The role of social media used by patients within the doctor-patient relationship

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The role of social media used by patients within the

doctor-patient relationship

University of Groningen

Faculty of Economics and Business

MSc. Business Administration

Change Management

First supervisor:

Prof. Dr. A. Boonstra

Second supervisor:

E. Smailhodzic

June 20, 2016

Iris van der Huizen

S2590867

i.j.van.der.huizen@student.rug.nl

Word count: 15,759

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2 Abstract

Nowadays, patients make increasingly use of social media for the purpose of health. This trend may have challenged the doctor-patient relationship and the level of authority of doctors. Therefore, this qualitative study explores how the use of social media by patients changes the doctor-patient relationship and how this particular change influences the medical professionalism logic adopted by doctors. To get a deeper understanding of these phenomena, twelve doctors were interviewed. The findings reveal that the use of social media by patients has changed the doctor-patient relationship in three ways. First, the role of doctors changed from being a “teacher” for their patients towards a “student” of their patients. Second, the doctor-patient relationship changed from being a “hard” towards a more “soft” relationship. Finally, the role of doctors changed from being a “leading” person towards a “coach” for their patients. These changes have influenced the medical professionalism logic in two ways. First, the authority level of doctors has decreased. Second, the task providing “technical” knowledge has decreased.

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INTRODUCTION

Traditionally doctor-patient relationships were characterized as long-term relationships, involving multiple face-to-face visits of patients (Smith & Christakis, 2008; Colineau & Paris, 2010). The doctors were the sole providers of medical information which was mainly based on diagnoses, prognoses, and treatment options provided by the doctors (ibid). Within this relationship, there was high-level of information asymmetry between doctors and their patients (Reay & Hinnings, 2005), because doctors had a central role in providing medical advice, which gave them a high degree of authority and power (van Offenbeek et al., 2013; Martin et al., 2015). Due to this, doctors have adopted the medical professionalism logic as their “dominant” logic within the field of health (Reay & Hinnings, 2005; Battilana, 2011; Pilnick & Dingwall, 2011; Currie et al., 2012). According to van Offenbeek et al. (2013), the medical professionalism logic concentrates on the central role of doctors in proving health.

Nowadays, the traditional doctor-patient relationship is challenged by the increasing use of Internet, and likewise the use of social media by patients (Colineau & Paris, 2010). In the old days, the provided medical information on Internet was solely based on scientific information presented as evidence-based “facts and figures” controlled and provided by the healthcare organizations (Ziebland & Wyke, 2012). However, Colineau and Paris (2010) showed that this “static” Internet has transformed itself into a place where patients can create, contribute, and interact with other patients. These interactive places are known as “social media”. Kaplan and Haenlein (2010) defined social media as; “a group of Internet-based applications that build on the ideological and technological foundations of web 2.0, and that allow the creation an exchange of User Generated Content” (p.61).

Antheunis et al. (2013) showed that the retrieved medical information from social media improved patient’s understanding of health related issues, influencing their treatment decisions, and leads them to share new medical information with doctors. Regarding this social media trend, patients have full access and availability to medical information (McMullan, 2006). More precisely, this created patients who are no longer satisfied with the traditional adopted attitude of the doctors (ibid). This means that patients want to be fully informed and likewise; they want to have influence on the overall decision-making process (ibid). Accordingly, Broom (2005) reported that the role of patients has shifted from passive participants towards more active participants within the doctor-patient relationship.

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4 (McMullan, 2006; van Uden-Kraan et al., 2010) and therefore, their adopted medical professionalism logic. However, it is still unclear and under researched “how” the use of social media by patients changes the traditional doctor-patient relationship and “how” this change influences the medical professionalism logic adopted by doctors. Hence, to address this gap in the literature, I undertake the study to address the following research questions:

1) How does the use of social media by patients change the doctor-patient relationship? 2) How does this change influence the medical professionalism logic adopted by doctors? To get a deeper understanding of these phenomena and to answer the research questions, I adopted a qualitative research approach. In particular, I interviewed twelve doctors from eleven medical practices.

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THEORETICAL FRAMEWORK

The purpose of this section is to get a deeper understanding on the use of social media by patients, the use of social media by patients related to the doctor-patient relationship, and the institutional logics within the healthcare.

The use of social media by patients

Nowadays, thousands of social media platforms, consistent of several of groups of patients, are created to read, talk and share medical information related to their diseases (Shirky, 2008). These places are known as “social media”. Social media is characterized as an online discussion platform; that enables individuals and communities to gather, communicate, share, and collaborate information with each other (Von Muhlen & Ohno-Machado, 2012; Gómez-Zúñiga et al., 2012; Modahl et al., 2011). Patients who participate in social media activities are called “ePatients” (Gómez-Zúñiga et al., 2012). This means that they are Equipped, Enabled, Empowered, and Engaged in their own health and healthcare decisions (ibid).

Research holds the view that the use of social media by patients has affected the healthcare sector (Von Muhlen & Ohno-Machado, 2012). For instance, Modahl et al. (2011) showed that social media has created an online discussion place for patients; this place goes beyond the reach of doctors. Moreover, recent research showed that the dominance use of social media by patients has created some essential changes for patients themselves (Antheunis et al., 2013). To illustrate, Gómez-Zúñiga et al. (2012) stated that social media has changed the way in which people access, create, and use information or services and it enables patients to get in contact with other patients who share the same interests and goals. Furthermore, social media provides four advantages for patients: (1) it provides new ways to obtain medical information, (2) it creates social support, (3) it creates collaboration and social support between patients, and (4) it develops connectivity and it enables users’ direct participation (Antheunis et al., 2013).

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6 The use of social media by patients and the doctor-patient relationship

Nowadays, research highlights the doctor-patient relationship as an important facet within the healthcare sector, since it determines the quality of care (Broom, 2005), which in turn, is affected by the extent of trust between the doctor and patient (Fugelli, 2001). The traditional doctor-patient relationship has been characterized as a long-term relationship, which involved multiple face-to-face visits by patients (Smith & Christakis, 2008; Colineau & Paris, 2010). The intrinsic quality of this relationship allows that two people, who are unknown to each other before the consultation, feel at ease with a diverse degree of intimacy (Kaba & Sooriakumaran, 2007). Although this relationship is long-term and highly based on trust, recent research showed that the use of social media by patients has challenged this traditional doctor-patient relationship (Colineau & Paris, 2010).

Broom (2005) stated that this challenge occurred because the use of social media by patients deteriorated the power imbalances between doctor and patients. The power imbalance between doctors and patients is deteriorated due to the increased knowledge and awareness of patients regarding medical information during consultations (van Uden-Kraan et al., 2010). This awareness makes that patients do not instantly believe or agree what doctors tell or advise them and therefore the power of doctors has decreased (McMullan, 2006). More precisely, doctors have encountered that, during consultations, patients use their retrieved medical information (van Uden-Kraan et al., 2010). Although this awareness, their attitude towards this increased awareness of patients are mixed. Some doctors showed a positive attitude towards the use of social media of their patients. One reason for this positive attitude is that it enables patients to cope better with the information provided by the doctors (Henry & Wyatt, 2002). Secondly, Rupert et al. (2014) showed that the use of social media by patients created more informed and engaged patients and van Uden-Kraan et al. (2010) stated that patients could better understand the treatment options provided by doctors. On the contrary, other doctors showed a more conservative attitude towards the use of social media by patients. For instance, van Uden-Kraan et al. (2010) indicated that many doctors felt that their authority was challenged as patients tested their knowledge or because some patients diagnose themselves and made their own treatment plan (ibid). Accordingly, many doctors felt unaware of the social media activities by patients, perceive these patients as misinformed and anxious, find it challenging to evaluate the credibility of the online content, and fear that patients may act on online recommendations without asking their doctor for information (Rupert et al., 2014). To clarify, table 1 presents a literature overview about the use of social media by patients within the healthcare sector.

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7 Institutional logics within the healthcare sector

The healthcare field is characterized as a highly institutional field (Currie & Guah, 2007). The concepts “institution” and “institutionalism” are related to strength, endurance, and stability (Smith & Graetz, 2011). Moreover, Smith and Graetz (2011) argued that the institutional theory is known as the “theory of stability”. Furthermore, the institutional logic perspective is a useful manner to address the plurality of norms and beliefs within an institutional field (Currie et al., 2012; Pahnke et al., 2015). This institutional logic perspective gives an overview of the connections that create a sense of common purpose within the healthcare sector (Reay & Hinnings, 2009). Thornton and Ocasio (2008) defined institutional logics as; “the socially constructed, historical patterns of cultural symbols and material practices, including assumptions, values, and beliefs, by which individuals and organizations provide meaning to their daily activity, organize time and space, and reproduce lives and experiences” (p.2). These institutional logics influence how organizational members perceive, pay attention to, and respond to environmental stimuli (Pahnke et al., 2015). Seo and Creed (2002) showed that institutional logics have a mutating and evolving character. Based on this, actors can create and diffuse the institutional logics (Currie & Guah, 2007).

Battilana (2011) and Currie et al. (2012) found evidence for the fact that the healthcare sector strongly favours the authority and power of doctors. Therefore, the medical professionalism logic is assigned as the “dominant” logic within the field of health (Battilana, 2011; Pilnick & Dingwall, 2011; Currie et al., 2012). The main objective of this logic is to provide only the necessary medical services to patients (Reay & Hinnings, 2005). A healthcare field regulated by the medical professionalism logic means that the doctor-patient relationship is guided by service provision (Reay & Hinnings, 2009). Additionally, within this logic, doctors have the privilege to do self-regulation and have a high degree of authority (Martin et al., 2015). To illustrate, patients are expected to follow-up the medical direction provided by their doctor (Reay & Hinnings, 2009) and doctors determine the level of quality and service within their relationship with patients (Reay & Hinnings, 2005). Besides the high level of authority, Ha and Longnecker (2010) have pointed out that doctors, who adopted the medical professionalism logic, communicate on a very formal basis.

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METHODOLOGY

The methodology section outlines the method used for this study, the type of data collection, and it elaborates on how the data was analysed. Additionally, it shows if the quality criteria controllability, reliability, and validity are met.

Research method

The aim of this study is to gain a deeper understanding on “how” the use of social media by patients change the doctor-patient relationship and “how” this change influence the medical professionalism logic adopted by the doctors. The existing healthcare literature lacks inside information about these two phenomena. Regarding this, a qualitative research approach is adopted. This research approach is characterized as a method that examines people’s experience in detail, by using a specific set of research methods such as in-depth interviews, focus group discussions, observations, visual methods, and life histories/bibliographies (Hennink et al., 2011). With this approach, participants can provide their own understanding of a particular situation through their own words and perceptions (Miles & Huberman, 1994). This allowed respondents to explore their own understanding about “how” the use of social media by patients changes the doctor-patient relationship, and “how” these particular changes influenced the medical professionalism logic.

The explorative method that was used for this study was the case study approach. Case study is a research method that is characterized as a research strategy that particularly focuses on understanding the dynamics presented within a single or multiple settings (Yin, 1984). Additionally, this study followed the eight stages of the theory development approach by Eisenhardt (1989); these stages are presented in table 2.

Qualitative data collection

To answer the research questions, cross-sectional case studies were conducted at eleven medical practices throughout The Netherlands. The data selected for this study was based on theoretical sampling. The participants of this study were twelve doctors who all work at Dutch medical practices. All doctors were gathered through the “snowball” recruitment technique (Hennink et al., 2011). Table 3 provides an overview is presented of the characteristics of all these doctors.

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11 medical practice?” were asked. In the second part of the interview, I asked some questions related to the medical professionalism logic. These were questions as: “Can you describe yourself as a doctor?” and “What are your norms and values as a doctor?”. The third part of the interview was related to the doctor-patient relationship. Questions as “Can you describe your relationship with the patients?” and “Can you describe the optimal doctor-patient relationship?”. Within the last three parts, I asked questions related to the use of social media by patients. These were questions as: “How does the use of social media by patients has influenced your role as doctor?”, and “How does the use of social media by patients has influenced the traditional doctor-patient relationship”. In appendix 1, the entire interview protocol is presented.

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14 Quantitative data collection

At the end of every interview, the doctors were asked to fill out a questionnaire that was consisted of fourteen questions. However, only 11 completed questionnaires were returned. This questionnaire was divided into two parts. The first part was focused on the medical professionalism logic. The second part was focused on the use of social media by patients. Appendix 2 presents the entire questionnaire. The results of this questionnaire confirmed the institutional logic literature by showing that doctors, still, adopted the medical professionalism logic as their dominant logic (see appendix 3).

Data analysis

After transcribing and coding the interviews, data analysis was started. First, the within-case analysis was conducted. This involves detailed write-ups for each particular case (Eisenhardt, 1989). After the within-case analysis was completed, cross-case analysis started. The cross-case analysis investigates several patterns within the data. To get a clear and rich answer on the two research questions, the data analysis was divided into two levels, the first and second level analysis (see table 4 and 5).

The first level data analysis was designed to explore “how” the use of social media by patients changes the doctor-patient relationship. After the within-case analysis, the cross-case analysis was executed. The data was coded on a deductive as well as an inductive coding procedure (see appendix 4). Accordingly, within the first level analysis a total amount of 47 codes were developed. However, only 30 of these codes were used within this study. Moreover, it is important to note that some codes (within the categories) were used twice. The coding procedure of the first level analysis is presented in appendix 5. Based on these codes, nine categories and three themes were designed. The first theme was labelled as: “from being a ‘teacher’ towards a ‘student’”. The second theme was labelled as “from a ‘hard’ towards a more ‘soft’ relationship”, and the final theme was labelled as “from a ‘leading’ person towards a role as ‘coach’”.

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Table 4: overview of the first level analysis

Phase Objective of the analysis Data Codes Categories Theme

1. First level analysis

To explore “how” the use of social media by patients change the doctor-patient relationship

12 interviews with doctors

30 codes 1. The doctor takes the use of social media by patients into account (based on 5 codes)

2. The decrease of medical information asymmetry (based on 6 codes)

3. The increase of the medical knowledge of doctors (based on 4 codes)

From being a “teacher” towards a “student” (based on 9 different codes)

1. Doctors have to deal with patients who are seeking for confirmation (based on 4 codes)

2. Doctors have to deal with insecure patients (based on 6 codes)

3. Doctors have to deal with patients who are more active (based on 5 codes)

From a “hard” towards a more “soft” relationship (based on 13 different codes)

1. Doctors have to deal with a more responsible patient (based on 5 codes) 2. Doctors have to deal with a more persist patient (based on 4 codes) 3. Doctors have to deal with patients who are more informed (based on 4 codes)

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Phase Objective of the analysis Data Codes Categories Theme

2. Second level analysis

To explore “how” the use of social media influence the medical professionalism logic adopted by doctors

12 interviews with doctors

12 codes 1. Doctors have to deal with patients who adopted a high level of self-awareness (based on 3 codes) 2. Doctors have to deal with a decreased information asymmetry (based on 4 codes)

The authority level of doctors has decreased (based on 7 different codes)

1. Doctors have to deal with an increased amount of providing “socio-emotional” knowledge (based on 3 codes)

2. Doctors have to deal with a decreased information asymmetry (based on 2 codes)

The task providing

“technical” knowledge has decreased (based on 5 different codes)

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FINDINGS

This section presents the findings of the first and second level analysis. Moreover, in the final part of this section, the findings of these two analyses were connected towards each other.

Findings first level analysis

The first level analysis provides an understanding of “how” the use of social media by patients has changed the doctor-patient relationship. The findings of this analysis showed that the doctor-patient relationship has changed in three ways. First, doctors are not the only providers of medical knowledge anymore; therefore, they adopted the role as “student” of their patients instead of “teacher” for their patients. Second, doctors have to provide more “socio-emotional” tasks, therefore, the relationship shifted from a “hard” towards “soft” relationship. Third, doctors have to cope with their new role as “coach”.

(1) From being a “teacher” towards a “student”

Traditionally, doctors were the only providers of medical knowledge towards patients and they were the only one who made the medical decisions for patients. Therefore, the doctor was the “teacher” for their patients. Nowadays, based on the use of social media by patients, doctors have become the “student” of their patients. The first level analysis showed three main reasons “how” doctors have become a “student” of their patients. First, the doctor takes the use of social media into account. Second, decrease of the medical information asymmetry. Finally, increase of medical knowledge of doctors. Figure1 presents an overview of these three main reasons.

The doctor takes the use of social media by patients into account

During consultations, doctors have to take the trend “use of social media by patients” into account. The data showed five main reasons that explored “why” doctors have to think about this trend. Table 6 shows an overview of these reasons.

First, five doctors explained that patients inform them about their use of social media. This means that doctors know that patients make use of social media. For example, when asked about the “the use of social media by patients”, one doctors answered:

“Some patients inform me about their use of social media for medical information. Moreover, in the first part of the consult they start with “I have pain in the back, and I searched on social media. I made my own diagnoses.” This helps me a lot. Thus, some patients inform me about their use of social media.” (D2) 1

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Patients inform their doctor

Doctors have to ask about social media

Doctors think about social media

Doctors have to deal with new types of

questions

Doctors check social media information

Doctors have to deal with well-informed

patients

Doctors have to deal with well-informed patients Patients have knowledge about long-time and special diseases Patients have knowledge about long-time and special diseases Social media improves medical knowledge doctors Social media improves medical knowledge doctors Balanced knowledge doctors and patients

Balanced knowledge doctors and patients

Doctors take the use of social media by patients into account

The decrease of medical information asymmetry

Increase medical knowledge doctors

From being a “teacher” towards a “student”

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19 In contrast, secondly, eight doctors said that their patients did not communicate their use of social media. When this is the case, doctors have to ask about them about their use of social media. In contrast to the communication, thirdly, doctors have to think about and evaluate the medical information obtained from the use of social media by patients. For example, when asked about “the use of social media by patients”, one doctor answered:

“If you see the general trend of social media use by patients, I think you need to take the information derived from social media into account (during a consult).” (D10) 2

Thirdly, ten doctors argued that patients have become, since their use of social media, (medical) well informed. These doctors argued that these well-informed patients have new types of questions (more socio-emotional) (fourth reason). Finally, it is important to note that three doctors said that they “check” the objectivity of the medical information obtained from the use of social media by patients. Altogether, nowadays, doctors have to take the medical information, obtained from the use of social media by patients, into account.

The doctors takes the use of social media into account

Doctor(s) Example Quote

1. Patients inform the

doctors about their use of social media

D1, D2, D3, D9, and D10

“Some patients inform me about their use of social media for medical information. Moreover, in the first part of the consult they start with “I have pain in the back, and I searched on social media. I made my own diagnoses.” This helps me a lot. Thus, some patients inform me about their use of social media.” (D2) 3

2. Doctors have to ask

about the use of social media

D2, D3, D6,, D7, D9, D10, D11 and D12

“Yes, I ask them if they use social media for medical information.

Moreover, during consultations, I ask patients if the they searched on social media.” (D2)4

3. Doctors think about the

medical information from social media

D1, D2, D3, D5, D6, D7, D9, D10, D11 and D12

“If you see the general trend of social media use by patients, I think you need to take the information derived from social media into account (during a consult).” (D10) 5

4. Doctors have to deal

with different questions

D9 and D10 “Patients have more medical knowledge, therefore they ask more medical

questions. Moreover, I think that the content of the questions have changed.” (D9)6

5. Doctors check the

medical information from social media

D2, D6, and D11

“I search on social media to assign if the provided medical information on social media is correct. Based on this, I endorse or not endorse the social media provided by the patient.” (D11)7

Table 6: doctor takes the use of social media into account

2_{“Als je de algemene trend van het social media gebruik van de patiënten ziet. Dan denk ik wel dat we met deze informatie rekening moeten gaan houden tijdens} een spreekuur” (D10)

3

“Sommige vertellen het gewoon, die beginnen gewoon van "goh, ik heb rugpijn en ik heb dat en dat opgezocht en ik denk dat ik dit en heb. En dit en dit kan er aan gedaan worden". Nou, dat is makkelijk he. Die zeggen het vanzelf wel.” (D2)

4_{“Ja, ik vraag meestal wel of ze gebruik hebben gemaakt van social media. Gedurende spreekuren, vraag ik ook of ze iets op social media hebben opgezocht.”} (D2)

5_{“Als je de algemene trend van het social media gebruik van de patiënten ziet. Dan denk ik wel dat we met deze informatie rekening moeten gaan houden tijdens} een spreekuur” (D10)

6_{“Patiënten hebben nu meer kennis, daarom hebben ze ook andere vragen. Ook de inhoud van de vragen is veranderd.” (D9)}

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20 The decrease of the medical information asymmetry

Traditionally, there was a medical information asymmetry within the doctor-patient relationship. However, several doctors explained that, based on the use of social media by patients, this medical information asymmetry has decreased. The data showed six reasons “why” this medical information asymmetry has decreased. Table 7 provides an overview of these six reasons.

To start, ten doctors explained that the level of medical knowledge of patients has increased. Secondly, four of these ten doctors mentioned that the medical knowledge of patients, with regard to long-time and special diseases has increased. For example, when asked about the “the information asymmetry”, one doctor answered:

“Yes, today, if a patient visits a consults, he/she has more medical knowledge about their disease.” (D7)8

Thirdly, nowadays, doctors receive medical information obtained from the use of social media of patients. Due to this, ten doctors said that they seriously take the social media based information in consideration. However, fourthly, it is still the case that doctors check the objectivity of this obtained medical information. For example, when asked about “the use of social media by patients”, one doctor answered:

“I search on social media to assign if the provided medical information on social media is correct. Based on this, I endorse or not endorse the social media information provided by the patient.” (D11)9 Although this check of objectivity, nine doctors explained that the social media based information has increased their medical knowledge. Fifthly, these four findings indicated that doctors learn from this obtained medical information. To illustrate, when asked about “learning from the use of social media of patients”, one doctor answered:

“If patients found something on social media, I support that. I can learn from it. Due to this, I learn more and I would become better. ” (D6)10

Finally, seven doctors experienced a more balanced knowledge between them and their patients. These six reasons together demonstrated a decreased information asymmetry between doctors and patients.

8_{“Ja, patiënten komen tegenwoordig met veel meer medische voorkennis een spreekuur binnen.” (D7)}

9_{“Ik zoek ook wel eens op social media om te kijken of de informatie die de patiënt van social media heeft klopt. Aan de hand hiervan zal ik de social media} informatie beamen of ontkrachten voor de patiënt” (D11)

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The decrease of the medical information asymmetry

1. Doctors have to deal with more well-informed patients

D1, D2, D3, D4, D6, D7, D8, D9, D10, and D12

“Yes. Today, if a patient visits a consults, he/she has more medical

knowledge about their disease.” (D7)11

2. Patients have more knowledge about long-time and special diseases

D1, D2, D7, D8, and D11

“Patients find each other in an easy way. This is a helpful trend for special

diseases, because people can find each other easy. Therefore, patients can bundle medical information.” (D2)12

3. Doctors think about the medical information from social media D1, D2, D3, D5, D6, D7, D9, D10, D11, and D12

“If you see the general trend of social media use by patients, then I think you need to take the information derived from social media into account (during a consultations).” (D10) 13

4. Doctors check the medical information from social media

D2, D6, and D11

“I search on social media to assign if the provided medical information on social media is correct. Based on that, I endorse or not endorse the social media provided by the patient.” (D11)14

5. The use of social media by patients improves the medical knowledge of doctors

D2, D4, D5, D6, D7, D8, D10, D11, and D12

“If patients found something on social media, I support that. I can learn

from it. Accordingly, I learn more and I would become better. ” (D6)15

6. Doctors and patients have a more balanced knowledge

D3, D4, D6, D8, D9, D10, D11, and D12

“The patients become more equal in relation with the doctors. Yes, the

relationship become more symmetric.” (D11)16

Table 7: decrease of the medical information asymmetry

The increase of medical knowledge of doctors

The data showed that the use of social media by patients has increased the level of medical knowledge of doctors. Therefore, doctors learn from the obtained social media based information (health related). Table 8 provides four reasons that show “why” doctors learn from the use of social media of patients.

Firstly, ten doctors said that they seriously take the medical information, derived from the use of social media by patients, into account. However, secondly, three of these ten doctors explained that they check the correctness of this particular medical information before using it within consultations with their patients. For instance, when asked about the “the use of social media of patients”, one doctor answered:

11_{“Ja, patiënten komen tegenwoordig met veel meer voorkennis een spreekuur binnen.” (D7)}

12_{“Mensen kunnen elkaar veel makkelijker vinden he, dus ik denk vooral voor zeldzame ziektes dat het een hele goede zaak is dat mensen elkaar makkelijk} kunnen vinden. Waardoor je allerlei informatie kan bundelen.” (D2)

13_{“Als je de algemene trend van het social media gebruik van de patiënten ziet. Dan denk ik wel dat we met deze informatie rekening moeten gaan houden} tijdens een spreekuur” (D10)

14_{“Ik zoek ook wel eens op social media om te kijken of de informatie die de patiënt van social media heeft klopt. Aan de hand hiervan zal ik de social media} informatie beamen of ontkrachten voor de patiënt” (D11)

15_{Kijk, als mensen zelf dingen gevonden hebben dan is dat voor mij alleen maar welkom he. Ik kan er alleen maar van leren he. Ik wil zelf ook steeds beter} worden. (D6)

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22 “Yes, in general doctors can learn from social media. But, I have to check from which website this information is derived.” (D2)17

Thirdly, if a doctor has approved this social media based medical information, then it adds value for the doctor his/herself. To illustrate, when asked about “learning from social media”, one doctor answered:

“Yes, I think that I can learn from the social media based information from patients. Accordingly, I think that you will know more about the background of the patient.” (D12)18

Finally, patients who make use of social media, have an increased level of knowledge about long-time and special diseases. Several doctors explained that they learn from this social media based information related to long-time and special diseases. In sum, these four reasons investigated that the medical knowledge of doctors has increased.

The increase of medical knowledge of doctors

1. Doctors think about the medical information from social media

D1, D2, D3, D5, D6, D7, D9, D10, D11, and D12

“The consults within our practice take the medical information from

social media into account (since a long time).” (D6)19

2. Doctors check the medical information from social media

D2, D6, and D11

“Yes, in general doctors can learn from social media. But, I have to check

from which website this information is derived.” (D2)20

3. The use of social media by patients improve the medical knowledge of the doctors D2, D4, D5, D6, D7, D8, D10, D11,and D12

“Yes, I think that social media platforms improve our knowledge.

Moreover, these platforms can also provide new information for doctors.” (D11)21

4. Patients have more knowledge about long-time and special diseases

D1, D2, D7, D8, D11, and D12

“Patients find each other in an easy way. This is a helpful trend for

special diseases, because people could find each other easy. Therefore, patients can bundle medical information.” (D2)22

Table 8: increase of medical knowledge of doctors

These three findings together showed that doctor’s level of providing medical knowledge has decreased, and therefore their knowledge providing role, known as “teacher”. Due to the use of social media by patients, doctors are the receivers of knowledge, labelled as the “student” of their patients.

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“Ja, klopt. Over het algemeen worden mensen daar niet dommer van. Maar je moet wel checken van welke sites deze informatie komt.” (D2)

18_{“Ja, ik denk dat je er altijd wel wat van kan leren hoor. Je leert altijd wel van dingen die patiënten hebben opgezocht door middel van social media. Daarnaast} denk ik dat je daardoor ook meer van de patiënt zelf weet.” (D12)

19_{“Onze consulten zijn daar al die jaren al op ingericht. Op het gebruik van informatie afkomstig van social media” (D6)}

20_{“Ja, klopt. Over het algemeen worden mensen daar niet dommer van. Maar je moet wel checken van welke sites deze informatie komt.” (D2)} 21_{“Ja, dat denk ik wel. De platformen geven soms toch wel eens nieuwe informatie ook voor ons als huisartsen” (D11)}

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23 (2) From a “hard” towards a more “soft” relationship

In the old days, doctors were the only providers of “technical” tasks towards patients. This relationship was labelled as “hard”. Regarding the well-informed patients, the doctor-patient relationship has become a more “socio-emotional” relationship, labelled as “soft”. Within this “soft” relationship, there is more interaction between doctors and patients. The first level analysis investigated three reasons that explored “how” the doctor-patient relationship has become a more “soft” relationship. First, doctors have to deal with patients who are seeking for confirmation. Second, doctors have to deal with insecure patients. Finally, doctors have to deal with patients who are more active. Figure 2 shows an overview of these three main reasons.

Doctors have to deal with patients who are seeking for confirmation

These well-informed patients set, by means of social media, their own diagnoses and, sometimes their own treatment plan. The relationship between doctors and these well-informed patients is based on providing “confirmation” instead of providing “objective” medical information towards patients. The data provided four main reasons “why” doctors have to deal with patients who are seeking for confirmation. Table 9 shows an overview of these four reasons.

To start, since patients make use of social media, doctors have to discuss this particular information during consultations. Secondly, eight doctors argued that they have to confirm the self-developed diagnoses of patients that are based on social media. For example, when asked about “changes in the role of the patients”, one doctor answered:

“The reason why the patient came to the consult was to control his self-developed diagnoses. So, he/she was a bit insecure. He was seeking for confirmation.” (D3)23

Sometimes, when doctors discuss these self-created diagnoses of patients, doctors become too patient oriented and likewise, too “socio-emotional” involved (third reason). Finally, according to five doctors, the “soft” relationship has changed the overall role of the doctors from mainly executing “technical” tasks towards more “socio-emotional” tasks, this role is known as “mentor”. To illustrate, when asked about “the changes in the role of the doctor”, one doctor answered:

“We become more patient oriented (connected with the patients). Therefore, nowadays, we are more the coach for patients.” (MP8)24

These four reasons showed that patients, with self-developed diagnoses, mainly visit consultations for obtaining confirmation.

23 “Hij/zij kwam alleen maar controleren of het dan echt wel zo was, een beetje onzeker dus eigenlijk. Ook kwam hij vragen of deze informatie wel klopte.” (D3)

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24

Doctors discuss the use of social media

Doctors need to confirm patients

Doctors become too patient oriented

Doctors become too patient oriented Doctor becomes a mentor Doctor becomes a mentor Social media is focused on negative patient experiences Social media is focused on negative patient experiences

Patient cannot judge social media

information

Patient cannot judge social media

information

Social media create wild stories

Doctors have to deal with uncertain

patients

Doctors have to deal with uncertain

patients

Doctors have to ask about social media

Doctors have to deal with patients who are seeking for confirmation

Doctors have to deal with insecure patients

Doctors have to deal with patients who are more active

From a “hard” towards a more “soft” relationship

Doctors have to deal with more assertive

patients

questions

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25

Doctors have to deal with patients who are seeking for

confirmation

1. Doctors discuss the use of social media by patients with their patients

D1, D2, D3, D5, D7, D10, and D11

“If the patient searches on social media for medical information, I discuss this medical information with the patient. So, I interact with the patient about their use of social media.” (D1)25

2. Doctors need to confirm the self-developed diagnose by patients (based on social media)

D1, D3, D4, D5, D8, D9, D11, and D12

“Yes, the patient searched on social media and he told me his own diagnoses. Moreover, he asked me for confirmation.” (D3)26

3. Doctors become too patient oriented

D8 and D10 “The risk is that you turn too patient oriented. It is important to remain

alert. Thus, do not forget all the facts.” (D8)27

4. Doctors become a mentor

D8, D9, D10, D11, and D12

“We become more patient oriented (fit with the patient). Therefore,

nowadays, we are more the coach for patients.” (D8)28

Table 9: doctors have to deal with patients who are seeking for confirmation

Doctors have to deal with insecure patients

In contrast to patients who are seeking for confirmation, several doctors argued that the use of social media by patients has created insecure patients. The data provided six reasons “why” doctors have to deal with patients who are more insecure. Table 10 provides an overview of these six main reasons.

Firstly, four doctors argued that the medical information provided by social media is focused on negative patient experiences. Secondly, several doctors explained that patients cannot judge the correctness of the medical information provided by social media. Moreover, thirdly, if patients cannot judge the correctness of the social media based information wild stories between patients arise. For instance, when asked about “the use of social media by patients”, one doctor answered:

“Patients search on social media to obtain (medical) information. I observed that patients, who make use of social media, create strange stories and theories.” (D8)29

Fourthly, nine doctors said that, since patients use social media, they have to deal with uncertain patients. To illustrate, when asked about “changes in the role of the patient”, one doctor answered: “Social media platforms created more insecure patients. For example: if a patient find a spot on his/her skin, he/she thinks that is related to cancer. ” (D5)30

25_{“Zo van, ik heb dit al zelf uitgezocht en daar is natuurlijk op zich niets mis mee. Als je, uuh ja, een gesprek aangaat. Dus ik ga in gesprek met de patiënt.”(D1)} 26_{“Ja, hij had het inderdaad op social media opgezocht. Hij zei “ik heb dit en ik heb dat”. En dat wilde hij alleen maar even bevestigd hebben, of dit dat wel echt} had.” (D3)

27_{Het gevaar is dat je teveel meegaat met je patiënten. Dus, je moet altijd op je hoede blijven. En dat je geen andere dingen over het hoofd ziet. (D8)} 28_{“We zullen meer aansluiten bij de patiënt zelf. Dus, we zullen meer de coach voor de patiënten zijn.” (D8)}

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26 Furthermore, fifthly, the majority of doctors mentioned that patients do not inform them about their use of social media. Therefore, doctors have to ask patients about their (eventually) use of social media. Finally, to create a secure patient, doctors have conversations with their patients about their use of social media. For example, when asked about “changes in the role of the doctor”, one doctor answered:

“First, I ask, “why do you think this, what are the causes for this developed diagnose? And what are the symptoms?”. Thus, you need to give the patient time to explain their obtained medical information from social media.” (D11)31

Due to these six reasons, nowadays, doctors have to deal with patients that are more insecure. Therefore, doctors have to provide more “socio-emotional” tasks.

Doctors have to deal with insecure patients

1. Social media has a focus

on negative patient experiences

D4, D7, D10, and D11

“The patient has to be strong, because there is a lot of misery and

negative information at social media.”(D11)32

2. The patient cannot judge

the medical information derived from social media

D8, D9, D11, and D12

“I think that it is good that the patient can share their medical

experiences with other patients on social media. In addition, it is also good that patients can search on social media for medical information. However, the question is ‘how can the patient judge the reliability of the medical information derived from social media’. ” (D8)33

3. The social media use of

patients create wild stories

D3, D5, D7, D8, D9

“Patients search on social media to obtain (medical) information. I observe that patients, who make use of social media, create strange stories with theories.” (D8)34

4. Doctors have to deal

with an uncertain patient

D1, D3, D5, D7, D8, D9, D10, D11, and D12

“The use of social media lead to more insecure people. These insecure

patients visit the medical practice.” (D9)35

5. Doctors have to ask

their patients about their use of social media

D2, D3, D5, D7, D10, D11, and D12

“Most of the patients do not inform me about their use of social media. I

need to ask them about their use of social media for medical information.” (D3)36

6. Doctors discuss the use

of social media by patients with their patients

D1, D2, D3, D5, D7, D10, and D11

“First, I ask, “why do you think this, what are the causes for this developed diagnose? And what are the symptoms?”. Thus, you need to give the patient time to explain their obtained medical information from social media.” (D11)37

Table 10: doctors have to deal with insecure patients

30_{“Social media platformen zorgen voor onzekerheid bij patiënten. Kijk, als je bijvoorbeeld een vlekje op je huid hebt, binnen “noodtime” denken ze dat ze} kanker hebben.” (D5)

31_{“Dan vraag ik eerst “waarom denk je dat je dit hebt? En wat zijn de redenen dat je dat denkt? En wat zijn de symptomen?” Dus, je moet de patiënt de tijd} geven om social media informatie toe te lichten” (D11)

32_{“Je moet als patiënt wel sterk in je schoenen staan, want er staat natuurlijk behoorlijk wat narigheid en negativiteit op social media.” (D11)}

33_{Ik vind het goed dat mensen ervaringen kunnen delen en dat ze informatie kunnen ophalen door middel van social media, maar de vraag is telkens “hoe kan je} als patiënt of leek zien of iets betrouwbaar is ja of de nee?” (D8)

34_{“Patiënten zoeken en verzamelen informatie op social media. Maar ik merk zelf dat er soms hele aparte verhalen van komen en vreemde theorieën” (D8)} 35_{“Mensen zullen er vooral ongerust door social media en daardoor zullen ze juist naar mij toekomen” (D9)}

36_{“De meeste patiënten geven dit niet aan, nee. Dat moet je echt een beetje uit ze vissen” (D3)}

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27 Doctors have to deal with patients who are more active

Social media has created a new type of patient, the more involved and active patient. The data showed five reasons that explored “why” doctors have to deal with this new type of patient. Table 11 provides an overview of these five reasons.

Firstly, today, several doctors noticed that patients search on social media for medical information instead of asking their doctor. Consequently, almost all the doctors mentioned that patients have become more assertive. For example, when asked about “changes in the role of the patients”, one doctor answered:

“The positive effect of social media is that people read and study a lot about their particular disease. Therefore, the patient adopted a more active role during consults. They ask questions as “what do I have?” and “What can I do the resolve it?” This active role can help patients to get well soon. ” (D10)38

Secondly, two doctors explained that, since patients became more assertive, they receive different and new types of questions. These questions are more related to “socio-emotional” factors instead of the “technical” factors. For instance, when asked about “the changes in the role of the patient”, one doctor answered:

“I think that people, if they have more knowledge, ask more questions. However, I think that the content of their questions changed” (MP9)39

Thirdly, since a couple of years, doctors have to keep in mind the medical information derived from social media. Furthermore, fourthly, three of the twelve doctors mentioned that, since patients make use social media, they know more about their line of reasoning. Finally, these more active patients have affected the leading position of doctors. Hence, five doctors explained that they have become, based on the use of social media by patients, a “mentor” of their patients. To summarize, these five reasons showed that the role of the patients have become more active in the doctor-patient relationship.

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28

Doctors have to deal with patients who are more active

1. Doctors have to deal with a more assertive patients D2, D3, D5, D6, D7, D8, D9, D10, D11, and D12

“The positive effect of social media is that people read and study a lot

about their particular disease. Therefore, the patient adopted a more active role during consults. They ask questions as “what do I have?” and “What can I do the resolve it?” This active role can help patients to get well soon. ” (D10)40

2. Doctors have to deal with new types of questions from their patients

D9 and D10 “I think that people, if they have more knowledge, ask more questions.

However, I think that the content of their questions changed.” (D9)41

3. Doctors think about the use of social media by patients

D1, D2, D3, D5, D6, D7, D9, D10, D11 and D12

“If you see the general trend of social media use by patients, then I think you need to take the information derived from social media into account (during a consult).” (D10) 42

4. Doctors know their patients better

D7, D8, and D11

“You learn more about the line of reasoning of the patient. And you have more interaction with the patients.” (D11)43

5. Doctors have become a mentor

D8, D9, D10, D11, and D12

“Yes, I think that our role will change. Hence, doctors will get a role as advisor.”(D12)44

Table 11: doctors have to deal with patients who are more active

These three findings together showed that the amount of providing “socio-emotional” tasks has increased. Therefore, the doctor-patient relationship has become more “soft”.

(3) From a “leading” person towards a role as “coach”

As mentioned in the previous paragraph, doctors have to deal with patients that are more assertive. Consequently, this has diminished the “leading” role of doctors. The first level analysis investigated three reasons “how” the “leading” role of doctors has decreased (see figure 3). First, doctors have to deal with a more responsible patient. Second, doctors have to deal with a more persistent patient. Finally, doctors have to deal with patients who are more informed.

40_{“Het positieve effect van social media is dat mensen zich inlezen over hun ziekte. Ik vind dat ze daardoor actief bezig zijn. Ze stellen dan ook vragen als “wat} heb ik nou?” en “hoe kan ik ervoor zorgen dat ik er weer vanaf kom?”. Ik denk dat hun actieve rol daarin wel erg kan helpen om beter te worden.” (D10) 41_{“Ik denk dat als mensen meer weten, dat ze ook meer durven te vragen. Maar ik denk wel dat de inhoud van de vragen anders zullen worden.” (D9)} 42_{“Als je de algemene trend van het social media gebruik van de patiënten ziet. Dan denk ik wel dat we met deze informatie rekening moeten gaan houden} tijdens een spreekuur” (D10)

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29

Patients search for medical information

on social media

Patients search for medical information

on social media

patients

Doctors have to deal with an accountable

patient

Doctors have to deal with an accountable patient Doctor becomes a mentor Doctor becomes a mentor

patients

Doctors find it hard to reject strong

arguments

Doctors find it hard to reject strong

arguments

Balanced knowledge doctors and patients

Doctors have to deal with a more responsible patient

Doctors have to deal with a more persistent patient

Doctors have to deal with patients who are more informed

From a “leading” person towards a role as “coach”

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30 Doctors have to deal with a more responsible patient

Social media has created a patient who takes more responsibility for their health status. This means that, since they use social media, patients have become more active in obtaining medical information. The data reported five reasons that investigated “why” doctors have to deal with patients who are more responsible. Table 12 contains an overview of these five reasons.

To start, as already mentioned, patients search and share a lot of medical information on social media. This trend is seen as one of the driving factors that created responsible patients. Secondly, ten doctors mentioned that patients have become more assertive within the doctor-patient relationship. Due to this adopted role, doctors faced more patients who are responsible. To illustrate, when asked about “changes in the role of the patient”, one doctor answered:

“I am positive about the trend “the use of social media by patients”. It makes the patient more proactive within the relationship.” (D8)45

Thirdly, the majority of doctors explained that they have to think about the medical information provided by their patients. Fourthly, four doctors explained that they have to deal with patients who have become more accountable for their own health status. For instance, when asked about “the changes in the role of the patient”, one doctor answered:

“In these days, people can obtain medical information through an easy way. Thus, this supports the level of autonomy of people.” (D10)46

Finally, five doctors said that they have become a “mentor” for their patients instead of the “leading” figure. To summarize, these five reasons together showed that patients have become more responsible for their health status.

45 “Ik sta positief tegenover deze trend, dus het social media gebruik van patiënten. Dat maakt de patiënt ook pro-actiever.” (D8)

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31

Doctors have to deal with a more

responsible patient

1. Patients search for (and share) medical information on social media D1, D2, D5, D7, D8, D10, D11, and D12

“Patients who search on social media for medical information are more

informed. For instance, if patients found some characteristics about their particular disease, then they will compare these characteristics with themselves.” (D11)47

2. Doctors have to deal with more assertive patients D2, D3, D5, D6, D7, D8, D9, D10, D11, and D12

“I am positive about the trend” the use of social media by patients”. It

makes the patient more proactive within the relationship.” (D8)48

3. Doctors think about the use of social media by patients D1, D2, D3, D5, D6, D7, D9, D10, D11, and D12

“Some patients explain all the social media information to me (even the

Latin names). I am positive about that, because this information helps the interaction between me and my patients.” (D2)49

4. Doctors have to deal with patients who are more accountable

D1, D2, D4, and D10

“In these days, people can obtain medical information on an easy way. Thus, this supports the level of autonomy of people.” (D10)50

5. Doctors have become a mentor

D8, D9, D10, D11, and D12

“Since patients make use of social media, our role is more as a coach. Also known as guide.” (D12)51

Table 12: doctors have to deal with a more responsible patient

Doctors have to deal with a more persistent patient

Regarding the more assertive patients, several doctors explained that this trend has resulted in the fact that they have to deal with patients that are more persistent. To clarify, during consultations, doctors have to deal with patients who stay close to their social media based arguments. The data supported this particular finding in four ways. Table 13 provides an overview of these four reasons.

To start, nine doctors explained that, since the introduction of social media, they have to deal with patients who have a higher level of medical knowledge. Secondly, these persistent patients have high influence on their doctor. Consequently, doctors argued that they have to think about and take this medical information, obtained from the use of social media by patients, seriously into account. To illustrate, when asked about “changes in the role of patients”, one doctor answered:

“I always take the use of social media by patients into consideration. In this way, patients have, sometimes, strange ideas about their particular disease.” (D3)52

47_{“Mensen die information opzoeken via social media zijn vaak wat beter geïnformeerd. Bijvoorbeeld: sommige mensen zoeken op welke kenmerken er bij een} ziekte horen en vervolgens vergelijken ze deze mijn hun eigen ziekte.” (D11)

48 “Ik sta positief tegenover deze trend, dus het social media gebruik van patiënten. Dat maakt de patiënt ook pro-actiever.” (D8)

49_{“sommige patiënten vallen gelijk met de deur in huis en weten zelfs ook de Latijnse namen. Ik vind dit wel fijn, want dan kan je makkelijker met die patiënt} praten.” (D2)

50 “Ik denk dat mensen tegenwoordig op een toegankelijk wijze medische informatie kunnen vergaren. Dus, ik denk dat dit bijdraagt aan de autonomie van mensen.” (D10)

51_{“Door het gebruik van social media, denk ik dat onze rol meer richting coach gaat. Ook wel gids genoemd.” (D12)}

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32 Thirdly, five doctors mentioned that it have become hard to reject the social media-based arguments developed by patients. These are strong and, in some cases, well-supported medical arguments. For example, when asked about “perceived reactions towards social media”, one doctor answered:

“The use of social media by patients created, sometimes, strange situations. Hence, based on my feeling, I (constantly) need to contradict patient’s arguments. However, I do not want to contradict the person, but I want to contradict the complaint.” (D7)53

Finally, because of the more persistent patients, the role of doctors has changed from “leading” towards a role as a “mentor”. These four reasons together resulted in the fact that, since the introduction of social media, doctors have to deal with patients who are more persistent.

Doctors have to deal with a more persistent patient

D1, D2, D3, D4, D6, D7, D8, D9, and D10

“Yes, I think that patients are better informed today. Moreover, at some point of time, patients will become an expert. In addition, at a certain moment, the patient will (perhaps) have more knowledge than the doctor.” (D9)54

2. Doctors think about the use of social media by patients D1, D2, D3, D5, D6, D7, D9, D10, D11, and D12

“If patients are better informed, it becomes easier to negotiate with patients. I ask them about their medical information obtained from social media. Next to this, I ask the patients ‘what do you want?’” (D10)55

3. Doctors find it hard to reject the strong arguments of their patients

D2, D4, D7, D10, and D12

“The use of social media by patients created, sometimes, strange situations. Hence, based on my feeling, I (constantly) need to contradict patient’s arguments. However, I do not want to contradict the person, but I want to contradict the complaint.” (D7)56

4. Doctors become a mentor for their patients

D8, D9, D10, D11, and D12

“Due to the increasing use of social media of patients, I have become more a coach for my patients. Therefore, now, we are more on an equivalent level.” (D11)57

Table 13: doctors have to deal with a more persistent patient

Doctors have to deal with patients who are more informed

The use of social media by patients created active, but also well-informed patients. As a result, the dominant “leading” role adopted by doctors has decreased. The data presented reasons, which investigated “how” patients have become well informed. Table 14 provides an overview of these four reasons.

53 “Social media creëert soms rare situaties. Ik moet namelijk continu mijn patiënten tegenspreken en onderuithalen voor je gevoel, maar ik wil niet de persoon tegenspreken maar de klacht onderuithalen.” (D7)

54 “Ja, ik denk het ook. Uiteindelijk wel ja. Als je een bepaald probleem hebt, op een gegeven moment wordt je als patiënt ook een soort expert. Op een gegeven moment heb je er misschien wel meer verstand van als een dokter zelf.” (D9)

55 “Als patiënten beter geïnformeerd zijn, dan wordt het makkelijker om met ze te overleggen. Ik vraag dan ook naar social media informatie. Daarnaast vraag ik wat de patiënt zelf wilt.” (D10)

56 “Social media creëert soms rare situaties. Ik moet namelijk continu mijn patiënten tegenspreken en onderuithalen voor je gevoel, maar ik wil niet de persoon tegenspreken maar de klacht onderuithalen.” (D7)

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33 Firstly, almost all doctors explained that social media created assertive patients. Secondly, according to nine doctors, patients are well-informed, because they search on social media to obtain, provide, and share medical knowledge with other patients. To illustrate, when asked about “changes in the role of the patient”, one doctor answered:

“Today, before the consultation, people are doing a lot of preliminary work. They searched on social media for medical information.” (D5)58

With these two reasons in mind, the majority of doctors said that, patients have an increased level of knowledge. Thirdly, regarding this, doctors have to deal with informed patients, and therefore the “leading” role of doctors has diminished. Fourthly, eight doctors mentioned that the increase of medical knowledge of patients has developed a more balanced relationship between doctors and their patients. For example, when asked about “the information asymmetry”, one doctor answered:

“Patients become more equal in relation with the doctor. Yes, the relationship becomes more symmetric.” (D11)59

Doctors have to deal with patients who more informed

1. Doctors have to deal with more assertive patients D2, D3, D5, D6, D7, D8, D9, D10, D11, and D12

“The use of social media by patients is a good trend. This makes the

patient more proactive.” (D8)60

2. Patients search for (and share) medical information on social media D1, D2, D5, D7, D8, D9, D10, D11, and D12

“Today, before a consultation, people are doing a lot of preliminary

work. They searched on social media for medical information.” (D5)61

D1, D2, D3, D4, D6, D7, D8, D9, and D10

“The most important difference is that patients are better informed

compared to the old days.”(D4)62

4. Doctors and patients have a more balanced knowledge

D3, D4, D6, D8, D9, D10, D11, and D12

“Patients become more equal in relation with the doctor. Yes, the

relationship becomes more symmetric.” (D11)63

Table 14: doctors have to deal with patients who are more informed

58 “Tegenwoordig hebben mensen veel meer voorwerk gedaan voordat ze op een spreekuur komen. Dat doen ze nu vaker, zoeken op social media voor informatie.” (D5)

59 “Patiënten zullen wat gelijkwaardiger aan de dokter worden. Ja, het zal meer symmetrisch worden.” (D11) 60 “Ik vind het social media gebruik door patiënten een goede trend. Het maakt de patiënt ook pro-actiever.” (D8)

61 “Tegenwoordig hebben mensen veel meer voorwerk gedaan voordat ze op een spreekuur komen. Dat doen ze nu vaker, zoeken op social media voor informatie.” (D5)