2.1Online doctor-patient communication: Issues and the status quo

Web 2.0 technologies sparked a digital revolution that has dramatically changed the ways of doctor-patient communication (Prestin and Chou 2014Prestin, Abby, and Wen-ying Sylvia Chou 2014 “Web 2.0 and the Changing Health Communication Environment.” In The Routledge Handbook of Language and Health Communication, edited by Heidi E. Hamilton, and Wen-ying Sylvia Chou, 184–97. London and New York: Routledge.Prestin, Abby, and Wen-ying Sylvia Chou 2014 “Web 2.0 and the Changing Health Communication Environment.” In The Routledge Handbook of Language and Health Communication, edited by Heidi E. Hamilton, and Wen-ying Sylvia Chou, 184–97. London and New York: Routledge., 184) by availing patients of better medical resources (Chen and Gao 2018Chen, Juan, and Jingwen Gao 2018 “The Mechanism of Trust in Online Medical Consultation.” Modern Communication 12: 136–42.Chen, Juan, and Jingwen Gao 2018 “The Mechanism of Trust in Online Medical Consultation.” Modern Communication 12: 136–42.) and more willingness of self-disclosure with doctors online anonymously (Dedding et al. 2011Dedding, Christine, Roesja van Doorn, Lex Winkler, and Ria Reis 2011 “How Will E-Health Affect Patient Participation in the Clinic? A Review of e-Health Studies and the Current Evidence for Changes in the Relationship between Medical Professionals and Patients.” Social Science and Medicine 72 (1): 49–53. Dedding, Christine, Roesja van Doorn, Lex Winkler, and Ria Reis 2011 “How Will E-Health Affect Patient Participation in the Clinic? A Review of e-Health Studies and the Current Evidence for Changes in the Relationship between Medical Professionals and Patients.” Social Science and Medicine 72 (1): 49–53. ; Wang et al. 2019Wang, Ruojia, Lu Zhang, and Jimin Wang 2019 “Research on the Influence Factors of User Satisfication in Online ‘Ask the Doctor’ Service Based on Grounded Theory.” Information Studies: Theory & Application 42 (10): 117–23.Wang, Ruojia, Lu Zhang, and Jimin Wang 2019 “Research on the Influence Factors of User Satisfication in Online ‘Ask the Doctor’ Service Based on Grounded Theory.” Information Studies: Theory & Application 42 (10): 117–23.). Another substantial transformation ushered in by the Internet is doctors’ steadily veering towards patient-centeredness in OMC settings. In other words, healthcare consultation is intended to ensure the decisions catering for the patients’ wants, needs, and preferences (Siebinga et al. 2022Siebinga, Veerle Y., Ellen M. Driever, Anne M. Stiggelbout, and Paul L. P. Brand 2022 “Shared Decision Making, Patient-Centered Communication and Patient Satisfaction – A Cross-Sectional Analysis.” Patient Education and Counseling 105 (7): 2145–50. Siebinga, Veerle Y., Ellen M. Driever, Anne M. Stiggelbout, and Paul L. P. Brand 2022 “Shared Decision Making, Patient-Centered Communication and Patient Satisfaction – A Cross-Sectional Analysis.” Patient Education and Counseling 105 (7): 2145–50. ). That is to say, the patient is such an active participant in his or her healthcare that s/he is empowered with the final option of the doctor’s suggestions (Lindström and Weatherall 2015Lindström, Anna, and Ann Weatherall 2015 “Orientations to Epistemics and Deontics in Treatment Discussions.” Journal of Pragmatics 78: 39–53. Lindström, Anna, and Ann Weatherall 2015 “Orientations to Epistemics and Deontics in Treatment Discussions.” Journal of Pragmatics 78: 39–53. ). This could be partially explained by the fact that the doctors’ authority has been disempowered substantially in OMC (Atanasova et al. 2017Atanasova, Sara, Tanja Kamin, and Gregor Petrič 2017 “Exploring the Benefits and Challenges of Health Professionals’ Participation in Online Health Communities: Emergence of (Dis)Empowerment Processes and Outcomes.” International Journal of Medical Informatics 98: 13–21. Atanasova, Sara, Tanja Kamin, and Gregor Petrič 2017 “Exploring the Benefits and Challenges of Health Professionals’ Participation in Online Health Communities: Emergence of (Dis)Empowerment Processes and Outcomes.” International Journal of Medical Informatics 98: 13–21. ), and patients begin to hold more weight in communication than ever before, via more active engagement and decision-making in their own health care (Lindström and Weatherall 2015Lindström, Anna, and Ann Weatherall 2015 “Orientations to Epistemics and Deontics in Treatment Discussions.” Journal of Pragmatics 78: 39–53. Lindström, Anna, and Ann Weatherall 2015 “Orientations to Epistemics and Deontics in Treatment Discussions.” Journal of Pragmatics 78: 39–53. ). To cater for this trend, doctors give space to patient autonomy by highlighting patient-centered care (Yip and Zhang 2020Yip, Jesse W. C. and Chenjie Zhang 2020 “Understanding the Co-construction of Medical Consultations in Traditional Chinese Medicine: A Discourse Structural Analysis.” In Expanding Horizons in Health Communication: An Asian Perspective, edited by Bernadette Watson, and Janice Krieger, 133–160. Heidelberg: Springer. Yip, Jesse W. C. and Chenjie Zhang 2020 “Understanding the Co-construction of Medical Consultations in Traditional Chinese Medicine: A Discourse Structural Analysis.” In Expanding Horizons in Health Communication: An Asian Perspective, edited by Bernadette Watson, and Janice Krieger, 133–160. Heidelberg: Springer. ) through exploiting intimate vocatives and markers of politeness (Tseng and Zhang 2018Tseng, Ming-Yu, and Grace Zhang 2018 “Pragmeme, Adaptability, and Elasticity in Online Medical Consultations.” Journal of Pragmatics 137: 40–56. Tseng, Ming-Yu, and Grace Zhang 2018 “Pragmeme, Adaptability, and Elasticity in Online Medical Consultations.” Journal of Pragmatics 137: 40–56. ), more varied relational work like hedging, praising (Locher 2006Locher, Miriam A. 2006 Online Advice-Giving in an American Internet Health Column. Amsterdam: John Benjamins Publishing Company. Locher, Miriam A. 2006 Online Advice-Giving in an American Internet Health Column. Amsterdam: John Benjamins Publishing Company. ), empathizing (Tseng and Zhang 2022Tseng, Ming Yu, and Grace Zhang 2022 “Conceptual Metonymy and Emotive-Affective Meaning at the Interface: Examples from Online Medical Consultations.” Lingua 268: 103192. Tseng, Ming Yu, and Grace Zhang 2022 “Conceptual Metonymy and Emotive-Affective Meaning at the Interface: Examples from Online Medical Consultations.” Lingua 268: 103192. ; Zhang 2021cZhang, Yu 2021c “How Doctors Do Things with Empathy in Online Medical Consultations in China: A Discourse-Analytic Approach.” Health Communication 36 (7): 816–25. Zhang, Yu 2021c “How Doctors Do Things with Empathy in Online Medical Consultations in China: A Discourse-Analytic Approach.” Health Communication 36 (7): 816–25. ) as well as more mitigation strategies of trust constructing, solidarity seeking and emotion relieving (Mao and Zhao 2020Mao, Yansheng, and Xin Zhao 2020 “By the Mitigation One Knows the Doctor: Mitigation Strategies by Chinese Doctors in Online Medical Consultation.” Health Communication 35 (6): 667–74. Mao, Yansheng, and Xin Zhao 2020 “By the Mitigation One Knows the Doctor: Mitigation Strategies by Chinese Doctors in Online Medical Consultation.” Health Communication 35 (6): 667–74. ; Zhao and Mao 2021Zhao, Xin, and Yansheng Mao 2021 “Trust Me, I Am a Doctor: Discourse of Trustworthiness by Chinese Doctors in Online Medical Consultation.” Health Communication 36 (3): 372–80. Zhao, Xin, and Yansheng Mao 2021 “Trust Me, I Am a Doctor: Discourse of Trustworthiness by Chinese Doctors in Online Medical Consultation.” Health Communication 36 (3): 372–80. ).

Taking all of these into consideration, prior studies have explored the characteristics of online doctor-patient communication but only mentioning emotion in passing since it is not their focus. In other words, the extant studies only treat emotion as one of the factors that have an impact on the doctor-patient relationship, and a more systematic exploration of how doctors alleviate patients’ negative emotions through discourse still awaits to be explored explicitly. Accordingly, a study of doctors’ emotion-regulating endeavor in OMC settings in China could not only enrich the full picture of doctor-patient communication but also reveal more about the under-explored emotion issues, especially the negative ones, in the context of doctor-patient communication.

2.2Patients’ negative emotions: Causes and impacts

Negative emotions are found to be quite common among patients (Panasiti et al. 2020Panasiti, Maria Serena, Giorgia Ponsi, and Cristiano Violani 2020 “Emotions, Alexithymia, and Emotion Regulation in Patients With Psoriasis.” Frontiers in Psychology 11 (May): 1–8. Panasiti, Maria Serena, Giorgia Ponsi, and Cristiano Violani 2020 “Emotions, Alexithymia, and Emotion Regulation in Patients With Psoriasis.” Frontiers in Psychology 11 (May): 1–8. ). As an extensive survey using the Hospital Anxiety and Depression Scale (N = 11,766) showed, patients in all age groups had some degree of anxiety and even depression (Fan et al. 2010Fan, Qing, Jianlin Ji, Zeping Xiao, Liang Sha, and Yiyu Shi 2010 “Application of the Hospital Anxiety and Depression Scale (HAD) among Medical Outpatients.” Chinese Mental Health Journal 24 (5): 325–28.Fan, Qing, Jianlin Ji, Zeping Xiao, Liang Sha, and Yiyu Shi 2010 “Application of the Hospital Anxiety and Depression Scale (HAD) among Medical Outpatients.” Chinese Mental Health Journal 24 (5): 325–28.). Likewise, research uncovers that in OMC settings, health seekers also exhibit various degrees of anxiety (Tseng and Zhang 2022Tseng, Ming Yu, and Grace Zhang 2022 “Conceptual Metonymy and Emotive-Affective Meaning at the Interface: Examples from Online Medical Consultations.” Lingua 268: 103192. Tseng, Ming Yu, and Grace Zhang 2022 “Conceptual Metonymy and Emotive-Affective Meaning at the Interface: Examples from Online Medical Consultations.” Lingua 268: 103192. ), indicating the permeating negative emotions among patients.

Regarding the causes of patients’ negative emotions, prior studies showcase that doctors’ mindset is one of the main triggers for patients’ negative emotions. For one thing, in a disease-centered doctor’s mind, illness means symptoms to be tested instead of a person to be cared for, as expected by patients (Lv and Wang 2012Lv, Xiaokang, and Xinjian Wang 2012 “What Is Illness: The Differentiation of Doctor-Patient Discourse and the Manifestation of Somatization – from the Perspective of Medical Sociology.” Social Science in Guangdong 2012 (6): 193–9.Lv, Xiaokang, and Xinjian Wang 2012 “What Is Illness: The Differentiation of Doctor-Patient Discourse and the Manifestation of Somatization – from the Perspective of Medical Sociology.” Social Science in Guangdong 2012 (6): 193–9.), which echoes the finding that there are thematic differences in doctor-patient discourse, with patients focusing more on symptom description and causes enquiry, while doctors mainly on treatment suggestions (Lu et al. 2021Lu, Quan, Chang Li, Ting Liu, and Jing Chen 2021 “Research on the Knowledge Asymmetry in Online Doctor-Patient Communication.” Journal of Information Resources Management (1): 90–97,111.Lu, Quan, Chang Li, Ting Liu, and Jing Chen 2021 “Research on the Knowledge Asymmetry in Online Doctor-Patient Communication.” Journal of Information Resources Management (1): 90–97,111.). For the other, doctors’ dominance in doctor-patient communication (Mao and Zhao 2019Mao, Yansheng, and Xin Zhao 2019 “I Am a Doctor, and Here Is My Proof: Chinese Doctors’ Identity Constructed on the Online Medical Consultation Websites.” Health Communication 34 (13): 1645–52. Mao, Yansheng, and Xin Zhao 2019 “I Am a Doctor, and Here Is My Proof: Chinese Doctors’ Identity Constructed on the Online Medical Consultation Websites.” Health Communication 34 (13): 1645–52. ; Wang et al. 2021Wang, Xiaojiang, Yansheng Mao, and Qian Yu 2021 “From Conditions to Strategies: Dominance Implemented by Chinese Doctors during Online Medical Consultations.” Journal of Pragmatics 182: 76–85. Wang, Xiaojiang, Yansheng Mao, and Qian Yu 2021 “From Conditions to Strategies: Dominance Implemented by Chinese Doctors during Online Medical Consultations.” Journal of Pragmatics 182: 76–85. ) is another emotion-provoking issue, notably indicated in the occasions that doctors ask the majority of questions while skipping over the patients’ questions (Huiskes et al. 2020Huiskes, Victor J. B., Christine M. Cramer-van der Welle, Cornelia H. M. van den Ende, Liset van Dijk, Jacqueline M. Bos, Cornelis Kramers, and Bart J. F. van den Bemt 2020 “Communication about Drug-Related Problems (DRPs) during Patients’ Visits to Dutch Physicians and Pharmacies.” Health Communication 35 (2): 201–8. Huiskes, Victor J. B., Christine M. Cramer-van der Welle, Cornelia H. M. van den Ende, Liset van Dijk, Jacqueline M. Bos, Cornelis Kramers, and Bart J. F. van den Bemt 2020 “Communication about Drug-Related Problems (DRPs) during Patients’ Visits to Dutch Physicians and Pharmacies.” Health Communication 35 (2): 201–8. ; Liu et al. 2008Liu, Xingbing, Qin Liu, and Chengquan He 2008 “A Review of Contemprary Research Abroad on Doctor-Patient Oral Interaction.” Medicine and Philosophy 29 (4): 19–21.Liu, Xingbing, Qin Liu, and Chengquan He 2008 “A Review of Contemprary Research Abroad on Doctor-Patient Oral Interaction.” Medicine and Philosophy 29 (4): 19–21.). Consequently, patients seldom verbalize their concerns and emotions but exhibit indirect cues (Eide et al. 2004Eide, Hilde, Vicenç Quera, Peter Graugaard, and Arnstein Finset 2004 “Physician-Patient Dialogue Surrounding Patients’ Expression of Concern: Applying Sequence Analysis to RIAS.” Social Science and Medicine 59 (1): 145–55. Eide, Hilde, Vicenç Quera, Peter Graugaard, and Arnstein Finset 2004 “Physician-Patient Dialogue Surrounding Patients’ Expression of Concern: Applying Sequence Analysis to RIAS.” Social Science and Medicine 59 (1): 145–55. ; Tseng and Zhang 2022Tseng, Ming Yu, and Grace Zhang 2022 “Conceptual Metonymy and Emotive-Affective Meaning at the Interface: Examples from Online Medical Consultations.” Lingua 268: 103192. Tseng, Ming Yu, and Grace Zhang 2022 “Conceptual Metonymy and Emotive-Affective Meaning at the Interface: Examples from Online Medical Consultations.” Lingua 268: 103192. ), which are nevertheless often bypassed by doctors (Eide et al. 2004Eide, Hilde, Vicenç Quera, Peter Graugaard, and Arnstein Finset 2004 “Physician-Patient Dialogue Surrounding Patients’ Expression of Concern: Applying Sequence Analysis to RIAS.” Social Science and Medicine 59 (1): 145–55. Eide, Hilde, Vicenç Quera, Peter Graugaard, and Arnstein Finset 2004 “Physician-Patient Dialogue Surrounding Patients’ Expression of Concern: Applying Sequence Analysis to RIAS.” Social Science and Medicine 59 (1): 145–55. ). Accordingly, doctors are often perceived as being cold and lacking empathy towards patients (Liu et al. 2008Liu, Xingbing, Qin Liu, and Chengquan He 2008 “A Review of Contemprary Research Abroad on Doctor-Patient Oral Interaction.” Medicine and Philosophy 29 (4): 19–21.Liu, Xingbing, Qin Liu, and Chengquan He 2008 “A Review of Contemprary Research Abroad on Doctor-Patient Oral Interaction.” Medicine and Philosophy 29 (4): 19–21.).

As patients’ negative emotions impede their recovery (Zhou and Grady 2016Zhou, Peiling, and Sue C. Grady 2016 “Three Modes of Power Operation: Understanding Doctor-Patient Conflicts in China’s Hospital Therapeutic Landscapes.” Health and Place 42 (September): 137–47. Zhou, Peiling, and Sue C. Grady 2016 “Three Modes of Power Operation: Understanding Doctor-Patient Conflicts in China’s Hospital Therapeutic Landscapes.” Health and Place 42 (September): 137–47. ), continuous anxiety, stressful experiences and lack of emotional support in interaction can lead to delay of physiological recovery further (Wu et al. 2008Wu, Xiaoping, Dong Wang, Zhongjin Song, Congzhou Sun, Xiaolan Xiao, Youde He, Caiming Wang, and Xueli Sun 2008 “Impact of Anxiety-depression Symptoms on Clinical Recovery and Serum TNF-α and IL-6 of Patients with Burns.” Journal of Sichuan University (Medical Science Edition) 39 (1): 105–7.Wu, Xiaoping, Dong Wang, Zhongjin Song, Congzhou Sun, Xiaolan Xiao, Youde He, Caiming Wang, and Xueli Sun 2008 “Impact of Anxiety-depression Symptoms on Clinical Recovery and Serum TNF-α and IL-6 of Patients with Burns.” Journal of Sichuan University (Medical Science Edition) 39 (1): 105–7.; Priem 2020Priem, Jennifer S. 2020 “Emotional Support Processes and Physiology.” In The Oxford Handbook of the Physiology of Interpersonal Communication, edited by Lindsey Aloia, Amanda Denes, and John P. Crowley, 172–90. Oxford: Oxford University Press. Priem, Jennifer S. 2020 “Emotional Support Processes and Physiology.” In The Oxford Handbook of the Physiology of Interpersonal Communication, edited by Lindsey Aloia, Amanda Denes, and John P. Crowley, 172–90. Oxford: Oxford University Press. ). Besides, negative impacts of patients’ negative emotions on doctors or doctor-patient communication are also documented. Specifically, patients with negative emotions provoked by doctors tend not to trust in their doctors and feel dissatisfied with their doctors (Zhang et al. 2023Zhang, Xin, Linzi Li, Quan Zhang, Long Hoang Le, and Yijin Wu 2023 “Physician Empathy in Doctor-Patient Communication: A Systematic Review.” Health Communication 39 (5): 1027–37. Zhang, Xin, Linzi Li, Quan Zhang, Long Hoang Le, and Yijin Wu 2023 “Physician Empathy in Doctor-Patient Communication: A Systematic Review.” Health Communication 39 (5): 1027–37. ), and more severely, to be non-adherent to medication or medical consultation (Bazrafshan et al. 2023Bazrafshan, Fateme Dahaghin, Zahra Darvizeh, and Shokoh Sadat Banijamali 2023 “The Relationship between Hemodialysis Patients’ Treatment Adherence, Procrastination, and Difficulty in Emotion Regulation: A Cross-Sectional Study in Southeast Iran.” Frontiers in Psychology 13 (January): 1–10. Bazrafshan, Fateme Dahaghin, Zahra Darvizeh, and Shokoh Sadat Banijamali 2023 “The Relationship between Hemodialysis Patients’ Treatment Adherence, Procrastination, and Difficulty in Emotion Regulation: A Cross-Sectional Study in Southeast Iran.” Frontiers in Psychology 13 (January): 1–10. ). Moreover, patients’ individual emotions would turn to be socially contagious ones if proliferated by the Internet, since public health information is more likely to be passed on if it is framed to evoke negative emotions like anxiety (Berger and Milkman 2012Berger, Jonah, and Katherine L. Milkman 2012 “What Makes Online Content Viral?” Journal of Marketing Research 49 (2): 192–205. Berger, Jonah, and Katherine L. Milkman 2012 “What Makes Online Content Viral?” Journal of Marketing Research 49 (2): 192–205. ). In this sense, the investigation of the patients’ negative emotion regulation is meaningful for the patients both as individuals and as a societal group. In view of this, the paper is intended to describe the underexplored physicians’ emotion-regulating efforts in OMC settings in China, with the aim of theoretically extending the research line of emotion regulation and practically shedding light on harmonious rapport management during doctor-patient communication in both online and offline scenarios.

4.1Research question

Emotions play a central role in human psychology and sociality (Langlotz and Locher 2013Langlotz, Andreas, and Miriam A. Locher 2013 “The Role of Emotions in Relational Work.” Journal of Pragmatics 58: 87–107. Langlotz, Andreas, and Miriam A. Locher 2013 “The Role of Emotions in Relational Work.” Journal of Pragmatics 58: 87–107. ). Accordingly, doctors have a profound realization about the role of patients’ emotions in communication. Therefore, the article intends to answer the ensuing two research questions:

1. What types of emotion-regulating strategies are used by doctors discursively in OMC?

2. What are the effects of these emotion-regulating strategies in OMC?

4.2Data collection

The data are collected from Dingxiang Yisheng (literally, ‘Lilac Doctor’, https://​dxy​.com/), one of the most universally accessible OMC platforms in China, which enrolls more than 50,000 doctors nationwide and has provided medical assistance for more than eight million patients online.33.See https://​baike​.baidu​.com​/item​/%E4%B8%81%E9%A6%99%E5%8C%BB%E7%94%9F​/2060631​?fr​=aladdin. Time of access: October 16th, 2022. Specifically, the data are collected through the following steps: First, we visit the homepage of Dingxiang Yisheng, and click the “Ask Doctors” button, which links to the “Common Departments” page, covering dermatology, pediatrics, gynecology, obstetrics, gastroenterology, urology, orthopedics, otorhinolaryngology and stomatology, to make sure that the doctor-patient communication is situated in a wide range of medical issues (Giménez-Moreno and Ricart-Vayá 2022Giménez-Moreno, Rosa, and Alicia Ricart-Vayá 2022 “The Expression of Emotions in Online Medical Consultations: A Comprehensive Spanish-English Analysis.” Iberica 44 (2022): 239–62. Giménez-Moreno, Rosa, and Alicia Ricart-Vayá 2022 “The Expression of Emotions in Online Medical Consultations: A Comprehensive Spanish-English Analysis.” Iberica 44 (2022): 239–62. ). Then, the latest ten doctor-patient conversations of the doctor with the highest rating44.It is notable that the latest list of doctors includes these with highest rating given by the patients. So, it seems that there are two selection criteria applied here, namely time and doctor’s ratings, but the website combines them together and proposes the list. Therefore, there is no extra work for us to do any selecting calculations. (Tseng and Zhang 2022Tseng, Ming Yu, and Grace Zhang 2022 “Conceptual Metonymy and Emotive-Affective Meaning at the Interface: Examples from Online Medical Consultations.” Lingua 268: 103192. Tseng, Ming Yu, and Grace Zhang 2022 “Conceptual Metonymy and Emotive-Affective Meaning at the Interface: Examples from Online Medical Consultations.” Lingua 268: 103192. ) from the aforementioned departments are copied to compose of a dataset with ninety conversations (words amount to 210,154).

Further, comments from the patients to the above ten doctors are also collected (16,030 comments). It is important to note that the comments are all from patients and nest under each doctor mentioned above. However, there is no fixed one-to-one correspondence between the patient leaving a comment and the doctor being commented on. We tried to make a match between the consulting patients and the consulted doctors and those leaving comments until we found that it was insignificant to do so. For one thing, for the sake of privacy, even the surnames of the patients are not fully disclosed (like d***8) in the system, thus it is hard to identify them in different columns. For the other, we only collect ten patients’ conversations with the doctors, and even if the total of ninety patients can be identified and supposed to leave comments, the sum of the comments would be very limited. Generally, only those who received service from the doctors would bother to give comments. Therefore, the 16,030 comments we collected could represent the opinion of the patients in general.

As all the data are publicly available, they can be taken as a case of public environment to study without consent (Mao and Zhao 2020Mao, Yansheng, and Xin Zhao 2020 “By the Mitigation One Knows the Doctor: Mitigation Strategies by Chinese Doctors in Online Medical Consultation.” Health Communication 35 (6): 667–74. Mao, Yansheng, and Xin Zhao 2020 “By the Mitigation One Knows the Doctor: Mitigation Strategies by Chinese Doctors in Online Medical Consultation.” Health Communication 35 (6): 667–74. ). Nevertheless, following the ethical guidelines, all the (sur)names of the consultants and all (sur)names within the consultations were removed or replaced to protect their privacy (Ren and Guo 2021Ren, Wei, and Yaping Guo 2021 “What Is ‘Versailles Literature’?: Humblebrags on Chinese Social Networking Sites.” Journal of Pragmatics 184: 185–95. Ren, Wei, and Yaping Guo 2021 “What Is ‘Versailles Literature’?: Humblebrags on Chinese Social Networking Sites.” Journal of Pragmatics 184: 185–95. ).

4.3Data analysis

Before conducting data analysis, in line with the theoretical framework of the paper, data coding will be done accordingly, and the coding procedure is as follows.

Firstly, as for emotion identification, we draw on the terms, descriptions and definitions of emotions in the China National Knowledge Infrastructure (CNKI) (beta version) and the Dictionary of Emotional Meaning (Davitz 1969Davitz, Joel 1969 The Language of Emotion. New York and London: Academic Press. Davitz, Joel 1969 The Language of Emotion. New York and London: Academic Press. ; Jiang et al. 2023Jiang, Qingsheng, Yansheng Mao, and Zhou-min Yuan 2023 “Where There Is Panic, the Media Are Close by: A Pragmatic Study of the Alleviation of COVID-19 Panic by the Chinese State Media.” Pragmatics and Society 14 (4): 611–37. Jiang, Qingsheng, Yansheng Mao, and Zhou-min Yuan 2023 “Where There Is Panic, the Media Are Close by: A Pragmatic Study of the Alleviation of COVID-19 Panic by the Chinese State Media.” Pragmatics and Society 14 (4): 611–37. ). In other words, emotion identification is mainly based on emotion markers or indicators. Take the post “I have two small pimples on the bottom of my pubic area … I’m scared” for example. Since the patient explicitly expressed “scared”, the emotion can be labeled as “fear”. For less telling cases like “My son … has had diarrhea for four to five days straight, four to five times a day … What could I do?” Considering the description and the question “What could I do?”, we label the emotional state “anxiety” according to Davitz (1969Davitz, Joel 1969 The Language of Emotion. New York and London: Academic Press. Davitz, Joel 1969 The Language of Emotion. New York and London: Academic Press. , 36). Regarding emotion alleviation or emotion transition, i.e. the switching from one emotional state to another (Jain and Asawa 2015Jain, Shikha, and Krishna Asawa 2015 “EmET: Emotion Elicitation and Emotion Transition Model.” Advances in Intelligent Systems and Computing 339: 209–17. Jain, Shikha, and Krishna Asawa 2015 “EmET: Emotion Elicitation and Emotion Transition Model.” Advances in Intelligent Systems and Computing 339: 209–17. ), we observe it in interaction sequences. For example, by reading a patient’s follow-up turn “I feel much relieved after listening to you” after consulting the doctor, we conclude that the patient’s emotion is “alleviated from anxiety”.

Secondly, in terms of the doctors’ strategies, discourses deployed to gain the patients’ trust so as to regulate their emotions will be identified. Expressions of honorific addressing terms (e.g. nin honorific ‘you’), apology expressions (e.g. bu hao yisi ‘sorry’), gratitude expressions (xiexie xinren ‘thanks for trusting’), empathetic expressions (nage queshi nanshou ‘that is really hard’) etc., are coded as “politeness markers” for interpersonal relationship management (Giménez-Moreno and Ricart-Vayá 2022Giménez-Moreno, Rosa, and Alicia Ricart-Vayá 2022 “The Expression of Emotions in Online Medical Consultations: A Comprehensive Spanish-English Analysis.” Iberica 44 (2022): 239–62. Giménez-Moreno, Rosa, and Alicia Ricart-Vayá 2022 “The Expression of Emotions in Online Medical Consultations: A Comprehensive Spanish-English Analysis.” Iberica 44 (2022): 239–62. ). The frequency of politeness markers from the doctors is counted to showcase the online doctors’ unusual politeness to the patients. In addition, doctors’ diagnosis discourses like “cervical erosion”, “strephexopodia”, “HPV 16, 18” and so on are coded as “medical jargons” (cf. Zhao and Mao 2021Zhao, Xin, and Yansheng Mao 2021 “Trust Me, I Am a Doctor: Discourse of Trustworthiness by Chinese Doctors in Online Medical Consultation.” Health Communication 36 (3): 372–80. Zhao, Xin, and Yansheng Mao 2021 “Trust Me, I Am a Doctor: Discourse of Trustworthiness by Chinese Doctors in Online Medical Consultation.” Health Communication 36 (3): 372–80. ). And discourses like “It’s nothing serious” can be labelled as “attitudinal discourse” for uncertainty-reduction (Brashers et al. 2000Brashers, Dale E., Judith L. Neidig, Stephen M. Haas, Linda K. Dobbs, Linda W. Cardillo, and Jane A. Russell 2000 “Communication in the Management of Uncertainty: The Case of Persons Living with HIV or AIDS.” Communication Monographs 67 (1): 63–84. Brashers, Dale E., Judith L. Neidig, Stephen M. Haas, Linda K. Dobbs, Linda W. Cardillo, and Jane A. Russell 2000 “Communication in the Management of Uncertainty: The Case of Persons Living with HIV or AIDS.” Communication Monographs 67 (1): 63–84. ). In order to refine and categorize the initial coding, a second round of coding is done. Macro-categories like up-grading or down-grading patients’ emotions are focused on to describe the doctors’ emotion regulation endeavors. For example, in the second round of coding, uncertainty-reducing discourse like “It’s nothing serious” can be coded as discourse for “down-grading patient’s negative emotion” whereas some prognosis discourse like “it will be very serious without treatment” will be annotated as discourse for “up-grading patient’s negative emotion”.

Thirdly, in terms of the effects of doctors’ emotion regulation, the comments from patients will be analyzed. Comments like “I feel less anxious now” can be counted as direct evidence of doctors’ emotion regulation, whereas less direct expressions like “(The doctors’ explanation is) professional and comprehensive” can be labelled as the patient’s emotion attribution of the doctors’ expertise. By “less direct”, we mean that in an “ecologically valid context” (Shu et al. 2020Shu, Jocelyn, Niall Bolger, and Kevin N. Ochsner 2020 “Social Emotion Regulation Strategies Are Differentially Helpful for Anxiety and Sadness.” Emotion 21 (6): 1144–59. Shu, Jocelyn, Niall Bolger, and Kevin N. Ochsner 2020 “Social Emotion Regulation Strategies Are Differentially Helpful for Anxiety and Sadness.” Emotion 21 (6): 1144–59. ), a naturally occurring conversation might not provide exact information in an expected manner. Along the same vein, comments like “Thanks for the doctor’s patient explanation” can be coded as patients’ recognition of the doctor’s attitude. Though these comments are not direct expressions concerning the effects of the doctors’ emotion regulation strategies, they still indicate the patients’ evaluation of the doctors’ endeavor in a certain way.

Since a message is the core text unit of online communication, we employ it as our coding unit (Bobicev et al. 2015Bobicev, Victoria, Marina Sokolova, and Michael Oakes 2015 “What Goes Around Comes Around: Learning Sentiments in Online Medical Forums.” Cognitive Computation 7 (5): 609–21. Bobicev, Victoria, Marina Sokolova, and Michael Oakes 2015 “What Goes Around Comes Around: Learning Sentiments in Online Medical Forums.” Cognitive Computation 7 (5): 609–21. ). The authors coded each message independently. The inter-rater reliability is tested using the NVivo 11, and the Cohen’s kappa coefficient is 0.81. In light of the opinion that Kappa values above 0.70 are regarded as acceptable (Zhang et al. 2023Zhang, Xin, Linzi Li, Quan Zhang, Long Hoang Le, and Yijin Wu 2023 “Physician Empathy in Doctor-Patient Communication: A Systematic Review.” Health Communication 39 (5): 1027–37. Zhang, Xin, Linzi Li, Quan Zhang, Long Hoang Le, and Yijin Wu 2023 “Physician Empathy in Doctor-Patient Communication: A Systematic Review.” Health Communication 39 (5): 1027–37. ), this value indicates a high agreement between the researchers’ coding. The authors discussed each case in which the coding differed until a consensus was achieved.

5.1Results

In this section, the strategies of doctors’ emotion-regulating discourse will be identified, explained and discussed.

Extrinsic emotion regulation by doctors in Chinese OMC is usually manifested through downgrading and upgrading the magnitude and duration of the patients’ emotions (Gross 2013Gross, James J. 2013 “Emotion Regulation: Taking Stock and Moving Forward.” Emotion 13 (3): 359–65. Gross, James J. 2013 “Emotion Regulation: Taking Stock and Moving Forward.” Emotion 13 (3): 359–65. ). However, to “make the world a better place”, emotion regulation by doctors typically targets patients suffering from negative emotions (Gross 2013Gross, James J. 2013 “Emotion Regulation: Taking Stock and Moving Forward.” Emotion 13 (3): 359–65. Gross, James J. 2013 “Emotion Regulation: Taking Stock and Moving Forward.” Emotion 13 (3): 359–65. ). Interestingly, we also find some cases where the doctors upgrade the magnitude of patients’ negative emotions in due course of Chinese OMC.

5.2Patients’ comments: A discussion of patient-centeredness in OMC in China

Doctors’ behaviors are usually thought to be patient-centeredness, which cannot be fully sketched without taking into account the doctors’ endeavors of managing patients’ emotions. Likewise, as the doctors’ mentality of taking very close care of patients’ emotions is a very revealing indicator of patient-centered communication, a more convincing way of evaluating doctors’ patient-centeredness is to observe the patients’ response and self-disclosure of emotions towards the doctors. Therefore, an analysis of the patients’ responsive comments could not only demonstrate the effectiveness of the online doctors’ emotion-regulating strategies, but also reveal the relationship between doctors’ patient-centeredness and patients’ emotion attribution.

The comments from patients provide direct evidence for doctors’ emotion-alleviating endeavor, i.e., down-grading negative emotion effort, while almost no comment addresses directly the doctors’ negative emotion up-grading conduct. This suggests that the doctors’ up-grading work of negative emotion had not been accused by the patients while it is more likely to have a joint effect on building a patient-centered image of the doctors in OMC settings.

As for the effect of emotion regulation, it is found to be positively related between doctors’ discourse and patients’ emotion alleviation, as indicated in the comments from patients. To be specific, the most direct evidence comes from the patients’ reports of emotion alleviation, like “Thanks a lot for the doctor’s help, I feel much relieved” and “Thank you very much. The reply is very detailed and it dispels my doubts”, to name but a few. In the comments, expressions like “feel relieved”, “doubt removed”, etc. are quite universal, which in turn proves that doctors online are largely patient-centered. This finding aligns with the same finding from Lindström and Weatherall (2015)Lindström, Anna, and Ann Weatherall 2015 “Orientations to Epistemics and Deontics in Treatment Discussions.” Journal of Pragmatics 78: 39–53. Lindström, Anna, and Ann Weatherall 2015 “Orientations to Epistemics and Deontics in Treatment Discussions.” Journal of Pragmatics 78: 39–53. and Siebinga et al. (2022)Siebinga, Veerle Y., Ellen M. Driever, Anne M. Stiggelbout, and Paul L. P. Brand 2022 “Shared Decision Making, Patient-Centered Communication and Patient Satisfaction – A Cross-Sectional Analysis.” Patient Education and Counseling 105 (7): 2145–50. Siebinga, Veerle Y., Ellen M. Driever, Anne M. Stiggelbout, and Paul L. P. Brand 2022 “Shared Decision Making, Patient-Centered Communication and Patient Satisfaction – A Cross-Sectional Analysis.” Patient Education and Counseling 105 (7): 2145–50. among others. In addition, most of the 16,030 comments contain patients’ gratitude towards doctors,55.Special attention should be paid to the fact that patients express very much less gratitude in consultation sessions than in comment sections of the website. It is very likely that in the consultation, patients are gripped by health problems and negative emotions while after the patients’ problems have been solved and emotions alleviated, they show their gratitude to doctors by feeding back with positive comments. which corroborates the finding that a feeling of gratitude is generated by a sense of being helped (Tseng and Zhang 2022Tseng, Ming Yu, and Grace Zhang 2022 “Conceptual Metonymy and Emotive-Affective Meaning at the Interface: Examples from Online Medical Consultations.” Lingua 268: 103192. Tseng, Ming Yu, and Grace Zhang 2022 “Conceptual Metonymy and Emotive-Affective Meaning at the Interface: Examples from Online Medical Consultations.” Lingua 268: 103192. ).

Apart from providing evidence of emotion alleviation, the comments also suggest the patients’ attribution of the doctors’ expertise and attitudes (Liu et al. 2020Liu, Qianqian Ben, Xiaoxiao Liu, and Xitong Guo 2020 “The Effects of Participating in a Physician-Driven Online Health Community in Managing Chronic Disease: Evidence from Two Natural Experiments.” MIS Quarterly: Management Information Systems 44 (1): 391–419. Liu, Qianqian Ben, Xiaoxiao Liu, and Xitong Guo 2020 “The Effects of Participating in a Physician-Driven Online Health Community in Managing Chronic Disease: Evidence from Two Natural Experiments.” MIS Quarterly: Management Information Systems 44 (1): 391–419. ). For example, comments like “The analysis is very comprehensive”, “The explanation is comprehensive, thorough and professional”, etc., reveal the recognition of doctors’ expertise, while comments like “Excellent illustrations! Easy to understand!” highlight the doctors’ communication skills. Likewise, “Thank you very much doctor, your detailed and patient response cleared up my doubts” is about the doctors’ attitude. Another category like “I am very grateful for the timely treatment!”, “Pregnant mom got a quick response and had my anxiety removed” are both recognition of the doctors’ response with efficiency.

The recognition suggested in the patients’ online comments can further be perceived as referents of the patients’ emotional attribution of doctors’ personality (Filipowicz et al. 2011Filipowicz, Allan, Sigal Barsade, and Shimul Melwani 2011 “Understanding Emotional Transitions: The Interpersonal Consequences of Changing Emotions in Negotiations.” Journal of Personality and Social Psychology 101 (3): 541–56. Filipowicz, Allan, Sigal Barsade, and Shimul Melwani 2011 “Understanding Emotional Transitions: The Interpersonal Consequences of Changing Emotions in Negotiations.” Journal of Personality and Social Psychology 101 (3): 541–56. ), which in turn motivates doctors to provide patient-centered healthcare. More specifically, the patients’ comments reveal their emotional attribution, mainly including the doctors’ competence and attitude exhibited in epistemic expertise, response speed, patience as well as communication skills (Fan et al. 2022Fan, Jing, Huihui Geng, Xuan Liu, and Jiachen Wang 2022 “The Effects of Online Text Comments on Patients’ Choices: The Mediating Roles of Comment Sentiment and Comment Content.” Frontiers in Psychology 13 (May): 1–13. Fan, Jing, Huihui Geng, Xuan Liu, and Jiachen Wang 2022 “The Effects of Online Text Comments on Patients’ Choices: The Mediating Roles of Comment Sentiment and Comment Content.” Frontiers in Psychology 13 (May): 1–13. ), which are essential compositional elements of patient-centeredness in OMC settings. From the doctors’ side, the emotional attribution of the patients means a significant share for their career, which can be read from the doctors’ self-disclosure in our data. The doctors are found to encourage patients to make online comments (Fan et al. 2022Fan, Jing, Huihui Geng, Xuan Liu, and Jiachen Wang 2022 “The Effects of Online Text Comments on Patients’ Choices: The Mediating Roles of Comment Sentiment and Comment Content.” Frontiers in Psychology 13 (May): 1–13. Fan, Jing, Huihui Geng, Xuan Liu, and Jiachen Wang 2022 “The Effects of Online Text Comments on Patients’ Choices: The Mediating Roles of Comment Sentiment and Comment Content.” Frontiers in Psychology 13 (May): 1–13. ) and voice gratitude to physicians (Liu et al. 2020Liu, Qianqian Ben, Xiaoxiao Liu, and Xitong Guo 2020 “The Effects of Participating in a Physician-Driven Online Health Community in Managing Chronic Disease: Evidence from Two Natural Experiments.” MIS Quarterly: Management Information Systems 44 (1): 391–419. Liu, Qianqian Ben, Xiaoxiao Liu, and Xitong Guo 2020 “The Effects of Participating in a Physician-Driven Online Health Community in Managing Chronic Disease: Evidence from Two Natural Experiments.” MIS Quarterly: Management Information Systems 44 (1): 391–419. ), revealing that the doctors care very much about patients’ positive emotion attribution. In this sense, it is not surprising to find that almost all the doctors in our data ask for positive comments or likes from patients while showing special concern about patients’ bad comments. This further indicates their care for patients’ emotion attribution. In their eyes, a bad comment “would seriously affect my online reputation, which is far more important to a doctor than money”. Considering that peer-patients’ comments may have an information-optimizing effect on potential patients’ service selection (Hu et al. 2021Hu, Yajie, Huiwen Zhou, Yuangao Chen, Jianrong Yao, and Jiangwu Su 2021 “The Influence of Patient-Generated Reviews and Doctor-Patient Relationship on Online Consultations in China.” Electronic Commerce Research 23: 1115–1141. Hu, Yajie, Huiwen Zhou, Yuangao Chen, Jianrong Yao, and Jiangwu Su 2021 “The Influence of Patient-Generated Reviews and Doctor-Patient Relationship on Online Consultations in China.” Electronic Commerce Research 23: 1115–1141. ) in terms of doctor’s competence, benevolence, and personality in general (Liu et al. 2020Liu, Qianqian Ben, Xiaoxiao Liu, and Xitong Guo 2020 “The Effects of Participating in a Physician-Driven Online Health Community in Managing Chronic Disease: Evidence from Two Natural Experiments.” MIS Quarterly: Management Information Systems 44 (1): 391–419. Liu, Qianqian Ben, Xiaoxiao Liu, and Xitong Guo 2020 “The Effects of Participating in a Physician-Driven Online Health Community in Managing Chronic Disease: Evidence from Two Natural Experiments.” MIS Quarterly: Management Information Systems 44 (1): 391–419. ), it is fairly reasonable to argue that doctors are very likely to be patient-centered in OMC settings. In light of all these, the logical focus of doctors’ patient-centeredness lies in the close linkage between emotion regulation endeavor from the doctors’ side and emotional attribution from the patients’ side. In other words, the interaction forms a virtuous circle in which doctors care more about the patients’ emotions, and the patients, in turn, would attribute positive emotions to the doctors.

To summarize, the findings of this study suggest that online doctors’ text-based emotion-regulating strategies on the digital platform are effective (Nozaki and Mikolajczak 2023Nozaki, Yuki, and Moïra Mikolajczak 2023 “Effectiveness of Extrinsic Emotion Regulation Strategies in Text-Based Online Communication.” Emotion 23 (6): 1714–25. Nozaki, Yuki, and Moïra Mikolajczak 2023 “Effectiveness of Extrinsic Emotion Regulation Strategies in Text-Based Online Communication.” Emotion 23 (6): 1714–25. ). Online doctors’ endeavor of emotion regulation is not only aimed at the patients’ recognition of their competence and attitude, but also the proliferation of their comments through the Internet so that doctors may accumulate social capital. This would add new insights to the existing literature like Zhang (2021c)Zhang, Yu 2021c “How Doctors Do Things with Empathy in Online Medical Consultations in China: A Discourse-Analytic Approach.” Health Communication 36 (7): 816–25. Zhang, Yu 2021c “How Doctors Do Things with Empathy in Online Medical Consultations in China: A Discourse-Analytic Approach.” Health Communication 36 (7): 816–25. , which holds that patient-centeredness is for solving medical consultation problems. Moreover, it also echoes the claim that in online medical services, the process of providing consolation is more important than curing disease (Zhang and Xiong 2022Zhang, Zehong, and Jingjing Xiong 2022 “Subject Driving Factors of Supply of Internet Medical Services.” Journal of Hehai University (Philosophy and Social Sciences) 24 (1): 38–46.Zhang, Zehong, and Jingjing Xiong 2022 “Subject Driving Factors of Supply of Internet Medical Services.” Journal of Hehai University (Philosophy and Social Sciences) 24 (1): 38–46.). Also, it indicates that, being patient-centered, doctors are striving to achieve their own goals, including professional satisfaction, personal reputation and social capital. In these senses, the findings above would not only serve as a contrast to the prior finding that doctors are disease-centered and tend to ignore the patients’ emotional cues (Eide et al. 2004Eide, Hilde, Vicenç Quera, Peter Graugaard, and Arnstein Finset 2004 “Physician-Patient Dialogue Surrounding Patients’ Expression of Concern: Applying Sequence Analysis to RIAS.” Social Science and Medicine 59 (1): 145–55. Eide, Hilde, Vicenç Quera, Peter Graugaard, and Arnstein Finset 2004 “Physician-Patient Dialogue Surrounding Patients’ Expression of Concern: Applying Sequence Analysis to RIAS.” Social Science and Medicine 59 (1): 145–55. ; Hu 2007Hu, Yueying 2007 “Discussion on the Functions of Doctor’s Emotion Quotient in Hospital Patient Communication.” Chinese Hospitals 11 (10): 55–6.Hu, Yueying 2007 “Discussion on the Functions of Doctor’s Emotion Quotient in Hospital Patient Communication.” Chinese Hospitals 11 (10): 55–6.; Wang and Zhu 2015Wang, Danyang, and Dongqing Zhu 2015 “The Psychological Analysis of Doctor-Patient Miscommunication: The Information Exchange Perspective.” Advances in Psychological Science 23 (12): 21–9. Wang, Danyang, and Dongqing Zhu 2015 “The Psychological Analysis of Doctor-Patient Miscommunication: The Information Exchange Perspective.” Advances in Psychological Science 23 (12): 21–9. ), but also a mild challenge to the claim that doctors still exercise dominance over e-patients in favor of an effective and efficient consultation (Chen and Gao 2018Chen, Juan, and Jingwen Gao 2018 “The Mechanism of Trust in Online Medical Consultation.” Modern Communication 12: 136–42.Chen, Juan, and Jingwen Gao 2018 “The Mechanism of Trust in Online Medical Consultation.” Modern Communication 12: 136–42.; Wang et al. 2021Wang, Xiaojiang, Yansheng Mao, and Qian Yu 2021 “From Conditions to Strategies: Dominance Implemented by Chinese Doctors during Online Medical Consultations.” Journal of Pragmatics 182: 76–85. Wang, Xiaojiang, Yansheng Mao, and Qian Yu 2021 “From Conditions to Strategies: Dominance Implemented by Chinese Doctors during Online Medical Consultations.” Journal of Pragmatics 182: 76–85. ). In short, this paper is pro the judgement that in OMC, there is a shift in power from doctors to patients (Zhang 2021bZhang, Yu 2021b “Dynamic Power Relations in Online Medical Consultation in China: Disrupting Traditional Roles through Discursive Positioning.” Chinese Journal of Communication 14 (4): 369–85. Zhang, Yu 2021b “Dynamic Power Relations in Online Medical Consultation in China: Disrupting Traditional Roles through Discursive Positioning.” Chinese Journal of Communication 14 (4): 369–85. ). It also supports the observation that patients and doctors are reciprocal (Liu et al. 2020Liu, Qianqian Ben, Xiaoxiao Liu, and Xitong Guo 2020 “The Effects of Participating in a Physician-Driven Online Health Community in Managing Chronic Disease: Evidence from Two Natural Experiments.” MIS Quarterly: Management Information Systems 44 (1): 391–419. Liu, Qianqian Ben, Xiaoxiao Liu, and Xitong Guo 2020 “The Effects of Participating in a Physician-Driven Online Health Community in Managing Chronic Disease: Evidence from Two Natural Experiments.” MIS Quarterly: Management Information Systems 44 (1): 391–419. ), which would also shed considerable light on the current debate about patient- or doctor-centeredness in OMC (Mao and Zhao 2020Mao, Yansheng, and Xin Zhao 2020 “By the Mitigation One Knows the Doctor: Mitigation Strategies by Chinese Doctors in Online Medical Consultation.” Health Communication 35 (6): 667–74. Mao, Yansheng, and Xin Zhao 2020 “By the Mitigation One Knows the Doctor: Mitigation Strategies by Chinese Doctors in Online Medical Consultation.” Health Communication 35 (6): 667–74. ; Wang et al. 2021Wang, Xiaojiang, Yansheng Mao, and Qian Yu 2021 “From Conditions to Strategies: Dominance Implemented by Chinese Doctors during Online Medical Consultations.” Journal of Pragmatics 182: 76–85. Wang, Xiaojiang, Yansheng Mao, and Qian Yu 2021 “From Conditions to Strategies: Dominance Implemented by Chinese Doctors during Online Medical Consultations.” Journal of Pragmatics 182: 76–85. ).