Content-Type: text/html Bypassing the Middleman: The impact of Web use on public perceptions of physicians Bypassing the middleman: The impact of Web use on the public perception of physicians For submission to Mass Communication and Society Division of Association for Education in Journalism and Mass Communication National Convention, Aug. 7-10, 2002 in Miami Beach, FL A paper for the "Health Communication and Media" research panel Wilson Lowrey Assistant Professor Mississippi State University 200 McComas Hall, PO Box PF Mississippi State, MS 39762 (662) 325-7841 [log in to unmask] and William B. Anderson Assistant Professor Louisiana State University [log in to unmask] The Internet has been described as "disintermediative." This buzzword describes the phenomenon whereby Internet users bypass society's middlemen to acquire information or purchase products and services (Shapiro, 1999; Evans and Wurster, 1999). The term is usually used in an economic context, but, in a social context, removing the middleman may lead to a loss of valuable expertise (Shapiro, 1999). In some cases it may lead to diminished control over work by occupations and professions. Literature in the sociology of work suggests that when members of an occupation are no longer exclusively privy to the special knowledge and expertise that underlie an area of work, the occupation may lose control over the work to interlopers from beyond the occupation's boundaries. Control over clients may also diminish (Simpson, 1985; Abbott, 1988; Child and Fulk, 1982). According to this literature, the less inscrutable and arcane a profession's knowledge base is, the lower is its public legitimacy. This study assesses the case of the medical profession and the impact of Web use on the profession's public legitimacy. Occupations vary in the complexity of knowledge required to perform their work and in the level of legitimacy the public affords them. Medical work has high levels of both, and the consequences of disintermediation for society and for the occupation are greater. This study addresses questions such as: Does the increase in access to online health information have an impact on the way patients perceive physicians? Are today's physicians losing some of their authority when faced with clients who are empowered with online knowledge? This study proposes, and the data suggest, that use of online health information influences the patient-physician relationship. Findings should interest a medical community that is seeing its power base and public legitimacy challenged by corporate hospitals, insurance and drug companies, and politicians advocating healthcare reform. The study also should shed light on potential cracks in the important relationship between the medical profession and its clients. Although on the individual level an informed patient is likely to ask better questions of a physician, a visit to an Internet health site is arguably more communication poor than a doctor's visit because it is not tailored for individual needs and typically offers little interaction. A clientele that bypasses knowledge gained from clinical visits may undermine the medical profession and the expertise it offers. Such a trend would dovetail with efforts by healthcare and drug companies to encourage patients to make their own healthcare decisions (Pastore, 2001). Findings also have implications for theory about the role of the Internet in society. Some scholars are fearful of the effects of disintermediation on expertise in society, but others have viewed the Internet as a liberating source of empowerment for individuals in the face of professional dominance. Literature The changing patient- physician relationship Scholars of work and occupations stress the importance of the professional-client relationship in determining an occupation's degree of control over its area of work (Child and Fulk, 1982; Van Maanen and Barley, 1984; Simpson, 1985). Strong control is characterized as a relationship between dominant medical experts and a dependent, atomized clientele. A change in the physician-patient relationship could have an impact on the occupational status of those in the medical community. Over the past several decades, scholars have identified a number of factors that might have an impact on the patient-physician relationship. Reeder (1973) argues that an increasingly well-informed population treats the doctor-patient relationship as another provider-consumer affiliation rather than as a relationship requiring awe and deference. Haug and Lavin (1983) said that increasing complexity of medical care increases professional uncertainty about diagnosis and treatment, which undermines patient trust and confidence; yet, they recognize that concealing uncertainty can rebound adversely on a physician's credibility with patients. They also note that increasing specialization and interdependence of professionals weakens the stature of individual physicians as omniscient sources of medical services and information. The consumer, women's health, the holistic health movements, and the perception of physician indifference and greed have also changed the patient-physician relation ship dynamic (Hughes, 1994). These trends are often portrayed by sociologists as democratizing (Haug, 1976; Haug and Lavin, 1979, 1983) but are perceived by physicians with alarm (Hughes, 1994). Internet technology and deprofessionalization Occupations assert control over their work through both structural means (licensure, accredited schools, etc.) and through cultural means - e.g., legitimacy in the eyes of the public (Simpson, 1985; Abbott, 1988; Freidson, 1970, 1994). Occupations that maintain exclusivity over complex knowledge bases, as well as over the ability to access this knowledge, more successfully control their work because those beyond the occupation cannot easily "know" how to perform the work (Abbott, 1988). In addition, occupations whose work is perceived as indeterminate, mysterious and non-routine more successfully maintain legitimacy in the eyes of clients and therefore are more likely to maintain control over work (Nilson, 1979; Van Maanen and Barley, 1985; Abbott, 1988; Fine, 1996). Any contributor to increased transparency of a work process can weaken that occupation's control over work. The Internet is one such contributor (Shapiro, 1999; Kritzer, 1999). In a case study of 10 households in Great Britain, Hardey (1999) found that medical dominance was challenged by the exposure of medical information to "the public gaze" through the Internet: The basic design of the Internet . . . represents a challenge to previously hierarchical models of information giving. This shift in control _ may be seen as contributing to the decline in awe and trust in doctors. Hardey's study is theoretically grounded in Haug's "deprofessionalization thesis." Haug (1977) discusses the "computerization" of professional knowledge and the consequent accessibility of this knowledge to non-professionals. Haug speculates that greater public access to knowledge and the techniques of obtaining this knowledge may lead to a decline in public perception of legitimacy, which leads to a drop in professional status and an inability to control the work area. In the eyes of clients, physicians may become "just another commercial vendor." (p. 225) Annandale (1998) and Hardey (1999) argue that the availability of health-related information on the Internet may create a "revolt of the client." (Weiss and Lonnquist, 1994, p. 228) In the past, physicians were exclusive holders and arbiters of medical information, helping to maintain the elite status of the profession (Annandale, 1998). Access to health information on the Internet, however, may transfer more power to the patient (Slack, 1997) - empowering them to participate more in decisions regarding their health (Cullen, 1998; Hardey, 1999; Mechanic, 1999). Web use and reaction of medical community More and more individuals are using the Internet to obtain health information. Pastore (2001) says that 36.7 million persons in the United States searched for health information in May 2000, with this number growing to 88.5 million by 2005. In his national study, more than half of the respondents with Internet access reported seeking health information on the Internet. A separate national study by the Kaiser Family Foundation found that 75% of young adults surveyed searched for health information online, which is more than those who played games online (72%), downloaded music (72%), chatted (67%), shopped (50%) or checked sports scores (46%). The majority (55%) of those who have surfed the Web for health information do so just a few times a year, but 39% do so at least once a month ("Young Adults," 2001). Many consumers of health information see the information on the Internet as reliable (Robinson, Flowers, Alperson and Norris, 1999) and are using it in discussions with their physicians. More than 90% of physicians and nurses in one case study of a single hospital reported that patients had brought information from the Internet to them (Jadad, Sigouin, Cocking, et. al., 2001). Some evidence exists that online information is having some impact on the physician-patient relationship. In one national survey, just under half of those who reported using the Web for health information said online health material affected their decisions about health care. And among these, roughly half said online information led them to ask doctors further questions, and 28% said the information influenced their decision about whether to visit a doctor (Fox and Rainie, 2000). At least one recent study found positive correlations between frequency of Internet use and the degree to which patients questio n doctors and suggest their own diagnoses (Pastore, 2001). Physicians respond by raising concerns about the validity, quality, and consistency of medical information on the Internet (Kassirer, 1995; Jadad and Gagliardi, 1998). Physicians also worry that patients lack the required skill and knowledge to separate accurate information from inaccurate information found on the Internet. Berland, Elliott, Morales, et. al. (2001) and Kalichman, Benotsch, Weinhardt, et. al. (2001) found that online health information is frequently geared toward well-educated users. Another physician concern is the quantity of medical information found on the Internet (Jadad and Gagliardi, 1998). In 2000, the number of health related Web sites totaled close to 20,000 (Pastore, 2001). Coelho (1998) noted, "[A]s more information is placed on the Internet, the probability of a patient finding relevant and accurate information decreases." (p. 1454) Still, Coelho (1998) noted, "Whether we like it or not, our patients are turning to electronic resources as their primary source of medical information. This trend _ is decreasing our role in decision making." (p. 1454) Fox and Rainie (2000) agreed, noting that patients who are turning toward the Internet for information are demanding participation in "shared decision-making." Physicians, who in the past tended to have the ability to make autonomous decisions, now and in the future may have to engage in decision-making through consensus building ("Tomorrow's doctor," 1995). Concepts and hypotheses A handful of studies provide numbers on use of health Web sites and percentages of users whose healthcare decisions are influenced by online information. But, there has been little empirical research exploring the importance of Web use to perceptions of the medical profession or examining this relationship in a socially relevant theoretical framework. The expectations and questions of the present study are grounded in concepts from the sociology of occupations and work, especially Abbott's theory of the system of professions. Abbott (1988) posits that occupations exist in an interrelated system and compete with one another for control over areas of work. The degree to which an occupation's knowledge base is complex, or is perceived as complex, is an important predictor of the degree to which it can exercise control over a work area. Professionals attempt to control their complex knowledge base and the right to draw on it to make diagnoses and inferences for clients. When clients have access to this knowledge base, control is threatened. Haug's (1977) deprofessionalization thesis is also relevant here. According to this thesis, the computerization of occupational knowledge leads to greater public access of this knowledge and is therefore likely to lower the level of public legitimacy afforded the occupation and threaten the degree to which the occupation may control its work. Medical Web sites are not the only media source for medical knowledge, but it is arguably the most extensive and easiest to access. The Internet also offers a means by which clients may provide one another with information (through chat rooms, etc.). Greater use of the Web should lead to greater expertise in obtaining medical knowledge. This in turn should lead to a clientele that is less atomized, and feels less powerless and less dependent on knowledge gained from direct interaction with physicians. It is suggested in this study that the greater the use of Internet health information, the lower the level of legitimacy clients afford doctor s. H: The higher the degree of Web use by medical clients, the lower the degree of legitimacy that clients perceive doctors to have. Degree of use is conceptualized as time spent and variety of functions used - for example, chat rooms, forums, Web sites and personalized browsers. Degree of legitimacy is defined as the degree to which clients perceive doctors as being exclusive experts of medical decision-making. In Abbott's systems framework, the less occupations exclusively make decisions about diagnoses, the less the occupation is able to control the work area. This has special implications for the medical profession, which is seeing its authority increasingly challenged by drug companies, hospital bureaucracy, alternative healthcare, and insurance companies. Other literature has suggested alternative predictors for how clients perceive physicians. Studies on client perception of medical care (most often focused on "patient satisfaction") tend to focus on demographic characteristics such as education, income, family size (Aharoney and Strasser, 1993; Fox and Storms, 1981; Ware, Davies-Avery and Stewart, 1978) and health status (Rubin, 1989). Age and gender have proven to be particularly consistent predictors, with older respondents and women generally having significantly more positive perceptions of doctors (Laveist, Nickerson and Bowie, 2000; Aharoney and Strasser, 1993; Pascoe, 1983). Therefore, the hypothesis will be tested while controlling for the following rival predictors such as age, gender, income, education, family size, health status and perception of alternative medicine. A few studies have looked at predictors for use of online health information. The present study - while not its main purpose - will seek to contribute to the sparse literature in this area. The study provides descriptive information about use of the Web for medical information and a brief correlation analysis of factors that influence variability in the use of the Web for health information. Studies of Internet use suggest that age, income, education level and patterns of overall media use are significant factors affecting Web use (Gardner and Oswald, 2001; Johnson and Kaye, 2000; "Study of the social consequences," 2000; "The Internet news audience," 1999). RQ.: What are the significant demographic predictors for degree of use of the Web for health information? Method Data used in addressing the study's topic were obtained from a December 2001 telephone survey of a random sample of households with telephones in the Baton Rouge, La. metropolitan area. The metro area was defined as the population of the four major parishes (the name for counties in Louisiana) in Baton Rouge. Because of the exploratory nature of the study, it was deemed best not to conduct a national survey. The decision was made to sample a city because the boundaries of communities are less arbitrary than regions and states. Baton Rouge was selected because its occupational and economic mix was typical of the nation and promised sufficient variability in questions about Internet use. The median income in the United States is $36,169.94; in Baton Rouge, it is $30,297. The median age in the United States is 36 years; in Baton Rouge, it is 30.96 years. The percentage of the U.S. population who attended at least some college is 20.37%; the number is somewhat higher in Baton Rouge - 31.07%.[1] It was also thought that surveying the area local to the researcher's university would improve response rate. The survey was pre-tested on 37 university students and eight older non-students. Some questions were adjusted as a result of pretests. Interviews took respondents of the final interview approximately 10 to 12 minutes to complete. Of the eligible respondents contacted, 406 completed the interviews and the response rate was 95.7%. The sampling error for the data set is no larger than ñ 4.9%. Respondents were asked four questions designed to measure the dependent variable, Perception of Medical Legitimacy. On a five-point scale (5 = "Strongly Agree," 4 = "Agree," 3 = "Neutral," 2 = "Disagree," 1 = "Strongly Disagree"), respondents were asked if in the event of a medical problem it was better to research the problem on their own before talking to a physician (mean = 2.77, s.d. = 1.21). Using the same scale, respondents were asked: "In the event of a medical problem I think it is possible to gather enough information on my own to determine the cause of my problem" (mean = 2.76, s.d. = 1.18) and "With so many places to get health information, I feel I have less need to consult doctors for medical problems" (mean = 2.52, s.d. = 1.17). Respondents also were asked to use a five-point scale (ranging from 5 = "Not Difficult" to 1 = "Extremely Difficult") to rate how difficult they think it would be for them to master knowledge necessary to become a physician (mean = 1.59, s.d . = 1.10). These measures were tested for interreliabililty and had an alpha coefficient of .68. The four measures were summed into a single scaled variable, so that higher scores indicate a greater willingness to bypass or challenge the expertise of doctors. Research questions were assessed by using the scaled variable as well as by using the measures independently. The independent variable Degree of Web Use was measured through three survey question measures. Questions assessed frequency of use for health information. This measure was coded on a scale of 1 to 6, (6 = "4 to 7 days a week," 5 = "1 to 3 days a week," 4 = "at least once a month," 3 = "less often," 2 = "never use Web for health information" and 1 = "never use Web at all"). The mean for this measure was 2.66, and the standard deviation was 1.61. Using the same survey measure, respondents were asked how often they used interpersonal Web functions such as chat rooms, bulletin boards, listservs, and e-mail for health information. Because there were few respondents in the top three categories, these were combined, resulting in a 4-point scale (mean = 1.83, s.d. = .83). Respondents were also asked if they had ever personalized their Web browser page to include health information or links to health information. This measure was coded so that 1= "Never use the Web," 2 = "Use the Web but don't personalize browser," 3 = "Personalize browser but not with health information," and 4 = Personalize browser and include health information" (mean = 1.92, s.d. = .93). These three measures had an alpha of .82, and these measures were standardized and summed to create a single measure of Degree of Web Use. Basic demographic data were also collected to serve as controls in the statistical analysis, including respondent's age, gender, race, employment, education, marital and family status, health status and income. Respondents were also asked if they had ever worked or studied in a health-related field, and they were questioned about their perceptions of non-traditional health practices. Results Almost 65% of respondents said they made some use of the Internet, with 43% saying they used the Internet at least four days a week. Among respondents who said they used the Internet, more than three-quarters said they had visited Web sites to get health information, and 58% said they visited these sites at least once a month. Use of interactive forums such as chat rooms to get health information was less frequent, with a little more than 20% of Internet users saying they had done so and a little more than 11% saying they use these features at least once a month. More than 30% of Internet users said they had personalized their browsers, and among these, half said they had included health information or links to health information on the opening page of their browser. A bivariate correlation was conducted to answer the research question - what are the significant predictors of Web use for medical information? Consistent with findings from previous studies, age and education level correlated strongly with Web use, with correlations of -.393 and .312 respectively (Table 1). Other significant predictors were also consistent with previous studies, including level of employment (.240), income (.183), and overall media use (.173). Two other predictors were tested that did not derive from the Web use literature. Among these, children in the household was a significant predictor of Web use for medical information (.148), but surprisingly, health status (chronic illness in the household) was not a significant predictor. It appears then that those who use the Web for medical information tend to be younger, better educated, employed, more affluent, and heavier media users. They also tend to be parents. Next, correlations were conducted to examine bivariate relationships between Degree of Web Use and the individual measures of the dependent variable, Perception of Medical Legitimacy (Table 2). Degree of Web use correlates significantly (.165) with the scaled dependent variable. It also correlates significantly with the individual measures "Better to gather information before calling a doctor" (.179) and "Can diagnose own illness" (.140). There is no significant correlation between Web use and the two measures, "Don't need doctors," and "Not difficult to become a doctor." These findings lend some preliminary support to the hypothesis. A regression analysis was then conducted in which Perception of Medical Legitimacy was the dependent variable. Predictors were tested for multicollinearity (the highest correlation was .432) and were then entered in two blocks. The first block consisted of the traditional demographic predictors suggested by the literature: age, gender, education, income, employment level, family status (children in household), occupational affinity (have worked or studied in medical field), health status (chronic illness in household), and perception of alternative medicine. Degree of Web Use was added in a second block to test if it significantly improved the model (Table 3). The r-square of the first model is significant at .114. The dominant predictor is age, followed by perception of alternative medicine and income level. When Degree of Web Use is added in the second block, the r-square of the model improves significantly (at the .05 level) to .128. Degree of Web Use tests as a significant predictor at the .05 level with a beta of .132. This is further support for the hypothesis. Even when controlling for the traditional rival predictors, Degree of Web Use accounts for a significant amount of the variance in the degree of legitimacy afforded doctors by clients. The strongest predictor in the final model is age, with a beta of -.224. Income level is also significant with beta of .144. It appears younger and wealthier clients are more likely to challenge doctors and rely on their own devices for medical information. The only other significant predictor was perception of alternative medicine. Not surprisingly, those who said alternative health practices were helpful were more willing to bypass the traditional expertise of doctors. It should be noted that the r-square of the final model only explains about 13% of the total variance in the dependent variable. This suggests there are other important explanations for variability in the perceptions of doctors' legitimacy. Discussion While not generalizable to the national population, this study indicates substantial use of the Web for health information purposes. Approximately half of the total sample in this study had visited health Web sites, and almost a fifth of the sample said they personalized their browser to include health links or health information. Fewer used chat rooms for health information, but that echoes the trend on chat room use in general. The use of online health information in this sample mirrors results in previous studies; these studies suggest that the amount of Web use for medical information is likely to continue to increase (O'Connor and Johanson, 2000; Pastore, 2001). The disintermediative characteristic of the Internet appears to have had an influence on how Web users perceive the medical community. The data suggest heavy Web users are less likely to see physicians as exclusive holders of health information. Findings lend support to propositions by Abbott (1988) and Haug (1977) that media use may challenge the public legitimacy of professions. Much attention has been paid to social institutions, such as the insurance industry, drug companies and alternative health fields, posing threats to the medical profession. It appears that an increasingly interactive, encyclopedic and accessible mass media may also pose a challenge. The technology of the Internet makes it easy for users to gather a wide variety of health information quickly, which challenges the ability of professionals to control their knowledge base, as well as their special right to derive diagnoses from it. This is not to suggest physicians should attempt to control, or even limit, access to the Internet. Rather, the medical community, especially its professional associations, should provide and market its own online health content as a superior alternative to questionable information found on the Internet. Also, physicians should acknowledge the trend toward increased online research by patients and work with the client to ensure understanding of medical information, derived from the Internet or elsewhere. Findings add weight to the proposition by some scholars that the Internet has a democratizing effect on society, its institutions and individuals (Schultz, 1999; Bolter, 1991). Whereas access to professional knowledge through the Internet presents a challenge to the medical profession, it empowers clients. The modern medical profession has been criticized by some scholars of the professions for focusing more on its own power than on public health (Friedson, 1994; Larson, 1977). If Internet access and information levels the field, medical care may improve. The present study suggests media use is a potentially important predictor for medical researchers studying client satisfaction. Yet the present study's model explains only about 13% of the total variance in the dependent variable. This indicates more research is needed to examine other possible explanations for variability in the perceptions of doctors' legitimacy. Future studies might explore the impact the media have on the larger system of professions in which the medical field is situated. A national study that compares how Web users view physicians, insurance companies, drug companies and hospital administrators could be insightful. Yet, studies on media impact should not be limited to the Internet. Researchers should also examine how the media image of the medical community affects public satisfaction with services. For example, do motion picture and television show portrayals of physicians create unrealistic expectations of their services? How does print coverage of the medical field affect the profession? Some empirical research has been done in this area (e.g., Pfau and Mullen, 1995), but given recent social and professional changes, follow-up research would be helpful. References ù Abbott, A. (1988). 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Retrieved March 6, 2002 from http://cyberatlas.internet.com/big_picture/demographics/article/0,,5901_937711,00.html Table 1: Bivariate correlations between Degree of Web Use for health information and traditional predictors of Web use Predictors Degree of Web Use (N=406) Age -.393** Educational level (From 1 = "No school" to 8 = "Doctorate") .312** Employment (1 = "Full", 2 = "Part", 3 = "Unemployed") .240** Income level (From 1 = "Less than $25,000" to 5 = "Over $100,000") ..183** Media use (hours/per week of use) .173** Have children in household .148** Gender (1 = "male," 2 = "female") -.085 Have chronic illness (respondent or family member, 1 = "No", 2 = "Yes") .029 **Significant at the .01 level Entries are Pearson Product Moment Correlation Coefficients Table 2: Bivariate correlations between Degree of Web Use for health information (as a predictor) and measures of Perception of Medical Legitimacy (dependent variables) Dependent measures Degree of Web Use (predictor) (N=406) Perception of Medical Legitimacy (scaled variable, higher score means less legitimacy afforded doctors) .165** Better to get information before calling doctor. (1 = "Strongly Disagree"; 5 = "Strongly Agree) .179** Possible to gather enough information to diagnose one's self. (1 = "Strongly Disagree"; 5 = "Strongly Agree) .140** Don't need doctors as much with so many other ways to get medical information. (1 = "Strongly Disagree"; 5 = "Strongly Agree) .079 How difficult to master knowledge necessary to become a doctor. (1 = "Extremely difficult"; 5 = "Not difficult at all," ) .032 **Significant at the .01 level Entries are Pearson Product Moment Correlation Coefficients Table 3: Perception of Medical Legitimacy Regressed on Degree of Web Use and traditional predictors of perceptions of doctors Model 1: Without Degree of Web use (N = 406) Model 2: With Degree of Web Use (N = 406) R Square = .114** R Square = .128** F Change = 3.656* Age -.266** -.224** Alternative Health practices (1 = "Not at all Helpful"; 3 = "Very Helpful") .161** .158** Income level (1 = "Less than $25,000"; 5 = "More than $100,000") .159** .144* Employment (1 = "Full", 2 = "Part", 3 = "Unemployed") .041 .027 Educational level (From 1 = "No school" to 8 = "Doctorate") -.048 -.071 Gender (1 = "male," 2 = "female") .088 .082 Have children living with you? (1 = "No"; 2 = "Yes"} -.096 -.090 Have chronic illness (respondent or family member, 1 = "No", 2 = "Yes") .025 .010 Ever studied or worked in medical field? (1 = "No"; 2 = "Yes") -.026 -.017 Degree of Web Use .132* **Significant at the .01 level *Significant at the .05 level [1] Figures taken from Yahoo! Real Estate at http://list.realestate.yahoo.com/re/neighborhood/search.html?sa=&c=baton+rouge&s=LA&z=)