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Doctors’ interactions with and attitudes toward e-patients have an overall impact on health care delivery.
This study aimed to gauge surgeons’ interactions with e-patients, their attitudes toward those e-patient activities, the possible impact on the delivery of health care, and the reasons behind those activities and attitudes.
We created a paper-based and electronic survey form based on pertinent variables identified in the literature, and from March 2018 to July 2018 we surveyed 49 surgeons in Germany and 59 surgeons in Oman, asking them about their interactions with and attitudes toward e-patients. Data were stored in Microsoft Excel and SPSS, and descriptive statistics, Pearson correlations, and chi-square tests were performed on the data.
Of our sample, 71% (35/49) of the German surgeons and 56% (33/59) of the Omani surgeons communicated electronically with their patients. Although the German surgeons spent a greater percentage of Internet usage time on work-related activities (χ218=32.5;
The interactions show a high degree of engagement with e-patients. The differences between the German and the Omani surgeons in the preferred methods of communication are possibly closely linked to cultural differences and recent historical events. These differences may, moreover, indicate e-patients’ desired method of electronic communication to include social media. The low impact of surgeons’ attitudes on the activities may also result from a normalization of many e-patient activities, irrespective of the doctors’ attitudes and influences.
The overall impact of the engaged and better-informed patient on the patient-doctor relationship can be positive or negative [
This is not the place to give a more detailed account of e-patient activities; nevertheless, it is useful to note that typical activities involve searching for medical and health-related information on the internet, joining Web-based patient discussion groups, communicating electronically with their physicians, accessing their electronic medical records, accessing their laboratory results, using personal health records, researching their physician’s electronic footprint, and other electronically based health-related activities [
The term
Similar to the impact of the engaged patient before the advent of the internet, the e-patient’s activities’ impact on the patient-doctor relationship can vary, with some doctors reporting a worsening relationship and others reporting a strengthening of the relationship and improved health care [
In general, a more engaged patient can result in better health outcomes and lower costs [
There is strong evidence that doctors’ attitudes toward patients’ use of the internet, especially if they recommend sites to their patients, directly influence those patients’ usage; the quality of material found; and, by extension, the patient-doctor relationship [
In Germany and Oman, approximately 96% and 80% of the population has access to the internet, respectively [
There are currently no similar figures for e-patients in Oman. That said, the internet usage adoption rate in Oman, although behind Germany, has followed the trend of increasing usage seen in Germany and other countries [
This study focuses on surgeons’ attitudes toward e-patients in Germany and Oman. The aim of this study was to gauge surgeons’ interactions with e-patients, their attitudes toward those e-patient activities, the possible impact on the delivery of health care, and the reasons behind those activities and attitudes. This knowledge would give us some idea of the impact of e-patient activity on the patient-surgeon relationship in these 2 countries.
As part of the study was a comparison between the 2 countries, the first independent variable was the country in which the surgeon resided. Our selection of further independent variables to be studied was guided by the literature that had indicated possible predictors of attitudes toward e-patients. These included the doctors’ age and gender, amount of internet usage, and work-related time on the internet and the assumption that patients with chronic conditions who have access to the internet are more likely to be engaged in self-care and communicate electronically with doctors [
In addition, as there would be variations in usage and we wished to know if these variations might have an impact on attitudes, we asked questions about the specific internet sites that doctors visited.
The dependent variables were guided by the knowledge and activities described as typical e-patient activities, as listed above, also derived from the literature on the e-patient [
The description of the questionnaire design and delivery follows the Checklist for Reporting Results of Internet E-Surveys checklist (see
In Germany, the questionnaire was delivered to all surgeons from the General, Transplant, Visceral, Heart, and Orthopedic and Trauma Surgery Departments from the University Hospital, Tübingen, and the affiliated
In Oman, the questionnaire was delivered to surgeons in the Department of Surgery at Sultan Qaboos University Hospital (including those surgeons affiliated to the department from the Oman Medical Association). The questionnaire was on paper and in an electronic format, using SurveyMonkey (SVMK Inc, San Mateo, CA). As all doctors in Oman need to be fluent in English, the questionnaire was delivered in English. Ethics approval was obtained from the Sultan Qaboos University College of Medicine Research Ethics Committee (MREC#1628).
In all cases, the information sheet and consent form contained the title and a brief description of the research project, names and contact details of the researchers, a brief statement about risks to the participants, confidentiality, storage of information (256-bit encryption), the voluntary nature of the participation, and permission to retain (or obtain) a copy of the informed consent form. All surgeons signed the informed consent form or checked an appropriate box on the electronic form. After the collection of the paper forms, the signed consent form was separated from the questionnaire and stored in a separate location.
For the core of the questionnaire design, we elected to use the relevant part of the survey form designed by Moick and Terlutter [
In addition to the questions from Moick and Terlutter, other literature [
The surgeons were contacted through internal electronic mailing lists and WhatsApp groups and directed to the Web-based forms through URLs. Where surgeons preferred the paper form, these were delivered to them. No incentives were offered to the surgeons for the completion of the form. The data collection was performed from March 2018 to July 2018.
To maintain confidentiality and on the grounds that these are extremely easy to circumvent, no checks or preventative measures through cookies or internet protocol address identification were taken.
All questionnaires were analyzed. Data were stored in Microsoft Excel 2016 and SPSS (version 25). Means, standard deviations, and frequencies were calculated. The data were normally distributed. Owing to this, Pearson correlations were run to examine correlations between the appropriate variables described above. To test for the differences between the German and Omani surgeons, chi-square tests and
A total of 38% (49/128) German surgeons and 71% (59/83) Omani surgeons completed the survey. Of all the surgeons, only 6 Omani surgeons completed the survey on paper, so the number was too small to run any comparative statistical tests. In addition, the tables below show summary data only.
We established the surgeons’ age; gender; and whether the majority of their patients suffered from chronic, acute, or roughly the same types of condition.
Surgeons’ age, gender, and majority of patients, by country.
Category | Germany (n=49) | Oman (n=59) | Overall (n=108) | Statistics | ||||||
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Chi-square value ( |
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4.43 (104) | N/Aa | .001 | |||||||
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Mean (SD) | 36.27 (8.83) | 44.19 (9.59) | 40.56 (10.07) |
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Range | 26-62 | 25-61 | 25-62 |
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N/A | 2.2 (2) | .33 | |||||||
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Female | 17 (34.7) | 13 (22.0) | 30 (27.8) |
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Male | 31 (63.3) | 45 (76.3) | 76 (70.4) |
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Unknown gender | 1 (2.0) | 1 (1.7) | 2 (1.9) |
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N/A | 10.5 (2) | .01 | |||||||
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Chronic | 5 (10.2) | 22 (37.3) | 27 (25.0) |
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Acute | 10 (20.4) | 8 (13.6) | 18 (16.7) |
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Both | 34 (69.4) | 29 (49.2) | 63 (58.3) |
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aNot applicable.
For most of the practices and attitudes given below, the figures will be viewed in light of the figures in
We measured the surgeon’s internet usage, both broadly and more specifically, their knowledge and usage of sites and apps. When regarding the hours per day spent on the internet, there was no significant effect for origin (
The German surgeons had a higher percentage of time (mean 60.04, SD 17.95) devoted to work-related activities (
Delving further into work-related activities, we asked which sites and apps the surgeons knew about and used at least once per month. This would help to complete an overall picture of the surgeons’ general familiarity with medically related websites and apps. (As can be seen from the questionnaire in
Although there is similar knowledge of general references, databases, and journals, a significantly higher proportion of the German surgeons have knowledge about books, videos, networking sites, official sites, and magazines (
Interestingly, however, when looking at the
When viewing surgeon’s knowledge of apps, again we see differences, with the German surgeons usually having greater knowledge than the Omani surgeons. A notable exception is Continuing Professional Development (CPD) apps (
With app usage, most of the differences (including CPD) are removed, except for tools apps (
Hours spent per day on the internet.
Country | Hours | ||||||
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0 | 1-2 | 3-4 | 5-6 | 7-8 | 9-10 | >10 |
Germany, n (%) | 0 (0) | 21 (42.9) | 15 (30.6) | 5 (10.2) | 3 (6.1) | 2 (4.1) | 3 (6.1) |
Oman, n (%) | 0 (0) | 23 (39.0) | 24 (40.7) | 9 (15.3) | 2 (3.4) | 1 (1.7) | 0 (0) |
Overall, n (%) | 0 (0) | 44 (40.7) | 39 (36.1) | 14 (13.0) | 5 (4.6) | 3 (2.8) | 3 (2.8) |
Surgeons’ knowledge of sites, by country.
Site | Germany (n=49), n (%) | Oman (n=59), n (%) | Total (N=108), n (%) | Statistics | |
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Chi-square value ( |
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Books | 46 (93.9) | 42 (71.2) | 88 (81.5) | 8.4 (1) | .004 |
Videos | 36 (73.5) | 27 (45.8) | 63 (58.3) | 8.0 (1) | .005 |
General references | 41 (83.7) | 48 (81.4) | 89 (82.4) | 0.0 (1) | .90 |
Networking sites | 22 (44.9) | 10 (16.9) | 32 (29.6) | 9.7 (1) | .002 |
Official/institutional | 32 (65.3) | 24 (40.7) | 56 (51.9) | 6.1 (1) | .01 |
Databases | 49 (100.0) | 55 (93.2) | 104 (96.3) | 2.6 (1) | .11 |
Journals | 44 (89.8) | 50 (84.7) | 94 (87.0) | 0.3 (1) | .57 |
Magazines | 36 (73.5) | 11 (18.6) | 47 (43.5) | 32.0 (1) | .001 |
Surgeons’ use of sites at least once per month, by country.
Site | Germany (n=49), n (%) | Oman (n=59), n (%) | Total (N=108), n (%) | Statistics | |
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Chi-square value ( |
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Books | 33 (67.3) | 29 (49.2) | 62 (57.4) | 2.9 (1) | .09 |
Videos | 24 (49.0) | 17 (28.8) | 41 (38.0) | 4.1 (1) | .04 |
General references | 31 (63.3) | 39 (66.1) | 70 (64.8) | 0.3 (1) | .58 |
Networking sites | 9 (18.4) | 4 (6.8) | 13 (12.0) | 3.2 (1) | .08 |
Official/institutional | 10 (20.4) | 15 (25.4) | 25 (23.1) | 0.5 (1) | .48 |
Databases | 48 (98.0) | 42 (71.2) | 90 (83.3) | 12.1 (1) | .001 |
Journals | 31 (63.3) | 36 (61.0) | 67 (62.0) | 0.0 (1) | .99 |
Magazines | 9 (18.4) | 7 (11.9) | 16 (14.8) | 0.7 (1) | .40 |
Surgeons’ knowledge of these apps, by country.
App Types | Germany (n=49), n (%) | Oman (n=59), n (%) | Total (N=108), n (%) | Statistics | |
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Chi-square value ( |
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Monitoring | 25 (51.0) | 14 (23.7) | 39 (36.1) | 8.3 (1) | .004 |
Information | 34 (69.4) | 35 (59.3) | 69 (63.9) | 1.0 (1) | .33 |
Continuing Professional Development | 20 (40.8) | 36 (61.0) | 56 (51.9) | 4.8 (1) | .03 |
Tools | 34 (69.4) | 22 (37.3) | 56 (51.9) | 10.5 (1) | <.001 |
Videos | 27 (55.1) | 32 (54.2) | 59 (54.6) | 0.00 (1) | .99 |
Surgeons’ use of these apps at least once per month, by country.
App Types | Germany (n=49), n (%) | Oman (n=59), n (%) | Total (N=108), n (%) | Statistics | |
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Chi-square value ( |
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Monitoring | 8 (16.3) | 5 (8.5) | 13 (12.0) | 1.5 (1) | .22 |
Information | 27 (55.1) | 26 (44.1) | 53 (49.1) | 1.1 (1) | .29 |
Continuing Professional Development | 13 (26.5) | 24 (40.7) | 37 (34.3) | 2.6 (1) | .12 |
Tools | 23 (46.9) | 15 (25.4) | 38 (35.2) | 5.2 (1) | .02 |
Videos | 16 (32.7) | 29 (49.2) | 45 (41.7) | 3.3 (1) | .07 |
We wanted to know if the surgeons engaged in the types of communication with e-patients that the literature had identified, their experience with e-patients, and their attitudes toward some of the implications of e-patient activities. The last set of questions would also allow a comparison with the data from the study by Moick and Terlutter [
We began our investigation of the surgeons’ interactions and attitudes toward the e-patient by examining whether or not the surgeons were aware of the terminology. Of these surgeons, fewer German (23/49, 46%) than Omani (34/59, 57%) surgeons had heard of the term
Of these surgeons, 71% (35/49) German and 55% (33/59) Omani surgeons communicated electronically with patients (χ21=2.8;
Given that electronic communication can take various forms, we wanted to see if there were differences in the methods of electronic communication between the 2 countries.
The figures for email communication, WhatsApp, and Twitter are significantly different, with the German doctors preferring email, and the Omani surgeons use both email and WhatsApp equally, and some Omani surgeons use Twitter. We should also note that there are several
In addition to knowing how many surgeons communicate electronically with their patients, we wanted to know what percentage of their patients use email to communicate with them.
The results indicate that the German surgeons communicated with a larger percentage of their patients via email than the Omani surgeons (χ29=25.1;
Similarly, we wished to find out what percentage of their patients communicate with the surgeons via social media. The Omani surgeons communicated with a far greater amount of their patients via social media than the German surgeons (χ211=48.6;
An important aspect of the e-patient is the patient who brings material from the internet to the doctor. Of the surgeons, 89% (44/49) German and 84% (50/59) Omani surgeons indicated that patients bring information from the internet to the consultation (χ212=18.9;
Correspondingly, we wished to know how frequently surgeons recommend websites or apps to their patients. Of the surgeons, 40% (20/49) German and 49% (29/59) Omani surgeons recommended a website or app to their patients at least once per month (χ21=3.5;
For the German surgeons, the number of website recommendations was strongly associated with the amount of internet usage (Pearson
Interestingly, the impact of these recommendations on the patients appeared minimal, as there was no association between the number of recommendations and the frequency that patients are bringing information from the internet to the consultation (
Of the specific websites or apps recommended by the German surgeons, 19 sites were mentioned, but no site was recommended more than once. From the Omani surgeons, 13 sites were mentioned. The 3 most recommended sites were Google (11), Medscape, and YouTube (3 each). All other sites were recommended only once. (Of interest, the top 3 Omani sites [Google, Medscape, and YouTube] were not recommended at all by the German surgeons.)
Surgeons’ methods of electronic communication with patients, by country.
Method | Germany (n=35), n (%) | Oman (n=33), n (%) | Total (N=68), n (%) | Statistics | ||
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Chi-square value ( |
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32 (91.4) | 21 (63.6) | 53 (77.9) | 9.0 (1) | .003 | ||
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1 (2.9) | 21 (63.6) | 22 (32.4) | 18.6 (1) | <.001 | |
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0 (0.0) | 7 (21.2) | 7 (10.3) | 6.3 (1) | .008 | |
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1 (2.9) | 5 (15.2) | 6 (8.8) | 2.2 (1) | .10 | |
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0 (0.0) | 2 (6.1) | 2 (2.9) | 1.7 (1) | .19 | |
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Messenger | 0 (0.0) | 2 (6.1) | 2 (2.9) | 1.7 (1) | .19 |
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Other | 1 (2.9) | 0 (0.0) | 1 (1.5) | 1.5 (1) | .32 |
In addition to surgeons’ behaviors, we wanted to know about their attitudes toward e-patient behaviors, particularly regarding the patient-doctor relationship.
The surgeons from both the countries felt more positive than negative about patients’ bringing health-related information from the internet to the consultation, and there was no difference between the 2 countries on this question. There was an inverse effect with age for Germany, but there was no other effect by age (
The surgeons from both the countries were prepared to correct wrong or incomplete information, and there was no difference between the 2 countries on this question and no associations with age (
Although the surgeons from neither country felt very strongly about the loss of control, there was a difference between the 2 countries on this question, with the German surgeons feeling more strongly about this. There were no associations by condition type (
The German surgeons felt more strongly than the Omani surgeons about time-consuming consultations, and there was an inverse association with age among the Omani doctors (
Generally, the surgeons felt that the resultant communication would lead to an improvement in the patient-doctor relationship, and there was no difference between the 2 countries on this question and no effect by age (
The surgeons were disinclined to prescribe different medications, and there was no difference between the 2 countries on this question and no effect by age (
Finally, because surgeons’ attitudes can be associated with the amount of interaction with e-patients, we looked for any associations between the most common activities and the answers to the above 6 questions in general and on the country level. Of all these, the only association was between the percentage of patients bringing in information from the internet (Pearson
Summary of responses to attitude statements.
Item | Germany (n=49), mean (SD) | Oman (n=59), mean (SD) | Overall (n=108), mean (SD) | Statistics | |
I think it is generally positive. | 4.20 (1.5) | 4.03 (1.7) | 4.11 (1.6) | −0.56 (105) | .58 |
I am prepared to correct wrong, incomplete, and misunderstood information. | 5.12 (1.7) | 5.03 (1.3) | 5.10 (1.8) | −0.11 (104) | .91 |
I sometimes feel I might lose authority and control. | 3.43 (1.9) | 2.32 (1.3) | 2.82 (1.7) | −3.53 (106) | .001 |
I expect a more time-consuming patient visit than with uninformed patients. | 5.10 (1.4) | 3.92 (1.6) | 4.45 (1.7) | −4.03 (106) | <.001 |
The physician-patient relationship will be improved by better communication. | 4.41 (2.0) | 4.81 (1.8) | 4.63 (1.9) | 1.09 (105) | .28 |
I would be more likely to prescribe a desired medication than if the patients were uninformed. | 3.08 (1.7) | 3.53 (1.9) | 3.32 (1.8) | 1.27 (105) | .21 |
This paper reported the e-patient–related activities and attitudes of surgeons at 2 sites in Germany and Oman. There are many similarities between the 2 groups; indeed, many of these similarities can be found in other studies. There are, however, differences between the 2 sites, particularly in the methods of communication between the surgeons and patients. The discussion below will explore some of these similarities and differences in light of the literature.
As we based a large portion of our questionnaire on the one produced by Moick and Terlutter [
The surgeons in this study generally used the internet far more than the doctors in Moick and Terlutter’s study [
Overall, the German surgeons spent a greater percentage of their online time on work-related activities than the Omani surgeons. Earlier studies of internet usage by doctors [
As was noted in the Introduction section, patient engagement has led to better health outcomes [
With the surgeons in this study, we wished to have a more detailed knowledge of their baseline knowledge and usage of various sites and apps. Although the aims of the study did not require that we conduct detailed statistical analyses on the various sites and apps, we were able to gather a greater sense that, overall, the surgeons’ knowledge and use of the internet were extensive. This provided important contextual information so that we could be surer that any lack of site recommendation for patients would not be simply because of a lack of knowledge or awareness of these sites.
In this light, among the Omani surgeons, the high number of Google recommendations (11/29, 38%) is of great concern. Unsurprisingly, patients have long been using these general search engines as a starting point to health sites [
From our perspective, among the most interesting results were the figures on electronic communication with patients. For several years, studies have shown that, in spite of some reservations, many physicians are satisfied with email communication with patients and have continued to use email as a standard method of communication [
Noteworthy in this study, however, was the great difference in the
It would be dangerous to speculate too deeply on the Omani figures, and this could be the subject of later research. There are, however, 2 possible reasons based on sociological and recent historical differences between the 2 countries:
In general, Omani society is very close knit, and it is not unusual for doctors and patients to be related. Approximately 52% of Omani marriages are consanguineous, and more than 75% of these marriages are with first cousins [
Although Oman was not affected by the 2011 Arab Spring to the same extent as many other countries in the region, the power of social media became obvious during that time [
There may be a third reason: an overall growth in patient communication with social media. Currently, although there is international recognition of the role of social media in medical practice [
The implications for medical education are important: currently, medical education communication teaching still focuses on face-to-face communication teaching, in spite of the fact that there has long been a call for email communication to be explicitly taught [
Irrespective of the differences between the German and Omani surgeons, both groups show that more than half of the surgeons communicate electronically with their patients, thereby affording the opportunity for Web-based patient engagement; as indicated above, the literature has shown a positive association between patient engagement and better health outcomes [
From our study, the high percentage of surgeons from Germany and Oman reporting patients bringing information to them from the internet is consistent with the literature [
Other literature has found an association between recommendations from the doctor and patients bringing information from the internet [
The comparison of our results with those of Moick and Terlutter’s study [
Indications from the literature are that patients are increasingly requesting prescriptions by name, having found the information from both advertisements in traditional media and also from social media and other electronic sources [
These surgeons envisaged an improvement in the patient-doctor relationship caused by the better-informed patient. This is a controversial discussion point in the literature, in which some studies have found a negative impact, whereas others have found results similar to ours and have seen that the more engaged patient has resulted in improved health care delivery [
The differences between the German and Omani figures, however, are also noteworthy. The Omani surgeons were significantly less concerned than the German surgeons and Moick and Terlutter’s sample about the loss of control. Other studies have also indicated that even when physicians are generally positive about well-informed patients, sometimes arguing with patients over irrational points can lead to a fear of lack of trust in the doctor’s ability [
The other difference was the fear of loss of time; again, the figures show that the Omani surgeons were far less concerned than the German surgeons and those in Moick and Terlutter’s sample and also in other studies [
This paper focuses on the surgeons working with e-patients. As this is already a lengthy paper, it would not be wise to broaden it much further, although it is necessary to look a little at the broader context.
Reference has already been made to the implications of these findings for medical and health education. In short, these findings reinforce and then extend the notion that health education needs to be tailored to meet the demands of the e-patient, specifically on the effective management of electronic communication in health care.
In addition, moreover, there is the entire field of participatory medicine, in which patients move away from
The activities and especially the positive attitudes of the surgeons in this study appear to show a great opportunity for increased patient participation and engagement in their health care, and this bodes well for future positive health care delivery. Previous studies have indicated that doctors’ attitudes strongly impact patient activities, but this has not been strongly supported in this study. It may be that e-patients are now less impacted by doctors’ attitudes than before or it may be that there is a tipping point where a change from negative to positive is the main difference, after which the patients take greater control irrespective of small differences in surgeons’ positive attitudes.
Although the study was conducted in 2 countries, the centers were localized to the 2 hospitals associated with the researchers’ universities. That said, the figures for Germany conform to many of the trends found elsewhere, and Oman is a relatively small country with few surgical centers and only 2 medical schools. A second limitation is the sample size of a total of 108 surgeons.
Recognizing that doctors’ electronic interactions with patients impact health care delivery, this study has examined German and Omani surgeons’ interactions with and attitudes toward e-patients. We have seen that, overall, these doctors are comfortable with many e-patient activities and that the doctors’ attitudes do not have a significant impact on the e-patient activities. This may be because the e-patients see these activities as part of their normal lives and are performed irrespective of doctors’ opinions about the activities. Either way, the approach by these surgeons has created the opportunity for greater patient participation and engagement, and the literature indicates that this opportunity should have a great positive impact on health care delivery.
In addition, however, there were differences between the 2 countries, most notably in the methods of electronic communication, with the German surgeons using mainly email and the Omani surgeons’ heavy use of social media. Further research needs to be performed to determine the extent to which this difference results from cultural differences and recent historical events; it is also possible that the difference is an early indication of e-patients wishing to shift communication from email to social media.
Beyond medical practice, there are implications for medical education, and medical schools need to ensure that medical students receive comprehensive training on working with the e-patient, including appropriate electronic communication with patients.
Checklist for Reporting Results of Internet E-Surveys checklist and corresponding actions taken in the paper.
Questions for physician questionnaire.
More detailed charts.
Continuing Professional Development
The authors would like to thank all the physicians who participated in this study. The authors also wish to thank reviewers of previous versions of this paper. This study had no external funding or sponsorships.
None declared.