Family Practice Advance Access originally published online on February 7, 2006
Family Practice 2006 23(2):159-166; doi:10.1093/fampra/cmi117
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The use of an Internet-based Ask the Doctor Service involving family physicians: evaluation by a web survey
a Department of Public Health and Clinical Medicine, Family Medicine, Umeå University, b Mid-Sweden Research and Development Centre, County Council of Västernorrland, Sundsvall, and c Health Institute, Department of Health and Behavioural Science, University of Kalmar, Sweden
Correspondence to Göran Umefjord, Nyland Health Centre, Biskopsgatan 1, SE-870 52 Nyland, Sweden. Email: umefjord{at}ymex.net
Received 19 May 2005; Accepted 28 December 2005.
Umefjord G, Hamberg K, Malker H, Petersson G. The use of an Internet-based Ask the Doctor Service involving family physicians: evaluation by a web survey. Family Practice 2006; 23: 159–166.
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Abstract |
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Background. Internet consultation without a previous relationship between the doctor and the enquirer seems to be increasing in popularity. However, little is known about the advantages, disadvantages or other differences compared with regular health care when using this kind of service.
Objective. To investigate how an Internet-based Ask the Doctor service outwith any pre-existing doctor–patient relationship was used and evaluated by the enquirers.
Methods. We recruited to a web-based survey users of the non-commercial Swedish Internet-based Ask the Doctor service run by family physicians. The survey was conducted between November 2001 and January 2002. Questions included both multiple choice and free text formats, and the results were analysed quantitatively and qualitatively.
Results. The survey was completed by 1223 participants. It was mainly women who submitted questions to the service (29% men, 71% women) and also who participated in the survey (26% men, 74% women). Most participants (77%) wrote their question at home, and 80% asked on their own behalf. Almost half of the enquiries (45%) concerned a medical matter that had not been evaluated by a medical professional before. After reading the answer, 43% of the participants indicated that they would not pursue their question further having received sufficient information in the answer provided. The service was appreciated for its convenience and flexibility, but also for reasons to do with the mode of communication such as the ability to reflect on the written answer without having to hurry and to read it more than once.
Conclusion. In the present study, we found that an Internet-based Ask the Doctor service run by family physicians on the whole was evaluated positively by the participants both in terms of the answers and the service. Internet-based consultation may act as a complement to regular health care. In future studies, the cost-effectiveness, patient security, responsibilities of the Internet doctor and the role of Ask the Doctor services compared with regular health care should be evaluated.
Keywords. Access to information, gender, information services, Internet, remote consultation.
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Introduction |
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The Internet is becoming an important tool in health care1 both for administrative purposes and for patients. Email is increasingly used for communication between patients and health care providers. Content analysis of email communications between patients and providers have revealed that frequent topics are updates to the physicians, prescription renewals,2 instruction requests3 and requests for information about medication, treatments and specific symptoms or diseases.4 The Internet is also becoming increasingly important as a medical information resource, exemplified by the finding that US adult Internet users are equally likely to turn to the Internet for reliable information on medical issues as they are to contact a medical professional.5,6
Nowadays medical advice can also be accessed by consulting a doctor on the Internet. Email consultations are increasingly used, and encrypted web-based messaging systems with features such as medication refills, appointments, preventive care reminders and asynchronous consultations have been introduced.7 Both commercial and non-commercial Ask the Doctor services, where there is no previous relationship between the doctor and the enquirer, have been available on the Internet for several years, and seem to be increasing in popularity.8–10 Reported reasons for sending an enquiry to a doctor on the Internet are frustration or disappointment about previous doctors,11 convenience and anonymity.12 The value and appropriateness of Internet consultations outside pre-existing doctor–patient relationships have been debated,13–17 but it has not been widely studied how enquirers regard this kind of a service.
The aim of the present study was to investigate how an Internet-based Ask the Doctor service outside pre-existing doctor–patient relationships was used and evaluated by the enquirers.
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Methods |
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Since October 1998 the official Swedish non-commercial public health organization, Infomedica (http://www.infomedica.se), has been running a health service Internet site including the option to submit personal enquiries related to health and diseases. All enquiries have been answered by experienced family physicians. The enquirer could choose to be anonymous. Besides mandatory information on age group and gender, there were no predefined rules and the enquirer has been able to freely choose the topic of his/her question. An answer to the enquiry has been provided within 7 days. The Internet doctors were advised to be cautious concerning the diagnostic evaluations in their answers. For quality assurance measures, before publication the answers were reviewed by the co-ordinator of the service, also a family physician, and a few answers were returned to the answering Internet doctor for revision. The answer was retrieved on Infomedica's web server using a password. The name of the answering doctor was not presented to the enquirer until the answer was retrieved. Infomedica reimbursed the doctors who answered, but there was no charge for the enquirer.
Between 1 November 2001 and 31 January 2002, all enquirers at Infomedica's Ask the Doctor service were invited to take part in a survey for an evaluation of the service. The enquirers were informed of the survey when submitting their medical enquiry. On retrieving the answer, the enquirer was asked to participate in the survey in a separate browser window. The enquirer was informed that he/she would be anonymous while completing the survey. It was not technically possible to compare an incoming enquiry to the service with the corresponding answers to the questions in the survey.
In the present paper we use the term enquirer for an individual who posed a question to the service, and the term participant for an enquirer who also completed the survey. The answering doctor is called the Internet doctor.
The web survey
The questions in the survey concerned the use and experience of the service, and evaluation of the answers from the Internet doctors. In total, the survey comprised 15 questions: 10 multiple choice (of which two were combined with a free text option), 3 numerical and 2 free text questions.
Analysis
The results of the survey were analysed quantitatively and qualitatively. The frequencies of the multiple choice alternatives were computed using the software Publech version 3.0 (Ntech, Sundsvall, Sweden). Statistical differences between groups were determined by using the chi-square test. A qualitative analysis of the free text answers was made in three steps. In the first step, three of the authors coded the answers independently by analysing text for meaning and content. In the second step, the codes were compared and discussed, and thirdly re-coding and categorization was carried out. The results of a question concerning the reasons for consulting a previously unrelated doctor on the Internet have been published in a separate paper.12
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Results |
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The participants
During the course of the survey a total of 3622 questions were submitted to the service, 1036 by men (29%) and 2586 (71%) by women. A total of 1223 surveys were completed: 322 (26%) by men and 901 (74%) by women with a response rate of 34% (Fig. 1). The response rate increased almost linearly from 25% among the youngest age group to 75% in the 70–79 year age group. The enquirers gave their age in 5 year ranges when submitting their medical question. Thus, the mean age of all enquirers during the 3 month period cannot be computed exactly, but was approximated to 37 years. The survey participants gave their year of birth, giving a mean age of 41 years (range 8–88; men 45; women 40) and a median age of 38 years (men, 44; women, 38). Eighteen participants did not enter their year of birth.
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Circumstances when submitting the enquiry
The majority of the participants submitted their enquiry at home while one-fifth did so at work (Table 1). Most asked questions on their own behalf. Almost half of the enquiries concerned a matter not evaluated previously by a medical professional. Two-thirds of the participants reported that their enquiry was the first one they had submitted during the last year. Only a few were frequent enquirers, but one participant had asked 10–15 questions during the last year. Women more frequently asked about children, parents or other older relatives than men did (P < 0.01). The majority of the participants (953/1223; 78%) searched in the service's database for previous Questions & Answers before they wrote their enquiry.
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What the participant wanted to find out
The participant could choose one or more of six multiple choice alternatives (Table 2), including a free text box, regarding what they wanted to find out with their enquiry.
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Multiple choice answers. The modal response was ‘I have symptoms and wonder what the problem may be’, chosen more often by men than by women (52% versus 39%; P < 0.01). One-third of both the men and the women wanted another doctor's opinion. Approximately a quarter of the participants wanted more information on a specific disease or treatment. More information on drugs was an infrequent choice.
Of the 159 participants who used the free text option, 104 chose only that option. Fourteen participants did not select any multiple choice alternatives or enter any free text.
Free text answers. The qualitative analysis of the free text answers of what the enquirer wanted to find out by submitting their enquiry resulted in the following categories, presented in descending order of frequency. Each answer was assigned to only one category:
- Primary analysis of medical symptoms. In more than one-third of the free text answers (61/159; 38%), participants expressed a desire for a primary evaluation of a medical problem, including wanting advice as to whether it was necessary to see a doctor or not (‘get information whether I should see a doctor, don't want to bother the health care system if it's not necessary’) and from where to get help. Some wanted to obtain information in order to handle their condition autonomously (‘I want to get information to be able to relieve the symptoms by myself’).
- Explanation and information (44/159; 28%). Some of the participants (32/159; 20%) expressed a direct wish for more complete information on a medical issue (‘get an explanation of the significance of the diagnosis, and its consequences in the short and long term’) or a pharmaceutical drug (8/159, 5%). A few (4/159; 3%) wanted information on alternative treatments available to them.
- Relief of worry (12/159; 8%). A few participants said they wanted to obtain information in order to relieve their worry (‘get a decent answer to make me calm down’).
- Second opinion (9/159; 6%). Although ‘second opinion’ was a multiple choice option, some participants chose to express a wish for a second evaluation of a medical condition (‘different doctors have different answers and opinions’) in free text.
- Advice on lifestyle (8/159; 5%). A small number of the free text answers concerned lifestyle issues, including diet and other preventive measures (‘suggestions on change of life habits’).
- Miscellaneous (25/159; 16%). For example, genetic counselling, medico-legal issues, organizational questions and the like.
Evaluation of the answer
A majority of the participants reported that their question was answered ‘completely’ or ‘partly’ while one in ten found it ‘not fully’ or ‘not at all’ answered (Table 3). More than four-fifths of the participants in all age groups were satisfied with their answer. The participants were slightly more satisfied with the answers if the enquiry concerned a medical issue not evaluated previously by a medical professional. The most common reason for dissatisfaction was that the answer was felt to be ‘too short’. The answer was seldom considered ‘too simple’, and only three participants were dissatisfied due to ‘complicated words’ in the answer.
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Nearly half of the participants stated that they received sufficient information in their answer and that they would not pursue their question further. One-quarter of the participants said they would pursue their question with their previous doctor, whereas one-sixth planned to see a new doctor. A few of the participants stated that they would submit the question to another Ask the doctor service.
Evaluation of the service
One-third of the participants (386/1223; 32%) responded to the free text question ‘Do you have other thoughts concerning the answer to your question or to this Ask the Doctor service?’. In the qualitative analysis, the responses were sorted into three groups. A generally positive attitude to the answer provided or to the service was found in two thirds of the answers (258/386; 67%). A generally negative attitude was expressed by 49 participants (49/386; 13%), whereas the remaining answers (79/386; 20%) could not be classified as either positive or negative. Among the positive participants, 155 expressed an appreciation for the existence of the service (‘fantastic that you can get in contact with a doctor this way’). Some regarded the service as a valuable complement to regular health care with the potential to reduce pressure on services (‘the set-up is good and should reduce the pressure on the medical centres around the country’). Other positive comments concerned convenience (‘to be able to ask this way instead of having to get an appointment and take a half day off to get the answer’) and appreciation of the answer (‘very thorough answers and you feel like the doctor is talking to you’). The feature of asynchronous contact and written communication was also highlighted as an advantage (‘a written answer is much better because it is hard to remember what the doctor told you. With a written answer you can return to the answer and read it again’). Most of the negative comments were related to mistakes in communication, such as the Internet doctor having misunderstood the enquiry (‘the Internet doctor partly misunderstood my complaints’) or not answering all parts of the enquiry. Seven participants stated that their own question was incomplete (‘I did not get a good answer maybe because my enquiry was not precise’).
Suggestions for improvement of the service
About a tenth of the participants (171/1223; 14%) answered the free text question ‘Do you have any ideas on how this service could be improved?’. The most commonly expressed idea (30/171; 18%) was to shorten the time taken for an answer to be produced—up to 1 week was considered too long. A few participants stated that the service was appropriate for non-emergency issues. The second most common idea (19/171; 11%) was to have the opportunity of posing follow-up questions or being able to chat with the doctor. Seven participants requested the ability to get answers from specialist doctors other than family medicine specialists. A few comments concerned the provision of instructions as to how to formulate the initial enquiry to the Internet doctor (‘it is difficult to know what is important for the doctor to get information on’). Others suggested email notification when the answer becomes accessible, and to get the answer by email. Further individual proposals concerned the desire to get direct referrals to specialist doctors and how to make the Internet doctor your own private doctor.
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionDeclarationContribution of authorsReferences |
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The Ask the Doctor service run by family physicians was in general evaluated positively by the participants both in terms of the answers given and the overall service. The service was used as a first stop for new medical concerns, for obtaining more information on medical issues and problems that were already under treatment, and for obtaining a second opinion.
The age profile of both the enquirers and the participants in the present study differs from that in regular health care with the highest number of incoming enquiries, and also of completed surveys, originating from individuals aged 21–40 years old. This age distribution mirrors Internet use in general.18 Internet users are a selected sample of the population with socio-economic differences compared with non-users.19 By the time of our study, two-thirds of the Swedish population had access to the Internet, 56% at home.20 Although the access might be higher as many libraries provided free Internet access, the Internet consultation might be restricted to some groups due to differences in information literacy.21 Since the sample in our study comprised the users of an Internet-based Ask the Doctor service, generalizing results to non-users should be done with care. It is likely that the participants in our study had a more positive attitude than a population that has never considered the possibility of consulting an Internet doctor would have.
Internet surveys have the advantage of being executed at the responders' own pace. Disadvantages may be technical problems and different levels of computer experience, possibly leading to participation bias and contributing to lower response rates.22,23 Potential influences on response rates in Internet surveys are relationship, survey length, design issues, technical factors, research affiliation and compensation. Response rates are generally low in Internet surveys,24 often far lower than the response rate of 34% of our study, in which the participants were not personally related to the administrators of the survey nor compensated for completing the survey. It is possible that an enquirer who was satisfied with the Internet doctor was more motivated to participate, but it seems reasonable to presume that dissatisfaction could also increase motivation to participate.
The large gender difference in our study concerning the use of the Ask the Doctor service, with almost three out of four enquirers being women, roughly mirrors and even exceeds the difference seen in regular care.25,26 The finding contrasts with the preconception that women are less technically oriented than men, and it deviates from a recent Swedish study on Internet use in general where women were more cautious using the Internet.27 However, the large gender difference matches the findings of a physician telephone service at an outpatient medical practice,28 and also the use of NHS Direct, the national telephone service in the UK.29 Women have also been shown to be more active in going online to seek health-related information compared with men.30 In our study, men more frequently used the service as a first stop for an evaluation of a new medical concern compared with women. We have no plausible explanation for this finding. Nevertheless, in the survey answers, the gender differences were generally small except that women more often asked on behalf of relatives.
That the participants regarded the Ask the Doctor service as convenient is not surprising, since it was possible to use whenever preferred and from any location where an Internet connection was provided. Not having to leave the workplace for a doctor's appointment for minor medical enquiries saves time. The enquirer's most common positive evaluation of their answers might have been influenced by expectations regarding the Internet doctor as well as the nature of the enquiry. The fact that the service was free of charge probably reduced expectations. The Ask the Doctor service was used not only for the enquirers' own health issues but also to some extent for someone else, illustrating a need for medical advice not always being met in regular health care.31–33
Internet-based consultation may become an alternative as a primary contact with a doctor for non-urgent issues, evidenced by almost half of the participants presenting a new issue not presented previously to health care providers, in line with previous findings.8 However, in a few free text comments, we found participants having unrealistic expectations of the service, such as getting a distinct diagnosis of a skin rash. An important issue concerns informing enquirers of the inherent limitations of text-based Internet consultation services.
Consultation on the Internet mostly provides an answer from a doctor whereas telephone consultation services usually involve nurses. That telephone consultation has been shown to be appreciated by users34 may partly be explained by the dialogue and immediate response in contrast to Internet consultation in the form used in our study. On the other hand, the ability to phrase a written question more thoroughly, and also for the Internet doctor to give a more detailed answer, might be of importance in certain cases. It is likely that Internet consultation with the opportunity to read the answer more than once can lessen the risk of ‘recollection error’ reported from telephone triage.35 Still, a written answer can be misinterpreted. Internet and telephone consultations may each offer an alternative for people who prefer to talk or write, respectively, although a written question might imply a higher sense of anonymity.
One of the major uses of Internet-based Ask the Doctor services outside pre-existing doctor–patient relationships will probably be to provide a second opinion, which cannot easily be accessed in most countries' regular health care. Communication between a doctor and the patient cannot always be ‘perfect’ for several reasons. Frustration and communication problems with the existing doctor–patient relationship is not an uncommon problem in regular health care36–39 and might be the reason to turn to an anonymous Ask the Doctor service. However, it is not undisputed that a right to a second opinion should be taken for granted.40,41 Furthermore, the value of second opinions has been questioned.42
That many participants strongly expressed a view of the service as a complement to regular health care can be explained in several ways. In general, written communication, as in Internet-based consultation, allowing the patient to be able to read the answer repeatedly and to reflect on it without hurry, is probably underused in regular care.43 Information has been shown to be an important factor for success in doctor–patient communication and patient satisfaction.44 Another important success factor is patient-centredness, enabling the patient to express his/her own reasons, ideas, feelings and expectations without being interrupted by questions.45 Internet consultation of the type in our study could be regarded as patient-centred as it is led by the enquirer (patient) with the full freedom to choose what to tell the Internet doctor. From the enquirer's point of view, communication between doctor and patient based on text only often seems to be sufficient since participants did not comment at all on the lack of a previous relationship or a physical examination, i.e. potential limitations of the Ask the Doctor service. Maybe the participants accepted these prerequisites for getting a written answer or maybe they, as lay persons, were unaware how much valuable medical information and communication is based on the personal relation and body language.
Expectations of the relationship with the Internet doctor seemed to vary. For some participants a personal relationship was not essential or, on the contrary, not preferred since the enquirer wanted to be anonymous. Other participants wanted the option to pose follow-up questions, i.e. institute a dialogue, and even to establish future contact with the answering Internet doctor. Thus, they were asking for continuity and a personal relationship, basic elements of a doctor–patient relationship. However, in our opinion, Internet consultations should be regarded as a consultation type of their own. The Internet doctor's role should not be the same as a personal doctor's. Rather, the role of the Internet doctor should be to empower the enquirer to continue to be active in acquiring medical knowledge and to take an active part in treatment decisions.46 What the Internet doctor can do is to interpret enquiries, provide comments, explain and teach. Still, it is too early to predict the future role of anonymous Ask the Doctor services as they seem to meet different needs for different enquirers. In future studies, the cost-effectiveness, patient security, responsibilities of the Internet doctor and the role of Ask the Doctor services compared with regular health care should be evaluated.
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Declaration |
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Ethical approval: The study was approved by the Umeå Clinical Research Ethics Committee, Umeå, Sweden. Conflicts of interest: GU has been serving as 1 of 35 Internet doctors and as 1 of 6 coordinators at Infomedica's Ask the Doctor service.
Funding: GU was supported by grants from the County of Västernorrland, Sweden.
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Contribution of authors |
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GU, HM and GP were responsible for the study design and the Internet survey. GU, KH and GP were responsible for the qualitative analysis. GU reviewed the literature and wrote the initial draft. All authors participated in the writing process.
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Acknowledgments |
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We thank statistician Erling Englund, Mid-Sweden Research and Development Centre, County Council of Västernorrland, Sundsvall, Sweden for valuable contributions on statistical issues.
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References |
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1 Powell JA, Darvell M, Gray JA. The doctor, the patient and the world-wide web: how the internet is changing healthcare. J R Soc Med 2003; 96: 74–76.
2 White CB, Moyer CA, Stern DT, Katz SJ. A Content analysis of e-mail communication between patients and their providers: patients get the message. J Am Med Inform Assoc 2004; 11: 260–267.
3 Neville RG, Marsden W, McCowan C, Pagliari C, Mullen H, Fannin A. Email consultations in general practice. Inform Prim Care 2004; 12: 207–214.[Medline]
4 Sittig DF. Results of a content analysis of electronic messages (email) sent between patients and their physicians. BMC Med Inform Decis Mak 2003; 3: 11.[Medline]
5 Horrigan J, Rainie L. Counting on the Internet: Pew Internet & American Life Project 2002. Available at: www.pewinternet.org/reports/toc.asp?Report=80.
6 New American Academy of Dermatology Survey Finds Patients Do Their Homework: American Academy of Dermatology, 2002. Available at: www.aad.org/public/News/NewsReleases/Press+Release+Archives/Other/Homework.htm.
7 Liederman EM, Morefield CS. Web messaging: a new tool for patient-physician communication. J Am Med Inform Assoc 2003; 10: 260–270.
8 Labiris G, Coertzen I, Katsikas A, Karydis A, Petounis A. An eight-year study of internet-based remote medical counselling. J Telemed Telecare 2002; 8: 222–225.[CrossRef][ISI][Medline]
9 Ask the Doctor & Second Opinion Services: The Karolinska Institutet Library, Sweden. Available at: www.mic.ki.se/Diseases/askdoc.html.
10 Web-based second opinion service expanding quickly. Data Strateg Benchmarks 2001; 5: 161, 172–174.[Medline]
11 Eysenbach G, Diepgen TL. Patients looking for information on the Internet and seeking teleadvice: motivation, expectations, and misconceptions as expressed in e-mails sent to physicians. Arch Dermatol 1999; 135: 151–156.
12 Umefjord G, Petersson G, Hamberg K. Reasons for consulting a doctor on the Internet: Web survey of users of an Ask the Doctor service. J Med Internet Res 2003; 5: e26.[Medline]
13 eRisk Working Group for Healthcare: Guidelines for Online Communication: The Medem Network, 2002. Available at: www.medem.com/phy/phy_eriskguidelines.cfm.
14 Car J, Sheikh A. Email consultations in health care: 2–acceptability and safe application. BMJ 2004; 329: 439–442.
15 Collste G. The internet doctor and medical ethics. Ethical implications of the introduction of the Internet into medical encounters. Med Health Care Philos 2002; 5: 121–125.[CrossRef][Medline]
16 Miller TE, Derse AR. Between strangers: the practice of medicine online. Health Aff (Millwood) 2002; 21: 168–179.
17 Schafernak KT. World Wide Web medical consultations a global problem. N Z Med J 2001; 114: 146.[Medline]
18 A nation online: how Americans are expanding their use of the Internet: US Department of Commerce, Economics and Statistics Administration, 2002. Available at: https://www.esa.doc.gov/reports/anationonline2.pdf.
19 Horrigan J, Rainie L, Allen K, Boyce A, Madden M, O'Grady E. The ever shifting Internet population: Pew Internet & American Life Project 2003. Available at: www.pewinternet.org/PPF/r/88/report_display.asp.
20 The Swedes and The Internet 2002: World Internet Institute; 2002 (in Swedish).
21 Birru MS, Monaco VM, Charles L et al. Internet usage by low-literacy adults seeking health information: an observational analysis. J Med Internet Res 2004; 6: e25.[Medline]
22 Eysenbach G, Wyatt J. Using the Internet for surveys and health research. J Med Internet Res 2002; 4: E13.[Medline]
23 Braithwaite D, Emery J, De LS, Sutton S. Using the Internet to conduct surveys of health professionals: a valid alternative? Fam Pract 2003; 20: 545–551.
24 Vehovar V, Lozar K, Batagelj Z, Zaletel M. Nonresponse in web surveys. In Groves RM, Dillman DA, Eltinge JL, Little JA (eds). Survey Nonresponse Hoboken: John Wiley & Sons; 2001; pp. 229–242.
25 Lorber J. Gender and the Social Construction of Illness Thousand Oaks: Sage, 1997.
26 Wyke S, Hunt K, Ford G. Gender differences in consulting a general practitioner for common symptoms of minor illness. Soc Sci Med 1998; 46: 901–906.[CrossRef][ISI][Medline]
27 Hallström O, Lindén P. [II-stiftelsens internetundersökning, rapport 1], in Swedish 2005.
28 Delichatsios H, Callahan M, Charlson M. Outcomes of telephone medical care. J Gen Intern Med 1998; 13: 579–585.[CrossRef][ISI][Medline]
29 O'Cathain A, Munro JF, Nicholl JP, Knowles E. How helpful is NHS direct? Postal survey of callers BMJ 2000; 320: 1035.
30 Fox S, Fallows D. Internet health resources: health searches and email have become commonplace, but there is room for improvement in searches and overall Internet access: Pew Internet & American Life Project, 2003. Available at: www.pewinternet.org/reports/toc.asp?Report=95.
31 Theobald K. The experience of spouses whose partners have suffered a myocardial infarction: a phenomenological study. J Adv Nurs 1997; 26: 595–601.[CrossRef][ISI][Medline]
32 Rees CE, Bath PA. Exploring the information flow: partners of women with breast cancer, patients, and healthcare professionals. Oncol Nurs Forum 2000; 27: 1267–1275.[Medline]
33 Echlin KN, Rees CE. Information needs and information-seeking behaviors of men with prostate cancer and their partners: a review of the literature. Cancer Nurs 2002; 25: 35–41.[CrossRef][ISI][Medline]
34 Bunn F, Byrne G, Kendall S. Telephone consultation and triage: effects on health care use and patient satisfaction. Cochrane Database Syst Rev 2004; (4): CD004180.
35 Niemann S, Meer A, Simonin C, Abel T. Medical telephone triage and patient behaviour: How do they compare? Swiss Med Wkly 2004; 134: 126–131.[Medline]
36 Ong LM, de Haes JC, Hoos AM, Lammes FB. Doctor–patient communication: a review of the literature. Soc Sci Med 1995; 40: 903–918.[CrossRef][ISI][Medline]
37 Blanchard J, Lurie N. R-E-S-P-E-C-T: Patient reports of disrespect in the health care setting and its impact on care. J Fam Pract 2004; 53: 721.[Medline]
38 Johansson EE, Hamberg K, Lindgren G, Westman G. "I've been crying my way"—qualitative analysis of a group of female patients' consultation experiences. Fam Pract 1996; 13: 498–503.
39 Perneger TV, Etter JF, Raetzo MA, Schaller P, Stalder H. Comparison of patient satisfaction with ambulatory visits in competing health care delivery settings in Geneva, Switzerland. J Epidemiol Community Health 1996; 50: 463–468.[Abstract]
40 McGinnis EB. Patients' rights. BMJ 1995; 311: 671.
41 Rippere V. Are second opinions a right or a concession? BMJ 1995; 311: 1506.
42 Mustafa M, Bijl M, Gans R. What is the value of patient-sought second opinions? Eur J Intern Med 2002; 13: 445.[Medline]
43 Johnson A, Sandford J, Tyndall J. Written and verbal information versus verbal information only for patients being discharged from acute hospital settings to home. Cochrane Database Syst Rev 2003; (4): CD003716.
44 Williams S, Weinman J, Dale J. Doctor–patient communication and patient satisfaction: a review. Fam Pract 1998; 15: 480–492.
45 McWhinney IR. Textbook of Family Medicine. (2nd edn). Ontario: Oxford University Press; 1997.
46 Ferguson T. From doc-providers to coach-consultants: Type 1 Vs. Type 2 provider–patient relationships, 2001. Available at: www.fergusonreport.com/articles/tfr07-01.htm.
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