Introduction

The relationship between a physician and his or her patient is one of vital importance, as it has the potential to significantly impact the patient’s health and well-being. This relationship involves an interaction between a physician and a patient in which each takes on certain roles and responsibilities, with one of the principal responsibilities of the physician being information management (Ahmad et al., 2006). In the past, the physician alone had access to the bulk of the information necessary for making decisions regarding health and wellness. While managing this health information remains an important aspect of the physician’s job today, the Internet is significantly altering the environment in which this task is accomplished in Western, industrialized nations (Ahmad et al., 2006). For the first time, the patient may also have readily available and convenient access to vast amounts of health and medical information. The physician no longer has sole control over medical information in general, and the medical information that is given to his or her patients in particular, and this is altering the dynamics within the physician-patient relationship. At a societal level, the direction of this shift is toward a more balanced partnership between the two parties involved; however, at the individual level, the nature of the physician-patient relationship may depend more heavily on the patient’s and physician’s feelings regarding the use of the Internet to access health information and the information found, as well as on the physician’s reactions to the patient’s attempts to introduce this information into their relationship.


Evolution of the physician-patient relationship

The relationships between physicians and patients are dynamic interactions in which the roles and the responsibilities of the individuals may be continuously negotiated. Each relationship is different and depends to a large extent on the nature of the individuals involved. Although this is true on an individual level, it is also possible to characterize the physician-patient relationship in society more generally. This has often been based on the extent to which the relationship is seen as being either physician-centred or patient-centred.

The paternalistic physician-centred approach is often viewed as the traditional medical perspective. Traceable back to Ancient Egypt in 4000-1000 BC, this perspective views the physician as holding the dominant or paternal role in the relationship; he or she has sole control over medical information and the specialized knowledge and expertise necessary for patient care. Because of this, he or she has control over the interaction and is responsible for the patient and his or her health. The relationship is not characterized by two-way interaction, but rather by a one-way flow of information from physician to patient. The physician is placed in the active role of information disseminator, while the patient is the passive recipient of the information provided. The patient is characterized as a helpless and uneducated child, requiring the assistance of the physician and obeying the physician’s instructions without question (Kaba and Sooriakumaran, in press).

A variant of this traditional perspective, which has moderated the paternalistic model at certain times throughout history, has been described as a guidance-cooperation approach. While the physician remains dominant in this type of interaction, the patient takes on a slightly less passive role. The physician’s position in the relationship relative to the patient is less based on an inherent superiority and is more the result of the patient’s decision to give the physician power. The physician provides guidance based on his or her specialized knowledge, and the patient willingly cooperates with the physician (Kaba and Sooriakumaran, in press).

The push currently in Western society is for a patient-centred approach, characterized by the mutual participation of both individuals in the physician-patient relationship. This relationship is predicated on feelings of equality and places both physician and patient in active roles in their interactions. Both individuals are felt to have power and independence within the situation, while at the same time are encouraged to be interdependent in the provision of patient care. The patient has more control over his or her own health care and is thus also more responsible for his or her own health. The physician’s role is still to provide medical advice; however, he or she does so in order to help the patient make his or her own health-related decisions (Kaba and Sooriakumaran, in press).

One of these types of relationships, as identified by the roles and responsibilities of the two parties, may predominate in any society at any given time, and the type most characteristic of medical practice in Western society has changed over time. The transformation to patient-centred approaches in Western societies has not been linear, but rather has fluctuated between granting patients greater autonomy and control and then taking these away. At present, Western society has not yet reached completely mutual participation (Kaba and Sooriakumaran, in press).


Health information and internet use

These alterations in the nature of the physician-patient relationship result from and are facilitated by a number of factors in our society, with the Internet being one of the most significant. The Internet has become an integral part of life for many people in Western industrialized countries, providing immediate and convenient access to massive amounts of information, including health information, and its use has been rising dramatically (Erdem and Harrison-Walker, 2006). One of the most frequent search topics on the Internet is health information. In 2003, it was reported that 53 percent of Americans use the Internet to access health information (McMullan, 2006). Currently, it is estimated that 80 percent of the population in North America uses the Internet for this purpose (Ahmad et al., 2006). There were estimated to be over 10,000 medical websites in 2000 (McMullan, 2006). By 2004, over 100,000 health-related websites and other resources were available via the Internet and over 12 million citations were available through PubMed, an online biomedical database created by the United States National Library of Medicine, and these sites are being used. On any given day, more Americans use the Internet to obtain medical information than visit physicians or other medical professionals (Erdem and Harrison-Walker, 2006). The Internet has become and will continue to be a significant means by which individuals self-educate with respect to health (Broom, 2005b), and this self-education has the potential to result in important changes in the dynamics of the physician-patient relationship.

Several advantages of the Internet make it an ideal resource for accessing health information. Central to its use is its availability, convenience, and relative inexpensiveness. The Internet has become widely available and easily accessible for a significant percentage of the North American population. It is available 24 hours a day, seven days a week, requires no wait time, and can be used without having to leave home. As well, it is no longer as expensive as it once was, and depending on the location, may be much less expensive than a visit to the physician. A final advantage for many people is the relatively anonymous nature of the service; for health concerns that have the potential to cause embarrassment, people may feel more comfortable searching the Internet for information (Anderson et al., 2003).

A number of attributes characterize those more likely to utilize the Internet in their quest to obtain health information. It has been found that the most frequent health information seekers on the Internet are middle-aged women who desire information to assist them in making decisions regarding their family’s health care (Erdem and Harrison-Walker, 2006). Other factors are also associated with the use of the Internet to find health information; people who are younger, of higher socioeconomic class, better educated, white, and in good health are more likely to use the Internet for this purpose (Akerkar and Bichile, 2004; Kivits, 2006; Murray, Lo, Pollack, Donelan, Catania, White, et al., 2003). People who tend to take a proactive rather than reactive approach to health care and those who consider the quality of care they receive from their physician to be less than optimal also more frequently turn to the Internet for health information (Murray, Lo, Pollack, Donelan, Catania, White, et al., 2003).

In addition to there being certain types of individuals who are more likely to search the Internet for health information, there are also certain elements that characterize the search process. The majority of people utilize the Internet to search for information related to a specific disease or condition, primarily one from which they or one of their family or friends suffer (McMullan, 2006). However, significant numbers of others search for information about a specific treatment or for general lifestyle information related to nutrition and fitness (Akerkar and Bichile, 2004). While many people search the Internet before they visit physicians, it is rarely the case that they make appointments because of the information they have found. In most cases the visits are scheduled prior to the searches, and the searches are done in an attempt to be better informed at those visits (Murray, Lo, Pollack, Donelan, Catania, White, et al., 2003). If successful in obtaining information through their searches, these people may be termed “informed patients” (Gerber and Eiser, 2001). People also make significant use of the Internet to gather additional information after they have visited their physicians, some to gain a clearer understanding of their diagnosis and others to gather more information to make decisions regarding treatment or the management of chronic conditions (McMullan, 2006). These people have been classified as “knowledge acquirers” (Gerber & Eiser, 2001). Finally, the use of the Internet in the search for health information is rarely viewed as a replacement to visiting a physician, but instead is seen as complementary (McMullan, 2006).


Patient use of the internet

As the use of the Internet by consumers in general is increasing, so is its use by patients, specifically. The Internet is believed to offer a number of advantages to patients in terms of redefining their roles in the health care process and in the physician-patient relationship. The Internet has been shown to have the ability to empower patients and to increase their feelings of self-efficacy and control. Because it provides access to a wealth of information that was not previously available to the general public, it enables patients to increase their knowledge significantly; this may result in patients who have greater self-confidence in their abilities to take an active role in interactions with their physicians, to cope with health conditions, and to participate in treatments (McMullan, 2006). Due to the sheer volume of information contained on the Internet, patients are able to learn about even the rarest of conditions and to discover the latest experimental biomedical treatments or alternative therapies for conditions (Anderson et al., 2003). Patients can now contact medical experts and specialists on an international scale, rather than having to rely on those in the local area (Anderson et al., 2003; Hardey, 1999). Used properly, the information gained in Internet searches may improve patients’ understandings of their conditions and treatment options (Broom, 2005a), thus reducing unnecessary visits to physicians to clarify information and leading to more cost-effective medical care (McMullan, 2006). The Internet can facilitate patients’ efforts to be responsible for and actively involved in their own health care, and so has the potential to increase patient participation in the care process and improve management of chronic disease (Anderson et al., 2003; Broom, 2005a).

However, increased use of the Internet to meet the demand for health information is not without its disadvantages. The amount of information in general, and health information in particular, available online is vast and unregulated. This situation may be overwhelming to some individuals, causing more feelings of anxiety than of control. Conflicting information may be presented on different websites, as well as information that is simply inaccurate, leading to patient confusion. The accuracy of the information available on the Internet and the credibility of websites are often difficult to determine, especially for inexperienced users, and this may lead to incorrect self-diagnosis and the use of potentially dangerous treatments (McMullan, 2006).

There are a variety of reasons why patients turn to the Internet to provide health information despite the dangers of conflicting or inaccurate information. Since information pervades all activities of daily life, patients often view searching the Internet for health information as a natural thing and may do so without any real conscious thought guiding their actions (Kivits, 2006; Spitzer, 2004). Furthermore, the current focus on individual responsibility in all areas, including that of health, may influence patients’ feelings regarding the importance of being well informed. In an effort to be responsible, many patients actively seek information in preparation for an appointment with a physician (Kivits, 2006; Murray, Lo, Pollack, Donelan, Catania, White, et al., 2003) or for having to make decisions regarding health care (Akerkar and Bichile, 2004). Many other patients are simply looking for external confirmation of or supplemental information to the information that they have received from their physicians (Kivits, 2006) or reassurance that they know everything there is to know about their conditions (McMullan, 2006). Some desire or need information different from that which they have received or are looking to widen their options, both in terms of treatments and health care providers (Kivits, 2006).

Although many patients use the Internet to access health information for positive reasons, there are also negative motivators for doing so. There is a growing distrust of physicians in Western society (Akerkar and Bichile, 2004; Spitzer, 2004), and some patients expect more from their encounters with their physicians than they feel they receive (Erdem and Harrison-Walker, 2006; Kivits, 2006). These patients may not feel that physicians spend enough time with them, listen to them closely, or address their concerns satisfactorily (Kivits, 2006). They may feel that they are lacking in information generally and that physicians are not meeting their needs for information (Anderson et al., 2003; McMullan, 2006). All of these feelings can result in dissatisfaction and frustration, leading to the search for alternate sources of information. Finally, and dangerously, some people use the Internet for self-diagnosis, anticipating that they should be able to take care of themselves and that doing so is more convenient and will save them time and money (Erdem and Harrison-Walker, 2006).

Regardless of their reasons for doing so, patients are increasingly able to access health information via the Internet and are taking advantage of this opportunity. This change in access to health information, with physicians losing some of their traditional control in this area, is altering patients’ roles and thus the physician-patient relationship (Anderson et al., 2003). Patients are becoming both more informed and more misinformed, with potentially valuable information applicable to their concerns and with information that is inappropriate or even inaccurate. A significant percentage of patients are sharing their new, Internet-derived information with their physicians and are using it to assist them in making important health decisions (Broom, 2005b). This is changing the dynamic that exists between patients and physicians, as they seek or are forced into new roles and responsibilities within the existing frameworks of their relationships. The views of both parties regarding Internet use and the value of the information available, as well as physicians’ reactions to patients’ attempts to reverse the flow of information in their interactions, affect the likelihood that the information will be able to play significant roles in their relationships.


Patient views

Overall, patients tend to view their use of the Internet to locate health information very positively and feel that it provides them with a number of benefits. The use of the Internet fulfills patients’ desires to be informed, provides them with a sense of control (Murray, Lo, Pollack, Donelan, Catania, White, et al., 2003), and decreases the uncertainties around the diagnosis and treatment process (Broom, 2005b). Patients feel that the information they collect enables them to improve their health generally and their understanding of their condition specifically (Kivits, 2006). Many patients also feel that, because they have more information at their disposal, they are more confident and feel more comfortable talking to their physicians about their concerns (Murray, Lo, Pollack, Donelan, Catania, White, et al., 2003), participating in treatment decisions (Broom, 2005b), and adhering to their physicians’ advice (Murray, Lo, Pollack, Donelan, Catania, White, et al., 2003).

Use of the Internet as a provider of health information both stems from and results in patients having changing expectations of physicians (McMullan, 2006). Patients often expect much more from physicians today than may have been the case in the past and search for alternative sources of information when they feel that physicians are not living up to their expectations. At the same time, the general availability of medical information increases patients’ awareness of their options and of the fact that physicians are not perfect (Anderson et al., 2003; Spitzer, 2004); because alternatives exist physicians must consistently perform at exceptional levels in order to have patients view them positively (Spitzer, 2004). Furthermore, patients feel that the fact that they can access health information themselves necessitates that physicians remain up-to-date on the latest research and treatment options (Murray, Lo, Pollack, Donelan, Catania, White, et al., 2003).

Benefits aside, some patients also acknowledge that there are negative aspects to the increased availability of health information. Some patients believe that this can result in patients scheduling unnecessary appointments and occupying more of their physicians’ already limited time. Also, the information on the Internet is not always reliable; patients are aware of and concerned about this (Murray, Lo, Pollack, Donelan, Catania, White, et al., 2003). However, although there is a sense of concern about their ability to judge (Kivits, 2006), many feel that they are able to determine the value of the information they find (Broom, 2005b; Hardey, 1999).

Patients’ feelings about the value of the health information retrieved from the Internet influence the likelihood that they will bring that information to their physicians. It has been found that about half of the people who find information that they feel is relevant to their health share it with their physicians. The majority do so simply because they want the physicians’ opinions regarding the information; however, some patients do so to make particular requests for treatments or referrals. Patients feel very positive about the information they have found, feel positive about sharing it with their physicians, and feel that the reactions they get from their physicians are positive as well (Murray, Lo, Pollack, Donelan, Catania, White, et al., 2003).


Physician views

As the other participants in these interactions, physicians also have a range of views regarding the value of Internet-accessed health information, and their views may be even more influential in determining how the information affects the physician-patient relationship. Their views are again both positive and negative, and this distinction often depends on the points in the physician-patient interactions at which patients seek the information and to what use they put it. In theory, physicians may view the increase in information in a positive light (Murray, Lo, Pollack, Donelan, Catania, Lee, et al., 2003), believing that it has the potential to increase patients’ knowledge and thus improve their abilities to care for their own health. This in turn has the potential to make physicians’ jobs easier. Physicians agree that it may improve the confidence of patients, increasing their comfort levels in physician-patient interactions, and that this, combined with the increases in knowledge, can lead to more sophisticated and intelligent interactions (Akerkar and Bichile, 2004; Broom, 2005a; Gerber and Eiser, 2001). In practice, however, physicians often have a number of significant concerns that can overshadow their beliefs in the potential benefits of Internet use.

Physicians tend to be more skeptical of patients using the Internet to search for health information than are patients. They are perhaps most significantly concerned about the volume, nature, and accuracy of the health information found (Ahmad et al., 2006; Anderson et al., 2003; Erdem and Harrison-Walker, 2006; Malone et al., 2004). Physicians worry that patients will become overwhelmed by the amount of information available on the Internet or that they will not be unable to understand it. Depending on the websites viewed, information can be highly technical, complex, and detailed. Patients will often visit websites aimed specifically at physicians in their searches for health information because they feel that the information provided on other sites is too simple. Physicians fear that patients, lacking medical training and expertise, may believe that they understand the information when in reality they have interpreted it incorrectly (McMullan, 2006). Physicians also worry about the danger of patients engaging in self-diagnosis using the information they have found (Erdem and Harrison-Walker, 2006; McMullan, 2006). Self-diagnosis has the potential to cause significant harm if patients treat themselves based on inaccurate information or incorrect diagnoses. Furthermore, physicians worry that self-diagnosing will deter patients from seeing physicians about their conditions, since they feel as though they have taken care of the problems. If this is the case, any misinformation or incorrect treatment may not be corrected (Anderson et al., 2003).

Some physicians also hold negative views of patients’ use of the Internet for more personal reasons, viewing patients who come to appointments armed with information as difficult or problem patients (Akerkar and Bichile, 2004). These physicians may feel that, by introducing health information into physician-patient encounters, patients are challenging their authority and questioning their medical expertise (McMullan, 2006; Murray, Lo, Pollack, Donelan, Catania, Lee, et al., 2003). This can cause the physicians to feel threatened (Anderson et al., 2003) and pressured to appease patients by granting their treatment requests, no matter how inappropriate (Murray, Lo, Pollack, Donelan, Catania, Lee, et al., 2003). Some physicians also feel that they do not have the time to deal properly with the information that is brought into the encounters (McMullan, 2006; Murray, Lo, Pollack, Donelan, Catania, Lee, et al., 2003). Physicians frequently have limited time to spend with each patient and may view even implied requests for more time unfavorably (Ahmad et al., 2006; Anderson et al., 2003). Finally, some physicians feel unprepared to deal with patients who demand inappropriate treatments, specific treatments, or treatments that are very new and not yet available; this can cause significant amounts of discomfort for these physicians (Anderson et al., 2003; McMullan, 2006).

Patient use of the Internet as a source of health information is also creating a feeling among physicians that they have a responsibility to interpret the information for their patients and to correct any false information the patients may have found (Ahmad et al., 2006; Kaba and Sooriakumaran, in press). Some physicians welcome this as a way to give patients more control over decision-making, but some may be resentful of the amount of time it takes to review the information, unwilling or unable to spend this extra time with the patients, or uncomfortable with the new power dynamics in the relationships (Ahmad et al., 2006; Murray, Lo, Pollack, Donelan, Catania, Lee, et al., 2003). 

Within these more general physician views, physicians’ feelings regarding the patient provision of health information may be very dependent on the nature of the information introduced, the point in the care process at which it is introduced, and to what use the patients put the information. Most physicians have experienced patients who have brought information from the Internet to an appointment (Malone et al., 2004; Murray, Lo, Pollack, Donelan, Catania, Lee, et al., 2003), and this number is continuing to increase (Ahmad et al., 2006). When physicians feel that the information is both accurate and relevant to the patients’ conditions, they are more likely to react positively to it and to feel that it has beneficial effects on the interactions. However, if they feel that the information is inaccurate or irrelevant, reactions are more negative (Murray, Lo, Pollack, Donelan, Catania, Lee, et al., 2003). Physicians also react more positively to information that is gathered after initial appointments by patients who want to educate themselves about their diagnoses, rather than before these appointments by those who engage in self-diagnosis (Ahmad et al., 2006; Malone et al., 2004).


The changing physician-patient relationship

The ways in which patients approach physicians with information that they have found on the Internet and physicians’ reactions to these presentations of information may have significant effects on the physician-patient relationship. In general, both patients and physicians feel that patients’ use of the Internet to obtain health information has positive effects on this relationship, and there are several ways in which physicians can react that may further enhance their interactions (Murray, Lo, Pollack, Donelan, Catania, Lee, et al., 2003; Murray, Lo, Pollack, Donelan, Catania, White, et al., 2003). Relationships may be strengthened if physicians take active roles in supporting patients in their information seeking, acknowledging patients’ contributions as beneficial and encouraging them to continue to pursue information (Broom, 2005a; Gerber and Eiser, 2001). Relationships may be further improved if patients feel as though their physicians respect them and judge them to be competent (Broom, 2005b). When these feelings are nurtured, relationships may come to feel more like partnerships, and patients may become more likely to trust their physicians, to accept their diagnoses and treatment recommendations as appropriate, and to comply with their instructions, potentially improving health outcomes (Erdem and Harrison-Walker, 2006).

However, due to a number of factors, the changes in the physician-patient relationship may not always be this positive. Relationships may become strained if patients feel that they are more knowledgeable than their physicians (Anderson et al., 2003) or that the physicians disapprove of their information seeking (Broom, 2005b). Strain may also occur if physicians feel as though their authority or medical expertise is being challenged, especially if there are discrepancies between what the physicians and the patients view as appropriate treatments (Anderson et al., 2003; Murray, Lo, Pollack, Donelan, Catania, Lee, et al., 2003). Disagreements and negative reactions on the part of physicians can have negative effects on the health care provided and, ultimately, the health outcomes for the patients.

Many physicians have developed a number of strategies for dealing with additional health information and with the patients bringing it to their attention; these may serve to either strengthen or weaken the physician-patient relationship depending on the strategy. Physicians may use the opportunities positively to recommend websites that they know to be reliable; this supports and facilitates the patients’ desires for information, while simultaneously helping to regulate the sources of that information. Some physicians may be comfortable with admitting that they do not know everything about a subject, but are willing to review the information outside of the appointment time and schedule follow-up appointments to discuss it (Ahmad et al., 2006; Malone et al., 2004). Other physicians may respond more negatively; physicians may react to a perceived threat to their authority by discrediting the knowledge and abilities of patients in an attempt to reestablish their positions of dominance in the relationships (Broom, 2005a; Broom, 2005b). Still others may attempt to rid themselves of the patients by sending them to specialists to deal with the information or by charging them for the additional time it takes to review the information (Ahmad et al., 2006).

Regardless of how physicians view and react to patients’ introduction of health information obtained from the Internet into their encounters, it is altering the physician-patient relationship, as it is both enabling and requiring the two parties involved to take on new roles and responsibilities (Anderson et al., 2003; Broom, 2005a; Gerber and Eiser, 2001). Although physicians are still acknowledged by many people to be their primary sources of health information (Kivits, 2006), the Internet is removing from physicians their exclusive control in this area; where patients once had to rely on physicians for medical information, they no longer have to do so (Akerkar and Bichile, 2004; Broom, 2005b; McMullan, 2006). The boundaries that have existed between physicians and patients in terms of expertise are increasingly being dissolved as health information becomes more widely available (Hardey, 1999). Although technical medical training remains the domain of physicians, the realm of information has been opened to all.

This widespread availability of health information on the Internet is thus changing the dynamics of the physician-patient relationship in the direction of more patient-centred care (Kaba and Sooriakumaran, in press). Information can enable patients to take more active roles in their health care, becoming more involved in making decisions about their health and in questioning the decisions made by physicians (Anderson et al., 2003; Broom, 2005b). Patients often have both the time and the desire to become specialists in their own conditions, while many physicians frequently do not have this luxury (Alper, 2006). Although they have general medical backgrounds, physicians must be concerned with many more conditions and so may not be as intimately familiar with any specific one (Malone et al., 2004). Therefore, both parties have the potential to contribute significantly to their interactions in ways that are mutually beneficial.

As patients begin to take more active roles in their health care, the relationships between them and their physician may come to be characterized more by partnership and negotiation than by dominance and submissiveness (Akerkar and Bichile, 2004; Alper, 2006; Hardey, 1999). Patients may desire this change (Akerkar and Bichile, 2004), and physicians must adjust to this shift (Gerber and Eiser, 2001). Furthermore, physicians must take on the new roles of teacher and interpreter (Ahmad et al., 2006). Physicians at one time believed that patients should be told as little as possible about their conditions and treatments as they would either be unable to understand the information or unable to cope with it (McMullan, 2006). As patients are now more frequently demanding health information (Hardey, 1999), physicians must take responsibility for educating patients regarding health and the appropriate use of the Internet for health information (Anderson et al., 2003). Although physicians may no longer be providing as much information directly, they continue to have important roles to play in assisting patients to determine the accuracy of health information and in correcting any misinformation patients have discovered. They also must become translators, interpreting information for patients who lack understanding (Akerkar and Bichile, 2004; Kaba and Sooriakumaran, in press).

The extensive provision of health information on the Internet is also altering the responsibilities of patients. Patients are now not only able to locate health information for themselves, but are often expected to do so. In North American society, the emphasis on individual responsibility is creating the expectation that people should inform themselves and be actively involved in and take responsibility for their own health care. The expectation of physicians is that they will not only accept this change, but also facilitate it. Physicians’ jobs become to help patients help themselves (Kivits, 2006).


Conclusion

Whether or not these changes are perceived as positive, it is clear that there is a growing emphasis in our society on patient-centred care and that the Internet, with its ability to make a wealth of health information readily available to a huge number of people, is both a driving force behind and a facilitator of the changes that are occurring. For the first time in history, physicians no longer have virtually complete control over health and medical information. The Internet is enabling patients to e-ducate themselves, empowering them to demand interactions with their physicians in which they can contribute and enabling them to do so more effectively and with greater confidence (Kaba and Sooriakumaran, in press). Many patients have come to expect ready access to information and want to take active roles in their health care. Physicians must recognize that this is the case and react positively, accepting that patients’ contributions are valuable (Ahmad et al., 2006; Akerkar and Bichile, 2004). Patients value the physician-patient relationship highly (Erdem and Harrison-Walker, 2006) and are likely to become dissatisfied if they feel that their physicians are not meeting their needs; however, they now also feel that they have greater ability to influence their interactions with physicians. The Internet is creating a physician-patient relationship that is more of a partnership than ever before, and the health benefits of this could prove to be significant.

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