Teleconsultation via the web: an analysis of the type of questions that Iranian patients ask

Abstract

We evaluated an ask-the-doctor service which was set up as one of the accessory services of a health education website in Iran. The study lasted for five months. A total of 500 enquiries were submitted to the question and answer system. Eighty enquiries were excluded because they were duplicated submissions, not replied to by doctors or gave insufficient information for a reply. Most enquirers (33%) were female and aged 21–35 years. The most frequently asked questions were about embarrassing and sensitive topics, particularly on women's health and mental health. The majority of the questions were submitted on behalf of the enquirers themselves, with only 13% asking for others (children, parents, friends). Although there are various problems associated with online consultation, it does at least overcome one of the great drawbacks of some cultures, where people are reluctant to talk openly about certain matters, even with their doctors.

Introduction

Patients may consult a physician face-to-face or by telephone, and also online. Online medical consultations can be classified as:

Conferences between medical professionals about a particular medical condition or patient;

Follow-up consultations between the physician and patients who have been seen in the past;

Consultations between the physician and patients (or healthy people) about matters, without prior face-to-face communication.

The first two categories are widely accepted and in common use, but the third is still debatable, though very popular with people seeking medical information.¹ Patients say that their main reasons for using teleconsultation are to overcome the difficulty in visiting a doctor for a face-to-face consultation, to avoid feeling uncomfortable when asking sensitive or embarrassing questions, to seek a second opinion and to obtain a primary evaluation of a medical problem.²

In Iran, there are several web-based medical consultation services, mainly offered by non-government websites and usually free of charge. Web-based consultation is very popular, even though visits to a doctor are very cheap in most cities (only about US $8 to see a GP, even for patients without insurance). However, the effectiveness of web-based consultation is unknown. Some studies have sought opinions from the users of ‘ask-the-doctor’ services.³ The present study, carried out in a developing country (Iran), attempted to determine what subjects or medical complaints were of most interest to enquirers, and which of them would be suitable for response through teleconsultation.

Methods

We evaluated an ask-the-doctor service which was set up as one of the accessory services of a health education website (http://www.myhealth.ir). This ask-the-doctor service commenced in 2009. The service used a free PHP helpdesk software (HESK),⁴ which assigned a random code to questions for further follow-up. When an enquiry was posted, an email message was sent to the consultant and another message, containing the code, was sent to the enquirer. The unique 10-digit code assigned to each enquiry enabled the holder of the code (the enquirer) to see the reply, and nobody else – both questions and answers were entirely between enquirer and physician. Many Persian websites publish all the questions and answers with the enquirer's forename and the full name of the physician or health specialist. The HESK system, however, provided more privacy than this and was also very easy to use. The enquirer simply filled in a form with information, including the question title, enquirer's age, sex, past medical history, urgency of enquiry and a brief explanation of the problem.

Almost all of the questions were answered by two volunteer physicians, who replied to all enquiries asked in Persian, whether from inside or outside Iran. If the responder needed help with a difficult or complicated question, the doctor was asked to consult a colleague and look for up-to-date literature. The consultants were aware of the ethical and legal implications arising from online consultations and exercised particular care when dealing with questions on complicated health problems, unethical matters or any other subject where teleconsultation was likely to be misleading, useless or harmful. In these situations, the enquirer was asked to visit a health professional face-to-face. Prescription of medication was prohibited and online follow-up was rarely welcomed – enquirers were recommended to visit doctors in person. The service was free of charge to enquirers and the volunteer consultants were not paid.

When a consultant replied to an enquiry, a simple feedback form was provided below the reply. Thus when the enquirer read the reply, they could complete the feedback form, which asked them to rate the effectiveness of the reply from their point of view.

We gathered and analysed all the data resulting from these questions and answers.

Data analysis

Each question and answer was interpreted and grouped. Categories were defined by the subject matters asked by enquirers. Medical problems were initially categorized into 13 groups and then, for better statistical analysis, re-grouped into five: internal medicine, cosmetic, psycho-nervous, head and neck, and genitourinary disorders.

Each group contained information on the category of the medical problem, sex, age, urgency of question, whether the enquiry was personal or on someone else's behalf and feedback from the enquirers about the effectiveness of the physician's reply. All these data were entered into a standard package (SPSS version 16) and analysed by Pearson chi-square.

Results

The study lasted for five months. A total of 500 enquiries were submitted to the question and answer system. Eighty enquiries were excluded because they were duplicated submissions, not replied to by doctors or gave insufficient information for a reply. When the enquirer was asking on behalf of another person, for example children or relatives, information about the patient, not the enquirer, was gathered. Forty-eight percent of the questions were submitted by men and 53% by women (Table 1). The largest age group was 21–35 years (60% of participants), and there was no significant difference between the mean ages of men and women. The smallest groups were those over 65 years and under 15 years.

Table 1

Participants in the online consultations

	Female		Male		Total
Age (years)	No.	Frequency (%)	No.	Frequency (%)	No.	Frequency (%)
<15	6	1	8	2	14	3
15–20	43	10	44	11	87	21
21–35	137	33	114	27	251	60
36–45	19	5	18	4	37	9
46–55	9	2	11	3	20	5
56–65	2	0.5	2	0.5	4	1
>65	5	1	2	0.5	7	2
Total	221	53	199	48	420	100

There was a significant relationship between a positive past medical history (PMH) and the age group (P < 0.001, χ² = 67.2). The largest group without a positive PMH was the 21–35 year age group. Enquirers reported severe (9%), mild to moderate (22%) or no PMH (67%). There was no significant difference between the sex of enquirers and the co-existence of a PMH (P = 0.44, χ² = 1.6), see Table 2. There was a significant relationship (P = 0.04, χ² = 22.9) between disease group and the enquirers' rated effectiveness of reply, see Table 3.

Table 2

Age group of enquirers and co-existence of past medical history at the time of asking an online question (percentages in parentheses)

	Past medical history
Age group of enquirers (years)	No past history	Mild to moderate disease	Severe disease	Total
<15	9 (2)	2 (0.5)	3 (0.7)	14 (3)
15−20	67 (16)	18 (4)	2 (0.5)	87 (21)
21−35	180 (43)	53 (13)	18 (4)	251 (60)
36−45	18 (4)	14 (3)	5 (1)	37 (9)
46−55	7 (2)	7 (2)	6 (1)	20 (5)
>56	2 (0.5)	2 (0.5)	7 (2)	11 (3)
Total	283 (67)	96 (23)	41 (10)	420 (100)

Table 3

Relationship between the effectiveness of the replies (as rated by the enquirers) and the major group of complaints (percentages in parentheses)

	Reply effectiveness
Major complaints of enquirers	Effective	To some extent effective	Not effective	Total
Genitourinary disease	86 (23)	46 (13)	8 (2)	140 (38)
Head and neck	3 (0.8)	8 (2)	2 (0.5)	13 (4)
Internal medicine	55 (15)	47 (13)	19 (5)	121 (33)
Cosmetic	27 (7)	9 (2)	4 (1)	40 (11)
Psycho-nervous	21 (6)	26 (7)	8 (2)	55 (15)
Total	192 (52)	136 (37)	41 (11)	369 (100)

Overall, the genitourinary, internal medicine and cosmetic categories received the highest effectiveness ratings according to feedback from the enquirers. Head and neck, and psycho-nervous categories were rated to some extent effective. No group received predominantly not effective ratings. Among all age groups, the enquirers rated replies (n = 169) to questions as not effective (11%), effective to some extent (36%) and effective (52%).

The system allowed enquirers to send photographs, such as images of their skin lesions or scans of their medical documents, but less than 5% of the 420 participants took advantage of this facility. The majority of the enquiries (78%) were flagged as being of high urgency by the enquirers. There was no significant relationship between this flag selection and the age group, sex or question type.

The most frequently asked original question categories (before the re-grouping into five major groups) were sex life and relationships with partner, cosmetic matters, women's health, gastrointestinal discomfort, psycho-nervous problems, uncontrolled or harmful sexual relationships and STDs, see Table 4. The majority of the questions were submitted by the enquirers themselves, with only 13% asking for others (children, parents, friends, in that order).

Table 4

Topics asked about by the enquirers

	Female		Male		Total
	No.	Frequency (%)	No.	Frequency (%)	No.	Frequency (%)
Men's health	0	0	38	9	38	9
Gastrointestinal	12	3	22	5	34	8
Women's health	54	13	2	0.5	45	13
Cosmetic	19	5	7	2	26	6
Psycho-nervous problems	29	7	32	8	61	15
Sexual problems	21	5	31	7	52	12
Sexually transmitted diseases	3	0.7	6	1	9	2
Orthopaedics	12	3	12	3	24	6
Ear, nose and throat	7	2	4	1	11	3
Ophthalmology	1	0.2	4	1	5	1
Internal medicine	50	12	22	5	72	17
Dermatology	6	1	12	3	18	4
Paediatrics	7	2	7	2	14	3
Total	221	53	199	47	420	100

There was no significant difference between the sex of enquirers in age groups (P = 0.80, χ² = 2.3), feedback about usability of the replies (P = 0.75, χ² = 5.7), PMH (P = 0.44, χ² = 1.6) or urgency (P = 0.059, χ² = 5.7), but there was a significant difference between the sexes in the question categories they asked, see Table 4.

Discussions

Eysenbach's guidelines⁵ contain six principles for providing medical advice on the Internet. These include online physicians should be aware of the limitations of telecommunication; online requests should be responded to like conventional requests; informed consent is required; confidentiality should be maintained by all parties; appropriate quality control measures should be implemented. The online doctors in the present study were aware of these rules and respected them. However, the enquirers did not know what sort of enquiries could be answered by health professionals via the web. They needed to be informed that, in the absence of a previous patient-physician relationship, it is unethical to diagnose and treat via the Internet.⁵

The enquiries submitted in the present study could be divided into the following categories:

Enquiries about complicated or incurable medical conditions and from patients with a history of several years of poor health without satisfactory diagnosis or treatment;

Enquiries about embarrassing, sensitive or shameful matters, or about punishment – for instance, questions about uncontrolled or unethical sexual activities were common;

Enquiries about simple, common problems, especially in women's health. These made up a large proportion of the questions;

Enquiries about cosmetic problems (very common among female enquirers);

Enquiries about the effectiveness and trustworthiness of products advertised on TV and in other mass media. Many users considered an online doctor to be a trustworthy counsellor;

Questions related to sexual behaviour;

Recent complaints or the primary evaluation of a new medical condition.

As in many other studies of online medical consultations, women aged 21–35 years were in the majority. Whether the categories of problem asked about in the online consultations are similar to those asked about in face-to-face consultation is not known. This is a topic for future research.

To analyse the questions in terms of their answerability, we defined three groups of questions:

Those that were fully answered by the online medical consultation. These questions made up about half of all submissions (53%). They included simple questions about adverse drug effects, interactions between medicines, simple information about medical conditions, simple requests about medical complaints (stopping a nosebleed, for example) or asking the meaning of a medical laboratory result.

Those that were partly answered, or led to referrals to further sources of assistance. Most questions requesting a medical diagnosis or treatment fell into this category (39%). Given a list of symptoms, the practitioner could often identify the disease most likely to have caused them, but obviously could not rule out rarer diseases with the same symptoms.

Those where online consultancy could offer little or no help (8%). For example, a consultant asked us what to do for a patient with lupus erythematosus who desperately wanted help. Eysenbach's ethical guidelines say that the online doctor should reply to all enquiries, but what can be said in cases of this type? We think that simple supportive sentences are appropriate.

The clinical descriptions provided by many patients could not lead to a definite diagnosis or safe and effective prescription. In such cases it is controversial and possibly harmful to suggest even simple actions. No question asking for treatment, whether a side-effect is related to a previous treatment, or for prognoses, will be a good candidate for answering online. It is certainly possible to give a general reply by quoting a medical text, but there is no way to understand the applicability of this information to a particular patient, as the doctor has not seen the patient and the patient has probably never seen the condition before. We believe that it is unsafe to reply with any more than generalities, and that diagnosis and prescription should be avoided. We suggest the online doctor should:

Explain the major signs and symptoms of the probable diagnosis, so that the patient can evaluate their own condition more intelligently. In particular, the doctor should describe possible hazards and emergency or threatening situations, together with the actions to be taken if they occur. Follow-on actions, particularly referral to appropriate face-to-face health services, should also be described.

Explain exactly what services are available for the patient's particular problem, and where they can be found. This is very reassuring, and particularly useful in countries without a systematic referral system.

Explain clearly, if appropriate, that the question, by its very nature, is unsuitable for online consultation.

There are many ethical problems concerning online consultation, but it does at least overcome one of the great drawbacks of cultures like that of Iran, where a Muslim majority is reluctant to talk openly about certain matters, even with their doctors. If somebody is so ashamed of an action, or of speaking about a health matter, that they cannot talk about it face to face, what better than an online system where the doctor and the patient are ignorant of each other's identity and appearance?

On the other hand, doctors were disappointed about their inability to help in some situations, although there were very few of these (<1%). They knew the patient was searching for any solution or therapy that might help, yet no help was available. A patient asked for rescue as she was in the last stages of metastatic ovarian cancer, and the online consultant was helpless, ‘I do not know what to say in a few words to one facing death.’

Despite all the problems, the online ‘ask-the-doctor service’ continues to operate. We aim to provide a more detailed training tutorial for website visitors about how and what to ask online, to see whether or not it can improve this method of communication.⁶

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HESK Help Desk Online Application. See http://hesk.com (last checked 5 January 2011)

Eysenbach

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Online Medical Consultation Service. See http://www.myhealth.ir/help (last checked 5 January 2011)