Two-thirds of all internet users do Google searches to look for health information. So we shouldn’t be surprised that Google is entering the world of healthcare in a big way. A couple days ago Google Health went live. It’s still only in a beta version, but users can already give it a test drive. So what is it, exactly?

The fundamental notion is that it gives the patient, the consumer, access to (and therefore control of) the health record. A user can store in one spot all information about his health — medical records, laboratory test results, pharmacy records, and even general information about his health conditions. This last aspect is key. Your Google Health site can be a central repository about what your health needs are, what’s been done about them, and what you might or should do about them. Of course for the whole thing to work most third-parties, like hospitals, pharmacies, and doctors’ practices, have to sign on to participate. More fundamental than that, medical records need to be totally electronic so users can upload them, and at this time many, even most, are not — they’re still on paper.

Google also plans to do more than just be a search engine. Through its Knol project, it means to be a source of hard information about health issues with a whole library of signed articles by experts. I was one of the medical experts Google asked to help launch the project, which should go live later this year. I think it will be a very useful site and will generate a huge amount of traffic because all of the contributions are signed by people whose credentials you can check. It also will allow comments by readers.

One major concern about Google Health is how secure your personal health information is, and if Google (or anybody else) will use it to target marketing initiatives at you. Google says they are taking extra precautions to secure the data, but this is a serious concern. Also, as of now there is no advertising on the site, but there could be in the future. I would be concerned if Google used your personal health record to select ads targeted at you, as they do now according to what you search. You can read a general news story about the project here and an insider’s description by Dr. Bob Wachter here.

Edited to add: here’s another excellent review of what Google’s entry into healthcare might mean. It’s from Lynch Ryan’s Workers’ Comp Insider blog, and it weighs both the pros and the cons.

I’ve been doing some research for my next book, which is about how to use the medical literature to make sense of the often sensational medical headlines. One issue I’ve been thinking about quite a bit is the enduring power of the anecdote in how we humans understand and explain things. I suppose we should not be surprised by this. After all, an anecdote is a story, and humans are story-tellers by nature.

These days physicians are exhorted to use only the hardest of hard evidence to make decisions, to use only what is called evidence-based medicine. I have no objection to this, except to point out that for much of what we do, even in the high-tech environment of the PICU, there are little (or even no) evidence-based guidelines to use. We do what we think is best based upon what we have been taught and what has worked in the past. And we use anecdotes — stories we have heard or things we have seen.

Rafael Campo, the award-winning physician and poet, has some interesting things to say here about the power of the anecdote, the human story. At the end of one of Dr. Campo’s lectures, a distinguished physician posed this question — or challenge, really:

“Do you really expect physicians to accept the notion that what any ignorant patient tells us about his disease should carry a weight equal to what our years of training and expertise reveals to us about complex pathophysiology?” Then came what was clearly meant to be his coup de grace, delivered in an almost derisive tone. “Really, sir, do you have anything more than the anecdotal evidence you shared to support your thesis?”

For myself, I continue to see medicine as a complicated mish-mask of science, near-science, intuition, guesswork, and blind luck. Although we should always use the best science we can, somewhere in the mix there is a place for the anecdote, the story. I wouldn’t want it to be any other way.

A recent issue of the New England Journal of Medicine has a fascinating piece written by Michael Kahn, a psychiatrist who examines his reactions as a patient to the demeanor of his doctor. His term for what he is describing is etiquette-based medicine, and he asks the rhetorical question: “Patients ideally deserve to have a compassionate doctor, but might they be satisfied with one who is simply well-behaved?”

Doctor Kahn makes some excellent points. Medical schools and residency training programs do their best to teach, as much as they can be taught, such things as empathy and compassion for patients. He suggests they also teach good manners — things like properly introducing yourself, shaking hands, and explaining why you are there. Simple rituals like that are important.

I was particularly intrigued by one of the items on his behavior checklist — sitting down. That is a key thing to do for families, especially in the hectic world of the PICU. Standing by the door and eying the clock is not acceptable. I learned the importance of sitting down from my physician-father, who learned it from his, a man who practiced a century ago at a time when physicians often had little to offer except compassion, understanding, and even etiquette.

As Dr. Kahn writes, physicians should at least be as cordial as Nordstrom’s employees.

My child is sick all the time. If you are a parent of a preschool child, have you ever thought that? And, if you have, did you worry all those frequent illnesses meant there was something seriously wrong, some significant, underlying illness? Pediatricians and family doctors often hear this worry from parents.

Preschool children have a lot of infections, especially upper respiratory ones, called URIs. Children under three average five to six URIs per year, although the range of normal is quite broad — as many as ten in a year is not necessarily abnormal. One large survey from the Centers for Disease Control polled nearly three thousand households and asked the parents if their children had experienced URI symptoms during the preceding two weeks — a third of children under three had, as did a quarter of children three to five years old.

Where children are during the day matters in determining how many URIs they get, and the youngest preschoolers spending their day with six or more other children of similar age, such as in a daycare setting, get the most. In the CDC sample, for example, about half the children spent time in daycare, and those children had, on average, a fifty percent higher rate of infection. Considering how toddlers share hugs, toys, and crackers with each other, this is not surprising. But for a parent whose child is in daycare, does this increased number of infections mean anything? Is it worse for your child?

Various studies help answer this key question, and the answer is reassuring. In fact, although children under three attending daycare have more URIs than do their stay-at-home compatriots, there is evidence they have less URIs later on, during their early grade-school years. So things appear to even out; the children who are not exposed to as many respiratory viruses as preschoolers meet those viruses later.

Can all these URIs lead to further problems? The answer is generally no, but once in a while they are a problem for certain children, especially those under two. The principal complication of a URI is a middle ear infection, termed otitis media. The inflammation from the URI blocks the normal function of the eustachian tube, the connection between the back of the nasal passages and the middle ear, allowing bacteria normally present in the area to infect the ear. Children vary in their propensity for this to happen. However, the younger they are when they have their first ear infection, the more likely they are to have more of them. Susceptibility to ear infections also runs in families. Another complication of URIs among some children is wheezing whenever they get one. If your child has problems with repeated bouts of either otitis or wheezing, reducing the number of URIs by reducing exposure to sick children is a good way to help control the situation.

Even though experiencing many URIs is common among preschoolers, there are times when a doctor worries about the situation. For example, if the child is having recurrent high fevers, severe rashes, or diarrhea, this could mean there are problems with the immune system. A key red flag is if the child is not thriving — failing to gain weight or even losing weight, or is not keeping up with normal developmental milestones.

If you are concerned your child is too sick too often, discuss the situation with your child’s doctor. But for nearly all preschoolers, having lots of URIs is just part of growing up.

I have a new book coming out later this month from Prometheus Books. Titled How To Talk To Your Child’s Doctor: A Handbook For Parents, it’s not strictly about the PICU, as my first one was — this one is about communication between you and your child’s doctor, something relevant to all aspects of pediatric practice.

Like ships passing in the night – that’s how to describe what too often happens when you bring your child to the doctor. You do your best to describe your child’s problem; meanwhile the doctor listens and tries to fit what he or she is hearing into a diagnostic box. Most times the exchange results in your child getting what is needed, but this is too often in spite of, rather than because of, the dynamics of what happens in the examining room.

My book concerns a common and pernicious communication difficulty between doctors and parents. The problem is not language, although medical jargon sometimes impedes communication; the root of the problem is world view. Few parents understand what doctors are listening for when we talk to parents, and how we use what parents tell us to solve medical problems.

Both doctors and parents are increasingly pressed for time, making effective communication and understanding between them more important than ever — misunderstanding is wasteful and sometimes even dangerous. Additionally, these days many children rarely see the same doctor twice, and more and more encounters with doctors happen in emergency departments and walk-in clinics, places where you and the doctors are strangers. In these conditions you need to learn how to make the most of your brief time with the doctor.

The book will admit you to a doctor’s mental medical universe and explain how physicians solve problems. It will not make doctors of you, but it will make you better partners in the diagnostic and therapeutic enterprise when your child is sick. If you like, you can read the first chapter here.

This isn’t really about pediatric critical care, but it’s a topic that once again has come up for debate: how many doctors do we need? Do we already have enough? Is the problem mainly one of distribution, both in the sense of having too many specialists and a geographic maldistribution of doctors? A little over a decade ago the received opinion was that we were heading for a doctor glut, and should cut back on the number we trained. Now many predict we will not have enough doctors, especially with the progressive aging of our population. Several states have made plans for expanding the sizes of their medical school classes, and, for the first time in decades, new medical schools are opening. You can read a good discussion of this trend here.

On the other hand, some say the statement that we will be short of doctors is false. For one thing, we already have more doctors now than ever before — in 1950 we had 145 physicians for every 100,000 persons, and now we have 280 per 100,000. By 2020, even without expansion of medical schools, we are projected to have 294 doctors for every 100,000 citizens. The problem, some say, is a maldistribution of doctors and too many specialists. You can read a good summary of that argument here.

A major problem in all these discussions is that we really don’t know what the optimal number of doctors is. There is also vigorous debate over whether many things doctors do could be done, often more cheaply, by others, such as nurse practitioners and physician assistants. There is also the real probability that having more doctors will actually drive up demand for what doctors do, thereby increasing the costs of medical care even higher than they already are.

One thing most people don’t realize is that the federal government is the de facto gatekeeper for the number of new doctors we train because it controls much of the financial support for training of resident physicians, the next step after medical school. So it is residency slots, not medical school class size, that determines things. Currently we have more residency slots than we have medical school graduates — the balance is filled out by residents who went to medical schools in other countries. If we have more domestic graduates there will be less foreign residents, but the total won’t change unless the cap on residency slots is lifted.

What do I think? I think health care is not like other parts of our economy, and trying to use simple market-based reasoning will not work. In many ways, doctors drive the demand for our services. We do things, order things. This means, at least in our present system, having more doctors will stimulate more demand, demand which is in some ways insatiable.

There are many debates around the blogosphere about this complicated issue. You can follow a good discussion of it here.