This paper is in the following e-collection/theme issue:

Digital Health Reviews (1174) Information Seeking, Information Needs (419) Registered Report (516) Participatory Medicine & E-Patients (758) Consumer & Patient Education and Shared-Decision Making (636) Medicine 2.0: Social Media, Open, Participatory, Collaborative Medicine (1552) Quality/Credibility of eHealth Information and Trust Issues (485) Physician and Health Services Rating by Consumers (126)

Published on in Vol 24, No 2 (2022): February

Preprints (earlier versions) of this paper are available at https://preprints.jmir.org/preprint/23354, first published .
The Effect of Online Health Information Seeking on Physician-Patient Relationships: Systematic Review

The Effect of Online Health Information Seeking on Physician-Patient Relationships: Systematic Review

The Effect of Online Health Information Seeking on Physician-Patient Relationships: Systematic Review

Authors of this article:

Aijing Luo1, 2, 3 Author Orcid Image ;   Lu Qin2, 3 Author Orcid Image ;   Yifeng Yuan1, 2 Author Orcid Image ;   Zhengzijin Yang2, 3 Author Orcid Image ;   Fei Liu2, 3 Author Orcid Image ;   Panhao Huang4 Author Orcid Image ;   Wenzhao Xie2, 3 Author Orcid Image
Article Authors Cited by (52) Tweetations (12) Metrics

    Review

    1The Second Xiangya Hospital, Central South University, Changsha, China

    2Key Laboratory of Medical Information Research, The Third Xiangya Hospital, Central South University, Changsha, China

    3School of Life Sciences, Central South University, Changsha, China

    4Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, China

    Corresponding Author:

    Wenzhao Xie, PhD

    Key Laboratory of Medical Information Research

    The Third Xiangya Hospital

    Central South University

    No.138 Tongzipo Road

    Changsha, 410013

    China

    Phone: 86 0731 8861 8316

    Email: xie_wenzhao@126.com


    Background: The internet has now become part of human life and is constantly changing people's way of life. With the increasing popularity of online health information (OHI), it has been found that OHI can affect the physician-patient relationship by influencing patient behaviors.

    Objective: This study aims to systematically investigate the impact of OHI-seeking behavior on the physician-patient relationship.

    Methods: Literature retrieval was conducted on 4 databases (Web of Science, PubMed, China National Knowledge Infrastructure, SinoMed), and the time limit for literature publication was before August 1, 2021.

    Results: We selected 53 target papers (42 [79%] English papers and 11 [21%] Chinese papers) that met the inclusion criteria. Of these, 31 (58%) papers believe that patients’ OHI behavior can enable them to participate in their own medical care, improve patient compliance, and improve the physician-patient relationship. In addition, 14 (26%) papers maintain a neutral attitude, some believing that OHI behavior has no significant effect on doctors and patients and others believing that due to changes in the factors affecting OHI behavior, they will have a negative or a positive impact. Furthermore, 8 (15%) papers believe that OHI search behavior has a negative impact on doctors and patients, while 6 (11%) papers show that OHI reduces Chinese patients’ trust in doctors.

    Conclusions: Our main findings showed that (1) OHI-seeking behavior has an impact on patients' psychology, behavior, and evaluation of doctors; (2) whether patients choose to discuss OHI with doctors has different effects on the physician-patient relationship; and (3) the negative impact of OHI on China’s internet users is worthy of attention. Due to the low quality of OHI, poor health information literacy, short physician-patient communication time, and various types of negative news, patients' trust in doctors has declined, thus affecting the physician-patient relationship. Improvement of people's health information literacy and the quality of OHI are important factors that promote the positive impact of OHI on the physician-patient relationship.

    J Med Internet Res 2022;24(2):e23354

    doi:10.2196/23354

    Keywords

    online health information; search behavior; physician-patient relationship; physician-patient consultation. 


    About 4.66 billion people worldwide have access to the internet [1]. The internet has gradually become part of human life, constantly changing people's lifestyle. As the availability and immediacy of information services provided by the internet continue to improve, and patients' private information can be concealed to a certain extent, internet health information services have become increasingly attractive [2]. In addition, the lack of medical resources makes people choose to obtain health information online to meet their own health information needs [3]. The online health information (OHI) that patients search for on the internet mainly includes information about diseases, nutrition, treatments, physical and mental health, etc [4,5]. The uneven quality of OHI has a major impact on patients. The credibility of information perceived by patients affects whether the patients use the internet as a frequently used and preferred information source [6]. Physicians are still the most popular source of health information, but the internet has gradually become another important source of health information [7].

    OHI seeking can influence physician-patient relationships and patient compliance. Patients who can obtain more health information can better follow the treatment process and enjoy better therapeutic effects [8]. The rapid development of the internet has changed the access of patients to health information and affected the existing physician-patient relationship, which to a large extent determines the medical result that patients receive [9]. As mentioned before, patients choose to obtain health information online to meet their own needs. At the same time, the health information search results provided by the internet show that extreme situations, for example, advice that is contrary to the standard medical opinion or complex data provided by health care professionals, leads to misinterpretation, confusion, and other problems for patients [10]. Of course, the availability of health information on the internet is transforming many patients from passive medical service consumers to those who can participate in the medical process, which brings new challenges for many physicians [11,12]. When patients carry a lot of health information in a short consultation, can physicians deal with it as usual?

    With the continuous development of the internet, the physician-patient relationship has attracted much attention. In terms of importance, the relationship between patients and physicians is second only to that of family [13]. It is viewed as extremely or very important by 67%, exceeding relationships with spiritual advisors, pharmacists, coworkers, and financial advisors [13]. Due to the patients' lack of understanding of diseases and communication barriers between physicians and patients, some patients cannot understand the results of diagnosis and treatment of the disease and the treatment behavior, which causes a series of problems [14]. Physician-patient communication is a complex clinical behavior whose main goal is to share medical information to improve the education of clinical diagnosis, treatment, and specific diseases [14]. The quality of physician-patient communication affects the physician-patient relationship. In the past, physicians made decisions and patients obeyed them, which constitutes the traditional physician-patient relationship [15]. Patients and medical staff advocate the transition to mutual participation, that is, shared power and responsibility [15]. Previous studies have shown that processing patients' OHI-seeking behavior in daily consultation can improve the quality of medical services [16]. In an ideal physician-patient relationship, patients should be guided instead of looking for OHI independently [17]. However, at present, patients are mainly looking for OHI by themselves, and they are unable to control the quality of information and other aspects.

    In China, the total population is about 1.4 billion [18]. As of June 2021, the number of internet users reached 1.011 billion, and the internet penetration rate reached 71.6%. The “Healthy China” strategy is China’s priority development strategy [19]. By implementing internet medicine, the Healthy China strategy promotes the mobility of medical services, enhances the operation efficiency of the overall medical and health system, and optimizes the allocation of medical resources [19]. Due to China's large population and the impact of COVID-19, China's demand for medical resources is growing exponentially. Increasingly more doctors and patients are seeking health information through internet platforms, effectively breaking the time and space restrictions and giving China's unbalanced medical resources a chance to be redistributed [20]. Considering that OHI may have a positive or a negative impact on the physician-patient relationship, which is important in medical care, this study aims to examine the impact of OHI on the physician-patient relationship in China.

    In recent years, studies on health information seeking have been increasing. It is of great significance to understand the impact of the current health information seeking on the physician-patient relationship. Thus, the purpose of this study is to systematically review the current studies on the impact of OHI seeking on the physician-patient relationship.


    Literature Retrieval

    In this study, English references were obtained from the databases Web of Science and PubMed. The PubMed database contains references related to medicine and life sciences. Web of Science includes the most influential core academic journals on natural science, engineering technology, biomedicine, and other research fields. Chinese references were obtained from the databases China National Knowledge Infrastructure (CNKI) and SinoMed. The CNKI is China's largest full-text journal database, while SinoMed focuses on collecting the biomedical literature in China.

    After consulting with librarians, the search strategy for this paper consisted of all possible keywords related to 4 topics: (1) online OR internet OR web OR network, (2) wellness information OR health information, (3) search* OR seek* OR inquiry OR query, and (4) physician-patient communication OR doctor-patient communication OR physician-patient relation* OR doctor-patient relation* OR physician-patient interaction OR doctor-patient interaction OR physician-patient trust OR doctor-patient trust. The papers were published before August 31, 2021. Combinations of these keywords were searched in the 4 databases to make the literature search as comprehensive as possible. In addition, we searched the PubMed database separately with Medical Subject Headings (MESH). The Mesh terms were “patient-physician relations” and “internet.”

    This systematic review conforms to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement (Multimedia Appendix 1).

    Inclusion and Exclusion Criteria of Publication Standards

    To make the coverage of this study comprehensive enough, the types of papers included were journal papers, conference papers, and academic dissertations. Paper retrieval covered all regions and languages, but only papers with full text in English or Chinese were retained. Papers involving only OHI-seeking studies or only physician-patient relationship studies were excluded. We also excluded all nonempirical research papers, including reviews, research on websites, and research commentaries. Then, we evaluated the quality of the included papers. We used the Critical Appraisal Skills Programme quality assessment tool for qualitative studies, which comprises 10 questions [21] (Multimedia Appendix 2). We also used a quality assessment tool for quantitative studies that comprises 14 questions customized by Tan et al [22] (Multimedia Appendix 3). Papers with a quality assessment score lower than 0.7 were excluded.

    Paper-Screening Process

    The literature screening in this study was independently carried out by 2 researchers. They screened the titles and abstracts, respectively, and read the full text to extract opinions. We compared the 2 researchers' screening results and the consistency of the extracted views, discussed the discrepancies to ensure the consistency and integrity of results, and used quality assessment tools to assess the quality of the papers. Endnote 20 was used to merge related search results and delete duplicate papers.

    Data Extraction and Management

    The research data of papers were independently extracted by 2 researchers according to the predesigned table. It mainly included the following information: country, research design method, sample size, respondents, and conclusion. Where there was ambiguity, the 2 researchers discussed it and reached an agreement.


    Characteristics of the Papers

    In this study, we searched the PubMed and Web of Science databases and retrieved 10,303 and 9345 records, respectively, for a total of 19,648 initially searched records and 15,801 (80.42%) exported records that remained after duplication removal using Endnote 20. According to the screening criteria, whether the papers discussed OHI seeking and the physician-patient relationship, 173 (1.09%) papers were included according to the title and abstract for further screening. Through the application of inclusion and exclusion criteria, of these 173 papers, 72 (41.6%) did not involve the impact of the physician-patient relationship; 7 (4%) were reviews; for 9 (5.2%), the original text could not be obtained; 19 (10.9%) did not have health information seeking as the main research object; 13 (7.5%) had full text in languages other than English; 10 (5.8%) were on nonempirical research; and 1 (0.6%) focused on physicians. The screening process is shown in Figure 1.

    Finally, we included 42 of 173 (24.2%) English papers in the study; see Table 1. From the perspective of literature research methods, most of the studies were carried out in the form of questionnaires and interviews, and there were 11 (26%) studies in which research models and hypotheses were first proposed and questionnaires were designed for verification to study the mechanism of OHI seeking affecting the physician-patient relationship from different perspectives [11,23-32].

    ‎
    Figure 1. Flowchart of the selection process (English papers). OHI: online health information.
    View this figure
    Table 1. Summary of included English papers (n=42).
    NumberReferenceCountryMethodParticipants, nParticipant characteristicsFactors affecting OHIa use covered in this paper (Y=yes/N=no)Impact of OHI seeking on patients covered in this paper (Y=yes/N=no)OHI seeking affects patients\' evaluation of physicians covered in this paper (Y=yes/N=no)Discussion of OHI and physician-patient relationship covered in this paper (Y=yes/N=no)
    1[33]United KingdomSemistructured interview22 (12 [55%] female, 10 [45%] male)Adult patients with psychosisYYNY
    2[7]AustriaEmail interview562 (332 [59.1%] female, 230 [40.9%] male)Internet citizensNNNY
    3[34]United KingdomSurvey202 (102 [50.5%] female, 100 [49.5%] male)Consecutive adult hematology clinic patientsYYYN
    4[35]AustriaSemistructured interview26 (12 [46%] female, 14 [54%] male)Patients with schizophreniaNNYY
    5[36]United StatesSurvey154 (98 [63.6%] female, 48 [31.2%] male, 8 [5.2%] missing data)Patients at 3 osteopathic primary care medical clinicsNYNY
    6[37]United KingdomFocus group interview34 (12 [35%] female, 22 [65%] male)Adult patients with diabetes mellitus, ischemic heart disease, or hepatitis CNNNY
    7[38]United KingdomEmail interview31 (28 [90%] female, 3 [10%] male)Health information seekersNYNY
    8[39]Saudi ArabiaSurvey431 (181 [41.9%] female, 250 [58.1%] male)Adult dermatology outpatientsYNNY
    9[40]CanadaSemistructured interview56 (30 [54%] female, 26 [46%] male)Adults aged ≥50 yearsNYNY
    10[41]United StatesSurvey and semistructured interview120 (92 [76.6%] female, 28 [23.3%] male)Patients new to the rheumatology clinicNNNY
    11[42]United StatesSurvey70 (42 [60%] recent internet users [RIUs], 28 [40%] ever internet users [EIUs])Breast cancer patientsYNNY
    12[43]United StatesSurvey and semistructured interview61 (49 [80%] female, 12 [20%] male)New patients with multiple sclerosisNNNY
    13[25]United StatesIndividual and focus group interview20 (11 [55%] female, 9 [45%] male)Older adultsNYNN
    14[44]United KingdomTelephone survey3209 (1765 [55%] female, 1444 [45%] male)A household probability sample from the 48 contiguous statesNYNY
    15[45]United KingdomSemistructured interview47 (32 [68%] female, 15 [32%] male)Patients with contact with health services for information/treatment in relation to hormone replacement therapy (HRT)/menopause and Viagra/erectile dysfunctionNNNY
    16[46]AustraliaSurvey93 (44 [47%] female, 49 [53%] male)Oncology patientsNYNY
    17[47]United KingdomTelephone survey15 females (8 [53%] high school certificate, 5 [33%] bachelor’s degree, 2 [14%] postgraduate degree)Women faced with decisions concerning menopause and HRTNYNN
    18[48]ItalySurvey1039 (704 [67.76%] female, 335 [32.24%] male)Adults aged ≥18 years selected from among parents of public school studentsYYNN
    19[49]United StatesSurvey5075 (3141 [61.89%] female, 1934 [38.11%] male)Participants in the Health Information National Trends Survey 2007YNNN
    20[50]AustraliaSurvey400 (192 [48%] female, 208 [52%] male)Adult emergency department patientsYYNN
    21[51]United StatesStructured in-person interview1142 (346 [30.29%] female, 796 [69.71%] male)Adults hospitalized for acute coronary syndromesYNNY
    22[9]AustraliaInterview33 malesPatients with prostate cancerNYNY
    23[10]SwitzerlandSemistructured interview32 patients (12 [38%] female, 20 [62%] male) and 20 physicians (4 [20%] female, 16 [80%] male)Patients and physicians from primary care and medical specialist practicesNYNY
    24[52]IsraelSurvey138 (83 [50.7%] female, 54 [39.3%] male)Patients at 10 primary care clinicsYYNN
    25[53]United StatesTelephone survey2010 (1214 [60.39%] female, 796 [39.61%] male)Participants in the Surveying the Digital Future, Year 4, national surveyNNYN
    26[54]CanadaSurvey39 (27 [70%] female, 11 [28%] male, 1 [2%] unknown)Patients with thyroid cancer attending appointments with radiation oncologists at 2 tertiary cancer centersNYNY
    27[12]SwitzerlandQuestionnaire survey459 (207 [45.1%] female, 252 [54.9%] male)460 patients aged ≥18 yearsYNNY
    28[26]NetherlandsQuestionnaire survey，interview90 (31 [34%] female, 59 [66%] male)Patients recently diagnosed with colorectal cancer recruited from 6 hospitals in the NetherlandsYYNN
    29[55]United StatesQuestionnaire survey30 (15 [50%] female, 15 [50%] male)Consecutive patients presenting for preoperative consults for hernia repair requiring surgical meshYYNY
    30[56]RomaniaQuestionnaire survey485 (242 [49.9%] female, mean age 50.42 years)Adult patientsYYNN
    31[11]SingaporeWeb-based questionnaire survey423 (209 [49.4%] female, 214 [50.6%] male)Internet usersYNNY
    32[57]MalaysiaQuestionnaire survey381 (239 [62.7%] female, 142 [37.3%] male)Patients in a hospital-based primary care clinic in the University of Malaya Medical CentreYNNY
    33[58]BelgiumQualitative semistructured interview40 (22 [55%] female, 18 [45%] male)Adults between the ages of 50 and 64 years (middle-aged adults) and 65 and 80 years (older adults)YNNY
    34[59]ChinaFocus group interview46 (34 [74%] cancer patients, 12 [26%] family members)Patients with cancer or their familiesYYNY
    35[23]ChinaSurvey668 (320 [47.9%] preuse internet samples, 348 [52.1%] not-use internet samples)Internet citizensNYNN
    36[24]ChinaSurvey336 (180 [53.6%] female, 156 [46.4%] male)Participants who underwent treatment with a monthNYYN
    37[27]ChinaWeb-based questionnaire survey336 (180 [53.6%] female, 156 [46.4%] male)Chinese individuals who received treatment in the past month and searched the internet for health informationNYYN
    38[28]ChinaQuestionnaire survey316 (194 [61.4%] female, 122 [38.6%] male)OHCb usersNYYY
    39[29]ChinaWeb-based questionnaire survey280 (114 [40.7%] female, 166 [59.3%] male)Patients who visited the hospital within the past half year or who are visiting the doctor for the first timeNYYN
    40[60]Hong KongQuestionnaire survey1179 (717 [60.81%] female, 462 [39.19%] male)Patients attending the primary care clinic of a university in Hong KongYYNY
    41[31]ChinaQuestionnaire survey446 (224 [50.2%] female, 222 [49.8%] male)Patients in Tongji Hospital in Wuhan and the Huazhong University of Science and Technology hospitalNYYN
    42[30]ChinaOnline survey336 (180 [53.6%] female, 156 [46.4%] male)Chinese individuals who have experience seeking health information and going to hospitals within the previous monthYNN N

    aOHI: online health information.

    bOHC: online health community.

    With searching in the CNKI and SinoMed, there were 5440 initially searched papers, of which 5219 (95.94%) exported papers in Chinese remained after duplication removal using Endnote 20. Of these, 88 (1.69%) papers were included according to the title and abstract for further screening. Through the application of inclusion and exclusion criteria, of these 88 papers, 54 (61%) did not involve the impact of the physician-patient relationship; 10 (11%) did not have health information seeking as the main research object; 7 (8%) were on nonempirical research; for 3 (3%), the original text could not be obtained; and 1 (1%) focused on physicians. The screening process is shown in Figure 2. All 13 (15%) papers met the quality rating except for 2 (15%). Finally, 11 of 88 (13%) Chinese papers were included in this study; see Table 2.

    The conclusions of these papers were divided into 5 themes: (1) factors that affect patients' use of OHI, (2) the impact of OHI on patients, (3) OHI seeking affecting patients' evaluation of physicians, (4) discussion with physicians about OHI affecting the physician-patient relationship, and (5) the impact of OHI seeking on the physician-patient relationship, including positive effects, negative effects, and neutral views (Table 3). The neutral view refers to no significant effect or both positive and negative effects.

    ‎
    Figure 2. Flowchart of the selection process (Chinese papers). OHI: online health information.
    View this figure
    Table 2. Summary of included Chinese papers (n=11).
    NumberReferenceCountryMethodParticipants, nParticipant characteristicsFactors affecting OHIa use covered in this paper (Y=yes/N=no)Impact of OHI seeking on patients covered in this paper (Y=yes/N=no)OHI seeking affects patients\' evaluation of physicians covered in this paper (Y=yes/N=no)Discussion of OHI and physician-patient relationship covered in this paper (Y=yes/N=no)
    1[61]ChinaSurvey179 (85 [47.5%] female, 94 [52.5%] male）Outpatients with chronic diseasesNNNY
    2[62]ChinaSurvey, interview467 (277 [59.3%] female, 190 [40.7%] male)Chinese citizensYNNN
    3[63]ChinaSurvey446 (224 [50.2%] female, 222 [49.8%] male)Health information seekersNYNN
    4[64]ChinaSurvey951 patients (495 [52.1%] female, 456 [47.9%] male) and 888 physicians (348 [39.2%] female, 540 [60.8%] male)Patients over 18 and doctors in each departmentYNYN
    5[65]ChinaSurvey1232 (611 [49.59%] users of OHI, 621 [50.41%] non-users of OHI)Chinese netizensNYYY
    6[66]ChinaChina Family Panel Studies (CFPS) data29,647 (14,815 [49.97%] female, 14,832 [50.03%] male)Chinese citizensYNYN
    7[67]China2013 Chinese Social Survey data10,206 (2073 [20.31%] netizens, 4654 [45.6%] nonnetizens, and 3479 [34.09%] missing data)Chinese citizensYNYN
    8[68]ChinaSurvey336 (180 [53.6%] female, 156 [46.4%] male)ChunYu Doctors website usersNNYN
    9[69]China2018 CFPS adult questionnaire data25,015 (13,083 [52.3%] female, 11,932 [47.7%] male)Chinese citizensYNNN
    10[70]China2011 and 2012 Chinese General Social Survey (CGSS)5546 (in 2021) and 5797 (in 2012)Chinese citizensYNYN
    11[32]ChinaQuestionnaire survey464 (241 [51.9%] female, 253 [48.1%] male)Chinese citizensYYYN

    aOHI: online health information.

    Table 3. OHIa seeking affects physician-patient relationships.
    NumberReferenceCountryImpact of OHI seeking on physician-patient relationship



    		Positive effects covered in this paper (Y=yes/N=no)Neutral views covered in this paper (Y=yes/N=no)Negative effects covered in this paper (Y=yes/N=no)
    1[33]United KingdomYNN
    2[7]AustriaNYN
    3[34]United KingdomYNN
    4[35]AustriaYNN
    5[36]United StatesYNN
    6[37]United KingdomYNN
    7[38]United KingdomYNN
    8[39]Saudi ArabiaYNN
    9[40]CanadaNYN
    10[41]United StatesNYN
    11[42]United StatesNYN
    12[43]United StatesNYN
    13[25]United StatesYNN
    14[44]United KingdomYNN
    15[45]United KingdomNYN
    16[46]AustraliaYNN
    17[47]United KingdomYNN
    18[48]ItalyYNN
    19[49]United StatesNYN
    20[50]AustraliaYNN
    21[51]United StatesYNN
    22[9]AustraliaNYN
    23[10]SwitzerlandNYN
    24[52]IsraelYNN
    25[53]United StatesYNN
    26[54]CanadaNYN
    27[12]SwitzerlandNYN
    28[26]NetherlandsNYN
    29[55]United StatesNNY
    30[56]RomaniaYNN
    31[11]SingaporeYNN
    32[57]MalaysiaNNY
    33[58]BelgiumYNN
    34[59]ChinaYNN
    35[23]ChinaNYN
    36[24]ChinaYNN
    37[27]ChinaYNN
    38[28]ChinaYNN
    39[29]ChinaYNN
    40[60]ChinaNNY
    41[31]ChinaYNN
    42[30]ChinaYNN
    43[61]ChinaYNN
    44[62]ChinaNNY
    45[63]ChinaNYN
    46[64]ChinaYNN
    47[65]ChinaYNN
    48[66]ChinaNNY
    49[67]ChinaNNY
    50[68]ChinaYNN
    51[69]ChinaNNY
    52[70]ChinaNNY
    53[32]ChinaYNN

    aOHI: online health information.

    Factors Affecting the Use of OHI

    Studies show that education level, income, gender, age, health literacy, culture, and other factors can affect people's use of OHI [12,26,33,34,39,42,49,51,56]. Five papers showed that users with high education level and high income are more willing to use OHI [12,33,34,39,42,62]. This population has relatively high health literacy and can better deal with OHI. Patients with difficulties in understanding health information are less likely to ask questions or seek guidance during consultation. Gantenbein et al [12] found that women are more willing to conduct OHI searches, while Aref-Adib et al [33] found that young male psychiatric patients are more likely to discuss health information with their physicians. De Looper et al [26] and Drug et al [56] found that younger patients engage more in OHIS, but Waring et al [51] did not observe the age difference possibly because the large age-grouping scope could not reflect the difference between the elderly and the young. In addition to personal factors, Chiu et al [59] found that the cultural environment of patients may also affect the communication on health factors. In a hierarchical culture of patients and physicians, patients are unwilling to ask questions for fear that the physicians would be unhappy. Instead, they choose to listen to the advice of physicians [59]. In this paper, we only included papers studying the relationship between physicians and patients; however, maybe many other factors also affect the use of OHI by patients.

    Impact of OHI Seeking on Patients

    Several studies have shown that OHI can enhance the communication ability and decision-making ability of patients. The study conducted by Iverson et al [36] showed that 46% of patients said they would change their health-related behaviors after searching for health information online. After searching the health information online, patients have a certain understanding of their own health status and disease treatment and can better understand the medical terms used by physicians when talking with them [25,38,59]. Murray et al [44] showed that people who discuss health information with physicians often have higher self-assessment ability to assess their own health. Liang et al [61] showed that patients who think that OHI is important and helpful to health decision making are more inclined to think that it will be beneficial to the physician-patient relationship.

    However, some patients may show some negative effects after OHI query. Aref-Adib et al [33] found that some patients may have concerns over what they read and that they change medication adherence and behavior without communication with the physicians. Another concern raised by OHI seeking is related to the quality of OHI, such as the credibility and limitations of information [40]. OHI will affect patients’ decision making, but patients still regard physicians as the main source of health information [47]. Due to the uneven quality of OHI and the lack of quality control, in addition to patients lacking medical information literacy, the judgments made by patients based on OHI are generally unscientific and difficult to be recognized by doctors, which may have a negative impact on the physician-patient relationship [62].

    OHI Seeking Affects Patients' Evaluation of Physicians

    The impact of OHI is mainly reflected in patients' trust in and satisfaction with physicians [42]. Patients' satisfaction with physicians is composed of many factors, among which the the main influencing factors are related to the actual communication between patients and physicians [23]. However, most patients are afraid to challenge their doctors, so they are reluctant to discuss their OHI [41]. Patients' satisfaction with OHI has a direct and positive impact on psychological safety [34], while psychological safety might have a direct and positive impact on patients' trust in physicians [24]. When patients use the network health community, the trust relationship among community members also affects patients' trust in and satisfaction with physicians [71]. Liu [68] showed that continuous use of online health communities (OHCs) increases users' satisfaction with medical services.

    Discussion With Physicians About Health Information Affects Physician-Patient Relationships

    After OHI seeking, some patients choose to share health information with their physicians. Part of the motivation for discussing health information with physicians is that patients want to meet their psychological and emotional needs [42]. Iverson et al [36] showed that 73% of patients like to discuss OHI with physicians mainly because they think physicians are willing to discuss OHI. The willingness of physicians to discuss health information with patients is crucial. After discussing their concerns about OHI with physicians, the patients’ medication adherence and behavior remain unchanged and the anxiety caused by OHI reduces [33]. In addition, after discussing OHI with physicians, patients' satisfaction with physicians significantly improves [39]. People who discuss OHI with their physicians think it has a positive impact on the disease and their relationship with their physicians [7].

    However, some studies have also proved that the main reason patients do not actively discuss health information with physicians is the fear of challenging physicians' authority [33,35,38,40,42,43,59]. Patients worry that when they talk about OHI, or express some opinions that physicians cannot refute, the physicians will feel criticized [35]. Of course, there are also some health care professionals trying to maintain the existing authority by not discussing OHI [45]. Guanghua [62] showed that the negative impact of OHI is greater, which creates greater obstacles in the communication between doctors and patients in China.

    OHI Seeking Affects Physician-Patient Relationships in China

    A total of 53 papers were included in this study, of which 31 (58%) hold that OHI seeking has a positive impact on the physician-patient relationship, 14 (26%) have a neutral view, and 8 (15%) have a negative influence. It is worthy of in-depth study that 6 (11%) papers showed that OHI seeking has a negative impact on the physician-patient relationship in China. Therefore, the negative impact of OHI on China’s internet users is worthy of attention. Due to the large population of China, the time for each patient to communicate with the doctor is short, and patients choose to search online for health information more for convenience than for accuracy or authority [67]. Some studies have shown that the inclusion of some wrong medical information and reports of malignant incidents in the physician-patient relationship have a negative impact on physician-patient trust, confirming media depression theory [67,69,70]. Feifei [64] found that for ordinary patients, due to the professional barriers of medical knowledge, it is difficult for them to distinguish between true and false after receiving false health information on the internet. This causes patients to question doctors and leads to difficulties in the physician-patient relationship [64]. Therefore, it is important to improve patients' health information literacy and the quality of OHI.


    Principal Findings

    Based on the review of the included studies, we found that there are many factors that affect patients' choice of OHI, such as gender, age, education level, income, health literacy, and culture [33,34,39,42,49,51]. People with high income, education level, and health literacy are more likely to use OHI. The age difference is mainly between the young and the old. There is a digital divide between the elderly and the young [72]. One study found that older people prefer to choose people as sources of information, such as health care providers, pharmacists, relatives, and retired community workers [73]. From the perspective of patients, most of them think that OHI seeking does not affect the physician-patient relationship; some patients think it has a positive impact on the physician-patient relationship, and a few patients think it may have a negative impact on the physician-patient relationship [46]. As the impact of OHI seeking on the physician-patient relationship may be restricted by social and cultural factors, it may have adverse effects in a culture with distinct levels of patients and physicians [59].

    The mechanism of OHI seeking affecting the physician-patient relationship is relatively complex. According to the study findings, OHI seeking can enhance patients' understanding of medical knowledge and enhance their decision-making ability and communication ability with physicians. At the same time, OHI seeking can also have an impact on patients' own psychology. Good quality of health information has a positive impact on the psychological safety of patients. Bylund [74] found that high satisfaction with OHI can promote patients' psychological security when communicating with physicians. Psychological safety has a certain impact on the distrust in the physician-patient relationship so as to affect the relationship [75]. Side effects of drugs and other information cause anxiety in patients. As the internet provides an opportunity to communicate with others about their concerns, anxiety tends to increase [76]. A small number of patients even have drug compliance changes and changes in their own medical behavior [76]. Previous studies have shown that that OHI can affect the consistency of communication between physicians and patients and the compliance of patients [33].

    It is important that patients discuss health information with their physicians. Patients will seek OHI to prepare for seeing a doctor, fully participate in the decision making, and actively supplement their information during the process of seeking medical service [77]. However, this will also cause anxiety and a series of changes, such as compliance change and medical behavior change [33]. If patients do not discuss health information with physicians, the negative effects on some patients might even worsen. If patients discuss health information with physicians, these negative effects can be eliminated and alleviated. The survey results show that discussing health information with physicians is beneficial to patients' satisfaction with and trust in physicians. We must admit that patients need to discuss their health information with physicians to better promote the physician-patient relationship and improve medical services [78]. Good physician-patient communication can improve the clinical outcomes of some diseases [79].

    Several studies have mentioned that patients are afraid to discuss health information with physicians because they are afraid of challenging the authority of physicians and even of conflicts with physicians. The OHC is not well received by the professional medical staff. They have doubts about the quality of a lot of OHI and whether they can explain the medical information to the patients in a better way [16]. Patients tend to remain silent if they do not feel the physician's willingness to discuss OHI with them. When patients consult about traditional and nontraditional therapies, many physicians react defensively, resulting in adverse effects on patients’ trust in them and the communication between physicians and patients [80]. Some physicians try to maintain their authority as physicians by avoiding discussing OHI [45]. Due to the widespread popularity of OHI, physicians should be aware that many patients seek OHI before consultation, and actively discuss and exchange OHI with patients [81].

    Of the included 53 papers, 21 (39.6%) studied the impact of OHI seeking on the physician-patient relationship in China, of which 2 (9%) papers specifically mentioned that cultural factors play a potential role in OHI seeking for physician-patient relationships [59,62]. In the culture of hierarchical physician-patient relationships in China, the patient fully follows the physician’s recommendations [59]. The popularity of OHI allows patients to play a more important role in the medical process. However, under the medical environment of “more patients, fewer physicians” in China, the communication time between each physician and patient is too short [62]. If the doctor cannot convince the patient and deny the patient's opinion directly without explanation, the conflict weakens the authority of the doctor and exacerbates the negative impact on the physician-patient relationship [62].

    Several papers have shown that the internet usage time could reduce the patient's trust in the doctor [66,67]. Medical corruption, medical malpractice, physician-patient conflict, and other contents are more likely to spread among Chinese patients. Various types of negative news is frequently pushed to patients. The negative factors in the physician-patient relationship are magnified. The media often blame medical disputes on medical personnel, which exacerbates patients' distrust of doctors. In addition to negative news, the low quality of OHI has a negative impact on the physician-patient relationship [61,82].

    OHI is a double-edged sword for the relationship between physicians and patients. It is becoming increasingly important in the relationship between physicians and patients. With high-quality OHI, it is relatively easier to have a positive impact on patients, thus promoting the physician-patient relationship. With the rapid growth and wide use of medical websites, there are important problems about the necessity of quality control [83]. The pattern of patients' access to health information is changing from passive recipients to active service seekers [77]. Health care professionals should not only discuss health information with patients but also guide them to correctly seek and use health information. Patients who can reasonably understand OHI can reduce the burden of physicians in the consultation and improve the communication [63].

    Limitations

    This study has a wide range of retrieval. When references were included, the focus was on whether health information seeking has an impact on the relationship between physicians and patients. Papers studying the impact of health information seeking on patients were not included, which may have led to missing potential research. In addition, due to the lack of a large number of studies and more reliable evidence, we could not reach a strong conclusion about how health information seeking affects the physician-patient relationship.

    Conclusion

    This study mainly focused on the effects of OHI on the relationship between physicians and patients. There are many factors influencing people's use of OHI, and young, female, highly educated, and high-income patients are more willing to search OHI. OHI seeking can affect patients' mentality and behavior. Through understanding OHI, patients can have a better understanding of medical knowledge, improve self-confidence during communication, and enhance self-decision-making behaviors. However, some OHI can lead to negative emotions and even change patients' health behaviors, due to the uneven quality of OHI. OHI seeking also affect patients' evaluation of doctors, including patients' trust in and satisfaction with physicians. OHI users choose to discuss OHI with doctors, which is beneficial to the physician-patient relationship in most cases. However, due to the subjective consciousness of patients, they may be concerned that it might affect the authority of physicians, which is the reason some patients do not initiate the discussion of health information. Moreover, the negative impact of OHI on China’s internet users is worthy of attention; due to the low quality of OHI, poor health information literacy, short physician-patient communication time, and various types of negative news, patients' trust in doctors has declined. At present, China's vigorous promotion of “internet + medical health” and the reform of the hierarchical medical will be of great significance to improving the physician-patient communication model and promoting harmonious physician-patient relationships. At the same time, improving people's health information literacy and the quality of OHI is the crucial step in facilitating the positive effects of OHI on the physician-patient relationship.

    Acknowledgments

    The authors thank the State Key Program of the National Social Science of China (grant no. 17AZD037) and the Natural Science Foundation of Hunan Province (2019JJ80032) for their assistance in this study. We also appreciate the support of all participants.

    Conflicts of Interest

    None declared.

    ‎
    Multimedia Appendix 1

    PRISMA 2020 Checklist.

    PDF File (Adobe PDF File), 141 KB
    ‎
    Multimedia Appendix 2

    CASP (Critical Appraisal Skills Program) quality assessment for qualitative studies.

    PDF File (Adobe PDF File), 190 KB
    ‎
    Multimedia Appendix 3

    Quality assessment tool for quantitative studies.

    PDF File (Adobe PDF File), 224 KB
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    ‎
    CNKI: China National Knowledge Infrastructure
    MESH: Medical Subject Headings
    OHC: online health community
    OHI: online health information
    PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses

    Edited by G Eysenbach; submitted 10.08.20; peer-reviewed by K Lee, L Sbaffi, N Hirvonen; comments to author 21.10.20; revised version received 24.10.21; accepted 17.11.21; published 10.02.22

    Copyright

    ©Aijing Luo, Lu Qin, Yifeng Yuan, Zhengzijin Yang, Fei Liu, Panhao Huang, Wenzhao Xie. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 10.02.2022.

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