Off a desolate stretch of Route 4 in northern Calvert County, in a white dormered building sandwiched between a baseball field and an auto repair shop, a half-dozen physicians at computer screens are making virtual house calls to people they've never met -- and probably won't hear from again.
Welcome to America's Doctor, one of a growing number of online "clinics" that are changing the face of American medicine. Their lure: physicians who answer medical questions directly and -- in some cases -- diagnose patients and issue prescriptions.
Thousands of medical consumers, frustrated by the assembly-line pace of managed care and doctors who are too busy to chat about their health concerns, are turning to America's Doctor, as well as sites such as CyberDocs ("Where the doctor is always in") and WebMD ("Pay an office visit to the future of health care").
"People are saying, 'I want my doctor to spend more time with me,' " says Dr. David Stern, an assistant professor at the University of Michigan Medical School. "I think they're not getting the attention they need, they want, they deserve."
The online clinic is just one example of the Internet's impact on the traditional relationship between doctor and patient. From online support groups to cyberpharmacies to the use of e-mail between patients and doctors, medicine has taken to cyberspace.
"The role of the patient is shifting from someone who just passively follows doctors' orders to people taking charge of their own health care," says Dr. Tom Ferguson, editor of The Ferguson Report in Austin, Texas, which monitors the online health-care industry.
Dr. Andre Gvozden sits at the epicenter of the revolution. It's 8 p.m., and the Millersville pediatrician listens to a background of jazz and clacking keyboards while the questions roll in.
"How many liters of water should I drink per day?"
"What can you tell me about pin worms?"
"What causes memory inconsistencies?"
Gvozden, wearing braces on his teeth and a brilliant blue tie showing children holding hands, says he's seen it all.
Once a man logged on complaining of chest pain. Suspecting a heart attack, Gvozden told him to log off and call 911.
He hears from people who have no health insurance. From teens with sensitive sex questions they're too embarrassed to ask anyone face to face. From people who wonder whether massaging squirrel brains into their children's gums will ease their teething pain.
Those clacking keyboards are the sweet sound of vindication to Dr. Scott Rifkin, a Baltimore native who launched the service last fall on America Online, then on the Web a few months later. At the time, critics doubted whether anyone would stop by. They were wrong.
The America's Doctor Web site gets 500,000 visitors a month, Rifkin says. While not all visitors step into the virtual waiting room -- support groups and a medical reference library are big draws -- there's enough demand for face-to-face medical chat to keep the company scrambling for physicians. The service employs about 100 doctors in a variety of specialties.
"We could use twice that number," says Dale Hutchins, who operates the call center.
Its doctors see about 16 patients an hour on line, typically two or three at a time by clicking between "chat" windows. On rare occasions, Hutchins says, the virtual waiting room has been so packed that visitors have waited as long as two hours to see a doctor.
It's unclear how online clinics will survive financially. America's Doctor hopes to make money through contracts with local hospitals that sponsor the clinic as a "branded" Web service. Others hope to make money by charging patients directly, or through related businesses such as online pharmacies.
State regulators are watching online clinics closely because laws prohibit doctors from practicing in states where they're not licensed.
To deal with those restrictions, America's Doctor warns visitors that none of its doctors "will enter into a physician-patient relationship" or "engage in any conduct that involves the practice of medicine."
As a further precaution, patient and doctor are cloaked in anonymity -- the only information visitors provide is their ZIP code. Physicians are assigned at random, so visitors never know whether they'll get the same doctor twice.
"We don't try to diagnose. We don't prescribe drugs," Rifkin emphasizes.
Cheryl Wyatt, a mother of two who runs a day-care center out of her home in Shawnee, Kan., doesn't mind the limitations. "If you call the doctor's office with silly questions," Wyatt says, "they can get a little bit irritated after a while."
Wyatt turned to America's Doctor when she hit age 40. She wondered whether she should take vitamins, wanted to know more about attention deficit disorder after her son was diagnosed with it, and asked about a child in her day-care center who had a bump on his back that she feared might be from chicken pox.
"It's just nice to hear them say, 'If it was chicken pox it would be more than one bump,'" she said.
Some medical experts say, however, that defining the "practice" of medicine is difficult -- many doctors find it difficult to suppress their instinct to heal.
One of them is Dr. Claude Lanctot, a jovial 65-year-old gynecologist who is shaking his snow-capped head as he works two patients in the America's Doctor call center.
In one chat window, he's helping a young pregnant woman who fears she's showing signs of miscarriage. In another, he tends to a shaken middle-aged man whose mother is dying of cancer.
He tells the man to consider a hospice to "make your mother's last days as comfortable as possible." Then he types: "Good luck. My thoughts are with you." Later, he says he knows he's not supposed to encourage a relationship but finds it hard to forget his role as a doctor.
"Down deep, it's hard to hide," he says.
Not every online clinic is as conservative as America's Doctor. Doctors with CyberDocs, in Danvers, Mass., diagnose and prescribe drugs. First-time patients fill out medical history and credit card forms for the $50 consultation. When it's over, they receive discharge instructions. And if a prescription is needed, the doctor can send it via e-mail to an online pharmacy to fill and deliver.
Even so, doctors who work for the service treat only patients in their own state -- or outside the country -- to avoid breaking the law. They refuse to prescribe some potentially dangerous drugs.
In a less dramatic but equally important development, growing numbers of physicians are turning to e-mail to keep up with patients between office visits.
A recent survey of 10,000 doctors by Healtheon Corp. found that 85 percent use the Internet, an 875 percent increase from 1997. A third of the doctors have exchanged e-mail with their patients.
"There's no reason most medicine can't be practiced through e-mail," says Dr. David Voran, a family practitioner in Kansas City, Kan., who regularly corresponds with patients that way. "A large amount of what we do doesn't really require an office visit."
While a medical student in the 1980s, he and a classmate pioneered online medicine when they set up a primitive electrronic bulletin board. "We would get bombarded with medical questions," Voran recalls.
E-mail, he says, can eliminate one of the biggest health-care headaches: "telephone tag and voice-mail hell." Patients mail him when they run out of medication, want to reschedule an appointment, need a referral, or have a question like, "I'm starting to cough up this green stuff, should I come in?"
Patients with diabetes and other chronic diseases can send daily blood-sugar readings to Voran in an Excel spreadsheet so he can monitor them more closely. He also uses e-mail to tell patents of their test results quickly.
E-mail can head off medical emergencies. Voran recalls a hypertension patient in her late 60s who sent him six blood pressure readings a day via e-mail. One day Voran noticed the woman's pressure was shooting up. Alarmed, he had her come to his office, where he found that an artery to one of her kidneys had clogged. Surgeons saved the kidney.
"We would have never picked this up if we had waited for her to come in for a regular three-month visit," Voran says. If not for the e-mail, "she would be on dialysis on today."
Not all physicians are rushing to computers. More than a few fear unpleasant technological side effects, such as being deluged with e-mail about every sniffle and scratch.
"People are saying, 'Gosh, is this a dangerous thing or a good thing?'" says Stern, of the University of Michigan Medical School, who uses e-mail with patients.
Stern is launching a three-year study of doctors and patients who communicate by e-mail.
There are other concerns. Lawyers routinely dredge up old e-mail accounts for lawsuits, worrying doctors that their messages might be used against them.
"Malpractice attorneys are getting wise," says Dr. Daniel Sands, an instructor at the Harvard Medical School and an authority on e-mail and medicine.
Sands, who says he routinely fields requests from lawyers to produce patient e-mail, says, "I'm sure we'll see a lawsuit as this takes off more."
Online clinics are arming themselves with online malpractice insurance. "Believe me, I bled money to have it," says CyberDocs' Tom Caffrey. Americas Doctor purges the text of its chats from its computers at the end of each week to protect patients and themselves.
Privacy is also a concern. As more companies monitor employees' e-mail, patients run the risk of leaving a trail that contains sensitive health information -- such as an HIV infection or inoperable cancer -- that employers and insurers could use against them.
Most online patients aren't worried enough to return to the days of telephone tag, though. "I believe the benefits [of using e-mail] outweigh the risks," says Sands.
Cyber clinics
Here are Web addresses for online clinics in this article:
America's Doctor: www.americasdoctor.com
WebMD: www.WebMD.com
CyberDocs: www.cyberdocs.com
Pub Date: 06/07/99