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ORIGINAL ARTICLE
Year : 2019  |  Volume : 63  |  Issue : 3  |  Page : 215-219  

Internet and doctor–patient relationship: Cross-sectional study of patients' perceptions and practices


1 Medical Student, Department of Community Medicine, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India
2 Professor and Head, Department of Community Medicine, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India

Date of Web Publication20-Sep-2019

Correspondence Address:
Amitav Banerjee
Department of Community Medicine, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pune - 411 018, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_392_18

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   Abstract 


Background: With the rapid rolling out of the information highway, an increasing number of patients are accessing the Internet for medical information. Against this background, the present study was undertaken. Objectives: To ascertain patients' use and opinion on impact of Internet on doctor–patient relationship. Methods: A cross-sectional study was done. A total of 709 patients was interviewed, 307 from urban and 402 from rural field practice areas. Institutional ethical approval was obtained before data collection. Categorical data were summarized by percentages with 95% confidence intervals (CIs). Quantitative data were summarized by mean and standard deviation. Associations were explored using odds ratio (OR) with 95% CI for categorical data and two sample t-test for quantitative data. Results: Internet for medical information was used by 50.35% of the patients (95% CI = 46.68, 54.02). More urban patients, i.e., 79.48% used Internet compared to rural patients, i.e., 28.11%. This difference was significant, OR = 9.9 (95% CI = 6.9, 14.0; P < 0.0001). Users of Internet had about 4 years more schooling than nonusers. This was significant, P < 0.0001. More users believed that this trend will improve the doctor–patient relations (51.26%), compared to nonusers (17.05%). This difference was significant, OR = 5.11, 95% CI = 3.61, 7.22, P < 0.0001. Conclusions: A large proportion of patients used Internet to get medical information, significantly more urban patients compared to rural patients. The implication of this is that doctors in times to come will be dealing with patients empowered by online health information.

Keywords: Doctor–patient relationship, Internet, medical information


How to cite this article:
Singh S, Banerjee A. Internet and doctor–patient relationship: Cross-sectional study of patients' perceptions and practices. Indian J Public Health 2019;63:215-9

How to cite this URL:
Singh S, Banerjee A. Internet and doctor–patient relationship: Cross-sectional study of patients' perceptions and practices. Indian J Public Health [serial online] 2019 [cited 2020 Jul 14];63:215-9. Available from: http://www.ijph.in/text.asp?2019/63/3/215/267223




   Introduction Top


The rapid rolling out of the information highway as a result of the Internet has affected all aspects of life including health-related issues. Increasingly, people are accessing the Internet for their information needs.[1] Internet access for health information by people may change their health-seeking behavior and relationships with their physicians.[2] While some have expressed concern about the impact of the Internet on the doctor–patient relationship, others have reassured that overall, the doctor–patient relationship depends on the trust the patient has on the physician irrespective of the information sought from the Internet.[3]

It has also been suggested that during history-taking, doctors should inquire about the patient's use of the Internet to help them evaluate the quality of any health information they might have sought.[4] Access to the Internet is changing the traditional hierarchical dimension of the doctor–patient relationship to a more equal one due to empowerment of patients.[5]

Although empowerment of the patient is desirable particularly in chronic diseases where self-care is important, there are concerns that one should be alert to the negative effects of this phenomenon.[1] Some information may be misleading as patients may be influenced by personal blogs, anecdotal information, and opinions rather than peer-reviewed scientific information.[6],[7],[8] Another hazard is that Internet information may promote self-diagnosis and self-treatment.[7] Furthermore, Internet-informed patients may have more questions and coax the doctor to prescribe more tests and medications.[9]

Easy access to information on the Internet has the potential to change the doctor-patient relationship for better or worse depending on how the new dynamics due to the Internet affects the perspectives of the patient and physician. Studies done in developed countries have identified three ways in which patients' Internet health-seeking behavior may affect the doctor–patient relationship.[10],[11] The possibilities are: (a) doctor could go on the defensive due to threat perception and become more authoritative, (b) there is better communication between doctor and patient due to better information sharing, and (c) doctor can take the initiative in directing their patients to reliable websites for health information. Sometimes, conflicts stem from different interpretations of online information which may also lead to patients ignoring physician advice.[12]

It has also been reported that how doctors respond to patients when sharing online information also may determine whether the Internet has a positive or negative impact on the doctor–patient relationship.[13],[14],[15] Overall studies have found that Internet information is useful in improving patient empowerment.[16],[17]

Although number of studies of the impact of Internet health information has been carried out in the developed countries, including a systemic review,[2] no studies of similar nature have been carried out among the Indian population of patients. India is the global Internet hub driving the worldwide computer revolution by its much sought-after information technology professionals. Information on the Internet is now available in almost all the regional languages. Penetration of the Internet to remote villages has become possible by availability of Smartphone which is being used by over 300 million people in India, and 433 million people are planning to upgrade their mobiles to Smartphone by next year.[18] If this trend continues within the next 5 years, almost every Indian will have access to the Internet.

Against this background, it is important to carry out studies to find the impact of Internet health information on the doctor–patient relationship. The present study is therefore relevant and topical.

The research questions were as follows: What proportion of study participants use the Internet for health information? Is there urban rural difference? Does gender and education affect Internet use for health information? And finally, what is the opinion of participants about impact of Internet on the doctor–patient relationship?

No study exploring these issues in India could be retrieved in the medical literature. The present study explored these questions.


   Materials and Methods Top


Study setting

The survey was carried out in the OPDs of rural and urban health centres of Department of Community Medicine of a Medical College in Pune from 1 January to 31 March 2018. Only newly registered patients were included in the study.

Sample size

Being a preliminary explorative study, sample size was calculated on presumption of 50% prevalence of Internet use for health information in the study population. This is a default presumption which estimates for maximum sample size required for an exploratory study. Using this benchmark with 95% confidence limits, margin of error of 5%, and design effect of 1.5 (for two clusters, urban and rural), the sample size calculation using Stat Calc function of Epi Info 7[19] software was 288 for each cluster giving a sample size estimate of 576. The design effect of 1.5 was taken arbitrarily, it being within the usual range (1–3) as no inputs were available for calculating it. In the actual study, information was obtained from 709 participants, 307 from urban field practice area and 402 from the rural field practice area, well over the estimated sample size to compensate for any estimation errors due to arbitrary design effect.

Inclusion criteria

The target age group and gender was adults above 18–60 years of age belonging to both genders, attending the outpatient department (OPD) of urban and rural health facilities of the medical college who consented to participate.

Ethical issues

Before collection of data, ethical clearance from the institutional ethical committee was obtained. Informed consent was also taken from the study participants. Confidentiality of the participants was maintained by not noting down personal identification details.

Data collection

Information was collected from the patients on a closed-ended study instrument which was pretested in a pilot study. Patients' perceptions and practices regarding use and impact of internet us on doctor patient relationship were elicited by the following questions: Do you use Internet for health information? Do you discuss the information on Internet with your doctor? Did your doctor ever ask you whether you have accessed the Internet for health information? Did you find information on Internet better than that given by the doctor? Do you think Internet will improve the doctor–patient relationship? Will harm it? Will have no effect? How was the information on the net? Which health issues searched on the net? Was the net used for self-medication? Which is the popular Internet search engine? Most of the answers were recorded on Likert scale to increase the accuracy of responses and later compressed to categorical scale for tabulation and analysis. The Cronbach's alpha coefficient for the study instrument was 0.7 indicating satisfactory internal consistency. The questionnaire was translated in Marathi language and backtranslated back to English to ascertain any distortion of meaning. No discrepancy in the two versions was found. If a particular intern was not familiar with the local language, i.e., Marathi, medicosocial workers at the urban and rural health centers, trained in interview techniques, performed the role of interpreters.

Ten interns working at the rural health center and an equal number working at the urban OPDs were given the responsibility of data collection. The duration of posting at each center is 1 month. The interns were trained in data collection and interview techniques by the investigators. Each intern was given the responsibility of collecting information from at least 30 participants so as to meet the target sample size of approximately 300 in each study site urban and rural. Each intern was instructed to interview not more than 3 or 4 patients attending the OPD in a single working day to ensure accuracy of data collection. On any prescheduled day of data collection, 30 patients attending the OPD were randomly selected from the patients registered in the OPD by use of computer-generated random numbers. The sampling frame for this selection was the OPD register on the day of scheduled data collection. Thirty patients were randomly selected from the OPD register. Each intern (total about 10 interns) was allotted 3–4 patients from this selected sample of 30 for interviewing in a single day. The number of OPD registrations on a single day varied from 150 to 250. The OPD registration counter opens at 9 am. It was observed that within 2 h, about 50–80 patients used to get registered. On the day of data collection, a random sample of 30 was drawn from among OPD patients registered by 11 am using these 50–80 patients as the sampling frame. If a particular patient had left the health center by the time, contact was established on telephone to arrange the interview either at home or during next visit to the OPD depending on the patient's convenience. Almost all chose the OPD as the venue of interview. Information was collected on a pretested questionnaire by face-to-face interview in the patients' waiting room. Interview was conducted in the local language. Data were collected from the two sites over a period of 3 months.

Statistical analysis

Epidemiological and statistical software Epi Info 7 (Centre for Disease Control and Prevention, Division of Health Informatics and Surveillance, Atlanta, USA).[19] was used for data entry and statistical analysis. Categorical data were summarized by percentages with 95% confidence intervals (CIs), while quantitative data were summarized by mean and standard deviation (SD). For inferential statistics, Chi-square and odds ratios with 95% CIs were used for categorical data; the two sample t-test was used for quantitative data after checking for normal distribution and homogeneity of variances by Bartlett's test.


   Results Top


Information on Internet use for accessing health- and disease-related content could be obtained from 709 participants. Out of these, 307 (43.31%) participants were from urban areas and remaining 402 (56.69%) were from rural areas. There were 405 (57.12%) males as compared to 304 (42.88%) of females in the study sample. The mean age of the participants was 35.2 years (SD 13.6 years).

Almost half the participants used the Internet for medical information, of which almost 60% discussed the information with their doctor. However, higher proportion found the doctor more informative than the net [Table 1]. The mean years of schooling among users was 11.78 (SD 2.93) compared to the mean years of schooling of nonusers which was 7.58 (SD 2.91); this difference in years of schooling was significant (two sample t-test, t = 18.7; P < 0.001).
Table 1: Pattern of internet use for medical information (n=709)

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While significantly more urban patients used the net, gender was not associated with Internet use [Table 2]. Significantly more users believed that Internet would improve the doctor–patient relationship compared to nonusers [Table 3]. Same trend was seen in the belief of harm due to Internet to the doctor–patient relationship. Significantly more users believed that it will not harm the relationship compared to nonusers [Table 4].
Table 2: Rural urban and gender differences in internet use for health information (n=709)

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Table 3: Opinion of whether internet would improve doctor-patient relationship (n=709)

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Table 4: Whether internet would have adverse impact on doctor-patient (n=709)

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The top five conditions for which Internet search was used were as follows: respiratory illnesses 15.84%, gastrointestinal disorder 12.61%, women's health problems 9.97%, heart diseases 5.57%, and musculoskeletal disorders 3.52%. The top site for Internet search for health information was Google, i.e., 76.11%. Out of those who accessed the Internet for these conditions, 140/357, i.e., 39.15% (95% CI 34.22, 44.32), resorted to self-medication with the information obtained from the net.


   Discussion Top


In India, there is prediction of rapid penetration of the Internet through Smartphone in coming years.[18] Increasingly, people will be seeking health-related information on the Internet. This has the potential to impact the doctor–patient relationship both favorably or adversely depending on capability of physicians to cope up with this information revolution.

The Internet is a double-edged sword. Neglecting the impact of information highway on patient's perception can have an adverse impact on the doctor–patient relationship. On the other hand, if the issue is properly handled by the physician, the use of Internet for medical information by patients can facilitate the doctor–patient relationship.[2]

The present study gives valuable inputs for designing orientation programs for doctors to enable them to cope up with these emerging challenges. Overall, about 50% of the respondents had accessed the net for medical information. In the urban area, this proportion was almost 80%, while it was a little below 30% in the rural area. With increasing access to the Internet in the rural areas, the proportion of people using the net for medical information will increase in the near future across the country. A study in Saudi Arabia also revealed that about 58% of patients had accessed the Internet for health-related information before visiting the doctor.[20]

In our study, Internet users had on an average 4 years more schooling than the nonusers. More informed patient visiting the doctor is going to be a global trend. Longer schooling leading to more Internet literacy is going to accelerate this. Doctors have to adapt fast to this. The traditional hierarchical doctor–patient relationship will be getting blurred with more patient empowerment brought about by the Internet.[2] However, this should not be a cause of concern. In the present study, we found that almost 60% of those using the net discussed the information with their doctors and those using the net found the doctors more informative than the net. A systematic review concluded that discussion of online information during doctor–patient interactions is beneficial.[2] Discouragement by the doctor on the issue of online health information-seeking behavior by patients has been found to be a barrier for healthy communication.[5],[21] In the present study, about 50% users of net for medical information were of the opinion that Internet would improve the doctor–patient relationship. Transparency between doctor and the patient regarding Internet use for medical information is also important as in the present study, 39.15% users resorted to self-medication. If there is healthy communication on net use between doctor and patient, any adverse effect of such self-medication can be checked. Nonusers were more likely to believe that use of net would have an adverse impact on the doctor–patient relationship. Hence, it is likely that increasing net literacy and use of online health information are likely to lead to a more favorable opinion of the benefits of the Internet in cementing the doctor–patient relationships. This is supported by a study by Chiu[22] who in an in-depth qualitative study concluded that patients found the Internet helpful in understanding the doctor's jargon. Similarly, Ybarra and Suman[23] found that the Internet enhances the doctor–patient relationship. However, Powell et al.[24] caution that we need to be vigilant. They say that there is potential for adverse effect of the Internet on health due to misleading information.[24] In the present study, this was indicated by the finding that an appreciable proportion of respondents resorted to self-medication due to influence of the Internet.

The present study has a few limitations. First, we did not use rigorous calculation for estimating the design effect which we arbitrarily took at 1.5. We tried compensated this limitation to some extent by including a larger sample. Second, we explored the issue from the patients' point of view as has been done by Stevenson et al.[25] and Russ et al.[26] The doctors' perception too need to be explored to get the full picture on how the Internet is affecting the doctor–patient relationship. Third, no efforts were made to eliminate the social desirability bias. This may be an issue in eliciting self-reported behavior. In this study situation, some respondents may have overreported their Internet access to appear more computer literate.


   Conclusions Top


Due to rapid urbanization, increase in number of years spent at school, and increasing computer literacy, online access to medical information will become universal. Although this may be a good thing due to patient empowerment and a more healthy and balanced doctor–patient relationship, we cannot predict with certainty its impact. Irrespective of whether this trend will benefit or have an adverse effect on the doctor–patient relationship, the implication is that doctors have to equip themselves with special communication skills to deal with net literate patients. Whether the patient has accessed online medical information and how well he/she has understood it should form part of history-taking in clinical practice.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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