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To cite this article: Maria Caiata-Zufferey & Peter J. Schulz (2012): Physicians' Communicative Strategies in Interacting With
Internet-Informed Patients: Results From a Qualitative Study, Health Communication, 27:8, 738-749
To link to this article: http://dx.doi.org/10.1080/10410236.2011.636478
This article describes the strategies used by physicians to interact with Internet-informed
patients, alongside illustrating the motives underlying such strategies. Semistructured interviews were conducted with a sample of 17 physicians from primary care and medical specialist
practices in the Italian part of Switzerland. The sample was diversified in terms of specialty,
age, and gender. Data collection and analysis were driven by grounded theory and supported
by a computer-assisted qualitative analysis program. A typology of four communicative strategies has been outlined. The adoption of these strategies is shaped by physicians general
attitude toward Internet-informed patients, based on their conception of medical information
for lay people through the Internet. However, this general attitude is mediated by doctors
interpretation of the specific communicative context, that is, their appraisal of three aspects:
the patients health literacy, the relevance of the online information to be discussed, and their
own communicative efficacy. At the end, the process of interpretation underlying the strategies
is discussed to expand on it and to identify implications for practice and research.
Nothing has recently changed clinical practice more fundamentally than a communication innovation: the Internet.
This statement reflects the position of a number of scholars and health practitioners concerning the impact of the
Internet on patients, doctors, and their relationship with one
another. In general, the Internet has been seen as having
remarkable potential for improving the physicianpatient
relationship by increasingly sharing the responsibility for
knowledge, by offering the possibility of more collaborative
models of physicianpatient interaction, and by fostering
greater patient involvement in health maintenance and care
(Wald, Dube, & Anthony, 2007). As a matter of fact, numerous studies have shown that the role of the Web in regard to
health care delivery and the physicianpatient relationship
is actually more complex than these positive expectations
suggest.
It is well established that patients increasingly use the
Internet for health information in all western societies (Fox,
2006; Spadaro, 2003). Despite its potential to challenge the
position of the health care provider, patients appear to see the
Correspondence should be addressed to Maria Caiata-Zufferey,
University of Lugano, Institute of Communication and Health, Via G. Buffi
13, 6900 Lugano, Switzerland. E-mail: caiatazm@usi.ch
Internet as an additional resource to support existing and valued relationships with their doctors (Caiata Zufferey et al.,
2010). Moreover, Internet-informed patients (IIPs) usually
report the improvement of their understanding and their ability to manage their health conditions (Akesson, Saveman,
& Nilsson, 2007). But if the lay public generally thinks
positively about health information on the Internet, physicians perceptions are more ambivalent. According to some
authors, health care professionals hold that the popularization of information alerts patients to important symptoms
at an earlier stage (Laing, Hogg, & Winkelman, 2004) and
helps them in the decision-making process (Giveon et al.,
2009). Consultations with IIPs can thus involve a more
patient-centered interaction (Wald, Dube, & Anthony, 2007).
Yet many studies also report negative reactions from physicians. Some doctors believe that Internet information can
generate patient misinformation, leading to distress, or an
inclination toward wrong self-diagnosis and/or detrimental
self-treatment (Ahmad et al., 2006). The consequence is an
increase in the number of patients questions and in requests
for inappropriate or unavailable testing or treatment, which
complicates the medical consultation (Dilliway & Maudsley,
2008) and adds a new interpretive role to the doctors clinical responsibilities (Sommerhalder et al., 2009). In addition,
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RQ1: What are the communicative strategies used by physicians when facing IIPs?
RQ2: What are physicians general representations (theories) behind their communicative strategies?
RQ3: What are physicians specific interpretations (conjectures) that influence, in turn, their communicative
strategies?
METHODS
This article forms part of a larger Swiss study that was
designed to explore the impact of popularization of health
information on the Internet on doctorpatient relationships. We adopted a qualitative methodology using a general grounded theory approach (Strauss & Corbin, 1990).
Approval for the whole study was obtained from the governing ethical committee, and informed consent was obtained
from each participant before data were collected.
Semistructured interviews were completed between
2006 and 2008 with a sample of physicians from primary
care and medical specialist practices. We decided to recruit
physicians in one city of the Italian part of Switzerland and
to exclude psychiatrists and paediatricians because of the
specificity of their relationship with their patients. Based on
these criteria, a prominent physician helped us to identify
a set of medical practices that would allow us to explore
physicians communicative strategies with IIPs. Sixty-nine
medical practices were identified, contacted first by letter
and then by telephone. Ten never answered. Twenty-eight
answered that they did not have time. Nine felt that they were
not able to participate because their caseload was old and not
used to the Internet; at our insistence, four of them agreed
to participate only in case we did not find enough participants, but then were unreachable when we tried to recontact
them some weeks later. Twenty-two agreed to participate
straightaway.
In line with the grounded theory approach, data collection and analysis were performed simultaneously until data
saturation was achieved. At the beginning, we interviewed
physicians chosen among those who were more willing to
participate. Then we selected physicians according to the
ongoing analysis: First, we tried to diversify the sample in
terms of physicians age; then, we tried to diversify the sample in terms of their specialty. This procedure allowed us to
maximize the variability of physicians experiences. At the
end, the sample size of 17 participants was judged large
enough to provide a variety of experiences and to allow
sufficient depth in the analysis. Participants were 3 women
and 14 men aged between 40 and 64 years (mean age 52).
They had between 15 and 39 years of practice (mean years
25). They were general practitioners (n = 5), gynecologists
(n = 3), orthopedic surgeons (n = 2), urologists (n = 2),
oncologists (n = 2), and one each were allergist (n = 1),
endocrinologist (n = 1), and rheumatologist (n = 1).
Interviews were conducted in physicians medical practices and lasted about 45 minutes. Participants were asked to
describe their experience with IIPs in the order and manner
desired. However, to make sure all the points were covered, we prepared a flexible interview grid with the main
topics to be treated. Sixteen interviews were recorded and
transcribed to improve data management and content examination. One physician refused to be recorded. In this case,
detailed notes were taken during and immediately after the
interview. The collected data did not allow for a systematic
and refined analysis, as was the case with the other interviews. However, they were used to test the emerging model
and to expand on it. The interview was thus included in the
final sample, even though the lack of verbatim transcription
precludes quotations from it in this article.
During the transcription process, participants personal
data were removed. Data analysis was inspired by the constant comparative method (Strauss & Corbin, 1990). A general inductive approach was used to code every interview, to
link and group the identified codes into larger categories, and
to define more abstract concepts. These operations, which
had to be creative and rigorous at the same time, allowed
for reduction and interpretation of the large amount of data
and were realized with the support of the software for qualitative analysis Atlas.ti (Muhr, 2004). Literature was used
throughout the process of analysis as a means of questioning
and interpreting the retrieved categories. For example, after
we noticed that physicians appraised several characteristics
of the patient in order to decide how to behave, the article
of Willems et al. (2005) helped us to interpret these data by
suggesting the importance of patients education and, finally,
RESULTS
According to the participants, patients who search information on the Internet before their medical consultation are still
a minority, although their number has increased in recent
years. However, physicians recognize that probably some
IIPs do not explicitly say that they have been on the Internet
for fear of offending the physician.
When online information is brought to consultationon
the initiative of the patient or at the doctors invitation
doctors state that patients requests are threefold. Patients
may ask for clarification in order to better understand what
they have found. This request is usually followed by one
for contextualization: Patients may ask whether the retrieved
information can be applied to their case. Lastly, patients may
make suggestions on diagnosis and treatment, based on what
they found online.
For all the doctors, patients online information seeking constitutes a potential nuisance for their professional practice, as it disturbs the traditional course of
the consultation. Participants consider that the popularization of health information through the Internet has made
their role more complex, has broken routines and modified standard procedures. The following physician clearly
expresses this feeling, which was actually shared by all the
participants:
You are required to do more. More. You are required to
go beyond a known way of doing things, a usual way of
doing things. And this is not only due to the form of the
information or to the electronic tool. This has really to do
with the content of what you have to say. (endocrinologist,
man, 42)
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Excuse me, but where did you read that? And then I have
it. (gynecologist, man, 52)
Evidence-based medicine guidelines are used as an indispensable resource in order to evaluate the information.
However, doctors accept going beyond these guidelines in
order to integrate the patients perspective. As an illustration, another urologist justifies the importance of integrating
the patients perspective by claiming that each patient is
unique, while the doctor is not necessarily in possession of
the absolute truth:
We take care of patients, we do not treat prostates. Thus,
guidelines are suitable as they show a direction, but one must
be able to go beyond standard indications. Because, after all,
who needs guidelines? Those who are not good, those who
are not able to take responsibility for their patient. . . . I have
learnt to take responsibility for my patients. I do things, I
observe, I look, but I know that I am not the truth holder just
because I am the physician. Thats why I always take into
account the point of view of the patient. (urologist, man, 53)
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That kind of patient puts you on the spot, because you always
have to justify yourself, and the discussion takes long time.
. . . You fail to do your job, you cannot stop explaining.
(general practitioner, woman, 46)
In this conception, the Internet is considered an opportunity for the patient. However, the condition to exploit it at
its best is that patients acquire a high competence in searching and evaluating information. It is part of the doctors role,
then, to instruct the patient in properly using this medium.
The Good Reasons Behind the Strategies: Specific
Interpretations
The doctors general representation of the IIP as already
discussed is important to understand the adoption of
the communicative strategies. Resistant, repairing,
coconstructive, and enhancing doctors, indeed, differ
in their level of openness toward online health information
for patients: Resistant physicians are the least open, while
enhancing doctors are best disposed toward it. Based on
more benevolence than someone with a self-important attitude. A 53-year-old urologist provides a clear example of
this:
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TABLE 1
Physicians Communicative Strategies in Interacting With Internet-Informed Patients
Resistance
Characteristics of the
communication
strategies
General
representations
behind the
strategies
Specific
interpretations
behind the
strategies
Repairing
Coconstruction
Enhancement
Purpose
Neutralize the
patient
Techniques
Ultimate message
Conception of health
information for
patients
Information is useless
or harmful
Information is fine
only if it comes
from the
consultation
Information is fine
only if it is brought
to the consultation
Information is fine
only if it is of good
quality
Conception of the
Internet as provider
of health information
Internet as a damage
Internet as a risk
Internet as an
opportunity for the
doctor
Internet as an
opportunity for the
patient
Information relevance
Physicians
communicative
efficacy
747
studies argue that the way patients and doctors communicate influences patients behavior, quality of life, understanding of medical information, and even health outcomes
(Travaline, Ruchinskas, & DAlonzo, 2005). Thus, it would
be important to examine the outcomes of the different communication strategies. Third, experimental studies could
be conducted to investigate the work of arbitrage that
physicians do when their interpretation suggests contradictory communicative strategies. A standardized patient
design, for example, could be implemented to manipulate
the patients health literacy, the information relevance, and
the physicians communicative efficacy, in order to determine which of them has the largest effect on physicians
choice of communication strategies. These are all studies
that could help understand what really happens between
physicians and IIPs, why this happens, and what its consequences are, and that could contribute to making these
interactions as efficacious as possible.
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