A Current Review of Doctor–Patient Computer-Mediated Communication

JOURNAL OF COMMUNICATION IN HEALTHCARE, 2017 VOL. 10, NO. 1, 22–30 http://dx.doi.org/10.1080/17538068.2017.1282184

A current review of doctor–patient computer-mediated communication

Seungcheol Austin Lee a and Robert J. Zuercherb aDepartment of Communication, Northern Kentucky University, 434 Griffin Hall, Highland Heights, KY 41099, USA; bOffice of Institutional Research and Assessment, University of Alabama, AL, USA

ABSTRACT KEYWORDS Background: Scholarship related to doctor–patient computer-mediated communication (CMC) Communication (D003142); has been relatively sparse, which is unsurprising given the evidence that seldom makes use of electronic mail (D034742); this mode of communication. Although scholars have made use of a number of methods to interpersonal relations – study CMC within this relational context, few have examined the ways in which CMC serves (D007398); physician patient relations (D010817) to fulfill relational functions; task-oriented communication seems to comprise the majority of such mediated discourse. However, CMC exchanges between doctors and patients often include relationship-oriented communication, though it is not frequently studied. Method: A literature search was conducted using PubMed, PsycINFO, and Communication & Mass Media Complete to identify relevant articles. The search was supplemented by backward and forward reference checking as well as existing reviews. Results: The findings revealed a number of barriers that prevent the widespread use of CMC in doctor–patient communication, such as legal concerns, concerns over provider workload and reimbursement, and privacy/trust issues. Similarly, consistent with media richness theory, doctor–patient CMC appears to be perceived as effective for straightforward and relatively simple tasks. Conclusions: The current review examined the transformative potential of CMC that is enabled by task-oriented communication, and more importantly, relationship-oriented communication. Further research is warranted to examine the potential to foster deliberative doctor–patient communication through CMC.

Scholars have long speculated that the emergence of functions in doctor–patient communication. By exam- computer-mediated communication (CMC), such as ining the potentials and barriers of CMC in transform- e-mail and web messaging systems, will transform ing doctor–patient communication, this paper aims to the traditional, paternalistic doctor–patient relationship provide implications for future investigations. into a more deliberate and empowering partnership.1 Descriptive studies have also established a substantial The use (or lack thereof) of CMC interest and willingness to use CMC on behalf of patients and doctors alike. The emergence of new communication technology has Despite the speculation over the potential of the led scholars to investigate doctor–patient communi- medium, scholarship has demonstrated some inconsis- cation in this media environment. The primary CMC tencies regarding relational functions and outcomes channels that have been examined within this rela- (e.g. trust, satisfaction, adherence).2 The adoption tional context are e-mail and web messaging rate of CMC has been slow due to a number of systems, which are asynchronous text-based communi- constraints and concerns (e.g. privacy matters, liability cation platforms. A web-based messaging system is concerns, reimbursement issues).3,4 Scholarship has similar to e-mail, but uses a secure website instead of suggested that the medium may function efficiently personal or work e-mail accounts, and thus provides and effectively for only simple, relatively easy tasks.5 protected, encrypted communication. Those CMC Considering the complex nature of doctor–patient channels have some advantages over conventional communication and the serious implications of mis- face-to-face (FtF) or telephone consultations. The asyn- communication, this limitation may inhibit the wide- chronous nature of the media allows users to transcend spread use of CMC. traditional time and space limitations. Patients can con- To address the discrepancies between the potential veniently send messages whenever they want to of CMC to revolutionize doctor–patient communication without having to worry about interrupting their and the scarcity of actual CMC usage in doctor–patient doctors. The text-based nature of media allows easy interactions, the current paper reviews the use of CMC documentation and clear descriptions of symptoms to fulfill both task-oriented and relationship-oriented and instructions.

CONTACT Seungcheol Austin Lee [email protected] Department of Communication, Northern Kentucky University, 434 Griffin Hall, Highland Heights, KY 41099, USA. © 2017 Informa UK Limited, trading as Taylor & Francis Group JOURNAL OF COMMUNICATION IN HEALTHCARE 23

Acknowledging the convenience of these media, Functions of CMC both doctors and patients are willing to communicate Task-oriented functions via e-mail or web messaging systems. The majority of doctors believe in the effectiveness of the systems Empirical evidence suggests that CMC used within this and are willing to encourage their patients to use relational context serves to fulfill functions traditionally them.6,7 Patients also have a strong need for online served by the telephone, though not all scholars agree. communication.8 Moyer et al.7 reported that more Physicians often regarded e-mail as an alternative com- than 70% of patients are willing to communicate munication tool due to the difficulties they experi- with their doctors thorough e-mail, and more than enced with the phone system.13 Of course, the key 50% of patients believe that e-mail has the potential difference lies in the asynchronous and text-based to improve doctor–patient relationships. Indeed, nature of e-mail and web messaging systems. Regard- patients who had e-mailed their doctors believed less, the literature provides ample evidence of CMC that such consultations improved communication being used for task-oriented communication. with their doctor.9 However, evidence suggests that few patients Information seeking and sharing attempt to use e-mail or web messaging systems to Information seeking and sharing are thought to be the communicate with their doctors. It is reported that primary functions fulfilled through CMC in this rela- as little as 5.8% of the USA population has ever e- tional context. Information seeking and sharing are 10 mailed their doctors. Similarly, low figures were the most essential elements in doctor–patient inter- found among seven European countries, ranging actions; mediated communication offers more oppor- 11 anywhere from 0 to 10%. The low frequency of tunities for information seeking and sharing.14 CMC usage draws a sharp contrast with telephone In the CMC context, information seeking and sharing calls – a synchronous and voice-based communi- are regularly limited to non-urgent medical issues. The cation platform that has been successfully incorpor- majority of e-mails focused on patients’ inquiries ated into the medical practice. It is reported that related to non-acute issues and following up with thevolumeofe-mailmessageswasamere17%of their physician after an appointment.10,12 The content the volume of telephone calls, while the volume of of e-mail or web messaging communication between web messaging was only 9% of telephone call doctors and patients is often simple. Sittig15 reported 12 volume. that patients’ e-mails, on average, contained one This discrepancy between attitude and actual usage request per message; the majority of these requests raises a question: what aspects of CMC make it appear were for information regarding medication or treat- promising but actually deter such channels from being ments (26%), or about specific symptoms or diseases used? To address this question, the current paper first (22%). White et al.16 similarly found that patients’ e- reviews the functions of CMC in doctor–patient com- mails primarily focused on information seeking and munication and then examines the potential of the sharing, especially information updates regarding medium. patients’ medical conditions. Although it is evident that there is a surplus of studies focusing on the frequency of such content Method being communicated through CMC, some scholars A literature search was conducted using PubMed, Psy- have attempted to provide a deeper understanding cINFO, and Communication & Mass Media Complete. of this communication and how it serves relational Search terms included medical subject headings functions. Andreassen et al.,17 for example, reported (MeSH), such as Communication (D003142), Electronic that the use of CMC creates a ‘zone of reflection’,18 Mail (D034742), and Physician–Patient Relations (p. 23) in which patients are able to focus on their (D010817), as well as other associated terms such as health concerns and consider what to write and, poss- CMC and doctor–patient communication. The search ibly more importantly, why. was supplemented by backward and forward reference CMC appears to foster an environment in which checking as well as existing reviews, such as Ye et al.10 questions are easily asked. The ‘somewhat anonymous’ Articles were limited to those written in English and nature of CMC can allow patients to discuss sensitive published in peer-reviewed academic journals by matters, although such communication may not be January 2016. To create a comprehensive list of litera- as casual as telephone or FtF conversations.13 This rela- ture, no other restrictions were made. Abstracts of all tive anonymity may encourage reluctant patients to be articles identified were read and assessed indepen- more forthcoming about sharing their problems with dently by both authors. If an abstract was deemed rel- doctors.19 Similarly, CMC may lower the threshold. evant by at least one author, the full text was reviewed Patients feel more freedom to ask questions because by both authors. they are able to minimize their concerns over being a 24 S. A. LEE AND R. J. ZUERCHER burden to the doctor, wasting the doctor’s time with Complaints and criticism irrelevant questions, or otherwise ‘stressing’ the Roter et al.21 also found that non-medical topics were doctor.17 Thus, evidence suggests that CMC could be frequently discussed in patient e-mails, though phys- seen as an enablement tool as it provides an outlet ician messages were not as likely to feature such dis- for patients to overcome pressures caused by both course. Nearly one in four patient e-mail messages embarrassment and the pressures associated with contained a complaint or criticism, some of which time and space, which are often experienced in FtF were ‘strikingly angry’ as the authors noted. Physicians settings. in the study did not voice any criticisms of their patients through this medium, though they responded Requests for action to patient complaints with either apologies or by Empirical evidence has also established that patients suggesting another medium (e.g. phone or FtF) to who do contact their physicians through CMC chan- discuss the matter. Though descriptive in nature, their nels, often do so in order to request action to be study demonstrated that doctor–patient e-mails fre- taken. For instance, Sittig15 found that 20% of the quently contained content outside of the purview of e-mail messages examined contained some form of the ‘typical’ task-oriented message types. Further patient request for action regarding either medications research is needed to address whether such complaints or medical treatments. Similarly, White et al.16 found and criticisms, when voiced through CMC channels, are that patients’ e-mails frequently requested prescription beneficial to doctor–patient relationships. One would renewals (24.2%) and referrals (8.8%). hope that the doctor would at least receive constructive criticism from the patient, which in turn could Administrative functions facilitate greater adaptation to the patient’s concerns Although not necessarily the most common function, and subsequently strengthen the relationship. CMC has been found to facilitate a number of administrative tasks in this context. Evidence so far suggests that few e-mail messages contain such communication, Building a ‘good relationship’ but nonetheless, patients have been found to Some scholars have suggested that the informal nature occasionally use the medium for appointment requests of CMC interactions, along with informal language and questions related to billing.10,16,20 often used in such forms of discourse, may strengthen the patients’ perceptions of having a ‘good relation- ’ 17 Relationship-oriented functions ship with their doctor. Physicians also believe that CMC can have a positive effect on doctor–patient The bulk (if not the entirety) of studies examining CMC, relationships by establishing and maintaining rapport as it is used within this relational context, have not with the patient.13 However, what entails a ‘good gone much further beyond examining task-oriented relationship’ and how such informal discourse leads communication. However, CMC has been found to to this outcome has not been addressed. Whether facilitate other communication needs. White et al.,16 patients perceive such rapport is another unaddressed for instance, reported that patients delivered some matter. non-medical messages associated with relational func- Some evidence also suggests that the use of CMC tions aside from tasks and administrative actions, such could facilitate greater perceptions of trust in doctor– as discussion about an upcoming vacation. patient relationships. For instance, Nilsson et al.22 That said, the few examinations that have included reported that the use of CMC increased provider acces- an emphasis on relationship-oriented communication sibility for in-home patients with chronic conditions. in this context have provided a foundation for under- Healthcare providers subsequently reported higher standing how such communication functions in this perceived levels of trust in the relationship. However, context. whether patients perceive the same level of trust was not tested. Further research is necessary to delineate Socioemotional exchanges the ways in which relational functions are achieved Roter et al.21 found that patients used e-mail to facili- through the use of CMC in this context. tate socioemotional exchanges and ‘social chit chat’. More scholarship is needed in order to further assess As they noted, nearly 35% of patient messages in how CMC is used to fulfill relational functions, as the lit- their study were explicitly affective and were particu- erature on the matter is predominantly from research- larly expressive of concern or worry. Physicians not ers who are focused on other aspects of this specific only responded to these messages with medical infor- social phenomenon. This is evident in several studies, mation, but also expressed concern, reassurance, such as White et al.’s16 investigation, which collectively empathy, or partnership, and did so quite frequently. labeled all messages falling outside of the typical More than half of their messages, which were included message- type categories (e.g. information seeking/ in the study, contained such exchanges. sharing and other task-oriented communication) as JOURNAL OF COMMUNICATION IN HEALTHCARE 25

‘other’, which they noted contained messages expres- may facilitate such discourse just as CMC may sing gratitude or apologies and other types of ‘nonme- provide patients with a platform that allows for both dical’ communication. Until scholars start investigating control and greater self-disclosure. Such communi- this matter, scholarship is likely to remain uninformed cation may make it ‘easier to elaborate values and of these so-called other message types, which, in all beliefs that [patients] might not otherwise feel comfor- likelihood, may prove important in furthering our table articulating in an initial visit, sporadic encounters, understanding of how CMC is used to fulfill specific or even in the context of an ongoing relationship’.3 relational functions. (p. 245) Again, the literature suggests this mediated channel may be engendering such an environment that allows for easier self-disclosure and control of 10,13,17,23 Transformative potential of CMC presentation. The review of the functions revealed the potential of Barriers to CMC use in doctor–patient CMC to revolutionize doctor–patient communication. communication The task-oriented communication can provide a wel- coming environment for patients to share their con- Although Baur outlined a lofty, idealistic outcome cerns. The relationship-oriented communication can related to CMC use in this relational context, empirical facilitate socioemotional exchanges, open a door to evidence has demonstrated that such drastic changes constructive criticism, and build a trusting relationship. in doctor–patient communication have not occurred. In this regard, this modern form of communication has E-mail and other CMC channels are simply not fulfilling the transformative power which scholars often hope the transformative role at this current point in time; for. Baur noted that CMC could have the potential to such interactions are only useful and appropriate for foster deliberative doctor–patient relationships. Such certain tasks and the barriers for adoption will effec- relationships, she noted, tively prevent any widespread use of such media.3

… [A]re committed to the identification of a patient’s best interests through conversations between physicians and patient about values, beliefs, and what the patient should do … the physician should not only Provider workload and reimbursement help the patient understand what he or she can do One of the most prominent concerns voiced by phys- but also what the patient should do in accordance icians regarding CMC use is the perceived increase in with his or her own value structure.3 (p. 243) provider workload that would result from integrating This relationship differs from the traditional, paternalis- such mediated interactions into their practices. Phys- tic relationship model (i.e. the doctor knows what is icians are concerned not only about the perceived best for the patient). She further described the prere- time required to interact with patients through this quisites necessary in order to foster such relationships. channel, but also about reimbursement for the time First, opportunities for interaction are necessary in spent communicating with patients through CMC.3,12 order to develop satisfying relationships in this Increased provider workload and reimbursement context.3 CMC may aid in increasing these opportu- issues are often raised when a new communication nities because asynchronous communication technology is introduced in medical settings. For methods, such as e-mail, provide a relatively con- example, when the telephone was first introduced in venient outlet for communication as parties are not medical settings, physicians were concerned about a required to interact synchronously or simultaneously, potential barrage of calls from anxious patients day which is clearly difficult in this relational context since and night. Nevertheless, the telephone did not actually physicians’ time is generally restricted and con- increase healthcare provider workload as physicians strained.19 That said, scholars have established that began to utilize this technology for screening potential patients can and do use such media for information visits and assessing priorities.24 Similar concerns have seeking and sharing purposes,10 thereby suggesting been raised when e-mail and web messaging com- that the medium does offer more opportunities for munication are introduced.25 On the one hand, new communicative interaction. Baur noted that e-mail is communication technologies may curtail the demand best considered as another outlet for doctor–patient for ineffective services by replacing trivial appoint- communication – that it is simply one more channel ments and telephone calls. In addition, e-mail and in the ‘patient-physician interaction package’.3 (p. 245) web messages are quicker to deal with than phone Second, not only are opportunities to converse calls or appointments, and this enables physicians to necessary, but specific opportunities to discuss values cope better with patients’ demand. On the other and beliefs are also necessary in order to cultivate hand, new communication technologies may make it deliberative relationships. If used in conjunction with easier to send messages to physicians regarding see- office visits, e-mail and other relevant forms of CMC mingly trivial issues. An overwhelming number of 26 S. A. LEE AND R. J. ZUERCHER messages may reduce the amount of time for phys- Privacy concerns have also fueled legislation which icians to adequately answer each message, which has inhibited widespread use of CMC in this relation- may result in a decrease in the overall quality of service. ship. For example, it is currently illegal in Norway to Despite these concerns, scholars suggest that inte- discuss personal health matters that contain identifi- grating e-mail into doctor–patient communication able information via e-mail, unless a specified does not result in a great increase in the doctor’s encrypted service is used. A small fraction of physicians time spent at the computer. Studies have shown that have made use of this encryption service, thus doctor– the actual burden of CMC is considerably low for phys- patient e-mail correspondence is severely limited. icians. For example, Rosen and Kwoh4 found that phys- Other European countries have a number of other icians in their study received only 1.2 e-mails per day on regulatory and legal barriers that prevent this relation- average. In comparison to conversing over the phone, ship from utilizing CMC channels.11 e-mails took considerably less response time as well. Aside from privacy concerns, trust is also an impor- Liederman and Morefield26 also reported that the tant, related matter. Having a ‘trusting relationship’ volume of e-mail messages doctors received was has been found to be a prerequisite in order for CMC modest, ranging from zero to five per week. On to be effective in this relational context. This level of average, physicians spent 1 –5 minutes responding to trust, however, can easily shatter as a result of mistakes each message. that violate patients’ privacy. For example, a patient in To date, no empirical evidence has been estab- one study reported that her doctor had confused her lished, which demonstrates that providers will name with another patient’s and thus provided infor- become flooded with patient e-mails once such com- mation relevant to the other patient. Not only did the munication channels are integrated into practice. physician breech confidentiality, but the patient felt However, physicians should not expect CMC to offset as though the doctor lacked an understanding of her or substitute the time spent on the telephone.12 situation and did not care enough to ensure accuracy; Thus, current evidence suggests that physicians who this one mistake resulted in the termination of the offer e-mail correspondence to their patients may relationship.17 face somewhat of an increase in time spent communi- In the same study, a physician reported an instance cating with patients through mediated channels, where trust may have been damaged. The physician though not at the magnitude that has been suggested. noted that one of their married patients was having an affair; patient confidentiality was breeched due to Privacy and trust the doctor’s assumption that the patient was commu- The other primary concern preventing general CMC nicating information to the spouse, which was hardly use in this relationship involves the security and the case.17 Such confusion in the diffusion of infor- privacy associated with CMC exchanges. As Moyer mation through this channel is particularly proble- et al. noted, ‘Ensuring privacy and confidentiality may matic, as the sender cannot truly know who is on the be one of the most formidable challenges to the wide- receiving end. Trust may be weakened as a result of spread implementation of electronic communication in mistakes made in the transmission and reception of medical settings’.27 (p. 1520) They argue that even messages, which may take a long time to regain.13 coupling e-mail with encryption technology is not enough; privacy is never truly guaranteed in this par- Logistic concerns ticular CMC channel as messages are stored and the Ye et al.10 noted that physicians are wary of offering or opportunity for unauthorized access is constantly promoting e-mail correspondence due to logistical looming (e.g. leaving a browser window open and concerns. However, e-mail triage systems appear to unattended). Ironically, the ability to store e-mail corre- be the solution as they help to ensure timely responses spondence is perceived by patients as a benefit,10 from the appropriate parties and reduce the potential though it is also this feature that fuels privacy concerns. barrage of e-mail that physicians might face. In a It is found that a substantial number of patients triage system, patient e-mails are not directly expressed being concerned that someone besides addressed to their physician, but rather a central their physician would read their e-mail at the clinic or account. In Katz et al.’s12 investigation, an e-mail someone at their own end (e.g. spouse, child) might triage system was implemented such that a ‘nurse navi- read their e-mail, suggesting that patients are con- gator’ was in charge of routing patient e-mails to the cerned over privacy matters.12 Physicians also report appropriate recipients. This system ensured that e- mixed feelings regarding privacy concerns. Some feel mails were routed to the appropriate parties and that that as long as patients are comfortable using e-mail, recipients did not receive irrelevant messages (e.g. communicating via CMC presents no immediate pro- doctors receiving e-mails concerning appointment blems, though others simply omit personal information scheduling or billing questions). in e-mail correspondence in an effort to placate privacy However, patients in their investigation reported concerns.13 being disappointed in the time that it took to receive JOURNAL OF COMMUNICATION IN HEALTHCARE 27 a response; they also noted a preference with speaking made available, variety in language). The theory to a ‘real person’. Triage systems may resolve concerns argues that task performance is improved when task regarding the logistics of offering e-mail contact; needs are matched to a medium’s richness. For tasks nevertheless, such systems may not encourage or that are complex or equivocal, media capable of promote positive attitudes toward using CMC. More- sending ‘rich’ information (e.g. FtF) are more effective. over, the systems prevent the direct communication For simple and routine tasks, ‘lean’ media are more between doctors and patients and thus impede efficient. relationship building. In addition, concerns regarding A number of studies have established patients’ con- privacy and trust can be exacerbated as many individ- cerns over whether CMC is an effective and efficient uals may have access to correspondence between means of communication. Moyer et al.,7 for example, patients and doctors. found that patients generally preferred speaking to a ‘real person’ and that they would rather call their Gaps in knowledge and access doctor. Similarly, nearly one in three patients in Katz Similarly impeding widespread CMC use in this context et al.’s12 study perceived e-mail to be too ‘impersonal’. are the gaps in both knowledge and access. Sittig Consistent with media richness theory, the majority of et al.28 found that few patients actually e-mailed their physicians and staff reported that e-mail was appropri- doctors (6%), but that over half of their sample would ate for administrative functions and non-urgent ques- like to communicate with their physician(s) through tions. Physicians in Patt et al.’s13 study similarly this channel. Sometimes, they simply do not know reported that e-mail might be useful for patients with their provider’s e-mail address. Likewise, the over- chronic diseases or conditions (e.g. diabetes, hyperten- whelming majority of patients also reported not sion) who already had a relationship with the physician. knowing whether their provider actually used e-mail. Thus, for consistent health problems that pose little A larger concern, however, is the gap in access uncertainty, CMC is perceived to be an effective com- otherwise known as the ‘digital divide’. The digital munication medium. divide in this context does not necessarily arise from Although the asynchronous nature of e-mail does discrepancies in access to digital information technol- provide the opportunity for feedback, timeliness is ogy; instead, it is more likely to arise from attitudes clearly a salient issue. Katz et al.12 found that nearly toward CMC. Younger, male, more educated, and one out of two patients were concerned about the more urban patients were more likely to appreciate length of time that it would take to receive a response and have a positive attitude toward CMC discourse in from their physicians. This fear is not entirely this relationship.6,9,11 Singh et al.’s29 research also unfounded. More than 40% of physicians in Sittig’s15 paints a troubling picture: although they found that study failed to respond to patient e-mails within 24 nearly half of their participants (aged 65 and older) hours despite a general policy suggesting such a were enthusiastic about the prospect of e-mailing response time. Physicians replied within 31.1 hours on their doctor, only 1.3% had actually done so. average, though the response times ranged from 2 The digital divide is also evident when examining minutes to 13 days. E-mails from physicians were also socioeconomic status. Rosen and Kwoh,4 for example, extremely brief; the average e-mail length was 39 words. had over 300 families enroll in their study, yet of Preferences for mode of communication also those on a public health insurance plan, not a single demonstrate consistencies with media richness family contacted their doctor through e-mail. Evidence theory. Both doctors and patients endorse CMC and tel- thus suggests that only some patients may use CMC, ephone use for minor medical issues. For more which again may inhibit calls for widespread complex and private medical issues, they prefer face- implementation. The digital divide calls for a response to-face consultations. Katz et al.,12 for instance, com- considering that less educated and economically disad- pared patient preferences for mode of communication vantaged populations are more vulnerable to health based on a number of selected issues. E-mail was pre- threats. ferred the majority of the time for communication regarding cholesterol results, a normal Pap or PSA Perceived task complexity test result, prescription renewals, questions regarding Another potential limiting factor related to doctor– sore throat, and questions about back pain. The tele- patient CMC is the medium itself. Some communicative phone was preferred for scheduling/cancelling tasks may be perceived as too complex for relatively appointments and discussing the side effects of a lean channels (e.g. e-mail). Evidence from the literature new medication. Scheduling a visit was preferred for regarding doctor–patient CMC seems to support, albeit more complex and private issues, such as an abnormal implicitly, Daft and Lengel’s30 media richness theory. Pap or PSA test result, prolonged sadness or anxiety, This theory is concerned with the effectiveness of questions regarding breast or testicular pain, and STD media based on the ‘richness’ of the medium (e.g. test results. This finding indicates that the lack of the ability for feedback, number of cues and channels media richness limits the topic of consultation in CMC. 28 S. A. LEE AND R. J. ZUERCHER

Lack of immediacy being said, will limit the transformative power of A lack of immediacy can be a threat to building CMC. As Baur noted, doctor–patient relationship in a CMC context. Immedi- ‘ Physicians display a consistent tendency to prefer tech- acy refers to communicative behaviors that enhance nical instead of relational spheres of activity with closeness to and nonverbal interaction with patients … if physicians prefer interactions that another’.31 (p. 203) Immediate physical and verbal emphasize efficient use of their technical expertise, behaviors reflect approachability and involvement, then they are likely to think of and use the Internet and thus reduce psychological and physical distance in ways that emphasize the technical rather than interpersonal dimension of the physician-patient relation- between doctors and patients. Verbal immediacy ship.3 (pp. 248–49) behaviors include self-disclosure, using humor, prais- ing patients, and using inclusive pronouns (‘we’ and Evidence so far seems consistent with this argument. ‘our’) instead of exclusive pronouns (‘I’ and ‘my’). Non- Sittig,15 for instance, found that patients always initia- verbal immediacy behaviors include affective beha- lized CMC contact, which suggests that doctors may viors, such as eye contact, smiling, and leaning only respond to e-mails and not initiate communi- toward patients. cation in this channel. Roter et al.’s21 analysis found In medical settings, doctors’ immediacy manifested that physician e-mails were shorter, appeared to be in relational messages is a significant predictor of rushed, and rarely contained questions directed to patient satisfaction.32 A warm, immediate behavior, the patient, such as the patient’s medical condition, including closer proximity and more eye contact, regimen, or schedule. reduces patient uncertainties and enhances relation- Although one might speculate that more and more ships, and thus leads to higher satisfaction with com- CMC would occur in this relational context as the ‘Net munication and the quality of medical care.19,33 It Generation’ comes of age, little has changed in the also leads to patients’ disclosure of information last decade. In fact, physicians’ interest in e-mail corre- related to the patients’ beliefs and emotions relating spondence with patients actually decreased during this to illness.34 time. Even more troubling is the finding that phys- Despite their positive impacts on doctor–patient icians’ use of best practices, designed to preserve communication, immediacy behaviors are often not doctor–patient relationships, has similarly declined.36 available in a mediated communication environment. For instance, Mittal et al.’s37 simulated e-mail study McKinstry et al.35 documented that immediacy beha- showed that only 30% of physicians took active viors for rapport building via mediated communication measures to contact the patient in need for urgent did not occur as frequently as they did in FtF consul- medical attention. Future studies need to focus on tations. To address this lack of immediacy, researchers how to improve physicians’ communication compe- have suggested some solutions. For example, Wilson8 tence in CMC through training and education.38 suggested integrating richer media, such as voice From the perspective of media richness theory, CMC messages, into text-based asynchronous communi- has limitations as a lean medium. Some of these bar- cation media. riers may be reduced by the utilization of richer CMC channels that could facilitate more complex tasks. Indeed, researchers started to look into more diverse and richer channels, including social media (e.g. Face- Future directions – book, Twitter),39 41 Skype,42 and mobile applications.43 The current review examined the transformative Those new types of media have a higher capacity to potential of CMC that is enabled by the task-oriented express immediacy and focused on relationships. communication and, more importantly, relationship- Another way to address the limitations is to enhance oriented communication. While CMC has the potential other factors, such as communication skills and the to foster deliberative doctor–patient communication, mutual directionality of the channel. According to the such research has not been at the forefront of most theory of electronic propinquity (perception of proxi- scholars’ agendas. Future research is necessary to mity in the mediated environment), the bandwidth uncover the nature of this communication (e.g. affec- (i.e. richness) of media does not solely determine the tive statements and other socioemotional exchanges), sense of closeness or involvement.44 If individuals’ sub- which tends to be lumped into the ‘other’ category in jective perception of propinquity can be enhanced by content analyses. greater application of communication skills, and the Although CMC has the potential to transform the reduction of formality, lean media, such as CMC, can nature of doctor–patient communication, such trans- be used effectively for complex and demanding tasks formations are just not actualized due to a number of such as doctor–patient communication. barriers. Even if it is widely adopted, simply extending Those new types of CMC and the enhancement of communication between doctors and patients, into a communication skills may help doctors and patients new channel without necessarily changing what is benefit from the potential of CMC to reduce pressure JOURNAL OF COMMUNICATION IN HEALTHCARE 29 on the healthcare system, especially with an influx of 8. Wilson EV. Asynchronous health care communication. patient visits, questions, and requests, due to the enact- Commun ACM 2003;46(6):79–84. ment of the Affordable Care Act. More extensive 9. Gauld R. Factors associated with e-mail and Internet use for health information and communications among studies need to be performed to address the paucity Australians and New Zealanders. Soc Sci Comput Rev of research in doctor–patient CMC. 2011;29:161–71. 10. Ye JL, Rust G, Fry-Johnson Y, Strothers H. E-mail in patient-provider communication: a systematic review. Disclaimer statements Patient Educ Couns 2010;80:266–73. 11. Santana S, Lausen B, Bujnowska-Fedak M, Chronaki C, Contributors Both S. Austin Lee and Robert J. Zuercher gen- Kummervold PE, Rasmussen J, et al. Online communi- erated the research idea, carried out the literature review, and cation between doctors and patients in Europe: conducted the analysis. Both were responsible for drafting status and perspectives. J Med Internet Res 2010;12: and critical revision. S. Austin Lee is the guarantor. e20. Funding None. 12. Katz SJ, Moyer CA, Cox DT, Stern DT. Effect of a triage- Conflicts of interest The authors declare that there are no based e-mail system on clinic resource use and patient conflicts of interest. and physician satisfaction in primary care. J Gen Intern Ethics approval This study did not require ethical approval as Med 2003;18:736–44. it is a systematic review and did not involve any human 13. Patt MR, Houston TK, Jenckes MW, Sands DZ, Ford DE. subjects. Doctors who are using e-mail with their patients: a quali- tative exploration. J Med Internet Res 2003;5(2):e9. 14. Brashers DE, Goldsmith DJ, Hsieh E. Information seeking Notes on contributors and avoiding in health contexts. Hum Commun Res – S. Austin Lee (Ph.D., Michigan State University) is an Assistant 2002;28:258 71. Professor in the Department of Communication at Northern 15. Sittig DF. Results of a content analysis of electronic mess- Kentucky University. His research in health communication ages (email) sent between patients and their physicians. – focuses on provider–patient relationships. He has conducted BMC Med Inform Decis Mak 2003;3(11):1 5. fMRI studies to investigate neurobiological changes accom- 16. White CB, Moyer CA, Stern DT, Katz SJ. A content analysis panying patient-centered interviewing. of e-mail communication between patients and their providers: patients get the message. J Am Med Inform Robert (Bob) Zuercher (Ph.D., University of Kentucky) is an Assoc 2004;11:260–67. Institutional Research Analyst Senior in the Office of Insti- 17. Andreassen HK, Trondsen M, Kummervold PE, Gammon tutional Research and Assessment at the University of D, Hjortdahl P. Patients who use e-mediated communi- Alabama. His research interests include health/political cam- cation with their doctor: new constructions of trust in paign communication and new media. the patient-doctor relationship. Qual Health Res 2006;16:238–48. 18. Suler J. The psychology of text relationships. In: Kraus R, ORCID Stricker G, Speyer C, editors. Online counseling: a hand- book for mental health professionals. Chicago (IL): Seungcheol Austin Lee http://orcid.org/0000-0002-3985- Academic Press; 2010.p.19–50. 2505 19. Miller EA. Telemedicine and doctor-patient communication: a theoretical framework for evaluation. J Telemed Telecare 2002;8:311–18. References 20. 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