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Irresponsible Medical Advice And What To Do With It February 1, 2013 9:58 PM   Subscribe

If you see medical advice given in an AskMe and it seems irresponsible, is it better to refute the advice in-thread, ignore, flag?

I was frustrated with a question today about shortness of breath and chest tightness in which an answer suggested "sounds a bit like anaphylactic shock." Anaphylactic shock being a life-threatening diagnosis. To me, that was irresponsible, especially given that the asker had made quite clear that he was very anxious about his symptoms (and it was certainly apparent to many that the symptoms could be anxiety or panic related). I said as much in the thread, but I believe in-fighting amongst answers is discouraged, and I kept my response short. Another poster then stopped by to respond to me saying essentially "well, it could still be anaphylaxis!" which then prompted me to respond back, which I know I probably shouldn't have because it's more arguing with another poster than answering the question at hand. You can delete my response if you deem appropriate.

You know what, it could be anaphylaxis (although I still maintain that it does not sound like anaphylactic shock). It's technically possible. As a doctor I am well aware of that. There are very few absolutes in medicine. However, I would prefer if as a community we could agree that if we're going to offer up diagnoses to people based on a few lines or paragraphs or internet text, we try not to do so in an alarmist manner. A not infrequent question that just came up was about a lump on the abdomen. Yes, we could respond to such questions by saying "hey, did you know that could be metastatic cancer? Maybe ask your doctor about metastatic cancer." But I would argue that is irresponsible and unduly frightening. It could be metastatic cancer, but it's not likely to be. And you can't just say "I don't mean to frighten you, but let me bring up some ways you might be dying." Even if I read a post and thought it was absolutely likely that the person was describing symptoms of metastatic cancer, I would not offer that diagnosis over the internet. Even as an ER doctor, I'd much rather have everyone saying "go to the ER!" than trying to diagnose emergencies themselves. Like many things, I do think this is contextual - if 65 year old gentleman with high cholesterol stops by to ask about his current symptom of chest pressure in a way that seems dismissive or blase, I might think it more appropriate to mention possibilities like "You should take that seriously - it might be a heart attack."

I know that I not infrequently myself offer some suggestions about what a person might have, and perhaps might be guilty of giving irresponsible medical advice at times - although I try hard not to, especially because I know that as a doctor my answer might be given undue weight from what it should be as a medical comment on the internet, despite my constant addition that IANYD/TINMA. If I did do so I would want it to be addressed. I want to know what the protocol is if I read such a comment or if someone else reads a comment of mine and feels that way. Should I not have made a "meta" kind of comment in that thread? Should I have just flagged the answer or contacted a mod? Just let it stand but offered my own answer and reasoning? I checked the FAQ and did not see protocol for this.
posted by treehorn+bunny to Etiquette/Policy at 9:58 PM (66 comments total) 7 users marked this as a favorite

I thought your statement in the thread was strongly worded yet restrained enough to make your point and not get deleted.
posted by Think_Long at 10:06 PM on February 1, 2013


Okay, looking back over that, it looks like the person who introduced that idea responded that mods could delete his/her remark about anaphylactic shock (in response to your comment that it was needlessly scary), but the mod on duty left it and your response to it, probably to have a clear record of that idea being refuted, instead of just disappearing both comments.

Our standards are normally don't debate others in the thread – ie: don't fight with other commenters about their suggestions. Instead you can offer your own advice that presents an opposing viewpoint or recommendation. People should mainly be addressing the OP, not having a conversation with other people in the thread. So instead of "UserX, you're wrong about Y blah blah," it's better to say something like "OP, Y is unlikely to be the problem because of A, B, C."

Medical questions are always a bone of contention, but mostly people are pretty good about telling people to go to the doctor / emergency room instead of relying on the advice of people who are not trained, and even if they are, cannot diagnose a brief block of text. There are arguments for not allowing them at all, which might be a valid idea, but I do think that it can be better for someone who doesn't have access to medical care because of lack of insurance or whatever to get a whole lot of comments saying "go ahead and go to ER because this sounds bad," when that's the case. Opinions may differ.
posted by taz (staff) at 10:21 PM on February 1, 2013 [2 favorites]


Obviously, I'm not a mod, I thought your response was measured, qualified, and you supplied many reasons for your viewpoint - I reckon the OP, even an anxious OP, would pick up all these things from your - as ever - rational and thoughtful answer.

Personally, when I see something wrong in askme - like wrong, not just a difference of opinion - I say that it's wrong, try to link to some sources or highlight my own expertise/knowledge in the area, and breakdown where and how it went astray.

I've never had an answer like that deleted. Heck, even when it is a difference of opinion, I try to say my piece. I like to think my arguments stand for themselves, and if they don't, I should be more articulate.

Medical question can sometimes remind me of recommendation questions - rather than answering the question, people simply offer up their own experience, regardless of how representative that may be, or its relevance to the asker's criteria.

If it's something truly egregious, like dangerously egregious or abusive, I have been known to flag or use the contact form.
posted by smoke at 10:24 PM on February 1, 2013


Think_Long, I think the point is about trying to align Metafilter etiquette with basic medical ethics. Because if the feedback to users is, "You suggested what is clearly the medically responsible route, but you were too critical of others' suggestions, so your response got deleted," then something is wrong with Metafilter. In the past, this site has lost regular users over what they perceived as gross ethical violations and an overall lack of responsibility on the part of other members. If someone asked about an immediate risk of physical harm, users would have a harder time defending the value of a "multitude of voices" approach. Metafilter is not liable for anything, but that doesn't mean we can reasonably defend our ability to act unethically.
posted by Nomyte at 10:26 PM on February 1, 2013


My preference is to avoid answering the question in a high liability question like that, although I could probably avoid directly addressing the other post and limiting myself to "it's probably not other proposed diagnosis X because..." - that is what I normally do.

I agree that typically people do refer back to doctors or suggest going to the ER, the question today was less usual in that regard (of course the asker was not having current symptoms at the time of the question).

As a side note, I do think medical questions should be allowed. Despite the potential for bad advice, I usually think the quality of advice here even from non-health-professionals is pretty good, and even though there may inevitably be a few inaccurate or wildly inaccurate answers put out there, I am often pleasantly surprised that the majority seem on target or that someone comes up with a very plausible obscure diagnosis.
posted by treehorn+bunny at 10:31 PM on February 1, 2013 [3 favorites]


Yeah, ikkyu2 flamed out over a variant of this issue a while back but medical questions are still here.

Frankly, I think the mods already give us appropriate leeway in responding to other posters in medical questions. I know I've called people on the "you're most contagious before you show symptoms! By the time you show symptoms you can't really pass it along anymore!" bullshit repeatedly and never had a problem as long as I'm not a douchebag about it. On the other hand "there's no such thing as ghosts, don't be gullible" is deleted pronto in those "how do I get rid of these ghosts" questions, IIRC.

So, yeah, "that's a bad answer, OP, you shouldn't believe it" does seem to pass muster on medical questions in ways it doesn't work as an answer in other types. That's probably good.

But seriously people stop posting you're most contagious before you show symptoms. It's inane and doesn't make sense if you think about it for more than two seconds.
posted by Justinian at 11:07 PM on February 1, 2013 [3 favorites]


Oh, I do think it is highly ironic that the people most qualified to answer medical questions are probably the people least likely to actually do so. Same with legal questions. But they definitely should still be allowed. If you want to ask a bunch of people who get their medical information from WebMD about the thing on your thingie, hey, maybe at least you'll be convinced to go see a doctor.
posted by Justinian at 11:09 PM on February 1, 2013


AskMe is not a good substitute for a doctor or emergency room. Period. The only advice should be: "Go see a doctor."

Or

"If you eat that, be prepared to go see a doctor."
posted by KokuRyu at 11:12 PM on February 1, 2013 [3 favorites]


I think that if a situation did arise in which someone provided particularly dangerous or irresponsible medical advice in a thread, you countered diplomatically with alternative information as treehorn+bunny did here, and your comment was deleted for arguing too much with another poster, you'd be best served by contacting the mods through the contact form and working out a resolution that best helps the OP. I can't imagine the mods would be anything but gracious and helpful if you were trying to help in good faith (heck, they are usually pretty nice about people acting in bad faith too, unless they are spammers). You can also always MeMail the poster directly with a follow-up if she isn't anonymous.

I think it's a great thing that we have a community here where medical professionals (same for legal professionals and even mortuary professionals) feel comfortable enough to participate in questions about their fields, as long as everyone is fully aware of the limitations of the format and that strangers reading a paragraph or two of text on the internet is not a substitute for an actual medical examination. I hope that continues to be the case, and I think staying appropriately mellow and low-key about issues instead of flaming out can help. Refute bad advice with good advice, and the OP can ultimately make up his own mind as an adult and seek appropriate professional advice offline as needed.
posted by zachlipton at 11:29 PM on February 1, 2013


I think your comments have uniformly been very valuable, treehorn+bunny, and I think you'll get less pushback and more respect as people begin to realize how well you do know whereof you speak.
posted by jamjam at 11:50 PM on February 1, 2013 [1 favorite]


I think that endlessly having to "prove yourself" to user after user after user for the privilege of having your answer (possibly the only responsible one) stand alongside a suggestion to drink more water for your shortness of breath, because water is full of oxygen, is itself a special kind of failure.
posted by Nomyte at 12:27 AM on February 2, 2013 [28 favorites]


My favorites are the imaginary spider bite threads. As I recall, someone actually asked something like, "I woke up this morning with a small bump near my lip. It's swollen, and it hurts, but there's some numbness too. I didn't see a spider, but is this a spider bite?" Note the conspicuous lack of a spider, or bite marks, or a white blister, or intense pain, or a dime-to-quarter-sized red area, or other worrisome issues.

AskMe answer: OMG WTF, EMERGENCY ROOM NOW NOW NOW.

My answer: None--I didn't bother. With so much hysteria whipped up, creating a bigger problem than it addressed, seeing a doctor became the best answer, because who could go through their day thinking of how many people thought you'd be a fool not to get this checked out. But I thought it sounded like a zit.

Correct answer, supplied by an urgent care clinic: It was a zit. I was somewhat relieved to see that the OP had chosen a cheaper option than the ER to find that out.

I realize genuine brown recluse bites are nothing to mess around with and may need immediate treatment--or rather than immediate, let's say the moment you have some reason to believe it's not instead something incredibly common, ordinary, and harmless.

I've gone to the ER for some pretty eponysterical stuff, but really, the hyperbolic attitude that doctor/ER should be the only answer means AskMe will sometimes fail both at supplying expertise and at supplying calm, practical, non-controversial, reasonably-qualified hypotheses like, "Oh, I used to get zits I would describe the same way. Naturally, I never went to the ER for them, but I'm not going to tell you your thing isn't a spider bite. You're the only one who can see it, and you have to make your own decisions when there are multiple possibilities with varying risks."
posted by Monsieur Caution at 3:01 AM on February 2, 2013 [8 favorites]


I don't understand why this is A Thing. If someone posts a medical question, they usually receive different answers about several different things it could be. In some cases, there's even life-threatening things in there, so... wouldn't the natural reaction be to conclude that we really just don't know and to see a doctor anyway? (Barring inability to do so for financial reasons, etc.)

I feel like it's just the nature of the internet... even the official medical websites have a lot of scary entries for seemingly benign symptoms. I can't picture someone concerned enough about their symptoms to contemplate seeing a doctor to decide not to see one because of anything they see on the internet, because it's all so conflicting and most of it is "this could kill you." I can only see "you might have X" being helpful if the person was never planning to see a doctor and was just curious as to what they might have.

Regardless, I'm a fan of the "refute in-thread" method.
posted by Autumn at 5:15 AM on February 2, 2013


I've got a medical problem caused by Ghosts, should I just see myself over to Yahoo answers or...?
posted by Potomac Avenue at 5:29 AM on February 2, 2013 [5 favorites]


Basic math says that in most cases, it, whatever it is, will likely be a non-serious issue. For any given malady that may get asked about here, there are far more innocuous causes than there are serious causes. The worst case answers here are usually the equivalent of Googling your symptoms and convincing yourself that you have African Sleeping Sickness, when in fact you live in Iowa, and have a cold.

So I'm all in favor of people that actually know what they are talking about speaking up, loudly if necessary.
posted by COD at 6:01 AM on February 2, 2013 [3 favorites]


It difficult.

I do tend to back off of answering medical questions. Most of the time when I do provide an answer, I try to do so with the of boundary responding with a general education approach. For example, providing a list of really useful questions to ask a physician or provider or nurse about derm problems, or suspected endocrine problems, etc. While I may be drawing fine lines as far as directly answering the question ("might I be having seizures?"), I also feel like I an anticipating what the askers actual experience will be interacting with the healthcare community ABOUT their issue, and making that interaction better, and of a higher quality.

If I feel the asker is seeking nothing more than an answer from the internet, for whatever reason, and clearly has no intention of ever seeking professional evaluation, I never respond.
posted by rumposinc at 7:39 AM on February 2, 2013


I'm not showing symptoms.
posted by cjorgensen at 7:43 AM on February 2, 2013


In the past, this site has lost regular users over what they perceived as gross ethical violations and an overall lack of responsibility on the part of other members.

If people want to talk specifically about ikkyu2 and what his concerns were and why he left, we can have a conversation about that. However it was his personal choice and from a moderator perspective there are a lot of options available to people concerned about bad medical advice that are in-between sitting by while bad advice goes unheeded and savagely attacking other users repeatedly in areas that are both in and not in your own specialty.

I think treehorn+bunny's response "it's OK to tell people their symptoms sound serious, but it really bothers me if people stop by a thread and toss out a specific killer, scary diagnosis to someone who's obviously freaking out to begin with." was completely appropriate
posted by jessamyn (staff) at 7:54 AM on February 2, 2013 [2 favorites]


...a suggestion to drink more water for your shortness of breath, because water is full of oxygen...

Dangerously irresponsible answers like that is a problem with medical advice questions. Everyone knows that water's even more full of hydrogen. Oh the humanity.
posted by Drastic at 8:27 AM on February 2, 2013 [15 favorites]


Thanks for the reassurance. Shall proceed accordingly.
posted by treehorn+bunny at 8:29 AM on February 2, 2013


treehorn+bunny: I think all of the doctors I can think of that have been around here awhile have learned to shy away from medical AskMes, particularly anything that touches on the psychiatric. I know you have special perspective on these questions and its compelling to offer advice but participating professionally can be problematic. People expect the bar for you to be higher than random respondents and truly it is difficult to get even basic things right from one or two paragraphs. There was a case way back where someone posted a question about depression and got a lot of good advice about exercise and meditation but a year later it came out that this person was schizophrenic and having a psychotic break, and there were clues from the original question including some threatening behavior.

Additionally, It does sort of fall on you to call out the crazy misguided answers and this is why ikkyu2 flamed out. No one wants the job of de-facto medical moderator and you should tread lightly in questions that put you in that situation. If its a serious, or complicated medical issue I would rather pretend i didn't see it than have the responsibility of giving good medical advice on limited information and then also patrolling all the other people's good and bad answers. If people know you are participating in a thread, I do think you have the ethical obligation to raise objection to information and advice that is problematic.

That said, medical questions are not going away and I have no problem being public about my profession. But these days I tend to limit my participation in threads to the very easily answerable (what is this rash I took a picture of? Should I keep playing soccer when I have this pain right here?) or to questions about navigating the medical system (what questions should I ask my doctor before my gall bladder surgery? How can I find a mental health doctor in Seattle without insurance?) and stay far away from anything trickier (I'm peeing blood, what kind of cancer do I have?).
posted by Slarty Bartfast at 8:43 AM on February 2, 2013 [5 favorites]


The bottom of this MetaTalk thread has diagnosed me with a hug difficiency, however, I was thinking maybe a Bloody Mary would be a more efficient endorphin delivery mechanism. Can one of you MetaMDs maybe give me a second opinion? Also, there seems to be an extra ear growing on my back, and life seems like an endless maze of pellets. Is it possible that I am secretly a lab rat? TIA,
Algernon
posted by It's Raining Florence Henderson at 8:50 AM on February 2, 2013 [6 favorites]


Arguing with (or "correcting") strangers on the Internet requires a certain temperament. Something I've learned about myself is that I can be cool-headed about subjects where I have no particular stake like television shows, sports, or food. But on subjects where I have expertise, like law, I find it challenging to converse with someone who insists that he's right and I'm wrong despite the fact that he's a software engineer.

And with legal and medical questions, obviously we can't give legal or medical advice...but when somebody else says incorrectly, "Do this," then our problem is that if we respond, "Don't do that," we have just veered into giving legal or medical advice. I've dealt with this by trying to carefully-but-clearly nudge, "Generally speaking, you should ignore legal advice you find on the Internet. Including in this thread. Ahem."

But it really takes a particular temperament to do this regularly and civilly. It's why that comic, "Someone is wrong on the Internet," is funny and famous. When the subject is an area where you have developed expertise, and the advice is potentially harmful and coming authoritatively from somebody who's ignorant and just likes chatting on the Internet, it can be genuinely difficult to respond well.

I think in these conversations, it's worth remembering that some responsibility for bad advice falls on the person asking the question. He is asking his question on AskMe because he has a problem, yes...but also because posting on AskMe is easier and quicker and cheaper than going to see a doctor. Well, occasionally that's okay and other times it's downright foolish.
posted by cribcage at 8:59 AM on February 2, 2013 [2 favorites]


ikkyu talked a big game about medical ethics, but coming from a physician who admitted to intentionally giving confusing orders to nurses and pharmacists to remind them of their place, I can't say I found that totally convincing. To my mind, a licensed medical professional intentionally carrying out a bad patient safety practice is a far more serious ethical violation than some random internet fool who wants to play House, where at least people know to take their advice for what it's worth.

I will say that one ethical concern that I don't think gets considered enough in the context of medical AskMes is over-consumption. There's definitely a certain amount of advice that gets thrown for people to go to the ED when urgent care would do fine, or to go specialist-shopping before working through a problem with their PCP. I know everybody feels like they're doing the safest thing by telling people to go in to the ED, but in the US at least, consumption of higher acuity than necessary care is one of the biggest reasons that health care is so expensive, and the high cost of health care (along with the insane way that the US insurance system distributes those costs) kills a shit-ton of people every year.

The current crop of physicians who answer AskMe questions do a good job, and I think you all deserve thanks for it. I know you don't have any obligation to participate at all, but once you do, you voluntarily take on a higher ethical burden than the rest of us jackasses. I'm glad that you do and I'm glad that you take seriously thinking through the implications.
posted by strangely stunted trees at 9:16 AM on February 2, 2013 [9 favorites]


The bottom of this MetaTalk thread has diagnosed me with a hug difficiency, however, I was thinking maybe a Bloody Mary would be a more efficient endorphin delivery mechanism. Can one of you MetaMDs maybe give me a second opinion? Also, there seems to be an extra ear growing on my back, and life seems like an endless maze of pellets. Is it possible that I am secretly a lab rat?

A hug from Bloody Mary is clearly the best of both worlds. If you don't know where to find her, just stand in front of a mirror and say her name 13 times. The extra ear is probably a teratoma. That homeopathic "tag-away" stuff they sell on TV should take care of it. The endless maze of pellets is likely just the cubicle farm you work in, with occasional rewards of candy, donuts, and other goodies left by vendors scattered through it.

I agree with treehorn+bunny's concern, and it seems to come up in MeTa on a semi-regular basis. Some questions have such potential to become trainwrecks that I avoid them in the first place (I saw the specific question referenced in the post and immediately saw that answers were coming from all directions and decided I didn't feel like sorting it out). Other times I take Slarty Bartfast's approach and answer things I feel I have a good answer to and even then do so in generalities as much as posssible. My goal is usually to help the asker find the answer from their own physician or other provider rather than take on the impossible task of answering over the internet. To keep things in perspective, remember that many questions on AskMe can be fraught with peril, as I pointed out in this comment.


Everyone knows that water's even more full of hydrogen.

It's even worse than that! The hydrogen and oxygen are already in the proper stoichiometric ratio for complete combustion!
posted by TedW at 10:06 AM on February 2, 2013 [7 favorites]


Arguing with (or "correcting") strangers on the Internet requires a certain temperament.

So I have that certain temperament and, hey, professionals of AskMe: if you see me giving genuinely bad advice, for fuck's sake, correct me. You have my explicit permission regardless of what form the correction takes. I promose to never be offended or put off. It's a lot better to be slightly embarrassed on a website than to have bad or dangerous advice just stand there unchallenged.
posted by griphus at 10:11 AM on February 2, 2013 [8 favorites]


Being corrected by strangers on the Internet probably also requires a certain temperament, but that wasn't what I was referring to.
posted by cribcage at 10:18 AM on February 2, 2013


I think the most important bit is "don't make it personal." I mean, that's usually where people get offended - "YOU are wrong" is a hard thing to say politely under the best possible circumstances, and it's hard to hear even when it's super polite.

I know I've done the trying-to-be-oblique-about-it thing - saying something like "OP, please be aware of X, Y, and Z; I think it's likely that A, B, or maybe C is going to help you out in this situation."

If I think an answer is grossly irresponsible, I try to do the contact form/flagging thing because it seems like crappy answers are less likely to get deleted if they're directly responded to in-thread (that's for everything in Ask, actually: "don't eat it, feed it to your worse enemy" kinds of crap.)

Also, the over-use issue is something I now refuse to worry about, because the situations are so fact-specific. I certainly have no problem whatsoever telling someone whose psychotropic meds aren't working to try talking to an actual psychiatrist, for instance. The "nurse line" to "urgent care" to "emergency room" thing is similarly on a case-by-case basis. There was a day in which I managed to interact with all three in the space of fourteen hours and heartily regretted the choice to do anything other than go straight to the ER.

(Bearing in mind that I try to stay out of rash/bites/etc. threads for the most part - can't handle the photos.)
posted by SMPA at 10:21 AM on February 2, 2013


If people want to talk specifically about ikkyu2 and what his concerns were and why he left, we can have a conversation about that.

IANAD, but my money was on Oppositional Defiance Disorder.
posted by PeterMcDermott at 10:27 AM on February 2, 2013 [6 favorites]


If I think an answer is grossly irresponsible, I try to do the contact form/flagging thing because it seems like crappy answers are less likely to get deleted if they're directly responded to in-thread (that's for everything in Ask, actually: "don't eat it, feed it to your worse enemy" kinds of crap.)

That's never a bad option, but as taz said, we often consider that a rebuttal is a better idea than a deletion (assuming the bad answer was in good faith, of course.) The only trick - and treehorn+bunny, you've been good at this, so don't worry too much about it - is making sure your rebuttal is framed as an answer to the question, and not just a debate with the other user.

The other thing I tell people when they ask about this stuff is "you get one shot." That is, post your counter-answer, and then let it go and trust the OP can read and make a decision between the two positions. It's when it turns into a back-and-forth that we start deleting stuff.

It's always a tricky problem. What gets me are the clearly idiotic answers in relationship questions - part of me wants to stomp in there and bellow "YOUR WORLDVIEW IS COMPLETELY RIDICULOUS" and then delete all the idiocy. I don't, of course, but I sure want to.
posted by restless_nomad (staff) at 11:24 AM on February 2, 2013 [2 favorites]


I loved Ikkyu2, and still do love him, and the idea that he would have done anything to jeopardize a patient for any reason, much less personal vanity, is ridiculous and offensive, and it's expression in this thread bespeaks only a petty and craven vengefulness, in my opinion.

But I've been reading Metafilter since 2006, and he was smoldering from day one. That it took so long for him to burst into open flameout is the remarkable thing, not that he ultimately did-- and it had very little to do with bad medical advice.
posted by jamjam at 11:34 AM on February 2, 2013 [1 favorite]


it's expression in this thread bespeaks only a petty and craven vengefulness

It may be worth considering that you do not have the full picture here or have not read the threads that people are referring to. Everyone is entitled to their own opinion. I am neither petty nor vengeful but he was a handful to deal with on the site partly because people were so polarized about their support or distaste for him.
posted by jessamyn (staff) at 11:56 AM on February 2, 2013


I believe I have read the thread in question, in which, as I recall, he said he used scrupulously correct Latin in a prescription to remind some nurses and others of their place in the medical hierarchy.

Not his finest moments to be sure, and I hope he may have grown beyond that.

I do also recall you saying that his presence had led to "morale problems" among staff, and I remember thinking that you were perfectly justified in being unhappy with him. His parting swipe at you as a mere "librarian", and as such beneath him and unworthy to judge his contributions was completely deplorable, even disgraceful. Nothing anyone could say could ever justify or even begin to excuse it.
posted by jamjam at 12:21 PM on February 2, 2013


treehorn+bunny: "I know that as a doctor my answer might be given undue weight from what it should be as a medical comment on the internet, despite my constant addition that IANYD/TINMA"

I guess my increased hesitancy to respond to any question -- especially the psych ones or the obviously pathologic narcissistic or BPD ones -- stems from some legal advice I got from a health lawyer around a couple of years ago reviewing new communication modalities for doctors. Their advice was that any communication between a licensed doctor and someone reporting a symptom that encompassed a diagnosis or advice was creating a de facto patient-doctor relationship. It seems quite cumbersome and faintly ridiculous, not to mention pompous, to insert the IANYD/TINMA boilerplate into almost every statement, but that's at least the minimum required to provide some protection from potential torts and license board actions in the future. And it's still just relative protection, not an absolute defense. It's also why many patients get frustrated because they find they often can't email their doctor about anything substantial (the substantiality basically depending on how risk-averse the hospital or practice's risk management people are).

Specifically for this issue, I also asked about correcting or revising the opinions of others. The problem is that you then are basically providing a second opinion and there's a couple of problems with this. If someone ignores earlier advice or changes or delays or refuses treatment because of your second opinion or alternative diagnosis and then suffers injury, then you have just exposed yourself to action. And then there's the secondary issue of establishing inter-State doctor-patient relationships without multiple State licenses. The whole thing is just a huge minefield a couple of tragic cases away from infamy.

As a result I just basically avoid Ask health questions now.
posted by meehawl at 12:39 PM on February 2, 2013 [3 favorites]


jamjam, I'm not sure whether it's jessamyn or me who you're calling craven and vengeful, but I was still a lurker when ikkyu2 left, and never had any interaction at all with the man to my knowledge, so I'm not sure how my motive could possibly be vengeance.

I don't believe it was his intention to jeopardize patient safety, but there's simply no other way to characterize the action of a physician purposefully giving medical orders in a format he felt would be difficult to understand. It's not something I take any pleasure in dredging up when he's not around to defend himself, but when I see him held up as some kind of beau ideal of ethical behavior I think it has to be.
posted by strangely stunted trees at 1:03 PM on February 2, 2013


I'm glad you responded, strangely stunted trees.

It was wrong to imply that you were cravenly vengeful.

I apologize.
posted by jamjam at 1:17 PM on February 2, 2013


If we're discussing attitudes and behaviors of which Ikkyu2 was an example, cool. If we're just going to discuss him, maybe not so much.
posted by cribcage at 1:27 PM on February 2, 2013


Apology accepted, let's move on.
posted by strangely stunted trees at 1:38 PM on February 2, 2013


It's never lupus.
posted by TheWhiteSkull at 2:59 PM on February 2, 2013


I know you don't have any obligation to participate at all, but once you do, you voluntarily take on a higher ethical burden than the rest of us jackasses

I think anyone who posts an answer in a medical thread -- specifically any answer that isn't "ask your doctor" -- has a pretty significant ethical burden. And I think lots of people don't really acknowledge that burden because it's just words on a screen.

Empath's answer in this thread is the kind of thing I'm talking about (I only remember that one specifically because it's an area that I know about, but I see that kind of thing all the time). He's essentially saying "I have no idea what I'm talking about, but I'm going to give you advice anyways".

I'm not necessarily saying the mods should delete answers like that. I'd delete them, but I understand the idea that when you ask for free advice you get what you pay for. But I think the user base needs to realize that in general it's a good idea not to spout off when you don't know the first thing about a topic, and when it comes to health issues I think you have a moral obligation not to spout off when you don't know the first thing about a topic.
posted by no regrets, coyote at 3:54 PM on February 2, 2013


coyote, I'm with you on that.

meehawl, certainly I've heard the same thing about establishing a doctor-patient relationship, but I really question whether it is true or just an abstract concept people believe in. I mean, the asker of the question does not know the person's name answering the question nor even whether they are truly a physician or not, even if they say they are. The staff of Metafilter does not know my name or location either. The two people may not be in the same country not to mention the same state. I would love to see it if there are any examples you could point me to of successfully prosecuted cases like these.
posted by treehorn+bunny at 4:15 PM on February 2, 2013


These (diagnose and treat via askme) are tough. I think the most responsible thing is to point to the good free general educational sites (mayo, utdol) for their chief concern. These almost always include a 'when to go to the ED' section. Otherwise these questions can really drive you nuts.
posted by a robot made out of meat at 5:09 PM on February 2, 2013


treehorn+bunny: "The staff of Metafilter does not know my name or location either"

That's the kind of thing that could easily be found following a subpena or two.

"I would love to see it if there are any examples you could point me to of successfully prosecuted cases like these."

I'm not aware of any, but then I'm not a lawyer. I'm relaying to you the advice from some people who were lawyers and who had specific experience representing doctors during proceedings of their State licensing boards (note this is different from civil legal proceedings).

Ask yourself this. Even there is no established case law for this sort of thing, are you placing yourself at risk of being the first one to create it?
posted by meehawl at 5:50 PM on February 2, 2013


That's the kind of thing that could easily be found following a subpena or two.


Sort of. Maybe. We certainly can't guarantee otherwise, especially if your real name is attached to the Paypal account you signed up with.
posted by restless_nomad (staff) at 6:41 PM on February 2, 2013


I am not a lawyer, so this is obviously just a layman's opinion, but I think the test for establishing a doctor-patient relationship is just one of reasonableness, i.e. something like is it reasonable to believe a comment from someone who has repeatedly stated they're a doctor constitutes medical advice. They don't need to, like, check your ID and see your medical licensing info or see through any deception.

I would suppose there's theoretically plenty of room there to say some things and not create a relationship, but if you're not specifically following debates about telemedicine licensing from state to state and keeping up to date on this, it looks like it's being pushed forward all the time by people who're doing pretty dramatic stuff (think prescriptions and miracle cures with a cost, not idle observations on a forum), and states are responding with who knows how many different regulations. And a key problem may be that, if you do run afoul of what they're coming up with, you'd be practicing medicine in the patient's state, not yours. It seems incredibly hard to know if you're doing anything problematic, and I guess that's why Google is showing me a lot of stuff about the search for a national solution to telemedicine.

Incidentally, I really, really hate to say this, but I have a feeling an ambulance chaser's eyes would light up at this statement: "I ... perhaps might be guilty of giving irresponsible medical advice at times." As someone who has read many of your comments and who thoroughly appreciates your participation here, I don't believe for a second that's anything other than the wisdom of self-doubt talking. What makes me worry for you a tiny bit is a question in my mind about whether an insurer would just roll over on seeing that.

TL;DR: I'd look at what courageous, honest, helpful doctors you admire are doing and follow their lead, but from well within the middle of the "good" pack. :)
posted by Monsieur Caution at 6:43 PM on February 2, 2013


"I have no idea what I'm talking about, but I'm going to give you advice anyways".

I see this rather often in AskMes, and I'm puzzled by it. What drives this urge to offer factually unsound advice?
posted by nacho fries at 6:57 PM on February 2, 2013 [2 favorites]


I don't really know exactly why someone would offer bad advice, but I think it may be a medical condition.
posted by griphus at 7:05 PM on February 2, 2013 [4 favorites]


Only if it lasts more than four hours...
posted by nacho fries at 7:11 PM on February 2, 2013 [1 favorite]


Monsieur Caution, I appreciate your concern - really - but don't worry about me.

I have already considered that offering advice on AskMe is not a zero liability situation, but at the same time, I work in an emergency department and I see 20-30 patients PER DAY there who I offer real medical advice to. And I am human, and I can admit that I make mistakes, everyone does. Studies have shown that physicians who disclose errors openly are actually less vulnerable to lawsuits (amongst other benefits).

I'll probably get sued eventually because most physicians in my specialty do, but I'm a lot more concerned about getting sued by one of the thousands of patients I see every year, most of whom actually have potentially life threatening conditions. Statistically, I have to live with the fact that 2-4% of heart attack patients I see will be missed, for example.

So....compared to the risk I take every day when I go in to work and evaluate patients with chest pain, shortness of breath, sepsis, cardiac arrest, etc., I find the idea that some lawyer somewhere might try to subpoena someone to try to figure out who I am online and see if I could potentially be brought for a lawsuit for something that I've never heard of anyone actually getting sued for (especially given the low rates of success of malpractice lawsuits even when you actually do know who the defendant is and don't have to worry about trying to forge some new legal precedent for online medical advice cases).... well, it's not worth worrying about. I enjoy hanging out on AskMe. I plan to keep doing it unless I see more evidence that the risk is a serious one.
posted by treehorn+bunny at 7:59 PM on February 2, 2013 [20 favorites]


Then considering the various comments here, shouldn't any AskMe about medical matters simply be deleted with a note to the Asker saying, "Consult a physician."
posted by Splunge at 8:10 PM on February 2, 2013


I doubt it is the legal equivalent, but I see a doctor on this site offering advice as similar to a doctor who on a plane when a passenger has some sort of medical incident not in their specialty. They know more than the layman passenger in 22E, but they know nothing about the patient and their history so they do a sort of triage until the plane can land and get the person the proper help. Most of the answers to medical questions by physicians seem to take the same path of pointing the person in the correct direction to get the proper attention and advice.

Asking a medical question of a bunch of strangers (but nice ones!) on the Green has always struck me as asking for anecdotal advice and/or asking for reassurances by people who are reluctant to see a doctor that despite their reluctance, it really is time to see a professional. Or, unfortunately, it is a sort of grasping for straws by a person who has no insurance and can ill afford a trip to a ED or doctor if it is going to be a major non event.
posted by JohnnyGunn at 8:27 PM on February 2, 2013


JohnnyGunn, that is a good parallel, even though I am uncertain about its applicability to the legal situation. If a physician offers aid to a person in a situation like the one you describe, they also open themselves up to liability. However, such cases do have precedent as being protected situations under Good Samaritan law. From what I understand about Good Samaritan law, the time you open yourself up to liability and are not protected by this law is if you try to offer services that are outside your scope of practice - for example, a non-surgeon trying to perform surgery, although this would not happen in the situation you describe on a plane.

To me, ethically, if not legally, giving answers on AskMe is like being a Good Samaritan - I think the physicians here who do it do it because they enjoy helping people (contrary to popular opinion we're not all in it for the money). :-) It's also the reason I enjoy working in the emergency department - I don't have to worry about whether my patients can pay me or not. However, everyone's risk tolerance is different, and I have heard physicians say that they would not reveal themselves as physicians in a situation such as what you describe, because despite the Good Samaritan laws, that is also not a zero liability situation, and some people don't like taking any risk that they are not required to take as a part of their job (and I can understand their perspective too - we take a lot of risk at work and it's stressful enough).
posted by treehorn+bunny at 8:37 PM on February 2, 2013 [1 favorite]


So I have a boatload of medical issues and I cared for my dad and my mother-in-law, each of whom had a boatload of medical issues. That's three boatloads, and then also my father-in-law's hip replacements, for which I am and was a primary contact with doctors. I can give my opinion as a patient and caregiver on that range of issues with the disclaimer that this is my opinion from the perspective of a patient or caregiver.

As someone with a life-limiting chronic illness (or illnesses, but that's a story for another time) my own experience is that hearing fellow patients' experiences can be tremendously important, and sometimes more helpful than feedback from doctors, nurses, PAs, etc. The person who told me about the Mylanta/liquid Benadryl mouthwash for mouth sores, for instance, helped me more with that one issue than my doctor. Little things like that can be hugely helpful.
posted by Sidhedevil at 9:14 PM on February 2, 2013 [1 favorite]


I don't believe it was his intention to jeopardize patient safety, but there's simply no other way to characterize the action of a physician purposefully giving medical orders in a format he felt would be difficult to understand.

I brought this up then, and I'll mention it now. This is a rather melodramatic read of what ikkyu2 did that's been a talking point for folks here eager to vilify the guy for years. Without knowing specifically what the order was, you can't assume that a patient's welfare was jeopardized. Doctor's write lots of orders for patients -- some of them quite harmless/unimportant. Attacking someone's ethics because he wrote a confusing order for an as needed stool softener is a bit much, particularly when doctors' orders require clarification about a zillion times on any given day in any hospital. I'm not saying it was the right thing to do. Just that it's pretty weak sauce to use as a data point for a full on character assassination.

With respect to t+b's original question, I personally only provide general medical information now in these posts, though if I see bad/dangerous advice I do feel obligated to both point it out as such in thread, and potentially send the mods a message about it. In my opinion, Good Samaritan ethics apply only to emergent/urgent problems. If I see a question that raises red flags along those lines, I add to the usual pile-on about seeking care asap (and am happy to do so with my doctor hat on). Providing specific medical advice over the internet in any other context is an ethical grey area I generally choose to avoid.

And for what it's worth, I agree that over-consumption and useless, expensive trips to the ER are probably the biggest downside of responses to medical questions in AskMe. But I suspect it might be worth it if even a few really sick people end up getting care that they would have otherwise deferred.
posted by drpynchon at 9:40 PM on February 2, 2013


Let me see if I have this straight: you are a doctor who gives medical advice on the internet to people she's (most likely) never met and knows nothing more about their medical history and symptoms than what they're posting on the internet, and you think it's wrong for non-doctor people to give other people medical advice on the internet because they know nothing more about their medical history and symptoms than what they're posting on the internet? And your reasoning is that you think the OPs will take the non-doctor's advice more seriously than your Professional Doctor advice? On the internet, sight unseen.

I think the best thing would be for you to stop giving out medical advice on the internet if this is a real issue for you. There's got to be some kind of nutty liability or ethical issue there, and I don't understand why you would be doing something super-risky for free when you could be getting paid to do it responsibly and safely. Plus you are kind of feeding into a system that is really not that great for doctors. But... that's just like, my opinion, man.
posted by two lights above the sea at 11:08 PM on February 2, 2013


Well, yeah, you've got it straight. Sometimes the answers to some of these questions is pretty cut and dry, and sometimes they're not. Sometimes people post answers that are not just wrong, but also dangerous. Dangerous as in following their advice could lead to death. I'm not gonna dredge it up here, but there was an exchange a while back I had with someone regarding a question about asthma, and, well, it was very frustrating for me to continue the dialog.

Yes, I think OPs might take non-MD advice more seriously than an MD's advice. Some people believe that physicians are so strongly in cahoots with the pharmaceutical industry that we peddle meds for mutual profit. Some people believe that the whole medical profession is structured such that we protect our salaries and lifestyles by limiting the number of physicians our medical schools churn out.

And people do indeed take information they've gleaned from the internet, whatever the source, very seriously. I deal with it often at work, and do my best to direct patients, their partners, and their families to online or offline resources that are infinitely more legitimate than most forum postings, to the point of their comfort. In the past that has even meant going over individual articles and studies and giving mini-lectures on statistics and epidemiology.

But you're also right about the best thing being to stop giving out medical advice. But for me, it ain't about liability/ethics (although it's always in the back of my mind). It's about avoiding the headaches of trying to convince someone that a) you're trying to give good advice, b) some advice being given is wrong or dangerous or misleading, and c) if you've taken fifty Xanax and are sleepy or you can't fucking breathe, stop typing and dial 911.

So I try to avoid the medical questions (key word being "try"), and stick to questions about, well, anything else.
posted by herrdoktor at 12:09 AM on February 3, 2013 [2 favorites]


I will add that the physician members of MeFi whose comments I've read have, as best as I can recall, always given out reasonable, measured advice, and I consider them not just a great asset to the community, but to me as well, for looking at things from a medically different perspective.

Just as I consider many members as being well versed, if not experts, in their fields, be it cars, music, machinery or just being pretty damn wise.
posted by herrdoktor at 12:13 AM on February 3, 2013 [3 favorites]


"There was a case way back where someone posted a question about depression and got a lot of good advice about exercise and meditation but a year later it came out that this person was schizophrenic and having a psychotic break, and there were clues from the original question including some threatening behavior."

This question still haunts me for the absolutely life threatening advice AskMe is very very capable of giving in its ignorance to real people.
posted by Blasdelb at 6:28 AM on February 3, 2013 [1 favorite]


All the MeFi docs came out of the woodwork there.... I agree with you drpynchon and herrdoktor. I think with a little care taken to the wording of the answer, you can try to help answer a question by providing some general information without making it actual medical advice for that particular person's case, and I think members here do a good job of it. I know you don't generally answer the medical questions.... you clearly have more self restraint than I do. :-)

Let me see if I have this straight: you are a doctor who gives medical advice on the internet to people she's (most likely) never met and knows nothing more about their medical history and symptoms than what they're posting on the internet, and you think it's wrong for non-doctor people to give other people medical advice on the internet because they know nothing more about their medical history and symptoms than what they're posting on the internet?

No, you don't have it straight.
posted by treehorn+bunny at 6:31 AM on February 3, 2013 [8 favorites]


This question still haunts me for the absolutely life threatening advice AskMe is very very capable of giving in its ignorance to real people.

That and other questions like it are one of the reasons we accept many fewer medical (and legal) questions via the anonymous form than we used to.
posted by jessamyn (staff) at 6:57 AM on February 3, 2013 [1 favorite]


Some people believe that the whole medical profession is structured such that we protect our salaries and lifestyles by limiting the number of physicians our medical schools churn out.

In the 1980s, the Graduate Medical Education National Advisory Committee recommended decreasing the number of enrolled medical students by 10%. In the 1990s, the Council on Graduate Medical Education recommended decreasing the number of funded residency positions by 21%. These actions were taken to stop a feared "physician glut" which would almost certainly result in decreased U.S. physician salaries from their current levels, which are more than double the average salaries in developed nations. So there is a lot backing up this belief.
posted by grouse at 10:26 AM on February 3, 2013


That's based on old data. The recommendations from recent years have all been for increasing numbers of medical students and residency slots to address a projected shortage. Numerous new medical schools have been approved and opened in the past 10 years in the United States. The limiting factor is congressional funding for residency slots.

Physicians here graduate with $100K to $200K in debt, whereas in many other developed countries, medical school is paid for by the government. I pay $1800 a month on my loans right now. So that's a pretty major reason for why the salaries here are different, too.
posted by treehorn+bunny at 11:43 AM on February 3, 2013


That's true—that's why I said in the 1980s and 1990s. It's to the credit of the AAMC and others in the medical establishment that they are now trying to increase the number of physicians. But it's not like the belief that official MD bodies were trying to keep a lid on the number of doctors in the previous couple of decades is some crazy conspiracy theory—it is based on reality.
posted by grouse at 12:11 PM on February 3, 2013 [1 favorite]


Do "there's no such thing as ghosts" answers really get deleted from "help me get rid of these ghosts" AskMes, because that seems straight up ridiculous.
posted by adamdschneider at 7:33 AM on February 4, 2013 [1 favorite]


It depends. "There's no such thing as god" answers will get deleted from a "Help me figure out this religious problem I am having" and "Palm readers are charlatans" answers will get deleted from "I want to get my palm read in St. Louis; where can I go?" questions. People who are having issues with ghosts (I feel like I may have seen one or two questions about them, maybe?) will usually get answers gently suggesting that there may be some other problem that is causing whatever issues they are having. Similarly people asking for the best homeopathic remedy for a particular ailment will often get pointed to cited studies showing that homeopathy does not work and suggesting other remedies. Answers have to answer or at least address the question and jerkish answers get removed just like jerkish comments get removed in other places on the site.
posted by jessamyn (staff) at 7:43 AM on February 4, 2013


This question still haunts me for the absolutely life threatening advice AskMe is very very capable of giving in its ignorance to real people.

And yet the OP of that thread got emphatic and persuasive advice to quickly get to a doctor within an hour of posting their question. Had the OP just gone to a random friend, they might have gotten a dangerously wrong answer and been satisfied with it. It seems to me the system works. (And WTF with discouraging doctors and other knowledgeable people from answering medical questions? The system works because they are willing.)
posted by Wordwoman at 10:52 AM on February 4, 2013


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