**4. Findings**

#### *4.1. The Users' Perspective*

By adopting the users' perspective, we identified 10 representative types of doctor behaviors, as is shown in Table 2. In the following, we introduce quantitative coding results and representative behaviors of doctors in terms of the information providing, information interpreting, and relationship maintaining categories.


**Table 2.** Antecedents of poor DPR from the users' perspective.

#### 4.1.1. Barriers for Doctors in Information Providing

That doctors fail to provide accurate and adequate medical information for users over mobile consultation is a major reason that causes users' dissatisfaction. Nowadays, users of mobile medical services require richer information to understand their physical conditions and make reasonable medical decisions [7]. They not only require information about the treatment suggestions, but also require information about why they become sick, how to treat the disease, and why the doctor makes a specific diagnosis. However, in the mobile context, text-based and asynchronous communication makes it more difficult for doctors to reply to every message from users. Specifically, doctors may fail to explain etiology, diagnostic evidence, and fail to offer clear and effective suggestions, which leaves users' information-related needs unmet. As a result, users complain during their communication with doctors or in their service comments, such as "the doctor didn't explain the causes of my disease", "I'm not clear about how he makes this diagnosis", or "the advice is not detailed enough". Of all our codes for the doctors' behaviors from the users' perspective, the percentages of codes indicating lacking etiology analysis, lacking diagnostic evidence, lacking operational advice and ambiguous answers account for 6.42%, 18.92%, 16.22% and 25.00% of the dissatisfying conversations respectively.

Here we provide an example for lacking etiology analysis. A user consulted a doctor on the causes of his child's symptoms. The doctor diagnosed the symptoms as viral infections and gave drug recommendations. The user inquired again about the etiology, but the doctor ignored the user's question and gave advice on medication again. The user then complained, "I'm asking you about the causes of the disease, doctor. You only tell me what medicine to eat".

Users also frequently complain about a lack of diagnostic evidence during mobile consultation. Users sometimes ask their doctors, "how did you make your judgment?", "why did you choose this medicine over that one?", or "how did you come to the treatment plan?'. The doctor usually repeated his suggestions, ignored users' questions, or replied "it is too complex to explain to you".

Lacking actionable advice is another type of behavior frequently complained by the users. Sometimes, due to limited diagnostic clues or mild symptoms, doctors may sugges<sup>t</sup> continuous observation without any actionable advice. Many users find this suggestion unacceptable and evaluate the mobile consultation service as dissatisfactory. Actionable advice creates a sense of security because users feel they can do something to prevent the disease from worsening [16]. Moreover, actionable advice is consistent with users' offline consultation expectations.Most users decide to go to offline hospitals only when they have severe symptoms. As a result, most users ge<sup>t</sup> actionable advice from their doctors [52]. When users extend their offline expectations to the mobile consultation service, lacking actionable advice may easily cause dissatisfaction.

Ambiguous answers may cause dissatisfaction of users. Doctors sometimes provide general rather than customized suggestions to users due to limited diagnostic clues, time constraints, or simply because they ignore the specific requirements of users. An example of an ambiguous answer is shown in the following. A user described the symptoms of his child to a doctor, and the doctor answered, "that may be bacterial infection". Then the user asked again, "what are the causes?". The doctor said, "not sure. Many factors can cause infection". The user made a negative comment and complained "Too vague! The doctor didn't give explicit answers".

#### 4.1.2. Barriers for Doctors in Information Interpreting

In mobile consultation, doctors sometimes overlook information provided by users or provide irrelevant answers to users' questions. This is in part because the asynchronism feature of CMC increases the di fficulties of reading and interpreting information during the consultation. As a result, users feel their needs are neglected. Of all our codes for the doctors' behaviors from the users' perspective, the percentages of codes indicating doctors' ignoring information provided by users and irrelevant answers are 3.04% and 3.38% respectively.

A typical example showing doctors ignore information provided by users is described in the following. A user told the doctor that his child had allergic rhinitis last year and then he described the symptoms that the child had. The doctor replied, "it must be the symptoms of rhinitis". The user complained that the doctor only repeated the information provided in his symptom description.

Doctors sometimes provide irrelevant answers because they fail to understand users' intentions. Here we provide an example for this case. A user asked his doctor "what is the harm of low fever?". The doctor skipped this question and constantly asked "what is the temperature? Are there any symptoms?" As a result, the user complained, "I just want to know the harm of low fever. Why not answer this question straightway?".

#### 4.1.3. Barriers for Doctors in Relationship Maintaining

Representative behaviors that fail to meet users' emotional needs include delayed response, lack of initiatives, lack of emotional comfort, and being unfriendly, each takes 26.69%, 10.81%, 5.74%, and 13.18% respectively in our coding for the doctors' behaviors from the users' perspective.

During mobile consultation, doctors' delayed response is a prominent issue that causes dissatisfaction of users. Asynchronous communication makes it di fficult to guarantee the timeliness of doctors' replies in mobile consultation. If doctors fail to respond to users' questions promptly, users will feel neglected, disrespected and are not willing to establish a good relationship with their doctors [14]. Our data analysis reveals that when the mobile conversation is temporarily stopped due to doctors' delayed response, users may complain, "I've waited for so long", "I am very worried, can you hurry up to reply my questions", or "your response is too slow".

Doctors are coded as "lack of initiatives" when they fail to provide additional information that is usually closely related to the questions asked by their users. For example, a doctor asked about what medicine the user was currently taking. After receiving the users' reply, the doctor typed, "this medicine contains suspected carcinogen". Since the doctor failed to provide choices or precautions during the conversation, the user felt very anxious and rated "dissatisfied" in the end. Typical complaints from users include "the doctor merely answers the questions that I ask, but not provide any additional information", "cherish your words like gold", or "the doctor talks as squeezing the toothpaste".

Lacking emotional comfort is also a common phenomenon that causes dissatisfaction of users in mobile consultation. Doctors' emotional comfort has a strong e ffect on alleviating users' negative emotions [41]. However, due to the lack of visual and auditory cues, doctors cannot e ffectively perceive the negative emotions of users and omit to express emotional comfort. For example, a user expressed his worry and anxiety about his child's condition, but the doctor neglected the negative emotion and just put forward another question as a response. The user made a negative comment, "professional, but also so indi fferent".

Negative comments about doctors' unfriendly attitude frequently happened. During mobile communication, doctors may use a strong tone or words, express the impatient mood, or use rhetorical questions, which makes users feel uncomfortable. As a result, users may complain like "too fierce", "bad service attitude", "not friendly at all". Here we provide an example. When a user asked the doctor a question that he did not understand, the doctor replied, "I don't need to repeat the question that I have explained! Haven't I made myself clear?". The user complained that "that's terrible. I just ask a question, while he answers me like a teacher teaches a student".

#### *4.2. The Doctors' Perspective*

By adopting the doctors' perspective, we identified 6 representative types of user behaviors, as is shown in Table 3. In the following, we introduce the results of quantitative coding and the representative information providing, information interpreting, and relationship maintaining behaviors of users.


**Table 3.** Antecedents of poor DPR from the doctors' perspective.

#### 4.2.1. Barriers for Users in Information Providing

Users' failure to provide accurate or adequate medical information to their doctors through mobile consultation is a common cause of doctors' dissatisfaction. In traditional offline consultations, doctors acquire diagnostic clues through observation and examination. But in mobile consultations, medical clues, such as symptoms, prior medical treatment experience, and medicine usage, can only be provided by the users. However, due to the lack of professional knowledge, it is difficult for users to select useful medical information for doctors. Sometimes, they even provide a conflicting description or refuse to provide the information to assist the diagnosis. As a result, doctors complain during mobile consultation services, such as "why not answer my questions", "no picture to assist my judgment", or "I can't understand your description". Of all our codes for the users' behavior from the doctors' perspective, the percentage of codes indicating inadequate and vague diagnostic clues is 6.76%.

Here we provide an example of failing to provide adequate clues. A user consulted a doctor on the causes of his child's symptoms. The doctor replied, "it is hard to say, I can tell you based on a laboratory test, but it is hard to judge by naked eyes". The user complained, "You are telling me nothing". The doctors replied, "you did not even provide me a picture, you just keep sending me questions".

#### 4.2.2. Barriers for Users in Information Interpreting

During mobile consultations, users sometimes fail to understand the questions or suggestions offered by their doctors because they lack adequate medical knowledge or hold divergent medical opinions with their doctors. As a result, even though doctors spend much time repeating their opinions or explaining medical principles, users misunderstand their doctors' suggestions. Of all our codes for the users' behavior from the doctors' perspective, the percentages of codes indicating users' lacking adequate medical knowledge and holding conflicting opinions with their doctors are 4.39% and 1.01% respectively.

Here is an example that lacking adequate medical knowledge causes poor DPR. A doctor recommended formula milk to a mother because her child was diagnosed with milk protein allergy. Formula milk was suggested since it is easier for a child with dyspepsia to digest. However, this recommendation stimulated a strong objection from the mother. She said, "why not feed him with breast milk? He can't ge<sup>t</sup> better with the formula milk. Are you kidding me!" Although the doctor had repeated the detailed medical principle to the mother, she still posted a negative evaluation of the doctor's service. The doctor replied, "as a doctor, I recommend based on my knowledge and the condition of my patients".

Information interpretation issues caused by conflicting opinions also appear in our codes. Some users stick to their inherent opinions that are formed in their prior experience [52]. This "confidence" sometimes leads to users' difficulties in information interpretation. Conflicting opinions between traditional Chinese medical science and western medical science sometimes caused poor DPR. For example, the doctor made a diagnosis with western medical science, while the user tried to interpret the result from the perspective of Chinese medical knowledge. A user asked, "is that caused by the coldness of the body?" The doctor answered, "we are not talking about the same thing". This is special in the Chinese context where traditional Chinese medical science co-exists with western medical science. Another example is the conflicting opinions about the treatment. For example, the doctor offered a treatment plan, but the user thought that taking medicine had unavoidable harm and asked for more conservative treatment. The doctor answered, "this treatment is necessary and you should follow doctors' advice."

#### 4.2.3. Barriers for Users in Relationship maintaining

During mobile consultation, users sometimes doubt the information offered by doctors, causing tense DPR from the doctors' perspective. Users in the mobile era no longer rely on information from a single doctor. Instead, they search the internet, consult other doctors, and compare the information they collected from multiple sources and multiple times. Once there is conflicting information, the users tend to explicitly express their distrust towards their doctors during doctor-user communication. For example, users said, "I disagree with you", "you might be wrong, I consulted multiple doctors and received conflicting recommendations", or "no, I hear that ... while you said that ... ". In response, some doctors said during the interaction, "why do you distrust my opinion?". Of all our codes for the users' behavior from the doctors' perspective, the percentage of codes indicating that users doubt the information provided by their doctors is 13.51%.

Sometimes, when there are divergent opinions, users even doubt the identity of their doctors. Different from the traditional offline context, the sense of authority and security used to associate with doctors is weakened in the mobile context. Moreover, users have less tolerance and understanding when their doctors make mistakes. In our codes, some users wrote, "I doubt whether you are a registered doctor", "are you a real doctor/ an intern/a robot", or "you're not professional, I know it better than you". As a result, doctors replied to these comments like "I've been working for 5 years", "interns are not allowed to register for this service", or "you are too rude". Of all our codes for the users' behaviors from the doctors' perspective, the percentage of codes indicating that users doubt the identity of doctors is 3.38%.

In more extreme cases, users vent their negative emotions by giving personal remarks towards their doctors. For example, some users wrote, "I think you are a quack" or "why don't you go elsewhere and sell your quack medicine to others". As a result, during the interaction with these users, doctors replied by writing "please mind your tone", "please do not use terrible words", "show some respect", or "you show no respect to me". Of all our codes for the users' behaviors from the doctors' perspective, the percentage of codes indicating that users give personal remarks towards their doctors is 11.82%.
