Ophthalmology on the Internet: What Do Our Patients Find?

  The Internet has become a favorite source of medical information fora growing number of patients. At the same time, content on the Internet representsan amalgamation of viewpoints, commercial interests, and various biases. Acommon way to access Internet information is through commercial portals withproprietary search engines. Often these search engines prioritize their ranklist based on commercial interests. We evaluated whether Internet searchesof ophthalmic issues are slanted toward commercial sites and whether any differencesexist among the various search engines. We used age-related macular degenerationas an example. In this study, we found that some search engines are heavilytilted toward commercial partnerships, whereas others emphasize sites runby nonprofit and educational organizations. Our findings may guide physiciansin recommending to their patients some internet portals rather than others.This type of evaluation can be conducted intermittently by physicians andother health care professionals to assess the type of information that reachestheir patients and what biases may be influencing patient knowledge and decisionmaking.

The popularization of the Internet has made enormous amounts of informationavailable and easily obtainable by our patients. It is now common to see apatient in the clinic who brings printouts of Internet information on diseases,therapies, and clinical trials. Patients may also use the Internet as a secondopinion to our clinical judgments and diagnoses. Such activities can empowerpatients to participate in their own care and assist in the patient-physiciantherapeutic partnership. The quality of medical information on the Internetis variable.¹ However, a recent study of Internetmedical information failed to find strong evidence of harm associated withits use.²

Medical information on the Internet is neither monitored for accuracynor standardized. Rather, it contains a mixture of opinions, controversies,and financial opportunities that reflect societal diversity. Internet usersmust be aware of potential misinformation mixed within the wealth of valuableinformation. A recent article in the New York Times³ documented that merchants with poor track recordsfor customer support can, by paying higher fees, place their names and Webpages at the top of a search list ahead of well-known and highly regardedmerchants. Although the Internet industry is aware of such situations, theprofit motive causes some search engine companies to selectively ignore thepoor track records of well-paying customers.

A letter published in jama⁴ examinedthe information available on the Internet regarding cancer treatments andfound that patients commonly encounter sites with information on unprovenbut financially profitable therapies, often cleverly packaged with attractiveWeb page designs. Similarly, an article that examined ophthalmic informationon the Internet found that when using macular degeneration as the search term, 21% of search results featured unconventionaltreatments that were inconsistent with the peer-reviewed standard of carefor age-related macular degeneration.⁵

As specialists in the medical care of the eye, ophthalmologists mustprovide opinions on diagnosis and therapy as well as supporting information.Patients may, with or without the guidance of their ophthalmologist, turnto the Internet for additional information. Some familiarity with the informationavailable on the Internet may prove useful for providing the best possiblecare to our patients.

To evaluate the type of information on the Internet that may be encounteredby the curious patient and to assess the manner in which this informationis presented, we conducted a limited study in which we used 7 common searchengines to look for information with macular degeneration as the search term. Using go.com, aol.com, lycos.com, askjeeves.com,msn.com, yahoo.com, and google.com, we evaluated the top 10 search results(accessed October 20, 2002) from each search engine and placed them in 1 of3 broad categories: strictly commercial (eg, vitamin supplements or illuminationand vision aids), primarily or exclusively informational (organizations suchas the American Macular Degeneration Foundation) with occasional links tocommercial entities, or governmental or educational (eg, National Eye Institute,National Institutes of Health, and hospital or educational information associatedwith universities). We developed a scoring technique in which each entitywas first categorized and then ranked according to its position on the searchlist (1-10). We used a weighted score technique that combined the categoryof each site with its position in the top 10 search results list to give aweighted impact score. We then calculated the relative exposure of each categorywith the assumption that Internet users pay more attention to the top searchresults than to the bottom results.

Our investigation revealed 2 striking findings. First, whereas commercialsites composed only 25% of the total search results, their relatively highposition at the top of the results lists from some search engines increasedtheir weighted impact percentage by 20% (Table 1). In contrast, vision-related organizations, foundations,and educational and other noncommercial sites (ie, informational and governmental/educational)composed 75% of the total number of search results, but their weighted impactpercentage was nearly unchanged at 70%, indicating no benefit from list positioning.

Second, we found remarkable variability among the search engines. Forexample, in results from go.com, 80% of the list had a substantial commercialslant (Table 2). Results fromyahoo.com, on the other hand, had only 3 commercial sites in the top 10. Nevertheless,commercial sites occupied the 3 top spots on the list. In contrast, resultsfrom msn.com, google.com, and aol.com had minimal commercial information.Instead, these lists were composed mostly of informational sites of organizationsand research facilities. However, commercial sites did occupy the top spotson the google list.

The high position of commercial sites in the search results obtainedby some search engines is not coincidental. Some of these search engines havebusiness relationships with companies such as Overture (Pasadena, Calif),which places commercial information at the top of search lists for a fee.Overture was featured in the New York Times article³ as one of the leading fee-for-placement search engineservices. Other search sites, such as google.com, have their own fee-for-positionservice. Some search engines identify these sites as "sponsored," whereasothers do not⁶ (Figure 1). Most of the sponsored sites were related to vitamin supplementsand alternative therapies.

We conducted this study hoping to better understand the informationavailable on the Internet regarding age-related macular degeneration and theaccessibility of such information to patients. Our results surprised us, especiallythe high variability with which different search engines handle commercialsites. Although commercial sites may provide valuable information, if giventhe option, most physicians would prefer to direct their patients to informationalsites, which often have the assistance of advisory boards and harbor no ulteriormotives in their presentations.

As medicine becomes more specialized and technologically savvy, so doour patients. The Internet can be a wonderful source of information, empoweringpatients to take control of and participate in their own care. The use ofthe Internet can be guided by physician input, especially when requested bypatients. Periodic evaluation of search engines and Internet information canbe invaluable to our understanding of "what's out there" so that we can bestassist our patients. Hence, we recommend that physicians conduct regular Internetsearches on subjects important to their practice to remain abreast of therapidly changing world of the Internet.

An important component of our relationship with our patients shouldalso include the creation of an environment in which they feel comfortablesharing their information gathering with us. By asking our patients to bringto their clinic appointments materials that they may have obtained from theInternet, newspapers, magazines, and other sources, we can help educate themwhile increasing their involvement. By working with our patients, we can enablethem to use the Internet as a valuable source of information and support.

Corresponding author: Justin L. Gottlieb, MD, University of Wisconsin–Madison,2870 University Ave, Suite 206, Madison, WI 53705 (e-mail: jlgottlieb@wisc.edu).

Submitted for publication June 12, 2003; final revision received September29, 2003; accepted October 14, 2003.