The Doctor is ... YOU! Online Medical Symptom Checkers Examined
I'm a wreck. I think I might have osteomyelitis, or peripheral neuropathy, or even retrocalcaneal bursitis. I just hope it's not tarsal tunnel syndrome.
I'm also overstressed, overweight, losing my hearing and not sleeping enough. Even worse, I have a low IQ and my "real" age (taking into account my bad habits and so on) is 10 years older than my actual age.
Who needs doctors anymore? We've got the Web.
Yup, I learned all this stuff from visiting online health sites. There are dozens of them out there, and they all promise to help figure out what ails you. Of course, they all feature prominent disclaimers emphasizing that they should be used for information purposes only and you should see a medical professional for any real diagnoses.
But why bother? Even if you could schedule an appointment within the next three months (by which time the symptoms have usually disappeared ... or you have), it's much easier to type in few search terms or answer a few questions and get a list of potential causes of your symptoms.
And, people being people, you'll probably focus on the worst-sounding ailment and decide it's what you have. That's called "cyberchondria" by a couple of Microsoft researchers who have studied health-related search behavior. In their research paper, Ryen White and Eric Horvitz declared, "The Web has the potential to increase the anxieties of people who have little or no medical training, especially when Web search is employed as a diagnostic procedure."
No kidding. If I didn't suffer from anxiety before, I surely do now. Later, I'm going to take an online test to be certain.
My own self-diagnosis research wasn't scientific like Microsoft's. I just checked out five of the most popular (according to Google) health sites to see if they could tell me what's causing pain in my foot. (The sites are presented in the order I tested them.)
But I cheated. I know what I have, because a doctor told me. So I confess, I don't really believe I might have all those conditions listed above -- but I might have believed that if Doc hadn't told me I had plantar fasciitis. That's medical-speak for a strain of the fibrous tissue that runs along the bottom of the foot from heel to toe.
So, to gauge the effectiveness of online health sites, I used that example to focus on "symptom checkers" that typically let you indicate what part of the body is causing you problems and answer some questions to narrow down the list of possible causes.
The results weren't very encouraging. Some sites winnowed possibilities down to a manageable number that included plantar fasciitis, as shown in this video. But some didn't. And the logic underpinning the decision-tree process sometimes seemed absurd.
Being a layperson (with a low IQ, remember), I asked some bona-fide medical professionals to take a look at the sites and provide their assessments. Helping me analyze the symptom checkers were Dr. Laura Beaty, a family practice physician at Alliance Primary Care in Atlanta; Dr. Andy Spooner, a general practitioner with a specialty in pediatrics at Cincinnati General Hospital; and Dr. Viren Bavishi, a pediatrician at Wheaton Franciscan Healthcare in Franklin, Wis.
Dr. Bavishi said symptom checkers can be a good resource, but their usefulness varies on a case-by-case basis depending on what a patient's symptoms are, so he didn't want to compare them. One common problem he found: "There's a spectrum on what information they're giving you. It could be a lack of information depending on the illness, or it could be far too much [information] for what we're concerned about."
He would prefer that patients come in first so he can figure out what's going on, and then these sites could be "a great adjunct as an education resource. That's where I found it to be useful." But when the sites are consulted first, "I think it causes, in some cases, more stress and anxiety because people end up getting fixated on the worst-case scenario."
"Some of these symptom checkers are great," he said, "but it does sometimes leave out some of the questions or things that we may ask. Some variables that I think are important aren't accounted for."
Dr. Beaty and Dr. Spooner took my approach and worked through each of the sites to evaluate them individually. I conducted my own analysis before speaking to them.
Here's what we found.
My take: This is probably the most popular health-related site on the Web. Google ranks it No. 1. But I found some of that aforementioned absurdity here.
Upon landing on the symptom checker page, I was presented with a list of 76 possible symptoms or an interactive map of the human body that lets you select the bothersome part with a mouse hover.
After answering questions about age and gender (with optional questions about ZIP code and e-mail address, just in case you want another newsletter in your in-box), I eventually found the path to plantar fasciitis by clicking on the map's back view, then "leg" and then "sole."
I was then given a list of 21 possible conditions. A series of questions ensued, designed to zero in on the most probable cause.
Question No. 1 was the first of my problems -- how to describe the pain. I had a hard time deciding if it was:
- sharp or stabbing
- dull or achy
- burning or stinging
Is "sharp" that much different from "stinging"?
It turns out it didn't make any difference what answer I chose -- the end result was the same for every path I took through the process.
Not yet knowing that, I pressed forward through seven questions (although each one offered the option to "finish") and ended up with a list of 15 "conditions associated with the selected symptoms," with plantar fasciitis as No. 8 -- not that there was any indication that the ordering meant anything. (See the video below to track how I navigated through WebMD's symptom checker.)
Starting over and choosing the option to "finish" after the first question -- the pain description question mentioned above -- I was immediately rewarded with a list of the same exact 15 possibilities, but in a different order.
I started over yet again and chose "don't know" or "none of the above" for every single question, and yes, I got the same exact 15 possibilities.
So after choosing "sole" and "pain or discomfort," there was apparently no result possible other than the 15.
Except for one. The only way the list changed was if I indicated that I had suffered a catfish sting.
That's right, question No. 6 was:
Choosing option No. 2 added -- you guessed it -- "catfish sting" to the list of possibilities.
So if your sole hurts and you recently tangled with a catfish, you're told that the cause of your pain could be a catfish sting -- or 15 other things.
Excuse me? I mean, how many people have even seen a catfish? I can't figure out why "catfish sting" was one of the options and "stepped on a nail" wasn't, or maybe "walked over hot coals on a bet."
Conditions rounding out the 15 ranged from multiple sclerosis to poorly fitting shoes. Gee, thanks for narrowing it down. If you decide to click on each of the 15 items to get detailed descriptions and try to pinpoint your problem, I hope yours isn't No. 15 on the list.
WebMD does contain plenty of good information and services and looks like it could be quite useful, as do all the other sites. But for quickly and easily figuring out your specific problem through the symptom checker, not so much.
Dr. Beaty's take: She found WebMD and MayoClinic.com (below) to be very similar. Specifically, "they were literally too inclusive."
Her first test ailment of choice was a urinary tract infection. Going through the WebMD process, she ended up with 16 possible causes. "And then when you increase the number of symptoms -- which obviously in medicine helps you to better isolate the condition -- for these sites, it actually increases how many conditions they are including. So I went from 16 to 21 just by adding a few more symptoms. I thought that was kind of all over the map."
Dr. Spooner's take: He liked the way WebMD used a "Bayesian logic calculator" that lets users add multiple symptoms and tailored its results so, for example, the symptoms "cough and fever" would have a different result than "cough and wheeze." However, the results "are still very narrow. Clearly, these are small databases."
Physicians use a similar tool, he noted, that might come up with 200 possible causes, compared to the much smaller number offered by WebMD and some of the other sites. That helps him consider diseases that he might not otherwise have thought of. He said the professional tool also makes it easy to add many different symptoms and combine them in various ways to reach this large number of possible conditions.
My take: Here you're greeted with a standard (if rather ape-like) interactive human body map. But it operates a little differently.
Clicking on "Leg, Hip, Knee and Foot" and then "Toe, Foot and Ankle Injuries" brings up an overview page with all kinds of possibilities, some of which are categorized as "acute injury" or "overuse injuries." There are eight main acute possibilities and five under overuse, with plantar fasciitis No. 4 under overuse injuries.
But scroll down and things get weird.
Under a heading of "Check Your Symptoms" are a number of additional questions. One asks "Are you unable to free a trapped foot from an object, such as a pipe, toy or jar?" Another asks "Is an object, such as a nail, embedded in your toe, foot or ankle?" Answering "yes" brings up a page telling you how soon you should contact a medical professional.
I don't know about you, but if my foot is stuck in a pipe or has a nail sticking out of it, I'm thinking my first impulse isn't to go online to see what the problem might be and what I should do about it. I'm pretty sure I could muster up an accurate self-diagnosis here.
Giving credit where it's due, the site does go on to suggest calling a health professional immediately if -- and this is an actual example the site uses -- a high-pressure nail gun fired a nail into your foot. You know, just in case you logged on because you're confused about what to do: "Hmm, I just fired a nail gun into my foot, should I see a doctor or just try to walk it off?"
When I went back and clicked "noninjury," plantar fasciitis was No. 2 in a list of seven items under the heading of "Pain."
Dr. Beaty's take: "This is a more educational site. When you entered the symptoms, it didn't try to lead you to a diagnosis necessarily. It just opened up an entire page of information about -- for example -- urinary issues, so you went through everything and it was just sort of a dissertation on what all the problems were with little links where you could click and go into to get more information. So it was educational, but it would take a lot of time, and I don't think that most people want to spend that much time. Maybe some do."
Dr. Spooner's take: "They offer a very nice decision-tree-based ability to move through their information while paying attention to possibly serious conditions." He added that the site is "pretty much a database of articles with a symptom-based navigator."
Dr. Spooner noted that although the site offered limited combinations of symptoms, there wasn't a "blank box" where a second symptom could be typed in. He used the symptom "headache" to go through the checker and observed that if a child had a headache, there was no way to add the symptom of diarrhea. "It's quite necessary" to know if those two symptoms are being experienced at the same time, he said.
My take: No interactive map here. It starts out with a list of 28 adult symptoms and 17 child symptoms.
Going through the decision tree, I chose "foot or ankle pain" as the symptom. After several attempts to narrow down the final results, I ended up with:
"Located in: heel"
"Triggered by: injury"
"Accompanied by: inability to bear weight"
That brought up seven probable causes and a list of associated factors for each (with your choices in bold). Only three of those seven were included on WebMD's list.
Plantar fasciitis was No. 5 on the list. Clicking on it brought up pages detailing its definition, symptoms, causes, risk factors and other information, similar to all of the sites.
All combinations after choosing "heel" resulted in 11-item lists with just a few differences.
Dr. Beaty's take: She found MayoClinic.com to present fewer symptoms, but compared to WebMD "it was very similar in that you couldn't narrow down the scope at all, so I'm just not sure how helpful that would be to someone even with a common problem."
She thought both WebMD and MayoClinic.com let her navigate through the process well. But she was disappointed in both sites when she entered general leg pain as a symptom and neither site had prompts "to find out whether you had a deep venous thrombosis, which is something very significant with leg pain."
One feature that Dr. Beaty liked on the MayoClinic.com site was that after offering up a possible diagnosis, such as cystitis, "it listed the symptoms so you could go through at that point to see which one best fit you even if the symptom checker didn't get you to the place you wanted to get."
She was amused when she couldn't figure out how to specify female symptoms, "so it gave me prostitis. I thought that was kind of interesting."
Dr. Spooner's take: MayoClinic.com "offers a slightly more limited ability to combine symptoms, but has an excellent library of material with a strong pediatric section."
He said the lack of flexibility in adding symptoms "locks you into a path. They set up some guardrails -- here are the features you should focus on." There "weren't a lot of choices" offered after entering the initial symptom, he said; although those offered "were some logical choices" that worked fine sometimes, in other cases a regular Web search would provide more information if a user searched for two different symptoms.
My take: Like most of the other symptom checkers I looked at, About.com features an interactive human body map. The site tries to be all chummy and personal, stating, "We're sorry to hear you have foot pain!" and asking for forgiveness when it has to ask personal questions such as age and weight.
Because of confusing questions, I had to go through decision tree several times. Once I figured out the right responses, it took me seven questions to narrow down the probable cause to three conditions. Two of the three possible conditions matched WebMD's list, with plantar fasciitis listed at No 1.
The key was asking if I experienced pain after getting up in the morning and starting to walk around, after which the pain decreased greatly. That's a classic symptom of plantar fasciitis. None of the other sites I investigated asked this crucial question.
The site then offered the usual specific pages on symptoms, diagnosis, prevention, treatment and so on.
Dr. Beaty's take: "I did not like that one at all." She found that she couldn't even enter leg pain as an option. She could only enter ankle pain, "and it led you straight to strains, so it didn't get enough information and it didn't give you enough information. If you clicked on the pelvis area there, you couldn't even find urinary symptoms, so I thought it was just poorly designed and not helpful at all."
Dr. Spooner's take: He thought About.com allowed some combinations of symptoms, but it was more valuable as a "database of articles" rather than a tool to present a small number of possible causes through the decision tree.
"It's pretty much just a straightforward library of articles of high quality, with not a lot of ways to combine symptoms," he said. If he was worried about a complex set of symptoms that presented a whole picture, "this [site] wouldn't help me much." As far as content, however, he said "it's got great stuff" provided by Harvard Medical School.
My take: I couldn't figure out the point of this site's name. It functions like the others in providing a symptom checker and many other kinds of information, and it includes a "Misdiagnosis Center" that lists commonly misdiagnosed diseases. But I couldn't tell if its intent was to correct misdiagnoses or publicize the problem or what.
Anyway, the symptom checker boasts 10,000 medical conditions. It takes the list approach instead of an interactive map and lets you choose from common symptoms, browse alphabetically or pick from a full list of more than 3,000 symptoms.
I went to the alphabetical section and clicked on "heel pain." Sure enough, plantar fasciitis was listed as No. 5 of six causes. Three matched WebMD's 15. Adding many different second symptoms didn't result in any lists with plantar fasciitis.
Dr. Beaty's take: She found WrongDiagnosis.com to be "more geared toward the medical community, so I'm really not sure how a layperson would use that too well."
For example, she said that the urinary symptom pulled up 152 possible causes, and when you tried to limit them via the symptom checker, "you ended up finding things like urinary pain with acute Crohn's symptoms ... and you went through the whole diatribe of just really bizarre medical conditions that most people wouldn't even know. So unless you had a medical background, I don't see how that site would be useful for people at all."
Dr. Spooner's take: He said WrongDiagnosis.com "really feeds that need to find rare diseases. For some situations, that may be appropriate." For the general public, though, he said, "I wouldn't encourage people to go to WrongDiagnosis because it kind of overwhelms you with strange things."
He said a search of headache and bowel problems resulted in 268 possible conditions. The other sites, he said, do "a good job of putting up different guardrails so you don't go off on tangents." But here, for example, a bizarre condition called "arctic bearded seal syndrome" came up in a long list of results from one search. "I don't know how you would even process this," he said.
The final say
So here's the summary of how many clicks it took me to get a list of possible causes that included plantar fasciitis. These are the shortest routes I eventually found to get to the end result, often after several earlier attempts where questions were confusing and I ended on a page with no plantar fasciitis.
- WebMD: 12 clicks to get a list of 15 possible causes
- Revolution Health: 2 clicks to get a list of 13 possible causes
- MayoClinic.com: 5 clicks to get a list of 7 possible causes
- About.com: 9 clicks to get a list of 3 possible causes
- WrongDiagnosis.com: 1 click to get a list of 6 possible causes
So About.com narrowed down the list to the fewest number of possible causes, but WrongDiagnosis.com got to its final list quicker than any other site. There were surprisingly few common possible causes among the sites.
For my particular problem, About.com was the most useful because it asked the crucial question about initial pain experienced after getting up in the morning that decreases as you walk around. That's a classic symptom of plantar fasciitis and really focused in on my condition. Your mileage may vary.
Dr. Beaty's general observations about symptom checkers were mixed. "It's sometimes useful, I think, for patients to gain some information before they come in. But more often than not, it ends up wasting the doctor's time because they have to spend more time educating about why it's not certain conditions rather than just kind of dealing with the patient and the problem that they present and focusing on that."
She said patients often come in with printouts from magazine articles or other Web research about what their condition could be and ask, "'Why aren't we ruling out this?' when it's something like a urinary tract infection, which is very obvious. And then they're looking at it and getting 16 different options and wondering why we're not ruling out various pelvic pathologies like ovarian cancer."
It's not uncommon to see one or two patients a week with such printouts, she said. Patients coming in armed with information from the symptom checker sites are fewer, she said, averaging perhaps one or two a month.
She agreed with the Microsoft report that Web searches tend to escalate patients' fears. "Absolutely, just like when we were all in medical school, we all felt we had each thing that we learned about. It is human nature.
"It does make it a little bit more difficult as a physician. Once again not that it's more difficult for us to figure out what's going on, but then we have to deal with the misconceptions that the person walked through the door with."
Dr. Spooner said increased patient anxiety from Web searches has been going on for years, and in the pre-Internet days patients would come in armed with magazine articles.
Even though he sees only hospitalized patients now, he said "it's a pretty universal thing" for family members to bring in laptops and voice their concerns about possible serious conditions found on the Web. "I see it pretty much all the time," he said. "It's not a huge problem." Rather, he said, "It's a signal to the health care provider that you need to have a certain kind of conversation" with the family member, discussing what they're worried about and explaining "why I'm not worried about it."
He added, "If that's what they're worried about, that's what you should be spending your time on."
Dr. Bavishi said he probably experiences the cyberchondriac syndrome "once a week, if that much," depending on the season and other factors. More often, he said, his patients' family members consult Web sites while they're waiting for a call back from a doctor or just before a doctor's visit, a practice he encourages.
Some of the problems he pointed out with consulting the sites first, he said, are that their navigation can be confusing, their content and advice varies greatly, some vital questions may be missed, and a patient's "past and local history" isn't taken into account as it would be with a physician.
Also, "If someone were to take the advice of a symptom checker -- which again they're not supposed to -- but if they were to self-treat without the opinion of a physician, the problem is that follow-up may be missed and that can potentially turn into a problem as well."
He, of course, agreed with the sites' disclaimers that a diagnosis "is something that needs to be evaluated by a physician -- even by a phone call. A phone call to the doctor's office can actually be faster than scrolling through the symptom checkers, because we know what to look for, what questions to ask and what the concerns are."
"Bottom line for me is, nothing beats the advice of a doctor," Dr. Bavishi said. "We'd rather err on the side of you calling us to determine if the patient or the child needs to be seen."
See below for a list of many other online tools available to give you information about your hearing, weight, health habits, "real" age, mental ability, psychological soundness and much more.
I'm still worried about those. I'm off to my home computer to take that anxiety test -- if I can dodge those pesky catfish.