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RESEARCH: Hangwi Tang and Jennifer Hwee Kwoon Ng Googling for a diagnosis—use of Google as a diagnostic aid: internet based study BMJ 2006; 333: 1143-1145 [Abstract] [Full text]

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This is research?

T C Winthrop   (11 November 2006)

Value of Fulltext Searching

Joy C. Kennedy   (11 November 2006)

Google Medicine

Ward D. Merkeley,M.D.   (11 November 2006)

Google – Limited Usefulness as a Diagnosis Reminder System

Joseph Britto, P. Ramnarayan   (11 November 2006)

"Googling" a diagnosis - proceed with caution?

Owen D Moore   (11 November 2006)

The internet as a clinical aid for the dermatologist

Alex J Chamberlain   (12 November 2006)

Googling with Google

Michael D Innis   (12 November 2006)

Match the Tool to the User

Patricia F. Anderson   (13 November 2006)

Discontent and its Civilisations :) Re: The internet as a clinical aid for the dermatologist

Adrian Blaj   (13 November 2006)

The global/Google healthcare market

Alec Holt   (13 November 2006)

It's a major tool

J. Martin Wehlou   (13 November 2006)

Bias your search

Mark Taubert   (13 November 2006)

Not Just Human Medicine

Maurice E White   (14 November 2006)

Information should be verified

Pam White   (14 November 2006)

Need of education programmes for practicing physicians

Lukas A Holzer   (15 November 2006)

A poor suggestion at best.

Philip W Bradley   (15 November 2006)

Googling for a diagnosis - further research would be interesting

Caroline De Brún   (15 November 2006)

"Pubmedding" is better than googling

Daniele Torchia   (16 November 2006)

Googolplex

Oltunde A Ashaolu   (16 November 2006)

Search engines and diagnosis

Chris J Martin   (16 November 2006)

Handle with care

Soubhagya R Nayak, Ashwin Krishnamurthy, Latha V. Prabhu   (17 November 2006)

Check out Google scholar

Anuj Sharma   (17 November 2006)

Re: The internet as a clinical aid for the dermatologist

Stephen F Hayes   (18 November 2006)

Societal attitudes the real problem

Catherine A. Smith   (18 November 2006)

try with Google Health

Fuad Anis   (19 November 2006)

PubMed versus Google – a brief comparison

Reinhard Wentz   (19 November 2006)

Re: try with Google Health

Patricia F. Anderson   (20 November 2006)

Goggling and rational decision making for the busy GP

Frans Boch Waldorff, Christian Hermann   (20 November 2006)

Googling from an SHO Point-of-View

Sabrina M Butcher   (25 November 2006)

Googling - Never the best to fall back on !

Dr. ALLEN. P. UGARGOL   (25 November 2006)

Google = 10,000 Monkeys?

Reinhard Wentz   (30 November 2006)

Authors' reply

Hangwi Tang, Jennifer HK Ng   (30 November 2006)

Typographical error for reference 1

Daniel Weiler   (1 December 2006)

Googling for a diagnosis – don’t forget the geography

Anthony Bryceson   (2 December 2006)

Kindly Invited to read BMJ!

Ivan Y. Torshin   (2 December 2006)

Google as a diagnostic aid: A Latin American perspective

V Zarate   (2 December 2006)

Loss of experiential training time maybe replaced by the internet

Amit Patel   (4 December 2006)

Patients using google may miss common diseases presenting commonly

Hani J Marcus   (4 December 2006)

Diagnosis thanks to Google

Clementino Stefanetti   (4 December 2006)

www: Internet usage in patients with urological cancer

Junaid Masood, J. Shazad, M.T.Vandal, S.S.Gujral   (5 December 2006)

Re: Patients using google may miss common diseases presenting commonly

Daniel R. Hicks   (5 December 2006)

google's experimental co-op beta health searches

Lance Montauk   (5 December 2006)

Google - Answer for everything (almost)

Vivek Furtado   (6 December 2006)

Doctor Google?

Chika E Uzoigwe   (7 December 2006)

To Google… or not to Google

Jenny Hall, Keryl Michener, Liaison Librarian, University of Queensland Library   (7 December 2006)

Online onslaught

Dragan Ilic, Sally Green   (15 December 2006)

Evaluating Google-assisted Diagnosis versus Unassisted Human Performance : the Missing Control Group

Gerhard B. Holt   (26 February 2007)

Reconsider diagnosis

Ray Simkus   (16 April 2007)

This is research? 11 November 2006
T C Winthrop, research fellow Shriners, Boston, MA 02114 Send response to journal: Re: This is research?	I am amazed by the publication of this article. As a regular reviewer for numerous journals, this article would never have seen the light of day. The article does not offer any insight into an important topic. The results actually show an extremly poor correct diagnostic rate even with trained personnel to filter and process the information. As doctors we would never accept the same level of diagnostic accuracy of a colleague. The implication that 'googling' be an adjunct to proper medical school training, continuing medical education through courses and reading peer reviewed journals is laughable and bordering on dangerous. I am shocked that this has been published by the BMJ. Competing interests: None declared
Value of Fulltext Searching 11 November 2006
Joy C. Kennedy, Medical Librarian Arlington Heights, Illinois USA 60005 Send response to journal: Re: Value of Fulltext Searching	After a few moments of shock at the thought of using Google as a search tool in these days of Evidence-based Practice, peer reviewed journals, etc., I realized what the authors of this study were actually doing. By using Google to search the web, they were essentially doing a fulltext search of a giant database. Admittedly this database contains good, bad and indifferent material but the concept is not an unreasonable one. There is great value in searching the fulltext of journal articles, tables of content of books and other, more reputable tools (much better than searching web sites of dubious provenance.) Some vendors of electronic healthcare journals now allow fulltext searching of the journals they provide. Other vendors include the capability of fulltext searching of medical texts. In many cases this can pull concepts from the literature that are difficult for inexperienced searchers to locate. In my many years as a medical librarian, I've noticed that many physicians like to do their own searching rather than call on the expert skills of a masters-degreed professional. Yet I seldom see physicians wanting to do their own respiratory or physical therapy, set up their own IVs, and do other work that skilled and trained auxillary health care staff can ably perform for them. Is it the fault, I wonder, of the library profession that we have been unable to establish our reputation for expert searching. Is it the fault of medical schools that don't demonstrate the value of using the expert search skills of their masters-degreed library staff to physicians in training? Is this simply hubris on the part of the medical professional that they overestimate their skills in the complex process of doing expert searching? Or, is this simply the lure of having the power of the web at your fingertips--even if it only results in a only 58% success rate and takes time wading through masses of irrelevant data? As we get deeper into the 21st century I feel it is important that we explore the answers to these questions. Competing interests: None declared
Google Medicine 11 November 2006
Ward D. Merkeley,M.D., Emergency Physician Holy Family Hospital 99203 Send response to journal: Re: Google Medicine	Today an article titled" Googling for a diagnosis-use of Google as a diagnostic aid: internet based study" appeared in the November 10 issue of the BMJ, British Medical Journal. The article's authors , Hangwi Tang and Jennifer Hwee Kwoon NG, discuss the success of using Google search to diagnose patients by putting in their signs and symptoms(3-5). The diagnostic cases(26) were taken from the New England Journal of Medicine 2005. The results were impressive. What Google did was gather several pages of revelant articles and citations which when read by physicians who selected the correct diagnosis 58% percent of the time. Currently, the searches are performed by typing in multiple signs and symptoms, ie, sore throat, rash,.... fever, etc. Some short comings were noted. For one, searches were less likely iin complex dieases with non-specific symptoms or " common diseases with rare presentations" One can anticipate various ways to increase the accuracy of diagnosing: - input of vital signs: HR, T,BP, O2 sat - input of lab values - input of signs and symptoms in appearance order - imaging study results This paper shows there is a tremendous interest in medicine in using Google as a search tool in the diagnosing and possible care of patients. One can imagine the benefit to young doctor in developing country who now have access to a grand medical library in their hands. Thanks to the authors! Ward Merkeley, M.D. wardmerkeley@msn.com Spokane WA Competing interests: None declared
Google – Limited Usefulness as a Diagnosis Reminder System 11 November 2006
Joseph Britto, CEO & Clinical Director Isabel Healthcare Inc, Reston, Virginia. USA 20194, P. Ramnarayan Send response to journal: Re: Google – Limited Usefulness as a Diagnosis Reminder System	Time pressured clinicians overwhelmed with the exponential increase in bio-medical knowledge are desperately seeking diagnosis decision support systems (DDSS) and some have found Google useful in this application [1]. Google, whilst extremely helpful in shifting the ‘search paradigm', is of limited usefulness as a DDSS. This is understandable since Google was not designed to be used as a DDSS. It uses a Boolean search (and/or) engine to find query words in web-pages and ranks pages according to the links on the page and the popularity of the pages that link to other pages [2]. Google’s accuracy of 58%, reported by Tang and Ng, is less than that achieved by older generation rules based DDSS [3] and will not engender widespread adoption. Isabel (www.isabelhealthcare.com) is a web-based, point-of-care DDSS designed for use by healthcare professionals and has been extensively validated in clinical studies in terms of ease of use, accuracy and impact as a diagnosis reminder system [4]. Isabel has been shown to be accurate in over 90 % of cases [5] and to cause frontline physicians to consider an important diagnosis they should have considered in 1 in 8 cases [6]. Isabel uses natural language processing algorithms that searches by context and meaning a databse of medical textbooks and journals - to understand’ rather than just ‘find’. Isabel suggests diagnoses rather than documents and these diagnoses are filtered using the patient’s age, gender, pregnancy state and geographical-region prevalence heuristics. Further, as a quality metric, we analyze and make available on www.isabelhealthcare.com results of Isabel’s diagnostic performance on current NEJM CPC cases. A study submitted for publication looked at Isabel’s performance on 50 NEJM CPC cases from 2005 using whole text data entry [entire case presentation cut and pasted verbatim] and entry of extracted clinical features. Isabel came up with the final diagnosis in 74% and 96% respectively [7]. A powerful driver for adoption of DDSS is the importance of constructing a complete differential diagnosis, thereby minimizing diagnosis error (delayed or missed diagnosis) and improving patient safety and quality of care. A study of factors that contribute to diagnosis error showed that premature closure i.e. failure to consider reasonable alternatives was the single most common cause [8]. A metanalysis funded by the Agency for Healthcare Research Quality reported that diagnosis errors far outnumber medication errors as a cause of claims lodged and that one in six people had personally experienced a medical error related to misdiagnosis. The average rate of major missed diagnosis from 53 autopsy studies was of 24% [9]. The aim of DDSS is not to replace but to quickly and easily give the ‘learned intermediary’ (clinician) a differential diagnosis to consider. Sophisticated and validated DDSS are now able to rapidly assist diagnosticians and make the cognitive process of diagnosis more accurate and consistently reliable. 1. Tang H, Ng JHK. Googling for a diagnosis -use of Google as a diagnostic aid: internet based study. BMJ, doi:10.1136/bmj. 39003.640567.AE (published 10 November 2006). 2. Battelle J. The Search: How Google and its rivals rewrote the rules of business and transformed our culture. London: Portfolio Penguin Books. 2005. 3. Berner ES, Webster GD, Shugerman AA, et al. Performance of four computer-based diagnostic systems. N Engl J Med 1994;330:1792–6. 4. Ramnarayan P, Roberts GC, Coren M, et al. Assessment of the potential impact of a reminder system on the reduction of diagnostic errors: a quasi experimental study. BMC Medical Informatics and Decision Making. 2006 Apr 28;6(1):22. 5. Ramnarayan P, Tomlinson A, Rao A, et al: ISABEL: a web-based differential diagnostic aid for pediatrics: results from an initial performance evaluation. Arch Dis Child 2003, 88:408-13. 6. Ramnarayan P, Roberts GC, Coren M, et al. Diagnostic omission errors in acute paediatric practice: impact of a reminder system on decision-making. BMC Medical Informatics and Decision Making 2006, 6:37 doi:10.1186/1472-6947-6-37 7. Graber M, Mathews A. Performance of a web-based clinical diagnosis support system using whole text data entry. VA Medical Center, Northport, NY and the Department of Medicine, SUNY at Stony Brook, NY. Personal communication - submitted for publication 8. Graber M, Frankilin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med. 2005 Jul 11;165(13):1493-9. 9. Schiff GD, Kim S, Abrams R, et al. Diagnosing Diagnosis errors: Lessons from a Multi-institutional Collaborative Project’. In Advances in Patient Safety-2. 2005. 255-78. Competing interests: Dr. Britto is CEO & Clinical Director of Isabel Healthcare. Dr Ramnarayan now advises Isabel Healthcare on research activities on a part-time basis. Both hold restricted shares in Isabel Healthcare Ltd.
"Googling" a diagnosis - proceed with caution? 11 November 2006
Owen D Moore, Clinical Specialist Physical Therapist DE7 8LN Send response to journal: Re: "Googling" a diagnosis - proceed with caution?	I would be most interested to hear other clinicians opinions on whether this study could be replicated given the information published? Having just scanned through the NEJM online, can I presume the initial reference (quoted by the authors as Volume 359; reference #1) is actually this correspondence article >> N Engl J Med 2005; 353:2089-2090, Nov 10, 2005? Whilst I understand that this a new field of study, it would have been most helpful to understand the authors rationale for why those particular convenience sample papers were chosen; by contrast of course why other papers were not? With such a small sample size, we learn that 26 case were selected (?out of how many possible/total) and that 15 diagnoses correctly detected. However it is possible, given the wide confidence interval (38-77%), that you could have a deviation from the actual diagnosis nearly 60% of the time using Google! The selection bias inherent in their cases (again one presumes these are the "Case Records of the Massachusetts General Hospital"??) makes me wonder, given the CI, that chance findings from Google's archive are more likely. Do any readers have information to share from their own software packages/decision making tools? I'm very interested in this field and look forward to other researchers in fields such as public health, epidemiology and general practice collaborating with Google to produce a more accurate aid. On the strength of this publication I believe clinicians should exercise caution when relying on Google to retrieve an accurate case history series to aid treatment decisions. Competing interests: None declared
The internet as a clinical aid for the dermatologist 12 November 2006
Alex J Chamberlain, Consultant Dermatologist Alfred Hospital, Prahran, Victoria, Australia 3181 Send response to journal: Re: The internet as a clinical aid for the dermatologist	Tang and Ng (1) highlight nicely the benefits of using web-based search engines such as google as a diagnostic aid in difficult cases. This is not the only internet function that has revolutionised medicine as it is practised in the year 2006. In dermatology, there are in the order of 2000 diagnoses with many and varied presentations that one must be familiar with. Every week one is faced with challenging cases and without the internet I would be lost. Whilst we would have resorted to standard textbooks or a library of journals 10 or more years ago, nowadays online resources such as eMedicine (www.emedicine.com) or Bolognia's Dermatology (www.dermtext.com, subscription required) provide rapid access information. For more obscure cases, one can search the US National Library of Medicine's medline database (www.ncbi.nlm.nih.gov/entrez/query.fcgi?DB=pubmed). Full text journal articles can then be simply accessed both in the clinic, on the ward or at home when seeking diagnostic or management support. I can clearly recall numerous cases when PubMed searches have speedily yielded the correct diagnosis or the most appropriate treatment using these online resources and only a small number of clues (cases include ulcerative colitis associated pyodermatitis pyostomatitis vegetans, pachydermodactyly, nephrogenic fibrosing dermopathy and dyschromatosis universalis hereditaria). Via PubMed, one can also freely access up to date information on all genetic disorders using the Johns Hopkins University OMIM (online mendelian inheritance in man) database. If google, eMedicine and PubMed let me down, I can still call on free second opinion services such as DermConsult (www.dermconsult.com.au) or the International Dermoscopy Society (IDS) member's discussion forum for dermoscopic dilemmas. Australian dermatologists communicate freely via a Yahoo-based egroup discussion forum and this is yet another forum to gather help on difficult cases. Finally, I can simply use email to contact a local or international expert for their advice (email addresses are frequently published amongst the author details in most journals). When it is my turn to teach the students students in clinic, eMedicine and google image search are valuable resources once again. Using the latter I can rapidly access multiple images (both clinical and histological) of the case we have just observed, to reinforce the educational lesson. As a trainee, I relied on a number of internet-based educational resources that also included the interactive atlas of dermoscopy (www.dermoscopy.org), MDLive (www.mdlive.net/dermsurg.htm) for dermatologic surgery and DermConsult (www.dermconsult.com.au) for challenging short cases. After a consultation I will provide many patients with an information sheet, usually downloaded from either the New Zealand Dermatological Society website (www.dermnetnz.info/patient- information.html) or the NHS National Library for Health Skin Disorders Specialist Library (www.library.nhs.uk/skin/). When I need information on drug eruptions or interactions, there is Litt's drug eruption global database (www.drugeruptiondata.com, subscription required). For further treatment anecdotes and pearls, there is the online dermatology journal discussion archive (www.dermatology.cdlib.org/rxderm-archives) and if I need information on hard-to-access medications or compounded formulations, again...back to google! For the modern dermatologist, the internet is indispensible and google is only the start, and for this reason a desktop computer with high speed internet access is an essential tool for all clinicians. Long live the information superhighway! References 1) Tang H, Ng JHK. Googling for a diagnosis - use of google as a diagnostic aid: internet based study. Br Med J doi:10.1136/bmj.39003.640567.AE (published 10 November 2006) 2) Mehravaran M, Kemeny L, Husz S, Korom I, Kiss M, Dobozy A. Pyodermatitis pyostomatitis vegetans. Br J Dermatol 1997;137(2):266-9 3) Kopera D, Soyer HP, Kerl H. An update on pachydermodactyly and a report of three additional cases. Br J Dermatol 1995;133(3):433-7. 4) Cowper SE, Su LD, Bhawan J, Robin HS, LeBoit PE. Nephrogenic fibrosing dermopathy. Am J Dermatopath 2001;23(5):383-93. 5) Sethuraman G, Srinivas CR, D'Souza M, Thappa DM, Smiles L. Dyschromatosis universalis hereditaria. Clin Exp Dermatol 2002;27(6);477- 9. Competing interests: None declared
Googling with Google 12 November 2006
Michael D Innis, Director Medisets International Home Send response to journal: Re: Googling with Google	Editor, In response to Owen Moore's question, " do any readers have information to share from their own software packages/decision making tools? I'm very interested in this field and look forward to other researchers in fields such as public health, epidemiology and general practice collaborating with Google to produce a more accurate aid" I would like to refer him to the publication "Clinical problem solving - the role of expert laboratory systems"[1] Two novel features of that program are: 1 The Inference Mechanism is based on Fuzzy Set Theory [2] (the intersection of a Set and Its complement is not an Empty Set) a conundrum addressed by both Heraclitus and Aristotle [3] 2 With Biomedical knowledge doubling every 19 years [4] the program allows the user to update the elements (signs, symptoms, laboratory findings) of the various sets as and when necessary. This ensures a state of the art database. By building up a collection of biochemical and haematological patterns of disease any institution or individual can develop ones own in house data base. For example in India hypergammaglobulinaemia would mean Kala Azar but not so in the Rocky Mountains. McManus [5] believes that by the year 2021 "Specialists, (also skilled in computing) will oversee the computer programs" - perhaps his time scale is a little out! Michael Innis FRCPA; FRCPath References: 1 Innis MD. Clinical problem solving ¨C the role of expert laboratory systems¡¯ 1997:Med Inform; 2, (3) 251-262 2. McNeil D and Freibeger P Fuzzy Logic The Discovery of a Revolutionary Computer Technology ¨C And How it is Changing our World. 1992: Melbourne Victoria Australia Bookman Press p34. 3. Gomperz T. The Greek Thinkers. A History of Ancient Philosophy. Vol 4 p69-70 Translated by G G Berry London John Murray, Albemarle Street.Fifth Impression 1964 4. Wyatt J Uses and sources of medical knowledge 1991: Lancet 338;1368-1372 5. McManus IC. Designing a doctor. How will medical education change? 1991:Lancet 337; 1519-1521 Competing interests: The program was developed in conjunction with Richard Innis - a Computer Scientist. I provided the data for the Sets and own the program.
Match the Tool to the User 13 November 2006
Patricia F. Anderson, medical librarian Dentistry Library, University of Michigan, Ann Arbor, MI USA 48108 Send response to journal: Re: Match the Tool to the User	Personally, I am a big fan of the aphorisms "match the tool to the task" and "measure twice, cut once." As an author, educator and researcher interested in searching efficiencies (both for Medline and the Internet), I find this article interesting on several counts. In the past, I have tested a similar strategy to Internet searching with patients. This was used in educational settings rather than as a research project, and was intended to warn people away from relying on this tempting strategy. I found putting in the symptoms to reach a diagnosis an ineffective and worrisome strategy for persons not trained in diagnosis and not familiar with appropriate use of medical terminology, a strategy as likely to lead a person astray as to useful information. That was a couple years ago, and I am wondering now if the difference in findings is because of growth in the database or the perspective and experience of the clinicians. I confess to a small concern that this research may be interpreted by the media as an endorsement of this search approach for non-clinicians, and would caution persons writing in this area to be explicit in their caveats about applying this without clinical training, as was done quite well by the authors of this paper. Conversely, I am delighted that someone has published a reasonable methodology for testing the concept of symptom-searching in Internet search engines. Bravo for being the first to put your toe in the water. I am sure that many more will follow your steps with efforts to refine this process. I would particularly love to see research that modifies the strategy and tests it with patients. I would also be very interested in discovering what characteristics distinguished the accurate and inaccurate diagnoses -- the drop-outs or diagnostic failures. Was it something the searcher did different? Was it characteristics of the condition being searched? Was it that certain symptoms are too generic to be useful even in combination with more specific terms? The authors include as a caveat that selection of search terms was performed by a clinical expert aware of the ultimate diagnosis. I agree with their assessment that this could have compromised the results. It might be possible in a future variant on this study to blind that step of the process as well. Last but not least, it will be necessary at some time to compare this to other diagnostic methods. Is Internet searching more useful when traditional diagnostic methods have not succeeded? Is this more effective with common or rare disorders? Does it save time or money? At this point in time, the question of whether symptom-searching on the Internet is appropriate for anyone, clinician or health care consumer, has been opened, but is still very much undecided. I eagerly anticipate the process that will define this interesting area. Competing interests: Author/Editor: Medical Library Association Encyclopedic Guide to Searching and Finding Health Information on the Web / by P. F. Anderson and Nancy J. Allee
Discontent and its Civilisations :) Re: The internet as a clinical aid for the dermatologist 13 November 2006
Adrian Blaj, SpR Psychotherapy Addenbrookes Hospital, Cambridge Send response to journal: Re: Discontent and its Civilisations :) Re: The internet as a clinical aid for the dermatologist	The problem with your approach is that it requires a new integrative model of thinking: open mind, healthy logic, collateral and 'imaginative' thinking, good sense of humour, endless doubting, living with the unknown, acknowledgement of own limitations, partnership with the patient (to name just a few of the desirable attributes of the new era, which curiously enough, apply to psychotherapy as well -:) Competing interests: philosophical investigations (private)
The global/Google healthcare market 13 November 2006
Alec Holt, Director of the Health Informatics Program Dep of Information Science, Health Informatics, University of Otago, PO Box 56, Dunedin, New Zealand Send response to journal: Re: The global/Google healthcare market	These are topical results [1] however it is not surprising with the push to an Information Society. Furthermore it is not alarming as in this vein PubMed searches have being aiding diagnosis for years. However, PubMed and other medical search engines can be alarming when incorrect search strategies are used. Therefore we need to educate users (Google, Medscape, Medhunt, WebMD, OmniMedicalSearch) on correct search strategies. If doctors follow an evidence based practice approach then some concern about using Google for diagnosis is dampened, as Google becomes one of many sources utilised and will be given the appropriate validity score. There is a plethora of on-line material which Google points to, journals, abstracts, repositories, open access and blogs (a large amount is probably duplicated). This material can be searched as text, spreadsheets, databases, portable document formats (pdfs), postscript, video and images. Google’s query interface could be improved to allow for natural language processing, fuzzy logic or case-based reasoning techniques. We need to evaluate health information sites and identify the accredited quality sites, for example, Worldwide online Reliable Advice to Patients and Individuals (WRAPIN) and the Health On the Net Foundation (HON). Most online health resources are not created by healthcare professionals [2]. It is conceivable that health professionals themselves will become more efficient at placing their case notes (signs, symptoms and diagnosis) on-line. The Internet (Google) provides empowerment to rural doctors (and doctors in the Pacific and other developing countries) to deal with new and exceptional cases. The general public are also being empowered. It seems the benefits of Google Health to human healthcare are immeasurable [3]. Therefore, if we use a sound search strategy, focus on accredited quality health information sites and assign the correct validity to information items then we are better informed, both doctors and patients. References 1. Tang H, Ng JHK. Googling for a diagnosis -use of Google as a diagnostic aid: internet based study. BMJ, doi:10.1136/bmj. 39003.640567. AE (published 10 November 2006). 2. Potts, HWW. Is E-health progressing faster than E-health researchers? (J Med Internet Res 2006;8(3):e24) doi:10.2196/jmir.8.3.e24 3. Giustini, D. How Google is changing medicine. BMJ 2005;331:1487- 1488 (24 December), doi:10.1136/bmj.331.7531.1487 Competing interests: None declared
It's a major tool 13 November 2006
J. Martin Wehlou, GP, IT consultant Alunda, Uppsala 74730 Send response to journal: Re: It's a major tool	Besides being an MD I'm also a longtime IT professional, so using search engines in both of my professions has always come naturally to me. As an MD I'm able to formulate search terms much more accurately than a lay person, and much more able to act on the advice I find, so using Google does not in any way reduce the value of my training. Currently, Google offers the ability to define a subset of sites to search and have that made available as a custom search engine. This allows me to use my own specially configured Google search to automatically search only sites I know have value for professionals. This is just one example of tools to come. There is no doubt in my mind that integrating Internet search into electronic patient records systems, and thus into the daily work of physicians, will greatly enhance our diagnostic and therapeutic abilities. Competing interests: None declared
Bias your search 13 November 2006
Mark Taubert, Specialist Registrar in Palliative Medicine Holme Tower Marie Curie Centre, Penarth Send response to journal: Re: Bias your search	Editor- Whilst Google can be a valuable aid in reaching diagnoses in rare conditions the problem faced in a busy, fast-paced clinic can be the abundance of lesser quality material on the web. ‘Biasing’ or directing your search by adding the name of an online clinical knowledge base such as Emedicine can lead you to quality information quicker; you thereby avoid sifting through dozens of unknown journals, personal webpages, blogs or discussion forums containing your search-terms. For instance, by typing “pigmented lesion + buccal” into Google there are approximately 55,000 hits with a vast array of very different material. However, when typing “pigmented lesion + buccal + emedicine” there are only 106 hits(accessed 12/11/06), the first being a comprehensive emedicine review on Peutz-Jeghers syndrome. (1) In fact, you get similar results by adding “BMJ” to the end of your search, in this case the top hit is an 'ABC of Oral Health' clinical review article.(2) (1) www.emedicine.com/med/topic1807.htm (2) Scully C, Porter S. The ABC of Oral Health - Swellings and red, white and pigmented lesions BMJ 2000;321:225-228 ( 22 July ) Competing interests: None declared
Not Just Human Medicine 14 November 2006
Maurice E White, Professor Cornell University, Ithaca NY 14853 Send response to journal: Re: Not Just Human Medicine	If you enter the words veterinary diagnosis or the word consultant the #1-ranked term in Google is the Consultant Veterinary Diagnostic Database; URL <http://www.vet.cornell.edu/consultant/consult.asp>. About 350,000 sessions in Consultant will produce around 1.2 million hits this year. Online diagnostic assistantance is alive and well in a place where our clinical cousins practicing human medicine might not expect it. Competing interests: Author of Consultant
Information should be verified 14 November 2006
Pam White, Library Services Manager West Dorset General Hospitals NHS Trust Send response to journal: Re: Information should be verified	I am surprised BMJ editors let the authors get away with this statement: "Arguably, everything could be found on the web if only one knew the correct search terms." I am also not sure how thoroughly BMJ editors checked references. NEJM published a letter (Lindberg et al) correcting data on the use of PubMed to find full text, with reference to an article (10th ref) used to state "... and has far exceeded PubMed as the search engine of choice for retrieving medical articles." If people find information they would not otherwise find using Google, fine. I would recommend, however, following up with a literature search in a more reputable database, such as MEDLINE, or checking with your medical library to verify evidence. Google has begun partnering with libraries and I believe this will make it easier for people, affiliated with these libraries, to access full text. This does not negate the sensibility of searching a reputable database for citations to relevant literature. Donald A B Lindberg, John Sack, Robert Steinbrook Searching the Medical Literature/THE ABOVE LETTER WAS REFERRED TO HIGHWIRE PRESS, WHICH OFFERS THE FOLLOWING REPLY/DR. STEINBROOK REPLIES Donald A B Lindberg, John Sack, Robert Steinbrook. The New England Journal of Medicine. Boston: Jun 1, 2006.Vol.354, Iss. 22; pg. 2393, 1 pgs Competing interests: None declared
Need of education programmes for practicing physicians 15 November 2006
Lukas A Holzer, medical student and Orthopaedic research assistant Department of Orthopaedics, Medical University of Vienna, Waehringer Guertel 18 – 20, A-1090 Vienna Send response to journal: Re: Need of education programmes for practicing physicians	The Internet is a public and worldwide network that offers people from all over the world easy access to information. Therefore the internet had a massive impact on many different fields e.g. economy or medicine. This led to many pros and cons which are frequently discussed. However in medicine this is an even more serious problem because the ones who suffer from Google based decisions are the patients. Many databases exist that contain important and useful information, but there are also homepages that have economic or pseudo scientific content and are therefore not objective. Google is a tool that searches all homepages for certain words, but isn’t able to distinguish between truth and lie. As the study of Tang et al. shows, it might be possible to get the right information with Google [1]. This however is a dangerous tool when you think thank patients’ lives depend on that information. Therefore the curriculum at my university provides special study modules that sensitize students with research and associated tools e.g. databases. I think that it is important to know about databases like the Cochrane Database of Systematic Reviews that offers meta-analysis on different topics including the latest peer-reviewed data [2]. Databases or tools like this one, that are also easy accessible trough the internet, should be used as data sources by physicians. Therefore I think it would be a necessary step to educate or inform practicing physicians (primarily general practitioners and physicians who don’t attend scientific meetings or read literature frequently) about these valuable possibilities and the negative impact that the use of search engines like Google could have. References: 1. Tang H, Ng JHK. Googling for a diagnosis--use of Google as a diagnostic aid: internet based study. BMJ, doi: 10.1136/bmj.39003.640567.AE (published 10 November 2006) 2. www.cochrane.org Competing interests: None declared
A poor suggestion at best. 15 November 2006
Philip W Bradley, Internet consultant Freelance CM11 2DP Send response to journal: Re: A poor suggestion at best.	As both an Internet Consultant who specialises both in searching the internet and teaching others how to do so effectively I am very disturbed by the suggestions inherent in this article. I have taught a lot of doctors on the basics of internet search and it is perfectly clear to me that while they have an excellent understanding of their own subject areas if they have little experience in the basics of literature searching their results are going to be poor. This paper implies that searching for data on the internet is a simple and straightforward process, but anyone who has spent any time trying to locate data will know that this is far from the case. Literature searching is a specialised subject; this is why medical librarians exist, and their expertise in finding and evaluating content should not be overlooked. I would hope that a medical professional would be able to always tell the difference between a good resource and a poor one, and that they would know when it made more sense to search an online database such as Medline, rather than rely on a general search engine such as Google, but from my own experience of teaching doctors this is far from the case. Finally, it should be remembered that search engines are simply not reliable. Google gives different sets of results on a regular basis, and it simply does not have the depth or range of search syntax necessary to accurately identify key resources. I would strongly urge any medical professional who requires accurate and reliable data to consult a suitably qualified information professional; that is what they are there for. Competing interests: None declared
Googling for a diagnosis - further research would be interesting 15 November 2006
Caroline De Brún, Information Scientist National Library for Health, Oxford, UK Send response to journal: Re: Googling for a diagnosis - further research would be interesting	Editor, This study, although focusing on making diagnoses, rather than finding the evidence to support treatment choices, has been very thought- provoking, and I would like to see similar studies carried out, but with the following differences: * Searchers with the same clinical background - the study said that “the efficiency of the search and the usefulness of the retrieved information also depend on the searchers’ knowledge base.” This could have lead to bias because, dependent on their clinical expertise, some of the searchers might be more familiar with the terminology for some of the questions. I would, therefore, like to see the same study carried out by clinicians from the same clinical specialty, eg cardiology or primary care, so that search results for diagnosis questions in their clinical specialty can be compared with search results for diagnosis questions that are not in their clinical specialty. I believe that this would give a more accurate overview of how successful Google is as a diagnostic aid. * Patient or librarian searchers - asking patients or librarians to search Google using the same scenarios to see how successful they are at identifying conditions, without necessarily having the expert clinical knowledge. * Google compared to PubMed – carrying out the searches on Google and PubMed, using the same terms for each resource, and comparing the findings. Because it only provides access to citations from biomedical literature, the benefits of searching PubMed would be a reduction in the number of hits, thus saving valuable time. It is essential that diagnoses are made from high quality sources, and while I know that Google is quick and easy to use, and does contain good sources of information, it does also contain material that could mislead. While clinicians are expert in their clinical area, if they are relying on Google to make diagnoses, they need to be confident that they can filter the good results from the bad. References: 1. Tang H, Ng JHK. Googling for a diagnosis--use of Google as a diagnostic aid: internet based study. BMJ, doi: 10.1136/bmj.39003.640567.AE (published 10 November 2006) Competing interests: Information Scientist for the National Library for Health
"Pubmedding" is better than googling 16 November 2006
Daniele Torchia, resident University of Florence, Via della Pergola, 58/60, 50121 Florence (Italy) Send response to journal: Re: "Pubmedding" is better than googling	In order to verify whether Google is a useful diagnostic tool, Tang & Ng extracted some search terms from case reports published in 2005 in the New England Journal of Medicine, and matched them in that search engine. (1) Google was able to correctly diagnose 15 cases out of 26. My first impression was that Google, although containing billions of informations and being helped by expert humans either at the beginning of the process (selection of search terms) or at the end (selection of prominent diagnoses), had to be charged 11 times with misdiagnosis. My second thought was that the study completely lacked controls: at least, also other physicians should have performed the selections, and Google results should have been compared with those from other popular search engines, both general (e.g. Yahoo) and biomedical (e.g. PubMed). According to my daily experience, biomedical databases, such as PubMed and Embase, feature higher sensitivity and specificity than Google does. The Internet is immensely helpful for research and clinical practice. Studies capable to identify the best web-based search engines for physicians are welcome. References 1. Tang H, Ng JH. Googling for a diagnosis--use of Google as a diagnostic aid: internet based study. BMJ, doi:10.1136/bmj.39003.640567.AE (published 10 November 2006). Competing interests: None declared
Googolplex 16 November 2006
Oltunde A Ashaolu, SpR ED Scunthorpe General Hospital DN15 7BH Send response to journal: Re: Googolplex	The benefits of computer usage in the medical sciences are undeniable and it is only reasonable that we explore these to the limits. The idea of an electronic literature search was however established before Messrs Page and Brin incorporated their Google establishment in 1998. Google’s success largely depended on their pioneered system of ‘PageRanking’(1) that accords importance to web pages with the most links from other highly relevant pages. Google has grown to be the biggest internet search engine and the researchers have told us that the biggest internet search engine gives us the largest choice of options. Hardly surprising, but not in the least folly. The beauty of Google however lies in its accessibility and simplicity of use. It is much quicker than PubMed which often requires a password and a clear understanding of Medline with its MeSH organized index. A quick look at a Google page may juggle the memory or at least bring to attention differentials previously unconsidered. I have personally used Google and will probably continue to do so. I do not however rely on Google to supply a diagnosis lest my professionalism is undermined. Tang and Ng (2) seem to be comfortable with a correctly predicted diagnosis of 58% (with a lower CI limit of 38%) whereby a lot of my colleagues may feel much less so. They also addressed the need for ‘human experts’ to input data into Google but assumed all doctors to be experts! The researchers have expertly selected relevant symptoms to input data into Google and a yield of 58% is obtained. A junior doctor may input a slightly different set of symptoms and the array of available information in fact becomes a quagmire of confusion rather than being an educative medium. Tang et al claim to have avoided the use of specialist knowledge which is readily available to them. How this is achievable is an enigma. I entirely agree that rare syndromes are sometimes thrown up on Google pages and the expert clinician assesses the patient to determine the presence of such, after all we all want to diagnose that rare disease and appear knowledgeable and clever to our peers. The converse can also be said to be true unfortunately. Less experienced clinicians may glance a rare syndrome on the Google pages and instantly label their patients of such, a lobotomy may not convince them contrariwise. I have personally experienced this ‘Google Syndrome’ amongst some junior colleagues and amongst patients. It is a common reason for doctor-shopping which has little benefit for the patient. I believe we must continue to allow computers to assist in education and clinical decision making and I salute the courage of the researchers in starting a healthy debate. A balance must nevertheless be sought between expertise and mathematical wizardry. A simple, common diagnosis is still more likely than a rare syndrome. Perhaps we should always remember that oftentimes, greatness lies in simplicity. Ref 1. Google.com 2. Googling for a diagnosis. H Tang and JHK Ng. BMJ 2006 Competing interests: None declared
Search engines and diagnosis 16 November 2006
Chris J Martin, GP Laindon Health Centre Send response to journal: Re: Search engines and diagnosis	Sir, Owen Moore asks about other systems used for diagnosis. Also, Holt makes the point that Google indexes the entirety of the world-wide-web and that there may be an excess of 'noisy' hits that are irrelevant to the clinician. Taubert suggests that search engine results need 'biasing' in a busy clinic to reduce this noise. SearchMedica ( www.SearchMedica.co.uk )is a search engine designed for UK GPs, with all indexed pages categorized as 'patient information', 'reference', 'guidelines', 'education' etc. It also uses a 'whitelist' of sites that are particularly relevant to UK GPs. This helps to reduce the number of irrelevant hits in search results. Using a search engine in this way is helpful in unusual cases where suspicions are aroused, or in cases, where there is a vague recollection of a possible diagnosis, but the name or details are forgotten. Unlike 'expert systems', they are not substitutes for a clinicians skills and knowledge, however, they are a supplement to them. Competing interests: I am a GP that has been involved in the development of SearchMedica.
Handle with care 17 November 2006
Soubhagya R Nayak, Anatomist Kasturba Medical College, Bejai, Mangalore, India-575004, Ashwin Krishnamurthy, Latha V. Prabhu Send response to journal: Re: Handle with care	After going through the article and the comments render by T C Winthrop and J. Martin Wehlou, we personally think if the electronic search engine like goggle is providing a platform that helps to diagnose various disease that require greater skill and experiences to diagnose, it should be well come by the medical community, as the success rate is 58% percent, mentioned in the article's authored by Hangwi Tang and Jennifer Hwee Kwoon NG. J. Martin Wehlou supported the article quite well as he is a MD and with the skills of an IT professional, but the comments of T C Winthrop should not be ruled out, as diagnosis life threatening disease should not be completely trusted on the data provided by any search engine. The search engines are now very much popular in developing countries and those are new to it. We think that the search engine and the professional skills should blend together for accurate and fast results in diagnosing various diseases. Competing interests: None declared
Check out Google scholar 17 November 2006
Anuj Sharma, Senior Consultant Dept of Clinical Microbiology, Sir Ganga Ram Hospital, New Delhi, India 110060 Send response to journal: Re: Check out Google scholar	Google still does manage to surprise me at times, like a magician pulling things out of a magical hat, which is the internet. This is especially true when I am searching for information, which is not easily available. Despite the limitations of Google searching, it does make the task of searching for specific health information on the net relatively simple, and quite rewarding too. However, if you are looking for scientific health information not available on general medical websites, google scholar can be a good starting point, available at http://scholar.google.com/ Competing interests: Resource person for the National Informatics Centre, Delhi, India
Re: The internet as a clinical aid for the dermatologist 18 November 2006
Stephen F Hayes, GP, GPwSI dermatology Bitterne walk in centre, Southampton, Hampshire, England Send response to journal: Re: Re: The internet as a clinical aid for the dermatologist	I could not agree more with Dr Chamberlain about the usefulness of the internet in dermatology. I use it in my community dermatology clinic daily for decision support and patient education. The most useful site by far is the New Zealand based www.dermnetnz.org. I get the pictures up and show the patient their rash and give them the url for further study if they wish to educate themselves more about their condition. This is particularly helpful in the all too common case of patients asking about the cause of their condition when it is unknown-I find they will take this better from an authoritative web site than from a humble GP. I take the view that since my patients will use the web to obtain information about their condition, I should direct them to safe sites. Google images is surpisingly helpful for dermatology and other conditions too, although safe search needs to be disabled which may be problematic if highly risk averse management fears that the practitioner may misuse the web and view unsuitable sites. Long live medicine on the web, the only question is how can we make better use of it. Competing interests: None declared
Societal attitudes the real problem 18 November 2006
Catherine A. Smith, Assistant Professor University of Wisconsin-Madison, 53706 Send response to journal: Re: Societal attitudes the real problem	What fascinates me is how the mainstream media (in the US, anyway) reacted to this story. Headlines tended to read "Google diagnoses ..." when it is clear from the most superficial reading that the authors diagnosed and Google served as a clinical decision support; news stories often omitted that small detail about the 58% accuracy rate. Most interesting: complete omission of the fact that Google is not a content provider, has gone to court to stake its claim as a non-content provider, and so did not author the content that was used to make a diagnosis. However, the world speaks informally as if Google authored the content it provides. It would have been much more useful an article if the researchers had given us information about the sources of the diagnostic answers--both the correct and the incorrect ones! (Google "anti-SLAPP" and see Carafano v. Metrosplash.com, Inc., UNITED STATES COURT OF APPEALS FOR THE NINTH CIRCUIT, 339 F.3d 1119; 2003 U.S. App. LEXIS 16548) for caselaw on information systems and third-party content.) Competing interests: None declared
try with Google Health 19 November 2006
Fuad Anis, researcher Public Health Department, Faculty of Medicine, Gadjah Mada University, Jogjakarta, Indonesia 55281 Send response to journal: Re: try with Google Health	Dear Sirs; It's an interesting article showing the big potential of Google for health information seekers. While Google is unofficially developing a new feature for health (available at http://64.233.167.99/ ), I think it is important to use your research approach for evaluating this product. Google Health provides some filters related specific types of information for examples diagnosis, symptoms, treatment etc. Another concern with your research is that the final decision is the users. If the users are experts (like the authors: HW and JHKN), the decision perhaps will be more accurate. It will be influenced by the "english literacy" of the users. So, Google, IMHO is far from giving more help to non-english health information seekers. Competing interests: None declared
PubMed versus Google – a brief comparison 19 November 2006
Reinhard Wentz, Retired TW2 7PS Send response to journal: Re: PubMed versus Google – a brief comparison	Madam, Some correspondents have suggested that Tang and Ng’s Google searches (1) should be tried on PubMed. I entered two or more ‘Google search terms’ from the study (column 2 in their additional table (2)) into the PubMed search window, successively in a Google-like fashion and in one line, until a set of (usually) less than some 50 references was retrieved. I then added the ‘final diagnosis’ to the search (column 4 in the table) and judged the PubMed search a success if two or more papers in the final set mentioned the correct diagnosis. Out of Tang’s 26 scenarios a PubMed search identified potentially relevant studies in 23 cases (88%), a better success rate than the corresponding Google searches (58%). I did not count references, if they occurred, to the relevant NEJM case studies. I should mention that the searches on PubMed for this ad-hoc comparison were done without using MeSH terms, subheadings, or Boolean operators. No ‘nesting’ of concepts or use of double quotes was required. This is all done ‘in the background’ by PubMed’s very intelligent search and mapping algorithms, provided a succinct search formulation is entered. A search in the form ‘acute aortic regurgitation depression’ (case 5), ‘ulcerative colitis blurred vision’ (case 14), ‘sickle cell disease back pain’ (case 17), or ‘myopathy neoplasia dysphagia rash’ (case 29) is perfectly acceptable and retrieves 8, 3, 21, and 4 studies respectively (out of 14 million+ records on PubMed). Other examples retrieve slightly larger sets, but they are always much smaller and more manageable than those retrieved in the corresponding Google searches. Indeed, in case 29 above, this crisp search formulation retrieves 4 papers, all of which mention ‘dermatomyositis’ – a ‘pathognomic question’ perhaps? All 26 searches were replicated on PubMed in little more than one hour (about three minutes for each scenario). Tang and Ng’s study may have some methodological weaknesses (it is for instance not quite clear how they selected the correct diagnosis from the Google search result); still their method of extracting specific discriminating concepts from a clinical synopsis is fascinating. They quote Wikipedia(!) and use the term ‘statistically improbable phrases’ (3), a principle used for the amazon.com search interface (4). It could perhaps also, somewhat archaically, be described as the ‘telegram style’ of searching (5): Take a clinical scenario and extract terms, which, if sent as a telegram, would be sufficient for the addressee to understand what your query is. One could also invoke Occam’s trusted razor (5,6); its ‘law of succinctness’ is still relevant. Respectfully yours, Reinhard Wentz 1 Tang H, Ng JH. Googling for a diagnosis--use of Google as a diagnostic aid: internet based study. BMJ 2006 Nov 10 http://www.bmj.com/cgi/rapidpdf/bmj.39003.640567.AEv1 2 http://www.bmj.com/cgi/data/bmj.39003.640567.AE/DC1/1 3 http://en.wikipedia.org/wiki/Statistically_Improbable_Phrases 4 http://www.amazon.com/gp/search-inside/sipshelp.html 5 Clarke J, Wentz R. Pragmatic approach is effective in evidence based health care. BMJ 2000;321:566-7 http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=10968827 6 http://en.wikipedia.org/wiki/Occam's_razor Competing interests: None declared
Re: try with Google Health 20 November 2006
Patricia F. Anderson, medical librarian Dentistry Library, University of Michigan, Ann Arbor, MI USA 48108 Send response to journal: Re: Re: try with Google Health	Just a clarification. Google Health is more properly referred to as Google Coop Health, and the search feature to limit results to the Google Health collection no longer exists. This functionality has been merged into Google proper. The URL given in the response by Dr. Fuad Anis will direct people to Google proper, not to Google Coop Health, although it previously did function as described. There are a large number of innovative and exciting health search engines worth exploring. I would recommend that clinicians consider exploring these. Google is admittedly very good, but is not the only game in town. ClusterMed Healia healthfinder: Consumer Health Information Search Healthline Kosmix Mamma Health Search MedStory PubFocus Scientific Commons Others: Search Engine Guide: Health Search Engines I particularly encourage exploration of MedStory. I have no affiliation with any of the products listed above. Competing interests: Author/editor of the Medical Library Association Encyclopedic Guide to Searching and Finding Health Information on the Web
Goggling and rational decision making for the busy GP 20 November 2006
Frans Boch Waldorff, GP, Senior Researcher, PhD Research Unit of General Practice, Copenhagen 1014, Christian Hermann Send response to journal: Re: Goggling and rational decision making for the busy GP	Dear friends, We read with interest the article regarding Goggling for a diagnosis and agree with the conclusions that “Doctors and patients are becoming increasingly proficient with the Internet and frequently use Google to search for medical information” [1]. However, the article deals only with the diagnostic part of our work. As GPs we have the most challenging task in this rapidly changing information society, where we are presented with all types of questions regarding illness, well-being and health from a non selected population. As GPs we have found great use of skills acquired as researchers which leads us to valid answers at the internet often during the consultation together with our patients. For the last years we have shared our experiences with our colleques in short intensive courses [2]. The systematic approach The obvious advantages of a systematic approach (the PICO model) when dealing with medical intervention lead us to categorize all types of questions we met in the clinic into four types: “Practice management”, “gate-keeping and cooperation within the health-care-system”, “diagnosis”, and “disease-management”. Each question is further focused by describing on dimensions as; “time at your disposal”, “seriousness of the problem”, “local/national/global” and “relevant internet site/database” How much time have you got? Don’t go on the internet, if you don’t have time to do so. Using the internet as inspiration is OK, if you have plenty of time. In our practice with a constant patient load, this is not possible. We have to “dance on the internet”, and skip the old virtue of going into details, and don’t get lost in the millions of hits at the web. Go straight for the answer, expect it within a minute, or else proceed and postpone seeking till later on. Save some time during the day and have a cup of coffee while finding an answer that satisfies your question. Seriousness of the question? You have to interpretate the result and translate it into a decision. Is it an easy recommendation for common cold you are going to find? or is it a potential life threatening condition you should find an answer for. A Critical approach to the database source is today as important as the answer you find. Is the wanted information of local, national or global nature? Is the information universal, will instructions from the neighbouring county suffice, as the question reflects national culture of treatment, or do you need to know, how to refer a patient to the medical ward? Which databases do you use? The Google is good for some purposes, but not always sufficient. Pub Med, Cochrane, national databases and local instructions are also very handy and needy for the busy GP. When the information is retrieved, the principles of the steps of EBM can be applied, and with information on the web becoming increasingly exhaustive and accessible to “lay” as to “pro”, the physicians ability to performing this will remain of crucial importance. 1. Tang H, Ng JHK. Googling for a diagnosis -use of Google as a diagnostic aid: internet based study. BMJ, doi:10.1136/bmj. 39003.640567.AE (published 10 November 2006). 2. Waldorff FB, Hermann C. [Rational decision making for the general practitioner: the effect of courses in Internet-based searches]Ugeskr Laeger. 2004 May 17;166(21):2054-7. Competing interests: Conducting courses in internet searches for GPs
Googling from an SHO Point-of-View 25 November 2006
Sabrina M Butcher, SHO Plastic Surgery JCUH, Middlesbrough, TS43BQ Send response to journal: Re: Googling from an SHO Point-of-View	I have myself used Google on a couple of occasions when presented with patients whose symptoms did not appear to present a diagnosis I was familiar with. One of those was a patient with purple urine in the catheter bag. After ruling out the standard potential causes of this such as consuming beetroot and reviewing the patient's medication chart I Googled 'purple urine'. The search produced information on Purple Urine Bag Syndrome (PUBS), a rare syndrome affecting chronically catheterised/constipated women who have alkaline urine or contract a UTI. Whilst it would not have affected the management of her UTI and subsequent change of colour of her urine to normal it was helpful to have a diagnosis to give to the patient. I doubt I would have found this through conventional book searches. Whilst I feel Googling may be useful for rarer and eponymous syndromes doctors are less likely to come across in day-to-day practice, the diagnoses which can be offered are obscure and could worry patients or the doctors looking after them unnecessarily. It is a tool to be used with caution and with the same processes we use to formulate a diagnosis in regular practice. The authors state that they selected the three 'most likely' diagnoses offered from Google. It would have been interesting to know what other diagnoses were suggested when they feel the search produced a match to know if these were similar or not, and if not have different the diagnoses were. Whilst I appreciate this study was looking at the use of Googling for doctors, and thus they will have used their knowledge to select salient features to search with, and decide which 3 diagnoses were most likely, it would be interesting to give the same information to members of the general public and see how close their search terms were to those of qualified doctors, and also what diagnoses they would select. Competing interests: None declared
Googling - Never the best to fall back on ! 25 November 2006
Dr. ALLEN. P. UGARGOL, MPH Scholar Achutha Menon Centre for Health Science Studies, Trivandrum - 695011 Send response to journal: Re: Googling - Never the best to fall back on !	I am surprised and appalled to find that physicians and surgeons are resorting to internet-searches to arrive at a diagnosis. Although, the internet-based journals have been used hitherto for aiding in planning advanced therapeutic methodologies or diagnostic planning, the use in diagnosis of conditions is unethical. A doctor, be it a physician or a surgeon, is bound to be an astute clinician who knows his patient's history and condition better than anyone on the net. A diagnosis must therefore follow from the clinical acumen and experience of a doctor in the clinical setting and not from what happened in some other setting somewhere. Whatever be the accuracy of the document on the internet, it can never be equated to being the complete truth and since settings and patients vary considerably, it would be unethical to base your diagnosis on similarities found on the internet. Although, it would be easy to condemn such doctors, it is more prudent to check the over-dependence of medical students on the internet while at medical schools itself. Spare the rod and spoil the child ! Competing interests: None declared
Google = 10,000 Monkeys? 30 November 2006
Reinhard Wentz, Retired TW2 &PS Send response to journal: Re: Google = 10,000 Monkeys?	Madam, Tang and Ng’s convincing pragmatic study on using Google as a diagnostic tool (1) attracted some criticism in the Rapid Responses section of the BMJ. For instance, their suggestion that ‘arguably, everything could be found on the web if only one knew the correct search terms’ should, in the opinion of one correspondent, not have passed the BMJ’s editorial scrutiny. Actually the suggestion is valid, correct, and important. I have replicated all Tang and Ng’s Google searches which did not result in a correct diagnosis (eleven scenarios). I took the search formulations for each scenario as described in their Extra Table (2), and retrieved usually several thousand hits on Google. I then added the correct diagnosis, and excluded hits from NEJM or the Extra Table (2) (already visible on Google (!) and generating false hits). If the resulting list was too long I added words from the clinical scenario, or the word ‘case’ and/or ‘diagnosis’, to reduce the probability of Google hits just mentioning the given symptoms for instance in different chapters of an electronic book, or a long web page, but not in the same patient. I could then for all eleven ‘failures’ identify some items which mention the given constellation of symptoms and the correct diagnosis (search log with URL of websites selected available from RW). Interestingly, five of these hits came from e-Medicine (3), the database which, as another correspondent suggested, could be added to a Google search (in the form of ‘emedicine’), intentionally to bias the result in favour of a search retrieving true-positive results. The suggestion that ‘everything can be found on the web if only one knew the correct search terms’ is of course not surprising but invites some worrying conclusions: • Lawyers can with ease and within minutes find cases of patients displaying certain symptoms which also include the correct diagnosis, which, they will suggest, a ‘negligent’ clinician missed. • The excuse, used since time immemorial, ‘I couldn’t possible know’ and providing comfort to the ignorant, has lost some of its credibility. One can find everything on Google, given time. Is Google perhaps the modern version of 10,000 monkeys sitting at 10,000 typewriters, who, given time, will eventually produce a true copy of ‘Hamlet’? Among the one correct version there will of course be thousands with just one or two typos. So, can Mark Twain’s remark ‘Be careful about reading health books. You may die of a misprint’ (4) be applied to Google? Respectfully yours, Reinhard Wentz 1. doi:10.1136/bmj.39003.640567.AE 2. http://www.bmj.com/cgi/content/full/bmj.39003.640567.AE/DC1 3. http://www.emedicine.com/ 4. verified at http://en.wikiquote.org/wiki/Mark_Twain Competing interests: I use Google often, WHEN APPROPRIATE
Authors' reply 30 November 2006
Hangwi Tang, Respiratory and Sleep Physician Princess Alexandra Hospital, Ipswich Road, Woolloongabba, Brisbane, QLD 4102 AUSTRALIA, Jennifer HK Ng Send response to journal: Re: Authors' reply	Doctors, patients and the internet Our article [1] was intended to highlight a current phenomenon and to stimulate discussion. It is undeniable that both doctors [2- 4] and patients [5-7] use the internet as an important source of health information. Our article was widely reported in the lay press. A common misinterpretation in the lay press was that doctors/ patients could magically become diagnosticians simply by using web search engines. The art of diagnostic reasoning is difficul