A recent article in The Economist, after bemoaning a spate of medical scandals in Britain, closed on an optimistic note: the Internet promises to change for the better the future of health care in Britain. "More information will create a demand for more choice; and effective medical treatment is more likely where doctors bother to listen to their patients, and patients know enough to ask the right questions, and demand truthful answers."¹ Expressions of confidence about the powerful and positive difference the Internet will make for health care are by now commonplace. But, as Aristotle would have it, we ought to listen to the wise rather than the many. Should we be so confident about the benefits of the Internet for health care?

Insightfully, The Economist article turns our attention to the physician-patient relationship as the locus most impacted by the Internet. Some analysts suggest this relationship may be transformed by e-mail. Rather than spending valuable time in oral conversation with patients, physicians will, at their convenience, consult on line with those patients who pay flat-rate fees or time-based fees per on-line consultation. These consultations are unlikely to satisfy, or long satisfy, any but the most devout techies, never mind the moral issues that surround such consultations.

More plausibly, both patients and physicians will increasingly employ the Web as a new source of medical information. Medical textbooks are expensive and not easily digested. Popularizations of medical texts have not achieved a status significantly greater than folk medicine, however well they have sold. The likelihood of our becoming a nation of medical autodidacts has never been great. But it isn't as unlikely that the next generation may be a generation of medical technodidacts. It is quite conceivable that soon, just as we rush on line to CNN.com for the latest news or to the Weatherchannel.com for an up-to-date weather report, we will rely primarily upon the Web for health-related information.

Why not relish that possibility? Why the reservations in welcoming the Internet as a valuable new means of medical information? Why not embrace the Internet as a tool to liberate us from our reliance on the knowledge of physicians and other healthcare workers? To answer these questions we do well to reflect upon the ideal physician-patient relationship. And since our interest is in the information available to patients, in our understanding of health and well-being, let us focus upon the role of the physician as teacher.

COVENANTAL MEDICINE AND THE PHYSICIAN AS TEACHER
William F. May's The Physician's Covenant, republished last year in a second edition, continues to be one of the most helpful and insightful analyses and critiques of the physician-patient relationship. May argues that the core image that should inform and guide the practice of medicine is "the healer as covenanter." In developing this image of covenanter, he contrasts a "professional ethic that prizes technique as a shield against ties" with a professional ethic in which one understands oneself as part of a "bonded world."² Understanding the practice of health care as bonded, as covenantal, means, as one interpreter has put it, that:

Thus, May argues, the practice of medicine occurs in a social context, a community in which health is one good, but not the only good. Physicians and other healthcare workers are educated into the medical profession as a result of the values, and to some extent through the largesse, of the communities to which they belong. The practice of medicine is always, in part, a repayment of a debt to the community.

Health care at its best is covenantal rather than contractual, a relationship with "a gratuitous, growing edge."⁴ The health, the "well-working," of the patient is the goal for both patient and physician. This good of the practice of medicine cannot fit the constraints of contract, but demands that physician and patient reach further than the contract obliges. To recognize the "donative" shadow—cast by physicians, other healthcare workers, and their patients—is to grasp the minimalist character of contractualist medicine and to begin to understand how much more is required of both physician and patient in covenantal medicine. The physician stands in covenant with patients, a relationship of mutual trust and obligations.

This understanding of medicine and its goals, of the relationship of the healthcare team to community and to patient, leads May to consider other images of the physician. For example, the image of the physician as covenanter informs and transforms the image of the physician as teacher. The good of health is not the possession of the healthcare team nor theirs alone to impart. This good is achieved only, if at all, as a result of the cooperative efforts of both patient and an extended medical staff—a medical staff, May takes pains to point out, whose very base of expertise lies in "the communal origins of professional education and the duty to share generously what one knows."⁵ As the education of healthcare workers is, fundamentally, a gift of their community, so the healthcare team itself gives, offering the teaching they have received as gift to the patient.

Physicians must, then, be teachers to accomplish the telos of medicine; the role of teacher is an essential aspect of the physician's identity. Physicians teach and learn from other physicians and teach their healthcare teams and, ultimately, their patients. This teaching, is intended always for the particular good of the patient. It is aimed sometimes at cure or restoration (traditionally represented by the Greek god Asclepius), sometimes at prevention (traditionally represented by the goddess, Hygeia), and sometimes at care. If the well-working of the patient is to be achieved, then the patient must walk hand in hand with Hygeia as well as with Asclepius, a walk that requires the guidance of a teacher.

Some may argue that this conviction that physicians are teachers whose subject matter is the art of living well and suffering well is a view, thankfully, that we have outgrown. At last we've come to recognize and respect the autonomy of the patient. Patients have their own values, frequently values unknown to and not shared by their physicians. Physicians ought not to presume that they know what it might mean for a patient to live well, it could be argued. That is for the patient to determine. On the contrary, the knowledge of the physician is to be placed in the service of the values and aspirations of the patient.

There are, of course, many different types of teaching. A style of teaching appropriate in one context may not be appropriate in another.⁶ The style of Socratic teaching is most appropriate to the physician-patient relationship. On one hand, this style depends entirely upon the recognition of the student as independent learner, yet it does not reduce the teacher or the teaching-learning process to a mere tool to be used entirely for the student's gain. Socrates sees the teacher as midwife, one who aids in the delivery of a child that is not hers. The midwife recognizes that the goods of her practice—a healthy mother and child—are integral to the practice and are goods that exist independently of the desires of either her or her patient. The autonomy of the patient is recognized within the context of a mutual commitment to a healthy delivery.

As midwife, the teacher recognizes that which is to be taught and learned belongs to the student in a way that it does not belong to the teacher. Thus, Israel Scheffler writes:

Thus, to teach Socratically the physician must teach humbly, in recognition that she may not know what suffering means for this patient. To suffer well is inextricably linked to how the patient sees the world and her place in it.

As midwife, the teacher's relationship to a student is ordered by a practice and the goods of that practice. The point of teaching is the acquisition of knowledge and the development of wisdom, a goal to which both teacher and student must be committed. The student in this relationship cannot declare "I don't want knowledge; I want a silver Porsche," for to make this declaration is to dissolve the relationship of teacher and student by failing to recognize the practice in which the two are engaged. Analogously, the physician as teacher places her skills, her expertise, her knowledge, not in the service of any goods the patient may desire, but only those goods of the practice of medicine. She teaches Socratically when she assists the patient in the development of an understanding that will enable the patient to live well and suffer well.

At their best, then, healthcare teams and their patients work together toward the same goal, that of the "well-working" of the patient. This work requires an awareness of, and attention to, patients not only when they are ill, but prior to the onset of illness as well. In health care properly conceived and practiced, healthcare workers equip and enable patients to attend and observe, to anticipate, to record and respond to their physical well-being, and to articulate their observations and worries to those who cooperate with them in pursuit of their well-working. This training of patients does not come easily in a world in which patients may not seem as perceptive or as single-minded as their physicians might like. If the goal of health care requires good teaching, then good teaching requires not only dedicated students, but teachers with the time, energy, insight, experience, and patience to communicate with and to motivate their patient/students.

Throughout the history of medicine there have been challenges to this understanding of patients and physicians cooperatively pursuing patient well-being and to the image of the physician as teacher. Teaching is a demanding task, requiring intelligence, skill, and virtue in student and teacher alike if understanding is to be achieved. But those who suffer may be more interested in the relief of their suffering than in understanding. Those who are not suffering may feel no compulsion to understand that which does not plague them. And so it has long been. As Pedro Lain Entralgo has observed, in classical Greece the "rough empirics" practiced the equivalent of a "veterinary practice upon humans." Their patients, they argued, were interested in healing and health, not understanding, and so they made no attempt to teach their patients.⁸

More recently, the challenge has been that patients and their healthcare team cannot genuinely cooperate, for cooperation requires an approximate equality of status of the contributing parties, an equality that cannot be achieved in health care. The patient waits ever needy, while the healthcare team has the knowledge, skill, and experience to care for patients who cannot care for themselves. The gap initially created by the disparity between that which the physician understands and that of which the patient is but vaguely aware is assumed to have widened with the modernization of medicine post-Enlightenment. The technological developments and the explosion of medical knowledge in the last century were believed to have increased irreducibly the distance between physicians and patients, permanently establishing the partnership of two unequals. Thus, to quote William F. May:

THE PHYSICIAN AS TEACHER IN THE AGE OF E-HEALTH
Things have changed radically in the twenty years since May first wrote these words, and even the technicians, of whom May is critical, are considerably less sanguine about their corner on medical information. Today there are more than twenty thousand web sites devoted to health care¹⁰ and some predict that number will grow at a rate of about 10 percent each month for some time. A recent Pew study indicates that fifty-two million Americans, or 55 percent of those with internet access, have gone on line in pursuit of health or medical information.¹¹ Of these, over 90 percent said the information they found on line was useful, and thus indicated an intention to return to the Web for medical information. In short, the age of e-health has arrived.

It is not surprising, then, that many, like the author writing in The Economist, view this new burst of access to healthcare information as salutary for the physician-patient relationship, assuming that the ease with which patients can now access information will level the playing field between physician and patient. Thus, Wanda J. Jones writes, "The Internet . . . blows wide open the medical guild system's historic hegemony on medical knowledge."¹² Futurist John Naisbitt writes:

Already circulating are quips suggestive of the changes and problems that result from this new access to online information. There is, for example, the patient who is diagnosed by his physician as being "Internet positive"—he finds the information he needs exactly when he needs it rather than making an appointment to have an unnecessary conversation with a somewhat less than informed physician. And many are the concerns that have already been raised about e-health. Chief among these are concerns about the accuracy of the information patients are accessing on line. For example, researchers in Camden, N.J., recently reported an evaluation of web sites providing information about breast implants. Three major search engines turned up forty-one web sites focusing on breast augmentation. Having examined the sites for detail, for accuracy of information, for fairness in exploring alternative techniques, for honesty in presenting bad results as well as good results, the researchers could recommend only 15 percent of the sites to patients—and none of these could be recommended enthusiastically and without qualification; another 28 percent were considered neutral; and they would recommend against consulting the remaining 57 percent.¹⁴ A 1999 University of Michigan survey of 400 different health web sites found that at least half of the sites had not been scientifically reviewed and that at least 6 percent of the web sites surveyed provided incorrect information.¹⁵ The Pew study goes on to suggest that confidence in the credibility of web information increases as age and formal education decrease.

The information discovered on line may be not only incomplete or inaccurate, but also dangerously misleading, encouraging confidence in a diagnosis that is little better than guesswork. Joseph DeLuca and Rebecca Enmark mention a web site that offers patients an on-line questionnaire that may diagnose at least thirty-seven mental disorders, including major depressive disorder, bulimia nervosa, schizophrenia, and borderline personality disorder.¹⁶ Imagine the unwary web surfer who relies on such a diagnosis and begins her own regime of treatment in response!

Likewise, gullible web surfers may easily be lured into purchasing sham medical products distributed on line. A web distributor of a faulty home HIV test kit was prosecuted last October for misleading more than 600 purchasers into thinking that the Food and Drug Administration had approved his product. Quack doctors and sham medical products are, of course, nothing new, and the medical profession, precisely because it understood itself as a profession, was not at a loss to regulate and control dangerous and ineffective medical care and products. But that was before the age of e-health.

These examples suggest that a patient may jeopardize his well-working not only by his ignorance of or his failure to act upon what he ought to know about his physical flourishing, but also by his mistaken beliefs about his health and the actions he takes based on these mistaken beliefs derived from apparently authoritative internet sources. Physicians and healthcare teams increasingly may find themselves correcting misinformation gleaned from on-line sources and mistreatment that has resulted from inexpensive and faulty, yet apparently approved and safe, medical products. In short, in the age of e-health, physicians may need to teach subversively: less a matter of trying to teach a patient what she may not know and more a matter of convincing her that she is less knowledgeable than she may believe.

The readiness of patients to seek information on line, despite some warranted anxiety over the accuracy of that information, is a fact of health care in the age of the Internet. Some patients are confident that they can get better and faster information from the Web than from a medical clinic. Indeed, frustration with the quality and speed of information conveyed by a healthcare team appears to be the primary motivator in the quest for on-line information. Ironically, it is thus the failure of healthcare teams to effectively teach that is largely responsible for the evolution of a new and different task of teaching patients, a Socratic task of drawing out from patients what they believe they have learned from their web sources, followed by a critical examination of these claims to knowledge.

Unfortunately, as in the past too few physicians have found the demands of the delivery of modern health care hospitable to teaching, so it appears that too few physicians are currently in a position even to begin to develop a Socratic style. Physicians already exhausted by their heavy workloads have neither the time nor the technology to improve responsiveness to the informational needs of Internet-savvy patients. Flower and Guillaume refer to a recent American Medical Association study indicating that of the 600,000 doctors in the United States at least half of these are in one- or two-physician practices. "The majority has one standalone computer, just for billing, and it's not on the Internet."¹⁷ The children of physicians may be far more prepared to engage electronically-savvy patients than their parent-physician.

We should avoid simplicity about the psychology of belief, but, generally in a print culture, we more easily believe and rely upon what appears in print. Even the anxious, suspicious "health seeker," to use the Pew Study's term for those who seek health information on the Web, is disposed to believe information discovered on line. As a consequence, web-savvy patients will typically enter a conversation with the healthcare team with a firm confidence of belief. If patients believe they have knowledge that their physicians lack, or if patients believe they have knowledge that suggests that the physician is "holding back" information or treatment, the results are, in fact, often salutary for the patient. He or she may have the resources and the wherewithal to gain a second opinion, or to select a superior treatment unknown or unavailable in the area, or to educate the physician about what treatments are being tried elsewhere.

What is salutary on some occasions is not, however, salutary in all, and may in fact be erosive of highly valued practices. Patients whose confidence that their medical knowledge is growing as, correspondingly, their suspicion of their physicians is deepening, may be conferring with frazzled physicians increasingly skeptical of the presumed knowledge of their patients. The result may be two parties, neither of whom is able to hear and trust the other. Or, harried physicians with too little time to teach may dismissively refer web-ready patients to the Internet rather than undertake the more time-consuming task of teaching the patient themselves. In short, there is good reason to worry about the effects of the Internet upon physician-patient relationships, good reason to think that, whatever the benefits of the Web, they may not include supporting and encouraging covenantal relationships between physicians and patients, nor even tolerable contractual relationships.

Whether or not the Web genuinely levels the playing field of physicians and patients, it is conducive to the development of a confidence in patients and a dismissiveness in physicians that sets the stage for physician-patient confrontations. Unfortunately, we are ill-equipped to avoid such confrontations. In the absence of the conditions necessary for an informed and critical evaluation of information gained from web sites, in the failure of Socratic teaching about one's health, the already tenuous bond between patients and healthcare teams is likely to break. The hymns of information patients hear from Internet sirens are but noise to physicians rushing from patient to patient. "Tone-deaf physicians will not hear the music that sings my health," thinks the patient. And so the insufficiently skeptical patient may turn away from her physician in search of another who seems to hear what she hears, or she turns hopelessly from the practice of medicine altogether. What we can expect, in any case, is an increasingly adversarial relationship between physician and patient, an abandonment of Hygeia and Asclepius.

Our dilemma is this: our failure to protect the institutions that make possible the practice of a bonded, covenantal medicine has made it nearly impossible for physicians and other healthcare workers to fulfill their roles as teachers at the very moment the great knowledge explosion most demands. Although we have trained physicians to be teachers, we have tolerated a system of healthcare delivery and payment in which physicians cannot afford to teach. The fallout has been patient ignorance. Lacking understanding, patients have had little choice but to entrust themselves to physicians who have all but abandoned their duties as teachers, who have failed to provide the information that might have made patient trust something other than blind faith. In an era in which autonomy is viewed as the greatest of goods, the patient's reliance upon the superior knowledge of the physician cannot but be unsettling and unhealthy to patients. The Internet, which at first appearance promised to transform the relationship of physician and patients to a partnership of equals, has in fact fanned the flames of adversarialism. Either we resign ourselves to one more depressing characteristic of postmodernity—the perception that every relationship between individuals is, finally, a struggle for power—and learn to treat our bodies the way we treat our cars, shopping around for a mechanic who seems to have some sense of how I want to drive and care for my car, and who will do the work I want when I want it for a price I can afford, or . . .

Or what? With generosity and imagination we can try to discover resources within our current medical practice and the institutions that sustain that practice which will enable us to reclaim the teaching role of healthcare teams and respond to the new setting created by the Internet. We can, perhaps, imagine increasing stratification and specialization in the work of those who care for our health and allocate teaching responsibilities in light of this specialization. We can invent new areas of medical expertise, and equip individuals whose training prepares them to act as intermediaries between the technically knowledgeable and dexterous medical specialists and patients who have neither the leisure nor medical background for understanding the complexities of modern medicine. We can, in short, try to rethink what it might mean today for physicians to be teachers and covenantal healers and what the practice of covenantal medicine requires of us. Recovering medicine as a practice at this time and in this place will not be easy, but the alternative to this recovery, the alternative to a reaffirmation of the covenantal relationship of physician and patient and all that relationship entails, is a gradual yet increasing alienation from our bodies, an alienation already present in our inclination to seek knowledge and insight from things rather than persons. If I am more ready to encounter the world, more eager to gain knowledge, by some means that trims and pares those parts of my experience outside of my control, ready ever and always to shape my immediate world by the click of a mouse, I have begun to lose touch with what it means to inhabit the world as an embodied creature.

The Internet can be a marvelous tool in our recovery of attentiveness to the goods of health care. The speed and ease of access to information it makes available can be placed in worthy service. But mindfulness about its value as tool, and only as tool, is called for, lest we lose our bodies and, as a result, lose our very souls.¹⁸

NOTES
1. "Doctors in the Dock," The Economist, (Feb 3–10, 2001): 24.