentralised nature. This is what makes the Internet fascinating, but from the narrow point of view of this particular issue also somewhat dangerous. The World Health Organisation is moving to create a new top-level domain name (top-level domains are the likes of .com, .ie, .edu, .org) called .health that would act as a guarantee of quality information. This is probably the most sensible approach.
The Internet�s other great strength is the ease of global communication. Researchers all over the world can communicate and collaborate with each other; any medical practitioner, no matter how physically isolated, can find resources for evidence-based practice and discuss ideas and data with others all over the world.
As a medical student, what are the particular implications of the Internet for me? The Internet has several advantages for this particular cohort (in which we can include general practitioners in training) - it makes it comparatively simple to access the websites of universities and hospitals all over the world. It means I can organise an elective in New York or New Zealand almost as easily as one in a hospital in Galway or London. Well, almost. It means I can post a baffling problem on a newsgroup and discuss and argue about it with students in Mexico and Moscow. Medline and similar tools make the search for information exponentially easier.
But the essentials of a medical student's life will remain the same; attempting to keep pace with an ever-expanding body of learning, attempting to separate the wheat from the chaff while trying to keep the humanity and altruism that (one hopes) were the primary motivations for entering medical school in the first place. If anything, the Internet simply multiplies the dizzying amount of information which one could potentially study. More and more journals have an online presence, as well as hundreds of university and hospital websites, some of which feature on-line tutorials. So the conservative estimate of 2 million biomedical papers per annum is augmented by more and more information. I would argue that the problems faced by medical students are similar to those faced by not just general practitioners in formal training schemes, but all practitioners.
Indeed the dangers of too much information has always been recognised in medicine, and in all branches of learning. �Mega biblion, mega kakon� [A big book is a big evil.] said Callimachus, the Librarian at the gigantic Library of Alexandria in the 3rd century B.C, and one piece of medical student folk wisdom is to always use the slimmest textbook possible � information is never the same thing as knowledge, let alone wisdom. An intimidating morass of information is one of the biggest obstacles to learning. It would be an unusual medical student who could be heard bemoaning the lack of new information to study.
The ultimate aim of a medical education, in any event, is not to pass on a vast bulk of facts but to teach the often slippery art of clinical medicine. There is an excellent website (http://www.med.ucla.edu/wilkes/intro.html) devoted to the heart sounds, but nevertheless it is no substitute for listening in the old fashioned way with the stethoscope to the chest of an old-fashioned, flesh and blood patient. There are many excellent websites devoted to history taking and clinical skills, but none can replace actually sitting down with a patient and listening to their history. It is often estimated that 70% of diagnosis are made on history alone, with a further 20% after physical examination and only 10% requiring the further examinations beloved of the exponents of high-tech medicine. The art of history-taking does not lend itself to online learning. Who would you regard as the more competent GP � one who had never seen a patient but had read all the available online tutorials, or one who had spent even a couple of weeks actually practising?
And that�s why the tone of this essay has been somewhat sceptical. The cinema was meant to destroy books, television was meant to destroy cinema; it seems that there is a human need to live in decisive times where a revolutionary new order must inevitably sweep away the old. We look at the sepia-toned pictures of the 1920s and 1930s (for example) with a sense of a simpler world more at peace with itself, but those who lived in those �good old days� saw them times of massive social change, confusion and upheaval. True revolutions are few and far between.
What conclusions can we draw from all the above? The most crucial factor in the use of the Internet for all medical practitioners is discrimination; knowing how to evaluate information, knowing where one can get relevant information, and knowing what information is important. And doctors have an educational role to play as well; to medical students and to peers but also, and most importantly, to patients. It is all very well for the WHO to set up a .health top-level domain but unless patients become aware that this is a moderated source of reliable information it has not achieved its purpose. And despite all the adverse publicity, opinion poll after opinion poll still shows that the public trusts doctors far more than lawyers, politicians or indeed journalists.
Philosophers and ethicists will always debate whether technology is a morally-neutral entity or reflects, often extremely subtly, reflects the values of those who produce it. Nevertheless, for practical purposes it is clear that virtually all technology has great potential for either good or bad purposes; all depends on the use that human beings put it to. As the quote from Charles P�guy at the start of this essay suggests, technology has brought about massive changes in the way we live our lives; where, with whom, for how long. Yet some things, like passion and guilt and sadness and joy � and like sickness and health � remain constant. And these are the things that really matter, both to patients and to the general practitioner.
