Participants were recruited from among patients seen at the melanoma and psoriasis units at San Cecilio University Hospital in Granada, Spain between May 2010 and December 2011. Patients aged over 18 years old with a diagnosis of melanoma other than melanoma in situ or of psoriasis (history of a body surface area score of ≥5 or involvement of an anatomic region that causes particular concern among patient, i.e., face, hands, or genitals) were considered eligible for participation.

A random number generator was used to select 175 patients from a list of patients who met the selection criteria ordered by date of visit. These randomly selected patients were informed by telephone that they would receive a questionnaire to be completed anonymously and voluntarily.

Apart from patients with melanoma in situ, we also excluded all patients who, despite having answered and returned the questionnaire, were suspected of giving systematized responses (e.g., the same score in all items, or systematic or regular alternations in answers), or who gave clearly contradictory answers to inter-related questions or answered fewer than 70% of the items. No significant differences in results were observed in the sensitivity analyses of data from the excluded and nonexcluded questionnaires.

Data were gathered on age group (≤59 vs >59 years), sex, educational level (no schooling/primary or secondary education/university), and access to Internet at home (yes vs no). Based on the hypothesis that searches for medical information may be influenced by intellectual factors, we included two questions from the Need for Cognition Scale: Need for Cognition 1 (NFC1, “I would prefer complex to simple problems”) and NFC2 (“It's enough for me that something gets the job done; I don’t care how or why it works”).5,6 These questions measure the tendency for an individual to engage in and enjoy thinking. Respondents rated their level of agreement with these statements on a Likert scale ranging from 1 (minimum agreement) to 5 (maximum agreement).

Another section of the questionnaire investigated sources of information related to the patient's disease, namely, frequency of consultations and credibility given to the information source, rated on another 5-point Likert scale, where 1 indicated no consultations or no credibility, and 5 indicated very frequent consultations or maximum credibility. Sources of information were classified into three groups: healthcare professionals (family physicians, dermatologists, nurses, pharmacists), relatives/acquaintances, and communication media (Internet, magazines, books).

Patient views of the physician–patient relationship were examined through questions evaluating the reputation of the medical department, communication with the medical team, and level of trust in and satisfaction with their physician. Each item was rated on a 5-point Likert scale ranging from 1 (minimum degree of agreement) to 5 (maximum degree of agreement).

Finally, we investigated the type of websites used by patients who searched for medical information online (general medicine, disease-specific sites, associations, agencies and institutions, online support groups and forums, private centers), the aspects of the disease in which the patients were interested (prognosis, causes, symptoms, new advances, and treatment), and the reasons behind their searches (to get information prior to the visit with their physician, to complement sufficient or insufficient information from the physician during the visit, to check the appropriateness of the diagnosis or treatment, or to find an alternative diagnosis or treatment). The patients scored the credibility of the websites consulted from 1 (no credibility) to 5 (maximum credibility).

A descriptive statistical analysis was conducted for the general characteristics of the study participants. Qualitative variables were analyzed with the χ2 test or the Fisher exact test when at least 1 cell had an expected count of less than 5. Binary logistic regression models (Wald method) were used to measure the association between Internet searches for medical information and other factors. A P value of .05 or less was considered significant. SPSS 17.0 was used for the data analyses. For the statistical analysis, answers to qualitative variables were reclassified. The frequency with which patients consulted different sources of information was reclassified as never or infrequently (1–2) or quite frequently to very frequently (3–5); credibility of information was reclassified as low (1–2), moderate (3), or high (4–5); and patients’ agreement with statements regarding their relationship with their physician were reclassified as complete or partial disagreement (1–3) or agreement (4–5).

The variables associated with searches for medical information on the Internet were educational level, NFC1, NFC2, and consultation of mass media other than the Internet. Consulting other communication media and educational level had the greatest influence on the likelihood of using the Internet to find information (odds ratios [OR] of 8.93 and 7.98, respectively). Preference for complex mental problems (NFC1) also increased the odds of performing an Internet search (OR, 3.14). Those with a preference for results over reasons (NFC2) were less likely to use the Internet to look for information (OR, 0.234).

Ready access to the Internet at home was a predisposing factor for searches for online medical information, as previously reported.7,8 Fox9 suggested that having a chronic or disabling disease also predisposes patients to searches of this type. The present study included patients with melanoma or psoriasis, selected for their high mortality and morbidity, respectively. We found no significant differences in Internet search activities between these patient groups, but online searches would probably be less common among patients with diseases that have a lesser impact.

Age was associated with Internet searches in the bivariate but not multivariate analysis and will probably become less influential over the years, as the younger Internet-savvy generations grow older.

Educational level was also significantly associated with Internet searches for medical information, in both the bivariate and multivariate analyses, confirming previous reports.10–12 With regard to the intellectual motivation behind such searches, patients with a preference for more complex mental problems and for results over reasons were more likely to investigate their disease on the Internet.

In contrast with previous studies in this area,13 one of the main aims of the present study was to determine whether use of the Internet reflected patient dissatisfaction with their relationship with their physician. This does not appear to be the case, as the dermatologist was the most important source of information, both quantitatively and qualitatively. Our findings in this respect coincide with those of with Chen and Siu,14 who found physicians to be the main source of information for patients with cancer. In the present study, opinions of dermatologists did not differ significantly between patients who searched for medical information on the Internet and those who did not. We even observed a significant association between online search activities and agreement with the following statements: “The reputation of the medical team is better than in other hospitals” and “I trust the recommendations of my medical team”. In other words, the use of the Internet to search for medical information was not significantly greater among patients who gave their physicians a lower rating. There actually even appeared to be a trend for greater search activity among those who rated their medical team more highly, although statistical significance was not reached for the other statements. Rains15 observed that information obtained from web searches was more likely to be perceived as useful by those who trusted their physician and less likely to be perceived as such by those who did not.

The most visited websites in our series were disease-specific sites or sites that offered online support, indicating that the motivation behind these searches was to find a meeting point for patients and relatives as well as to obtain targeted information. The degree of empathy that people with a similar experience of a disease can bring to patients cannot usually be provided by a dermatologist. Websites of this kind can offer support, experiences, and behavior models, fomenting participation and exerting a community function among patients.16 The importance of these sites for patients strongly suggests that the Internet complements the more formal function of the physician during patient visits.

Despite the widespread use of the Internet detected in our study, a few patients (19.2%) talked to their physician about the information they had found online. It would seem desirable for physicians to have an open attitude, allowing patients to ask any questions they consider necessary and to speak naturally about the Internet. By accepting the Internet as a natural societal phenomenon, physicians could fulfill an important role as counselors.17 One of the major concerns about cybermedicine is the quality of Internet sites, which can contain incorrect and unsubstantiated data,18,19 in addition to the possibility that patients could make erroneous interpretations of information, with negative consequences for their health.20 Hence, the dermatologist could help by both recommending pages of interest during the patient's visit and promoting the development of pages with high-quality information by scientific societies.

New studies with larger number of patients with other dermatological conditions are necessary to confirm our findings.

In conclusion, the search for medical information is a widespread reality among patients with psoriasis and melanoma. It is associated with intellectual factors and not with a poor relationship with the physician. The Internet should therefore be regarded as a complementary means of information, whose limitations can be minimized by the physician taking an active role in resolving doubts raised by patients and by scientific societies publishing web pages that offer high-quality information for patients.

The authors declare that no experiments were performed on humans or animals for this investigation.

The authors declare that they have followed the protocols of their work center on the publication of patient data.

The authors must have obtained the informed consent of the patients and/or subjects mentioned in the article. The author for correspondence must be in possession of this document.