Table of contents
2. Theoretical Background
3.2. Data Collection Procedure
3.3. Coding Scheme
4.1. Realization of PPC and Empathy
4.2. Cross-cultural comparison
The evolution of the internet permanently offers its users new possibilities and opportunities to have access to a variety of services at the comfort of the own home. Ask-the-expert advice- giving websites and forums have become common in the world wide web, to provide users with lay person or expert opinions and support on specific topics. Online health support and intervention has become particularly popular, is frequently used by the online community and indeed offers several advantages. By using online healthcare services, costs for health service are reduced, the convenience for users is increased, the stigma for certain conditions is lowered and information is made readily available for users (cf. Griffiths et al. 2006). While it has been the quality and accuracy of internet health information that was investigated in medical research (e.g. Ademiluyi, Rees and Sheard 2003), the interactive and communicative functions have been rather neglected.
Next to interactive and communicative functions, the use of empathy and patient- centered communication (PCC) on online healthcare websites have also only been infrequently investigated. Studies (eg. Little et. al 2001, Bonvicini 2009) have provided evidence that the usage of empathy in clinical consultations can increase patient satisfaction, adherence to treatment plans and recovery rates. It is especially patients with psychosocial problems that have been found to be more likely to want and expect PCC (cf. Winefield 1995) in medical consultations. While it is widely accepted that empathy and PCC is key to successful medical face-to-face consultations (cf. Mead & Bower 2002), some research (e.g. Lovejoy et. al 2009) has suggested that emphatic communicative strategies are harder to achieve in online communication. It has even been suggested that empathy and PCC might not be deemed important by either the online expert and the patient (cf. Pounds 2016).
This study investigates whether online healthcare experts from Germany and the UK make use of empathy and PCC in their expert responses to online patients struggling with depression. The study primarily focuses on cross-cultural differences and similarities for which a discourse-analytical approach is used to analyze relevant communicative strategies. Based on the findings, the study aims to deduce possible implications and questions whether cultural awareness is needed in online ask-the-expert healthcare contexts. I claim that empathy and PCC is used differently in online healthcare context in Germany and the UK.
The paper starts with the theoretical background providing a comprehensive overview including general advice research, specifically on ask-the-expert online websites, in the light of empathy and PPC. The methodology chapter will present details of the data collected and the coding scheme used. The fourth chapter includes most important findings which are relevant to answer the research questions. The discussion chapter will be used to look at the results in the light of previous findings and theories. At last, the paper will close with a summary of all relevant and noteworthy findings and will offer an outlook and ideas for future research worth investigating to get greater insights.
2. Theoretical Background
Human beings ask and receive advice on a daily basis, whether it takes place in private or public sphere, face-to-face or even online. The online Merriam-Webster Dictionary defines advice as a “recommendation regarding a decision of course of conduct: counsel”, the online Oxford Learner’s Dictionary defines it as “an opinion or a suggestion about what somebody should do in a particular situation” and the online Collins Dictionary as a “recommendation as to a appropriate choice of action; counsel”. All definitions describe scenarios in which advice- givers give their opinion, suggestion or recommendation on how to solve a problem. It implies that if the advice-receiver implements the given recommendations, it will be beneficial for him or her. The act of advising is, however, in itself critical. While it has been found that in some cultures, such as Japanese, Korean or Chinese, to give advice can be a sign of solidarity, there are other cultures in which advice-giving is rather considered face-threatening as for example in Anglo-Western contexts (Locher 2006: 4). In contexts in which advice is perceived as threatening, Goldsmith and MacGeorge (2000: 235) claim that the hearer’s identity as a competent social interlocutor is questioned. Locher (2006: 4) claims that thus a certain asymmetry between interactants exists which is perceived as threatening and may require mitigation such as praise or empathy. Another study by Morrow (2006) investigating advice on depression in an internet forum also reports that advice-givers make use of expressions with positive regard and solidarity. However, depression is a rather sensitive and delicate topic, which is why it is questionable whether it is the advice that attracts solidarity or the topic itself.
Bromme et al. (2005: 570) further examine advice from a communicative angle in online healthcare advice contexts stating that “online advice is a communicative activity that is already difficult in face-to-face interactions to establish a common ground between health experts and laypersons. Studies (e.g. Hall, Roter & Katz 1988) have shown that clinical experts talk more compared to their patients, but still must be careful not to overload the patient with expert terminology which would disturb the interaction if the patient does not understand what the expert is trying to say. If this is the case, the advice would eventually come to nothing and would not be effective. Hence, it is important that both interlocutors take care of what the other is saying and adapt it to the respective context.
One such context to ask for and give advice are ask-the-expert healthcare websites. On ask-the-expert healthcare websites users have the opportunity to get informed about medical conditions and healthcare problems, but can also send in their own questions anonymously and ask for advice. The questions are then asynchronously answered by healthcare experts and are usually made public. The purpose of this is twofold: on the one hand this kind of communication serves a personal exchange, but at the same time serves the public as well (cf. Locher 2010: 48). Some other users of the website might identify with the same problem and find first points of advice. As mentioned above, while it is already challenging to find common ground in face-to- face interactions between experts and laypersons, computer-mediated communication obviously does not make it any easier. It is essential that healthcare experts linguistically adapt to their target audience. In the investigation of an American online healthcare advice service, Lucy Answers, Locher (2010: 55) has found that there is a general avoidance of technical vocabulary, except if the interlocutors asking for advice use it themselves. Humor and empathy are also readily used to create solidarity (cf. Locher 2010: 55). The interactive nature of virtual healthcare consultations have been investigated in a review by Dedding et al. (2011). Some of the disadvantages in online healthcare consultations listed are for example that patients cannot be directly investigated and that certain treatment plans cannot be translated into e-versions (cf. Dedding et al. 2011: 50). There are however also advantages for online patients, which can create improvements for patient participation. Due to the fact that online patients can anonymously ask for advice, they may, for instance, overcome stigmata for certain conditions and increase self-disclosure (cf. Dedding et al. 2011: 50-51). The review further reports a lever effect of online healthcare websites which may stimulate a changing process towards a more patient-centered care. However, the review does not offer any empirical evidence for the findings and the analyzed articles report rather contradictory effects on the patient-expert relationship in which a patient-expert relationship already exists throughout previous face-to-face consultations. Pounds (2016: 119) claims that asynchronous exchanges with unknown experts “may be expected to be less conducive to the establishment of interpersonal rapport”. Thus, Pounds (2016: 119) suggests that in these contexts patient-centeredness and mitigation strategies such as empathy might not be deemed as important by either interactant.
Nevertheless, patient-centered communication is a key feature in primary face-to-face healthcare interactions and is highly advocated (cf. Mead & Bower 2002). Stewart (2001: 445) states that “being patient centred […] means taking into account the patient’s desire for information and for sharing decision making and responding appropriately”. This means that the patient and his or her needs take central stage and that the doctor must be considerate to give advice which is appropriate for the individual patient. Thus, PCC includes that the doctor has to be emphatic towards the patient on the one hand, but also involve him or her into future decisions and choices. Little et al. (2001: 1) elaborate on these characteristics by promoting five principles of a patient-centered model:
exploring the experience and expectations of disease and illness, understanding the whole person, finding common ground regarding management (partnership), health promotion, and enhancing the doctor-patient relationship.
Patient-centeredness can have major benefits for patients. Little et al. (2001: 1) suggest that if it is applied correctly it can improve the patient’s satisfaction and the medical development and recovery. Patient-centeredness is explicitly taught to physicians throughout their education, and studies (e.g. Little et al. 2001: 3–5) have shown that patients want and expect patient-centered communication when talking to their doctor. However, if patient-centeredness actually is exercised, it is restricted to individual characteristics of the doctor and the patient. A further question that arises is if the model provided by Little et al. (2001) can or should be implemented for all domains of healthcare practices. A cancer patient might need a different level of patient- centeredness compared to a patient with a foot placed in a plaster cast. It might really be dependent on the healthcare issue or problem itself that differences in preferences to patient- centeredness arise (cf. Little et al. 2001: 2). Supporting this, a study by Winefield (1995) has shown that it is especially patients with psychosocial problems that are more likely to want and expect a patient-centered consultation. The same study also shown that the doctor’s patient- centeredness was highest for psychosocial consultations compared to complex and straightforward consultations (cf. Winefield 1995: 406). Conducting a literature review on patient-centeredness, Mead and Bower (2002) report several shortcomings of studies on patient- centeredness lacking high scores of internal and external validity. They claim that the typical investigated patient participant in their analyzed studies are female, mid-40 and married, which results in rather unvaried and unrepresentative outcomes (cf. Mead & Bower 2002: 59).
As already mentioned above, directly linked to patient-centeredness is the concept of empathy. Doctors should not only be sensitive regarding patients with psychosocial or other problems, but also display emphatic behavior. Ilie and Metea (2015: 214) define empathy as “an emotional understanding of other people’s behavior […]”. Being emphatic means to mirror the psychological state of the interlocutor in which his or her perspective is granted and acknowledged (Ilie & Metea 2015: 217). In an investigation of the impact of empathy on patient encounters, Bonvicini et al. (2009: 4) declare that empathy is a core part and essential to quality medical care. They report a meta-analysis of medical interactions by Beck et al. (2002) that found that a doctor’s application of empathy is connected to higher scores in patient satisfaction, adherence, comprehension as well as to the perception of a good patient-expert relationship (cf. Bonvicini 2009: 4). In face-to-face patient-expert interactions, the expert is able to directly read the patient’s gestures and body language which is crucial for communicating empathy or concern. In asynchronous computer-mediated communication this is not possible and has to be linguistically offset. Some researchers (e.g. Lovejoy et al. 2009) have suggested that PCC and emphatic communication is harder to realize in online communication. However, in her study on patient-centeredness and empathy on ask-the-expert healthcare website, Pounds (2016) has shown that experts from the UK make wide use of patient-centered and emphatic expressions in their online responses. All previously described restrictions do not hinder them to express their concern and sympathy with the online patient, although they have never met and most probably never will.
As mentioned earlier in this chapter, some studies (e.g. Locher 2006, Chentsova-Dutton & Vaughn 2012) have suggested cross-cultural differences in general advice giving. Locher (2006) claims that while in East Asian cultures advice-giving is perceived as welcome and a sign of solidarity, it is perceived as face-threatening in Anglo-Western cultures. Mitigation measures are, hence, more likely to appear in the latter in order not to attack the interlocutor’s face. Chentsova-Dutton and Vaughn (2012) have shown that Russians were less likely to modulate their advice-giving behavior and more likely to describe advice as characteristic for supportive relationships. These studies suggest that advice-giving is a culturally dependent behavior and is realized and anticipated differently in different cultures. In the context of online ask-the-expert healthcare websites, research is rather scarce, with a few exceptions (e.g. Morrow 2006, Pounds 2018). Especially the investigation of PCC and empathy has so far exclusively been discussed by Pounds (2016) and Pounds and De Pablos-Ortega (2016). Although some medical studies (e.g. Saha et al. 2008) have emphasized the importance of both PCC and cross-cultural awareness in healthcare settings, there is, as to the knowledge of the author, only one systematic study by Pounds and De Pablos-Ortega (2016) which is concerned with the implementation of PCC and empathy in online ask-the-expert healthcare cross-cultural contexts. In this study, Pounds and De Pablos-Ortega (2016) report differences in expert responses on healthcare websites in the UK, Spain and Italy. While all experts make use of advice in their responses, Italian experts encourage self-disclosure, Spanish experts specifically focus on giving explanations and UK experts focus on advice, explanation and support (Pounds & De Pablos-Ortega 2016: 238). It is questionable, however, whether the study’s results are fully comparable, because the sample sizes are rather different and range from 10 to 30 queries sampled. This present study aims at trying to add to the current research by investigating two ask-the-expert healthcare websites from the UK and Germany: NetDoctor and Lifeline.
German and English expert responses from health service advice interactions were collected from the German website Lifeline and from the UK website NetDoctor (cf. Appendix 1). Two subsequent corpora were created, each containing 20 expert responses amounting to a total of 40 responses. The expert responses all relate to queries dealing with depression.
The German website Lifeline was chosen, because it a well established healthcare website which is managed by the publishing company Funke-Mediengruppe. It offers a range of healthcare advice in the form of articles and expert discussion forums. The website is run and supported by doctors and medical journalists which interview experts, evaluate studies and attend medical congresses on a regular basis. They emphasize that the website’s aim is not to substitute an actual doctor’s appointment, but rather aim at increasing the quality of doctor- patient relationship by offering information. Lifeline’s health advice services are free of charge and users who have medical questions only have to register to post a question. All doctors and their credentials are listed in the impress of the website. User’s questions and expert responses that were sampled for the purpose of this study were posted between 2011 and 2017.
The website NetDoctor was chosen for investigation, because it is UK’s leading independent healthcare website offering users access to a variety of different health information. NetDoctor is run by the publishing division Hearst Magazine UK. The website’s operators claim that their aim is to break down medical language barriers and not replace a face-to-face doctor’s appointment, meaning to simplify medical information so that it is understandable for everyone. Users have access to articles on conditions, healthy eating, medicines and frequently asked questions (FAQs) on different topics. NetDoctor further offers to answer personal medical questions, but advise users to search the archive section first. The archive section contains over 6,000 user-expert interactions in which doctors answer queries handed in by users. All expert responses were taken from the FAQs archive section on depression. The website lists all interacting doctors and their credentials on the ‘About NetDoctor’ section. All queries that were sampled for the purpose of this study were posted in 2011.
The topic depression was chosen, because, as Pounds (2016: 120) claims, “the experts’ interpersonal communication skills are, arguably, particularly relevant in this context”. Symptoms for depression cause suffering and interfere with a human’s personal, social, work life and other important areas in a clinical meaningful way (cf. American Psychiatric Association 2013). Psychological strain is high for affected patients which is why medical advice should be especially patient-centered and emphatic.
3.2. Data Collection Procedure
Both questions and answers were collected in order to be able to look at each exchange as a whole. The answers were, hence, always analyzed in relation to the question posted. The expert responses all display responses to issues dealing with depression. The users in the forum were rather explicit about their problems, which could be due to the fact that the topic of depression itself has strong effects on human’s emotions and actions. To answer the research questions of this study, only the answers to the queries were analyzed and coded.
Both websites offer specific platforms in which (non-)members can read and have access to queries posted by users. For this, Lifeline offers several publicly available discussion forums to which users can contribute for free. In the ‘Expertenrat’ forums, all queries are answered by qualified doctors. Posts from the individual ‘Expertenrat’ forum for depression were randomly sampled for the purpose of this study. The posts were either answered by individual doctors or by the ‘Lifeline Gesundheitsteam ’ (cf. table 1). The ‘Expertenrat’ forum further offers the opportunity for users to reply to the doctor’s response. Subsequent responses were by users, however, not collected.
- Quote paper
- Katja Grasberger (Author), 2018, A cross-cultural comparison of Patient-Centered Communication and empathy on Ask-The-Expert healthcare websites, Munich, GRIN Verlag, https://www.grin.com/document/497956