Marcus Lewis is a salaried GP and medical educator in London.
GPs have never met patients as blank slates. People have always arrived with ideas about what is wrong, what it means, and what they hope we will do. Those ideas may come from family stories, previous illness, bad experiences, cultural beliefs, media headlines, a conversation with a friend, or a half-remembered comment from another clinician. Often they also come from fear, which is one of the most powerful interpreters of symptoms.
General practice has always taken place in the middle of that. We help patients work out which parts of the story matter, which do not, and what might sensibly happen next.
The internet has been part of this sense-making for more than two decades. Patients have long searched symptoms, read forums, compared stories and arrived with printouts, questions or convictions. General practice has learned to work with that.
‘… a social media feed is not a set of search results. It does not wait for a new question. It learns from what holds the user’s attention and offers more of the same.’
But a social media feed is not a set of search results. It does not wait for a new question. It learns from what holds the user’s attention and offers more of the same. By the time patients arrive, the information may have been following them for weeks.
There is already a language for this. In 2007, Gunther Eysenbach set out three ways people reach health information (Box 1). His argument was that patients who bypassed the traditional gatekeepers would not be left unguided. Other guides would appear.¹
| Box 1. A quick guide to Eysenbach’s terms |
| Intermediation Someone stands between the patient and the information, filtering or interpreting it before it reaches them: traditionally the doctor, the pharmacist, the health visitor. |
| Disintermediation The patient bypasses the gatekeeper and goes to the information directly, through search, video, social media, forums or symptom checkers. |
| Apomediation Eysenbach’s coinage: mediation that does not stand between the patient and the information, but beside it. Peers, online communities, ratings, comments, reviews and recommender systems do not control what a patient can reach. They shape what seems relevant, trustworthy or worth acting on. |
The guide beside the patient is now often a feed optimised to keep them watching, an influencer with something to sell, or a community with its own settled explanation. So the question is not only where information came from, but how one explanation came to dominate.
Health content built around urgency and personal testimony does well in an attention-driven feed. Those same qualities make it harder to judge whether any of it applies to the patient watching.
‘Algorithms do not act alone.’
Algorithms do not act alone. They learn from what users watch, pause over and share, then feed that behaviour back to them.² Engagement-based ranking can give emotionally charged material more prominence than a chronological feed, more than users say they would prefer.³ Health worries are already emotionally charged. The feed does not need to invent the worry. It only needs to notice it.
When the general becomes personal
A woman in her early thirties comes to see me to ask for a referral for fertility treatment. She is single, not trying to conceive, and has no history that would suggest a problem. But she has been watching short videos about declining egg counts and the ‘fertility cliff’, and has arrived convinced that she is probably already infertile.
She would like in vitro fertilization (IVF), or failing that an anti-Müllerian hormone (AMH) blood test, to find out how many eggs she has left. But AMH is not a reliable test of natural fertility in women who are not infertile, however widely it is marketed as one.⁴
Fertility does change with age, and AMH measures something real. Repeated general warnings have come to feel like a diagnosis of her own fertility, carrying an urgency that her history does not support.
‘The feed does not need to invent the worry. It only needs to notice it.’
Eysenbach made a point that still feels very familiar: doctors’ frustration with internet information was often not that it was wrong, but that it did not apply to this patient, in this situation.¹ Social media makes that problem harder because its ranking systems know nothing of her clinical history or whether testing would help. They respond to attention, not clinical relevance.
Tests promise knowledge, control and early action. An analysis of social media posts about tests with potential for overdiagnosis, including AMH, found that benefits were mentioned far more often than harms, that overdiagnosis and overuse were rarely mentioned, and that many account holders had financial interests.⁵
My advice may be measured and appropriate, but it arrives after several weeks of alarm. ‘Let’s not rush’ can sound like ‘you are not taking this seriously’.
When what is visible is what can be sold
A woman in her early fifties comes in with menopausal symptoms. She has read widely. She asks about magnesium, tailored bioidentical hormone replacement therapy (HRT) and ashwagandha. When I mention vaginal oestrogen, often highly effective for urogenital symptoms, it is new to her.
‘Let’s not rush’ can sound like ‘you are not taking this seriously’.
Some treatments gather momentum online through personal stories, commercial promotion, and repeated recommendation. Others, including effective but unglamorous treatments, may hardly appear at all.
A cross-sectional study of UK online information on HRT and menopause found frequent conflicts of interest, with many claims falling outside British National Formulary (BNF) and National Institute for Health and Care Excellence (NICE) guidance.⁶
She has done exactly what we often ask patients to do: read, prepare, and take an interest. But what she has encountered is not a neutral survey of the available options. Some things are repeatedly placed in front of her; others are not.
When disagreement has already been explained
Online communities are not the same as a social media feed, but patients increasingly reach them through the same routes: search, video, recommendations and repeated posts. They can offer recognition, practical help, and language for symptoms that have felt scattered or dismissed.
‘… what [is] encountered is not a neutral survey of the available options. Some things are repeatedly placed in front of [the patient]; others are not.’
A patient arrives convinced they have chronic Lyme disease, using the term in the broad way it is often used online: not simply persistent symptoms after recognised infection, but a wider explanation for multiple symptoms, often linked to extensive testing and prolonged treatment.
Following the evidence as I understand it, I explain that this is not how I would frame the problem, and that prolonged antibiotics can do harm. The consultation can tighten almost immediately. I think I am offering clinical judgement. The patient hears the dismissal they were told to expect.
This is the extra work the community may have done before the consultation begins. It has not only named the symptoms. It may also have supplied a script for disagreement: doctors will not understand; they will say the tests are unreliable; they will refuse the treatment.
Eysenbach wrote about the power of first-hand experience. In health, people may give great weight to accounts from others who seem to have lived the same thing. If you have been in pain, frightened or repeatedly unheard, someone who says ‘I know exactly what this is like’ may feel more useful than someone who says ‘the evidence does not support that explanation’.
‘I think I am offering clinical judgement. The patient hears the dismissal they were told to expect.’
Shared trust
Fertility videos, menopause marketing, and online communities work in different ways. But each can make one explanation feel established before the consultation begins.
Among 18–34 year-olds, nearly half agreed that an ordinary person who has done their own research is as knowledgeable on most health matters as a doctor. Similar numbers had ignored a healthcare provider’s advice in favour of friends and family, and more than a third had done so in favour of social media. At the same time, ‘my doctor’ remained the most trusted health voice.⁷
The problem is not that trust in doctors has disappeared. It is that trust is now shared, and sometimes pulled in opposite directions.
That is why these consultations can feel different. The patient may still trust me. But they may also trust the woman on TikTok who sounds like them, or the community that recognised them.
‘Among 18–34 year-olds, nearly half agreed that an ordinary person who has done their own research is as knowledgeable on most health matters as a doctor.’
When the feed gets there first: what I try in the consultation
I cannot compete with the feed for volume or repetition. The consultation offers something different: the patient’s clinical context, the opportunity to explain my reasoning, and the possibility of returning to the question over time.
The first task is to avoid turning the patient’s search into a test of loyalty. A patient who has looked something up is not necessarily challenging my authority. They may be frightened, prepared, curious, frustrated, or trying to avoid being dismissed.
So I try to begin with the effort and the concern.
‘I can see you’ve looked into this carefully. Tell me what you’ve found, and let’s think it through together.’
That does not mean pretending every claim is equally valid. It means staying with the patient long enough to examine the claim together.
It can also help to explain how the information reached them without dismissing what they have seen.
‘The algorithm is very good at showing you more of whatever you have already watched. If you saw one video about running out of time to have children, it may have shown you many more — not because that is likely in your case, but because that kind of video keeps people watching.’
‘A patient who has looked something up is not necessarily challenging my authority.’
OR
‘Some treatments have much more marketing behind them than others. That does not mean everything you read was wrong, but it may explain why some options appeared again and again, while others did not appear at all.’
When a consultation is stuck, more facts may not help. We can keep arguing inside the disagreement — about the test, the referral, the treatment — while the real difficulty remains untouched. Sometimes the disagreement itself is what needs discussing.
‘I think you and I may be coming at this from different angles. Can we pause and work out how to handle that?’
OR
‘If the patient has already been given a confident explanation, a bald conclusion from me may look thin, even when it is clinically sound.’
‘You have seen something that makes this feel urgent. I am looking at your history and risk, and seeing it differently. Can we slow down and look at this together?’
Another old skill matters more here: sharing our thinking out loud. If the patient has already been given a confident explanation, a bald conclusion from me may look thin, even when it is clinically sound.
‘I can see why that explanation makes sense. Here is what I am seeing in your history and examination that makes me think differently.’
That kind of explanation does not need to become a lecture. It simply makes clinical judgement easier to trust.
Finally, there are times when the patient will leave believing what they believed when they arrived. The temptation is to push harder. Sometimes it is better to state the view clearly and keep the door open.
‘… much of this guidance is now built into systems designed around attention, repetition, and commercial interest rather than the circumstances of an individual patient.’
‘I have explained how I see it. I understand that you see it differently. I am not sure we will be able to resolve this today. If things change, or if you want to come back to it, I am here.’
That lets the patient return without losing face. It also leaves room for the possibility that the person who eventually changes their mind might be me.
Algorithm vs the consultation room: working in tandem
Online communities can mislead. They can also notice, organise, and insist. AIDS activism and Long COVID are reminders that patients sometimes describe reality before institutions have caught up.⁸,⁹
So when a patient brings an explanation that sits outside mainstream medicine, I need judgement, but also humility. I may be hearing something mistaken. I may be hearing something medicine has not yet understood.
‘It … leaves room for the possibility that the person who eventually changes their mind might be me.’
Eysenbach was right that direct access to information would not leave patients unguided. What has changed is that much of this guidance is now built into systems designed around attention, repetition, and commercial interest rather than the circumstances of an individual patient.
Against all that, the consulting room is a slower place: somewhere to ask whether this explanation fits this person, here and now.
References
1. Eysenbach G. From intermediation to disintermediation and apomediation: new models for consumers to access and assess the credibility of health information in the age of Web 2.0. Stud Health Technol Inform 2007; 129(Pt 1): 162–166.
2. Metzler H, Garcia D. Social drivers and algorithmic mechanisms on digital media. Perspect Psychol Sci 2024; 19(5): 735–748.
3. Milli S, Carroll M, Wang Y, et al. Engagement, user satisfaction, and the amplification of divisive content on social media. PNAS Nexus 2025; 4(3): pgaf062.
4. American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 773: The use of antimüllerian hormone in women not seeking fertility care. Obstet Gynecol 2019; 133(4): e274–e278.
5. Nickel B, Moynihan R, Gram EG, et al. Social media posts about medical tests with potential for overdiagnosis. JAMA Netw Open 2025; 8(2): e2461940.
6. McCartney M, Morgan-Young R, Sullivan F, et al. Does online information about hormone replacement therapy (or menopause hormone therapy) reflect indications from the British National Formulary and guidance from National Institute for Health and Care Excellence: a cross-sectional study of UK media. BMJ Open 2025; 15(9): e094773.
7. Edelman. 2025 Edelman Trust Barometer Special Report: Trust and Health. 2025.
8. Epstein S. Impure Science: AIDS, Activism, and the Politics of Knowledge. Berkeley: University of California Press; 1996.
9. Callard F, Perego E. How and why patients made Long Covid. Soc Sci Med 2021; 268: 113426.
