Paging Dr. Google

By Emily Margosian, Assistant Editor, August 1, 2022

“There is no doubt that the modern internet age has empowered people with more information than ever before in human history. Like any tool, there are positives and negatives to this. I was able to watch some videos online that explained exactly how to fix our toilet and it was incredibly satisfying to do so without needing to hire a plumber. On the other hand, such ‘just in time’ information can embolden people into taking on tasks that really do require more specialized expertise and experience, including our health,” said Peter Lio, MD, FAAD, clinical assistant professor of dermatology and pediatrics at Northwestern University Feinberg School of Medicine.

Self-practiced medicine — sometimes referred to as the ‘Dr. Google’ phenomenon — is not a new concept for many dermatologists. Although the phrase itself was first coined 10 years ago in a study detailing a case of missed appendicitis (N Z Med J. 2012; 125(1367):135-7), self-diagnosis has been around for many years, lately emboldened to a greater degree by the internet.

Beyond self-diagnosis, however, some online platforms and influencers have gone further, demonstrating how to self-administer filler or other injectables, giving rise to the trend of ‘DIY dermatology.’ Given the popularity of dermatology-related information, the specialty is often more susceptible to medical misinformation, which frequently receives more interest from patients than researched information and is then amplified on social media and search engines. “I think a lot of patients are of a generation that’s more reliant on digital sources of information and are exposed to constant information about medicine and dermatology specifically,” said Benjamin Stoff, MD, MA, FAAD, associate professor of dermatology at Emory University School of Medicine. “Many dermatologic conditions also have historical home remedies that have been propagated throughout the internet and are readily available over the counter.”

What are dermatologists seeing?

While the ‘Dr. Google’ phenomenon is not a new one, many dermatologists have reported seeing an increase in self-practiced medicine attempts since the start of the pandemic. “This is something I’ve seen frequently. Many patients were afraid to go out during the pandemic, and decided to attempt their own cosmetic treatments,” said Amy Spizuoco, DO, FAOCD, FAAD, clinical instructor in dermatology at the Icahn School of Medicine at Mount Sinai.

According to Dr. Spizuoco, patients have attempted a range of at-home procedures, including mole removal, facial tattooing, and home microneedling. “I have had a lot of personal experience with patients performing ‘DIY dermatology.’ For example, I’ve treated patients who burnt their faces and chests with homemade ‘mustard’ chemical peels. I’ve also treated patients who have tried self-tattooing and caused bruising and scarring. Many have attempted to remove moles and caused skin infections.”

“The consequences of self-administered care in many cases are infection, inflammation, swelling, pain, and scarring. As quick as it took people to mix up these potions, it takes much longer to resolve the damage caused.”

Dr. Lio agrees that COVID-19 may have put more pressure on patients to attempt self-treatment. “The pandemic pushed this even harder as we were all forced to be more self-reliant. Our office was closed for a few weeks initially, and that can put a lot of stress on someone who has a skin problem and truly feels isolated.”

Misinformation about the pandemic itself has also led to an increase in patients who may initiate conversations with their dermatologists about the use of certain drugs. “For example, ivermectin is something that is prescribed by dermatologists for several different things and has become a medication that is thought by some to treat COVID-19, even though that’s really been debunked by the mainstream scientific community. Similarly, hydroxychloroquine is something that we use to treat certain diseases — usually connective tissue diseases like lupus or dermatomyositis — and has been advocated incorrectly by some groups as a potential treatment for COVID-19,” said Dr. Stoff. “I think many of us have encountered patients who’ve been exposed to sources of misinformation. Dermatologists by nature have long-term relationships with patients, and they often come to us with questions about their health that are not always strictly dermatologic in nature. These sorts of questions have certainly been on the rise since the pandemic began.”

Consequences of self-practiced medicine

According to Dr. Spizuoco, patients often pay a steep price for attempted at-home care. “The consequences of self-administered care in many cases are infection, inflammation, swelling, pain, and scarring. As quick as it took people to mix up these potions, it takes much longer to resolve the damage caused.”

Dr. Lio agrees that patients may not always anticipate the long-term consequences of self-diagnosis. “Removing a skin tag seems harmless enough, but I can’t tell you how many times that ‘skin tag’ was actually a skin cancer or a different type of lesion that required more surgery or discussion. Removing a ‘mole’ can also mean that people have damaged and scarred a melanoma that now may take much longer to properly diagnose — or not be diagnosed at all,” he explained. “Our journals are now filled with the complications of self-injected filler and toxins, everything from infections to terrible inflammatory reactions, it forces us to shake our heads. It’s not always easy for patients to know when something should be fine — such as gently exfoliating rough, bumpy skin on the backs of the arms — and when something would be an absolute ‘no-no’ — such as using a home ‘mole remover’ on a new, growing black mark on the belly.”

What can physicians do?

Tackling online misinformation requires a hands-on approach to patient education, advised Dr. Spizuoco. “In this internet age, we as dermatologists must be able to present the current data on just about everything. All patients feel they have done their research and are therefore the most informed. They don’t realize they are not reading validated information from actual medical professionals. I spend a lot of time counseling patients to seek professional, expert skin care from a board-certified dermatologist before performing any attempts at self skin care.”

Beyond directing patients to vetted sources of information, an empathetic communication style and the utilization of shared decision-making tactics can play a large role in re-establishing patient trust in their physician’s expertise. “When someone is misinformed, I think there may be a desire to simply dismiss a patient’s theory about a disease or treatment when we know it to be false, and that is not an effective way to change minds,” said Dr. Stoff. “Gentle attempts to correct, perhaps by citing one’s own experience as a physician or patient, is often more powerful. It’s important to express to patients that you are making these corrections out of a place of care and concern for them. In other words, you’re not doing this to be righteous.”

“I often joke, ‘The person who told you that on the internet, you don’t even know their name. They are unaccountable, but I’m right here. I really am responsible for what I say and for the treatments I recommend.‘”

Dr. Lio agrees that an emphasis on the human element of the physician-patient relationship often makes the most compelling argument. “I think the most important thing is trust. I have known many of my patients for years. I have been with them through tough skin issues; I have supported them, and they have counted on me. I live in Chicago; my children go to school here; I am part of their community. I often joke, ‘The person who told you that on the internet, you don’t even know their name. They are unaccountable, but I’m right here. I really am responsible for what I say and for the treatments I recommend,’” he explained.

Tackling misinformation at the source has also been proposed as a potential area of focus for physicians. In a recent JAAD study examining the online presence of dermatologists, it was found that approximately 75% of the top dermatology-related YouTube videos are from non-dermatologist sources. This suggests a potential new role for physicians as stewards and contributors of online information.

“There’s a new-ish role for dermatologists in their relationship with the public at large,” said Dr. Stoff. “What is your social presence? Whether that be social media, or other public-facing forums. Are you using it as an opportunity to put out good sources of information, and try to correct things that you’re hearing about, while also being careful not to perpetuate the problem by spreading things that just seem interesting and/or clickable? I think doctors today really have to take a moment to be deliberate and understand that they have an obligation to vet information before they disseminate it.”

While the internet has afforded patients access to instant information on just about everything, an increased desire for knowledge doesn’t necessarily signal the death of the physician-patient relationship, suggests Dr. Lio. “The more equitable distribution of information has allowed for a more balanced relationship, I think, and the concept of shared decision making really wasn’t possible in the same way years ago,” he said. “I would be remiss if I didn’t point out that many times people do find good information about their skin condition, and that can actually be helpful. When someone comes in and says, ‘I’ve been reading about this, and I think that I have lichen planopilaris. It seems like it can be tough to treat. What do you think?’ that can be a wonderful place to start the discussion.”

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