Kerbside Consult

The Doctor Is In — But Is Anyone Listening?

Thirty years of medicine, patients and the changing meaning of trust.

Cyberdoc — writing on medicine since 1995

‘I read somewhere…’

For most of modern medicine, information flowed in one direction. The doctor had the textbooks, journals and training; the patient brought the symptoms, the history and the experience of living with them. The consultation depended on both, but the doctor usually held the authority to interpret and to decide. The Internet changed who could reach the information. It did not make the two roles interchangeable.

The question is no longer whether the patient should have a voice. Of course the patient should. The harder question is what the doctor must still do when medical information is already in the room.

The consultation may be a partnership, but clinical responsibility is not divided equally. The patient’s experience, values and right to decide must be respected; nevertheless, the doctor remains the trained professional responsible for making the diagnosis, weighing the evidence, recognising danger, recommending the appropriate course and warning against unsafe choices. Information may be shared and decisions discussed, but clinical judgement and professional accountability cannot be outsourced. The patient must have a voice — but clinical accountability cannot be shared away.

When the library door opened

In 1997, I was writing Cybermed columns to help doctors find MEDLINE. Now patients bring the search results with them. Vads Corner went online in October 1995. When I began writing Cybermed for Berita MMA in March 1997, the immediate problem was helping doctors use the Internet: where to find a paper, how to search MEDLINE, whether a website deserved to be trusted. We spent less time asking what would happen when patients found the same door.

By 1998, Malaysian doctors were already describing how the Internet was changing practice. Dr Alan Teh spoke enthusiastically in a Cybermed interview about PubMed and online journals. Surgeon Dr Davaraj Balasingh had been online since the early JARING days of 1993 and was already conducting Internet roadshows for doctors by 1994. But what strikes me most today, reading back through those interviews, is Davaraj’s warning:

“Most of the resources are already available on the net. But one has to be careful of the amount of information that is available. Some of the information are put up by patients and laypersons, and not by doctors, and may be controversial.”

That was 1998. We had barely learnt to browse the Web, yet the problem that would define the next three decades was already visible: access to information was becoming easier; deciding what deserved to be trusted was becoming harder. That warning about provenance was reasonable, and it remains reasonable. But it is worth saying plainly that patient experience and lay knowledge have their own value — and that professional authorship alone has never guaranteed accuracy. What Davaraj was pointing to was a need for critical appraisal, not a case against access.

By 2000, patients were already arriving online, and my friend and then Berita MMA editor Dr David KL Quek had already seen where this was going. In his July 2000 editorial, he wrote:

“Information empowerment of the public is already upon us and will daily grow ever stronger. The World Wide Web and the Internet has put paid our hitherto monopolistic control of whatever medical information that we thought we had to ourselves alone.”

He also anticipated what this would mean inside the consultation: patients would expect to be “better heard” and to have a bigger say in decisions about their care. What strikes me now is not that we saw the information shift coming. It is that we underestimated the second half of it. Losing a monopoly on information is not the same as losing the responsibility to practise medicine.

What the patient now brings

The better-informed patient is one of the Internet’s genuine achievements. Someone with a rare disease can find a specialist centre; someone facing surgery can read the alternatives; someone frightened by a result can arrive with questions worth asking. The early Vads Corner outbreak pages — enterovirus, Nipah, haze, SARS — were built for exactly that purpose, and the messages readers sent back taught me something important: people searching for health information were rarely looking only for facts. They were looking for interpretation and reassurance.

Consider a son who accompanies his father to the doctor: “I read somewhere and I think my dad has dementia.” Managed well — the concern heard, the history taken, the relevant signs examined — the son’s anxiety can be addressed honestly and his trust in the doctor deepened rather than lost. Managed poorly, they leave with the same fear and less confidence in the person they came to. That is not a technology problem. It is a consultation problem.

But the information now comes from very different places. A clinical guideline, a patient forum, an influencer and a family WhatsApp message can all arrive prefaced by “I read somewhere.” Social media delivers claims before anyone goes looking; confidence and repetition can make a claim seem well evidenced. The doctor has to understand not just whether something is correct but why it was persuasive to the person who brought it.

The pattern is visible closer to home. In one Malaysian primary-care study, 54.7% of 381 patients had searched online for health information, yet discussion of what they found with their doctor was uncommon. Trust in healthcare professionals (87.9%) remained substantially higher than trust in websites (45.6%) or social media (20.7%). One clinic, not the whole country — but it reveals a real possibility: online information may shape a patient’s expectations before a word is spoken.

Google weakened the doctor’s monopoly on information. Social media weakened the traditional hierarchy of expertise. Generative AI has now given patients not just information but interpretation — a differential diagnosis, an explanation of a result, a proposed course of action. I have dealt with that particular arrival separately. The point here is historical: AI did not create the redistribution of medical information. It is the latest step in a process that has been under way since 1995.

What information cannot do

A search result can tell someone that headache occurs with brain tumours. It cannot say how likely a brain tumour is in the particular person sitting in the chair. Clinical medicine lives in the gap between what is possible and what is probable. History, examination, time course, risk factors and the absence of expected findings all change the picture. A list of diagnoses is not a diagnosis.

The same symptom, with a different history or examination, can call for reassurance, investigation or urgent action. A web page cannot determine which situation has walked into the room. Nor should the doctor promise certainty where none exists: part of sound judgement is explaining what would change the assessment and when the patient should return.

This is where the doctor remains essential — and where shared decision-making is most easily misunderstood. It does not mean laying out a menu and withdrawing. Patients differ greatly in how much decisional responsibility they want; the same person may want to examine every option for one problem and need clear guidance when frightened by another. There is a difference between giving a patient a choice and leaving a patient to choose. A doctor who merely lists the options and asks the patient to decide has not necessarily practised shared decision-making. Sometimes that is responsibility transferred under the language of autonomy.

Most patients still deserve to hear: “Given what I know about you, this is what I recommend — and this is why.” That is not a command. If two reasonable courses carry different burdens, the patient’s priorities may determine which is preferable. If a proposed course is unsafe, the doctor must say so plainly. The patient’s authority over what happens to his or her body and the doctor’s authority in clinical judgement are not the same kind of authority. Good medicine requires both, with the difference made explicit rather than blurred.

Information equality is not expertise equality.

What gets between us

While patients acquired screens of their own, doctors acquired the electronic record. Its advantages are real: legible notes, accessible results, medication information, continuity of care. But it also introduced a third object into an encounter that had traditionally been between two people. In an observational study of 100 primary-care visits, doctors spent about 31% of visit time looking at the record. Research on screen-sharing suggests that technology does not have to disengage the patient: when doctors actively showed the patient what was on screen, engagement was higher than when the screen remained a private workspace.

Even a sensible act of checking can be misread. A doctor who quietly searches for an unfamiliar drug interaction or the latest guideline may seem unsure or inattentive. Saying “Let me check the current recommendation while you’re here” is enough. Careful verification should inspire confidence, not require the patient to guess at it.

Time makes all of this harder. A systematic review of more than 28 million primary-care consultations across 67 countries found extraordinary variation — from under a minute in some settings to more than 20 in others. Where long-run trends could be examined, they differed by country; the evidence supports short consultations and international variation rather than a universal decline. The safer conclusion: more to discuss does not guarantee more time to discuss it.

How trust is earned

It is tempting to read a patient’s questions as evidence that trust in doctors has collapsed. But asking why an antibiotic is necessary, whether an operation has alternatives or what the evidence shows is not an act of disloyalty. It is participation. The older consultation could feel easier because the patient had fewer ways to question the doctor. That was not necessarily deeper trust.

Trust now has to survive competing claims, publicised medical errors, commercial interests and an online environment where every confident assertion finds an audience. It is earned when the doctor takes a concern seriously, explains what is relevant to this patient, is honest about uncertainty and makes a recommendation. It is also earned when the patient can say what has already been read, feared or told to them without expecting ridicule.

One question is worth asking early: “What have you already read about this?” Another should follow: “What worries you most?” The first reveals what is already shaping the consultation; the second reveals why it matters. Neither requires the doctor to agree with what the patient found. Both make it easier to address it honestly.

Listening works both ways — but the obligations are not symmetrical. A frightened patient does not have to earn permission to speak. The professional carries the greater duty to make room for that voice, and then to use clinical expertise rather than retreat from it.

The doctor is still in the chair

In 1997, I was helping doctors find MEDLINE. The search results now arrive with the patient. What has not changed is what the person across the desk needs: someone who will listen, examine, think and stay accountable for the advice given.

The doctor is in.