Unable to obtain the online advice they seek from their own docs, e-patients by the millions are discovering a new breed of online health professionals who are only too happy to hear from them. But their electronic interactions with these virtual providers are strikingly different from their face-to-face encounters with their own physicians. In one of the most important and unexpected developments in Information Age healthcare, the Net is giving rise to an entirely new type of provider-patient relationship.

Let's first define a few essential terms: Type 1 patient-provider e-mail (Type 1 because it developed first) is that which occurs between a patient and a health professional when no previous clinic-based relationship exists, e.g., when patients send e-mail to doctors they've found on the Net, or when clinician and patient 'meet' as fellow participants in an online forum or support group. Type 2 provider-patient e-mail is that which occurs between patients and the medical professionals with whom they have a preexisting clinic-based relationship.

When doctors and their face-to-face patients exchange Type 2 e-mail, they generally discuss the same things they would if speaking on the phone. Patients ask about managing their medical concerns, ask advice on whether a trip to the doctor's office is necessary, and ask follow-up questions after a clinical visit. Docs check in to see how patients are doing and to remind them of upcoming appointments, immunizations, etc.

Most of the early-adopter Type 2 Docs who currently invite e-mail from patients are those who had previously made themselves easily available to patients by phone. These physicians typically say that they like communicating with patients electronically because it eliminates phone tag, it allows them to respond to patients at their convenience, and makes it possible for them to send and receive more detailed and useful information. A few have gone even further, discovering innovative new ways that clinical information can be exchanged, e.g., customized text documents, Web links, charts, graphics, x-rays and test reports, patient journal entries, database files with patient-collected data, etc. By contrast, docs who are currently difficult or impossible for patients to reach by phone are understandably less enthusiastic about the prospect of communicating with patients electronically, explaining that to do so would require additional work for which they would not receive additional pay.

Once they invite patients to communicate via e-mail, Type 2 docs are under an implied obligation to respond to all the messages they receive. But Type 1 docs have a much greater degree of freedom. They may offer to answer only e-mail from certain types of patients, from those in certain zip codes, or from those who pay a monthly subscription fee. And they may, at their option, either reply to or ignore unsolicited Type 1 e-mail..

These two types of provider-patient e-mail define two distinctly different kinds of provider-patient relationships.

The Type 2 doctor-patient relationship is the one with which we are most familiar. In most cases, both doctor and patient consider the physician the team leader, or, at the very least, the senior partner in the provider-patient dyad. Indeed, Type 2 docs take on a number of well-established legal responsibilities for their patients' care.

Type 2 docs are expected to take a history, to do a physical exam, to order any necessary tests, to prescribe any needed drugs or surgical procedures, to monitor the patient's progress, to maintain the patient's medical record, and to be available for follow-up care. A patient will usually consult only one Type 2 doc for a given problem. Type 2 docs are typically paid by the patient--or the patient's insurance company or health plan. Type 2 docs may thus best be understood as Doc-Providers.

Type 1 health professionals are those which e-patients have found on the Internet. They typically take on none of the obligations that Type 2 Doc-Providers take for granted: They do no physical exams, order no tests, prescribe no drugs (those who do may hear from their State licensure boards) and maintain no records. They are not typically expected to be available for follow-up care. For one detailed legal description of a Type 1 doctor, see the disclaimer patients must agree to before chatting with a health professional at AmericasDoctor.com.

Most Type 1 medical professionals do not expect to be paid by the patient, although a few charge modest fees. Some are paid by the Web sites to which they contribute, while others consider their offerings as a part of their marketing efforts, or as a part of their self-education in online health.

Type 1 docs typically answer questions, recommend Web sites, books, journal articles and treatment centers, and offer informal second opinions. They sometimes provide forums in which their visitors can communicate with each other. They frequently advise patients to consult with their Type 2 docs, often suggesting specific questions or treatment options to discuss.

Type 1 docs don't diagnose, treat, or offer the kind of authoritative and prescriptive advice a Type 2 doc (even the same doc, seeing the same patient in the clinic) might routinely provide. Type 1 docs thus don't really 'practice medicine' in the traditional sense. Instead, they serve as coach-consultants.

Having access to such an online coach-consultant is much like having a well-informed pal you can check in with informally, without assuming that they will feel that they must take on all responsibility for your care. These Type 1 coach-consultants are thus not just traditional doctors (and other health professionals) who are now operating online. They are something new.

Most Type 1 health professionals provide their services for free. When I've asked these online good Samaritans why they answer anonymous patients' online questions, they often tell me that while they first got started because they wanted to be of help, they've continued because their interactions with Type 1 patients has proved to be such a valuable learning experience. Type 1 docs who've developed especially effective online offerings are sometimes shocked by the numbers of visitors they receive. When California pediatrician Alan Greene, and his wife and producer, Cheryl Greene, first launched a Web site for their patients they expected no more than a dozen viewers per week. Their site, drgreene.com, now receives about a million visitors per month. (See Top 10 Tips in this issue.)

The infrastructure of most medical practices puts the Type 2 doctor at the center of the medical information loop. Most clinical interactions take place on the doctor's turf and at the doctor's convenience. Doctors order all medical tests, receive all test results, and write all prescriptions, and most docs have access to a wide variety of additional medical resources that are not available to their patients. They effectively own and control their patients' medical records. And because it is so by not so easy to get a second opinion, and harder still to change doctors, they often effectively 'own' and control their patients as well.

Some Type 2 docs consider it their prerogative to make most of the important medical decisions for their patients, and to decide what, if any, patient education materials each patient needs to receive. Thus it's easy to sympathize with Type 2 docs who say they're not sure how to respond when their patients come to the clinic bringing information they've found on the Internet. And one can readily understand why they might consider patients' requests to discuss such materials as an inappropriate and inconvenient demand on their time.

In spite of the very limited nature of the services they offer, Type 1 docs are emerging as an unexpectedly valuable resource for online patients. Some of this appeal can be explained by the convenience and accessibility they offer. But in some cases, e-patients' enthusiasm for the information and guidance Type 1 docs provide appears to reflect their dissatisfaction with the treatment they receive at their own doctors' offices.

Many online patients say that they are more comfortable exchanging e-mail with an online doctor they have never met than in discussing their medical concerns with their own physicians. When I've asked online self-helpers what it is about their Type 2 docs that makes them uncomfortable, they typically explain that at their doctor's office, the physician is in such a rush that they rarely or never get a chance to fully explore or discuss their concerns.

When I've asked them to walk me through their experience of a typical office visit, they explain that their Type 2 doc typically takes charge of the medical interview, asking a quick series of questions, reviewing recent test results, issuing 'doctor's orders,' and, on the way out, telling them when they will need to return to the clinic. Not uncommonly, they say, their doctor will disappear without explanation in mid-sentence, will be heard talking with another patient in the next examining room, and will then reappear, picking up the conversation as if nothing unusual had happened. In this intensely time-pressured situation, some patients say that they feel that to ask further questions or to request more extensive discussions would be an unfair imposition on the doctor's already overcrowded schedule. As a result, many issues which they consider important are rarely or never satisfactorily addressed.

While the Type 2 relationship makes physician the hub of the medical enterprise, the Type 1 doctor-patient relationship puts the patient at the center of the medical information loop. The professional is available at the consumer's convenience. As one Type 1 site explains, "*Our* doctors wait for *you*." And if a Type 1 doc does not provide what an e-patient is looking for, a hundred other cyberdocs are only a mouse-click away.

Type 1 coach-consultants encourage e-patients to learn all they can about their medical conditions, to make their own decisions whenever possible, and to manage as much of their own medical care as they can. And while many Type 2 docs are still uneasy with patients who seek to control their own medical destinies, Type 1 docs typically encourage patients to learn everything they can about their conditions and to hold onto their power.

For many online self-helpers, the best thing about Type 1 docs is that that they allow e-patients to pose the questions, to take all the time they want, and to engage with providers in extended back-and-forth discussions. This allows the end-user to play a proactive role in gathering, judging, and making decisions based on the available information, and in making many important decisions themselves. By contrast, the clinical constraints of the typical Type 2 visit often reduce the end-user to the status of passive patient whose only choice is compliance or noncompliance with professional directives.

Will most rank-and-file physicians need to develop the skills of the Type 1 coach-consultant? Probably not. Most docs will have enough of a challenge learning to communicate electronically with their existing patients. But the growing availability and sophistication of free or inexpensive Type 1 docs is sending a seismic shockwave through the healthcare industry, providing net-savvy health consumers with yet another valuable online resource, and raising the bar on the level of quality, convenience, and communication clinicians must provide to attract and retain end-users. The new model of the Type 1 health professional as coach-consultant thus offers innovative developers, practitioners, healthcare executives, and health policy planners another tool they can use to design more effective, accessible. and affordable health care systems.