1. Introduction
We have witnessed rapid worldwide development of the Internet. The number of Internet users in North America reached 346 million by June 30, 2018, with the Internet penetration rate being 95% [
1]. As for China, the Internet has experienced a breakneck development over past decades, with the number of Chinese netizens reaching 802 million in June 2018. Furthermore, the Internet penetration rate, which was 57.7%, exceeded Asian and global average levels and is expected to grow steadily. At the same time, the number of mobile netizens reached 788 million, which made the rates of mobile phone usage reach a new record [
2]. According to the “Internet Plus” policy proposed in the government work report, the medical industry is facing great opportunities [
3]. More doctors and patients are benefiting from various Internet services, such as professional–patient interaction, knowledge-based, and comprehensive medical services.
As an essential factor in the medical environment and China’s healthcare reform [
4], professional–patient relations are inevitably affected by the Internet [
5]. Incidents of violence against medical staff have increased in intensity, showing deteriorating professional–patient relations under the traditional medical mode in China over the past few years [
6,
7,
8,
9,
10]. However, the Internet undoubtedly brings important opportunities for the improvement of professional–patient relations, such as professional–patient interaction websites, new media, and the implementation of a hospital information system [
4]. In the Internet era, patients have an empowered voice, have begun to make shared medical decisions with doctors, and will replace doctors as the center of the medical service system in the 21st century [
11]. As a result, the development of the Internet seemingly breaks the traditional professional–patient pattern [
12].
In addition, professional–patient relations in the Internet era have attracted significant attention from many scholars and become a research hotspot. Subsequently, a sharp rise in the number of articles on this topic has occurred, and some of these articles are quite significant and influential (e.g., Lai and Yang [
13]; Dai [
14]; Wang [
15]). These articles explore how to effectively improve professional–patient relations in the Internet era in line with the current health situation in China. For example, under the implementation of a hierarchical medical system, the use of Internet technology to improve professional–patient relations is discussed [
16]. New healthcare reform priorities include increasing patient satisfaction with healthcare and improving the quality and safety of care [
4]. China is in the midst of reforming and modernizing its health care system. At the same time, China is also the largest developing country in the world, facing the dilemma of using extremely limited and unevenly distributed health resources to solve the medical problems of one-fifth of the world’s population. Its exploration of how to improve professional–patient relations will help other developing countries facing similar dilemmas to improve their professional–patient relations. In addition, such an exploration provides references for scholars from all over the world to study the professional–patient relations model in developing countries.
However, until now, only a brief overview of professional–patient relations in the Internet era in China has been available, and a review of previous related literature on the topic shows some research limitations. That is, few Chinese scholars have explored the research structure based on quantitative methods. The primary goal of the present study is to analyze the research status of professional–patient relations in the Internet era in China and further reveal its research pattern and trends, as well as address the limitations by conducting a comprehensive analysis of the professional–patient relations in the Internet era in China based on bibliometric and co-word analyses.
2. Materials and Methods
2.1. Search Strategy
We performed a systematic literature review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [
17]. Here, we focused on searching for articles related to professional–patient relations in the Internet era in China. The search strategy is as follows, and is provided in
Figure 1.
(SU: ((Internet or network) and (professional–patient relations or professional–patient communication or professional–patient interaction or professional–patient harmony or professional–patient dispute)) + (TI (title) or KY (keywords)): ((Internet or network) and (professional–patient relations or professional–patient communication or professional–patient interaction or professional–patient harmony or professional–patient dispute)) + AB (abstract): ((Internet or network) and (professional–patient relations or professional–patient communication or professional–patient interaction or professional–patient harmony or professional–patient dispute)))*Date: –2018
Given that the review aimed to provide a quality overview of professional–patient relations in the Internet era in China, we included only journal articles written in Chinese with a more academic nature than other journal articles. The term “Internet” was combined with the term “professional–patient relationship” to limit the scope to the professional–patient relations field.
The Wanfang Data Knowledge Services Platform is one of the most comprehensive databases for medical journals in China. Since 2007, it has exclusively included a series of journals of the Chinese Medical Association. Furthermore, we retrieved journal articles with the advanced search function in the China Academic Journals (CNKI) and Wanfang Data Knowledge Services Platform. We chose the Wanfang Data Knowledge Services Platform as the data source because the amount of literature embodied in it is more than that in CNKI.
2.2. Data Collection
We screened the titles and abstracts of the identified articles to assess inclusion in the full review (
Figure 2). Articles were included in the analysis if they involved at least one of the following:
- (1)
A discussion on how to promote the harmonious development of professional–patient relations in the Internet era;
- (2)
A general review of how the Internet affects professional–patient relations;
- (3)
A detailed exploration of how the Internet affects professional–patient relations in a specific dimension, such as technology, media, and information resources;
- (4)
The use or development of Internet products to improve professional–patient relations, such as applications, a follow-up interaction platform in the hospital, and an online health community.
Then, we extracted and downloaded the bibliographic records of 522 articles selected for subsequent bibliometric and co-word analyses, to analyze the research status, hotspots, and trends of professional–patient relations in the Internet era in China.
2.3. Method of Data Analysis
We carried out the statistical analysis using BICOMB2 (China Medical University, Shenyang, China), Microsoft Excel 2016 (Microsoft Corporation, Washington, DC, USA), and IBM SPSS Statistics 24 (IBM Corporation, New York, NY, USA). We also conducted five stages for the hierarchical cluster and strategy diagram analyses.
First, we sorted out the keywords and calculated the frequencies of each keyword with BICOMB2. We initially imported the bibliographic records of these articles into BICOMB2. To get more precise results, we subsequently standardized some keywords by merging the synonyms (e.g., “Internet + medical” and “Internet medical” were replaced by “Internet + medical,” “communication” and “professional–patient communication” were replaced by “professional–patient communication”) and excluded the general terms that were meaningless or too broad (e.g., study, analysis, influence, and apply). Finally, after sorting out the keywords, we calculated the frequencies of all keywords.
Second, we chose 22 high-frequency keywords from the total keywords using the g-index [
18]. Then, we analyzed the distribution of high-frequency keywords and chose 22 keywords with frequencies of no less than eight to generate a 22 × 22 co-occurrence matrix for the social network analysis, and a subject heading–source literature matrix for the hierarchical cluster analysis [
19].
Third, we conducted a hierarchical cluster analysis using SPSS 24, with average linkage (between groups) as the cluster method and squared Euclidean distance as the distance measure [
20]. Thus, keywords with higher correlations with one another are more likely to be put into the same cluster than those with lower correlations. Different cutoff steps may be set up in the hierarchical clustering to get different clustering results, which can provide more explanations of the correlation between keywords or themes [
21]. Each cluster denotes a possible research theme.
Fourth, we calculated the centrality and density of each cluster using Excel 2016. Density corresponds to the internal correlations of the cluster, whereas centrality corresponds to the weight of the external links of the cluster [
22]. The theory of strategic coordinates, put forward by Law et al. in 1988 [
23], describes the correlation between contents in a particular field and the mutual influence between different fields. We used the following formulas to calculate density and centrality [
24]:
where
stands for the co-occurrence frequency of keywords i and j, and
stands for the frequency of keyword i.
belongs to [0,1]. In addition, φ represents the entire keyword network, whereas
is a certain cluster. N is the number of total keywords in the entire network, and n is the number of keyword(s) in a certain cluster.
Finally, we drew a strategic diagram to intuitively present the hotspots and trends of professional–patient relations research in the Internet era in China [
22]. The strategic diagram uses a two-dimensional space to plot clusters according to their centrality and density. Therefore, the theme clusters located in four quadrants, with different centralities and densities, can indicate the developing status of research themes.
4. Discussion
4.1. Key Findings
In this study, the methods mainly covered statistical, social network, hierarchical cluster, and strategic diagram analyses. On the basis of the results, we drew the following valuable conclusions.
First, the number of articles has risen continually since 1998, which follows the growth law of literature. Furthermore, the journal distribution follows Bradford’s law of scattering, and there are 22 journals in the core zone. As for classic literature, ‘The new changes of physician-patient relationship in the network environment and its improvement measures’, published by Medicine and Philosophy in 2013, classifies the new changes of the professional–patient relationship in the Internet era in China and proposes measures on how to improve it. The core author group has not been formed, but the author’s collaborative degree is on the rise. In addition, research institutions are distributed unevenly, and the Second Military Medical University remarkably topped all the institutions in its publication outputs during the past 21 years.
Second, we selected 22 keywords with high frequency (≥8) and the distribution of these keywords’ frequencies follows Zipf’s Law. These keywords, which are more active, better reflect the research hotspots and trends of relevant research in China to a great extent. Furthermore, we divided them into eight clusters, which focus on website building (especially for professional–patient interactions), telemedicine, professional–patient communication and network public opinion, professional–patient contradiction and health education, new media, follow-up interaction platforms, healthcare reform, computer networks, and medical ethics. Each cluster represents a research direction of professional–patient relations in the Internet era in China.
Finally, the major research topics have not yet formed and are in an imbalanced development on the whole. That is, quadrant I has no cluster, quadrants II and IV have two clusters, and quadrant III has four clusters. Specifically, topics in Cluster 3 (professional–patient communication and network public opinion using new media) and Cluster 4 (professional–patient contradiction and health education in Internet media and social software platforms) may be a newly appearing research theme with great potential for development.
We searched literature on PUBMED, without any result, using the following search strategy:
((((“Professional–Patient Relations” [Mesh]) and “Internet” [Mesh]) and “Bibliometrics” [Mesh]) not “China” [Mesh]).
There is no similar research using bibliometrics to study professional–patient relations in the Internet era in other geographical areas. Then, we obtained 157 review papers about professional–patient relations in the Internet era in other geographical areas with the following search strategy.
((((“Professional–Patient Relations” [Mesh]) and “Internet” [Mesh]) and “Review” [Publication Type]) not “China” [Mesh]).
After reading the abstracts of these review papers, we found that scholars in other geographical areas mainly focused on online health information seeking [
37,
38,
39,
40,
41], social media use in healthcare [
42], Internet-based interventions (IPIs) [
43], online community [
44,
45], and e-health [
46]. Compared to our results, scholars in other areas mainly focused on online health information seeking and Internet-based interventions. In addition, social media in healthcare, online community, and e-health obtained attention from scholars from both China and other geographical areas.
In summary, the present study provides the basis for a comprehensive understanding of professional–patient relations in the Internet era in China, which can be a potential guide for researchers in launching new projects in the future.
4.2. Limitations
Due to some constraints in the construction of any bibliometric map, future improvements are recommended to address the following limitations.
The limited scope of data collection in this study may have underrepresented publications in this domain, and some other document types, such as monographs, edited books, reports, and conference proceedings, may be valuable for analysis [
47]. This exercise also demonstrated that relevant records can be missing if the query phrases for the topic search do not appear in subjects, titles, abstracts, and keywords [
48]. However, we excluded non-Chinese papers, which may constitute a selection bias. The coverage of languages also causes intractable problems for bibliometrics [
49].
We analyzed the degree of author collaboration. Other researchers can try collecting the locations of authors, draw their geographical distribution maps of cooperative networks, and examine the geographical distance between co-authors with the help of Google Earth. This information would be useful to describe the flow of knowledge and ideas through collaboration in the field.
5. Conclusions
Based on the hierarchical cluster analysis, the Internet hospital, as an emerging new form of telemedicine services, is developing at a substantial speed in China. It is an innovative practice of “Internet Plus Medical Health” with strong Chinese characteristics [
50]. Furthermore, it is of great value for the improvement of professional–patient relations in China. With the Internet, people can overcome geographical obstacles and shatter time barriers to healthcare access. In big-city and top-flight hospitals, patients only get approximately two minutes to communicate with a doctor. However, visits to the Internet hospital last 10 min or more, and, as a result, patients’ satisfaction ratings are higher [
51]. In addition, visits to the Internet hospital are cheaper than outpatient costs in a traditional hospital [
35]. Therefore, the Internet hospital can help improve professional–patient relations significantly. This outpatient service is in use in Guangdong province, China, where the first officially approved “Internet hospital” went online on 25 October 2014 [
35].
Nevertheless, the Internet hospital program is still in the exploratory stage, and quite a few problems remain to be solved, such as the incorporation of Internet medical services into health insurance programs, quality control, the applicability of Internet diagnoses for some diseases, possible medical disputes, and the long-term return on investment [
35]. If the problems cannot be adequately solved, it may harm professional–patient relations in turn [
52]. Therefore, the Internet hospital program needs to be further perfected in China.
According to the strategy diagram analysis, we discover two potential emerging research hotspots.
First, with the development of the Internet and information technology, increasingly more diverse ways for professional–patient communication are emerging. In addition, social media, especially WeChat and Microblog, has played an important role [
53]. Based on the highly cited paper analysis, one paper on WeChat and Microblog exists. Moreover, the utilization of health social media can provide increased opportunities for communication, health promotion, and access to vital health information [
54]. With social media platforms, we can improve professional–patient communication efficiency and relationships to a great extent. Therefore, the communication of doctors and patients through social media platforms may be a new trend for research in the future.
In recent years, incidents about the medical network public opinion have frequently appeared, causing irreversible loss and damage to society and people [
55]. Furthermore, research about network public opinion has deepened, and findings have increased day by day. For example, among the top 10 highly cited papers (shown in
Table 1), there are two papers about the network public opinion. Scholars have analyzed the evolution of network public opinion from different angles [
56]. Compared with traditional news media, the dissemination of information on the network can be more timely and rapid [
57,
58]. Therefore, for medical institutes to maintain their image and improve professional–patient relations, learning how to predict potential negative network public opinion trends and deal with them timely and adequately is useful. It is necessary to establish early warning mechanisms and study the evolution laws of involved medical network public opinion events [
59,
60]. Medical institutes should formulate contingency plans to deal with potential network public opinion events. In addition, active cooperation with new media is helpful [
59]. Above all, medical institutes must improve their quality of medical services [
60] to fundamentally reduce adverse network public opinion events. The accurate prediction of and proper response to network public opinion trends has great significance in building harmonious professional–patient relations.
The shortage of medical resources, which is impossible to solve worldwide in the short term, causes the professional–patient contradiction. Therefore, it is fundamental to further promote the Health Care Reform and solve the problem of difficult and expensive access to medical services. With the implementation of China’s health care reform policy, patients’ feelings and medical treatment environment have been greatly improved. In addition, it is helpful for the improvement of professional–patient relations [
61]. China’s health care reform will affect not only China’s future, but also the global healthcare model [
62]. Improving health insurance coverage, reducing costs, and dealing with the huge challenge of disease is a problem facing the whole world. China’s health care reform will ultimately enrich the achievements of the global health care reform, which will be especially valuable for areas with a shortage of health resources.
Follow-up is an observational method used by hospitals for the patients who have visited the hospital, in which they regularly supervise the changes in patients’ conditions and guide their recovery by means of communication. It is helpful for the improvement of professional–patient relationships to build the follow-up interaction platform. It not only helps hospitals to supervise patients’ conditions and provide guidance, but also to improve the interaction between medical staff and patients. Moreover, it can be used to aid clinical research. However, according to the above results, we find that researchers pay more attention to the construction of platforms, while few explore how to ensure the effective management and use of platforms. Therefore, this may be a potential research theme [
63].