Sunday, June 19, 2011

The Filter Bubble in Medicine - Patients beware!

Eli Pariser coined the term "Filter Bubble" to suggest how web services customize the information we see online and thus can prevent us from getting exposed to information that could challenge or broaden our vision.  You can see his Ted Talk video here:



So how does this apply to medicine?
When a patient gets admitted to the hospital via the Emergency Department or gets transferred from another hospital, the information about the original reason for presentation is progressively filtered till an attending physician or a consultant on the hospital ward is at serious risk of being in a filter bubble.
So what does that mean?

  • The first person to see the patient and the family has the best chance to get a true history about the symptoms and the course of illness that led to the presentation.  That person has no other source of information but to talk to the patient and the family.
  • That person then, usually, documents this history in the paper or electronic medical record.  
  • Everyone who subsequently sees the patient tends to look at this record before interviewing the patient.  This does spare the patient repeated questioning but removes the physician one step away from the original source of information.  
  • In addition, the family members often leave the patient after they have given their version of the story to the first health care worker.
  • The patient often is also tired, unwell, and every physician has had the experience of the patient telling them, "I already answered all these questions.  Why don't you look it up and leave me alone!"  
  • What most patients are unaware of is that the history alone when properly elicited can diagnose more than 50% of the cases correctly!  History taking is an art and science and improves with experience.  Often the first person to interview the patient is either the least experienced or the least qualified.  
  • Also as the patient makes his/her way through the various tiers of the health system, a number of tests get ordered and results become available.  The information from these tests gets tagged into the history and often even replaces it.  Thus the patient with severe abdominal pain and nausea and vomiting becomes the patient with ileus and then the patient with pancreatitis and high triglycerides.  Somewhere along the line the fact that a new medication was recently started is filtered out of the information that the consultant or attending physician gets.  
  • The electronic health records have exacerbated this problem as the documentation is available long before the patient actually reaches the hospital ward and thus the filter bubble is created before any chance of getting the history from the original source!  
So what is the moral of the story?  
If you are a patient, or a relative, as far as possible try and provide history whenever a doctor asks about it.  History taking is critical and some information you provide might prevent a catastrophe'.  To all doctors in training, remember to go to the original source and get the story from the "horse's mouth" as far as possible.  Patients don't present with community acquired pneumonia, they present with fever, chills, shortness of breath and a cough!