An excellent place to start, David. You've zeroed right in on the ambivalence doctors often feel about all the random information sloshing around out here on the Internet. I've had many of the exact same feelings, but like you seem to, I wonder how much our concerns make sense when we scrutinize them more closely.
You begin with two extremely interesting cases that are worth dissecting for a moment. It might help us figure out what we are looking for as we shop the Internet's health & beauty aisles. The first thing that struck me about your cases, the cases of Mr. Psoriasis and Mrs. Mohs, was that they actually got pretty decent information off the Web. They just used it badly. The second thing was that either case could have happened no matter where they got their advice--whether from onhealth.com, a TV ad, or old Uncle Flatus who says he used to be a dermatologist in Albania. People have gotten bad advice, and used good advice badly, for centuries. The question is whether there's anything special about the Internet version.
I can think of at least two reasons we might be particularly concerned about medical Web sites. One is if they provide new ways to circumvent basic protections in our health system against harm--for example, providing potentially dangerous prescription drugs to people sight unseen. Fortunately, none of the Web sites we're looking at do these sorts of things.
The second concern is whether information anarchy (I'm not sure it's quite yet a democracy) will turns out, on the whole, to be bad for people. It's not inconceivable, although it would surprise me. The only study I know of that attempts to answer this question was a randomized study of 40 women with invasive breast cancer. The researchers gave half of them home computers with access to medical staff by e-mail, patient discussion groups, and Web site information. And compared with the control group, these women had significantly less depression, anxiety, and distress about their condition. But the study was unfortunately way too small to measure any actual cancer outcomes.
I'm going to take it as a given--and I suspect you will agree with this--that the medical Internet will turn out to be at least neutral overall for people's well-being. What I think is cool, though, are all the different ways in which the Internet could transform public health for the better. Providing basic medical information, which is what all the Web sites we're looking at do, seems like only the simplest level. It is certainly fine and dandy, but it's also incredibly boring--sort of like encyclopedias. Now, I love a good encyclopedia, and I suppose we'll have to spend some time sorting out for people which one seems like the best one, but who wants to spend a full week reviewing encyclopedias? (My vote so far, by the way--and it's not without qualms--is for drkoop.com. And yours?)
Much more interesting would be if the Web sites actually helped people figure out not how to be a doctor but how to get more out of the doctors you see. Rate them. Provide clues about what to look for when you're getting snowed and when you're getting reasonable care. Offer access to the gossip, both good and bad, that their patients have about them. My experience is like yours in that most of the patients I see feel no compulsion to control much of their care. They simply want a doctor. You mentioned the art of medicine, the art of doctoring, and what's striking is that there is now an art to being patient, too. Patients have to know when to assert themselves and know when to trust.
Now, do any of the Web sites actually provide clues about how to know this? That seems like a question worth getting into.