Constructing Rhetorical Ethos : Traditional Chinese Medicine Doctors’ Management of Patient Resistance in Online Medical Consultations

Abstract

Introduction

This study examines how doctors address patient resistance in Traditional Chinese Medicine (TCM) online consultations, aiming to understand how culturally grounded communication practices influence care quality and patient engagement.

Methods

A total of 395 TCM consultations (307,414 Chinese characters) from Chunyu Doctor were analyzed using interactional discourse analysis and multiple correspondence analysis, informed by rhetorical ethos theory.

Results

TCM doctors managed resistance by balancing credibility, ethical care, and empathy. Phronesis was demonstrated through dynamic diagnosis or recommendation adjustment and integration of theory with experience, linking with personalized and TCM-based rationales and the value of hé (和, harmony). Arête appeared in transparency in limitations and patient-safety prioritization, occurring with consensus-based rationale, digital adaptation of Western medicine (WM) tool usage, epistemological integration of WM and TCM, and the values of chéng (诚, sincerity) and zhōngyōng (中庸, doctrine of the mean). Eunoia was reflected in offering patients affective alignment, and empowerment through education, associated with procedural-based rationale and rén (仁, benevolence) and lǐ (礼, ritual propriety) values.

Conclusion

Patient resistance can be used as a resource to enhance patient-centered care. By integrating cultural values, medical tradition, and digital interaction practices, TCM doctors sustain trust, improve adherence, and promote effective online care. These findings highlight the importance of culturally sensitive communication and relationship-building in healthcare delivery, providing practical implications for designing digital health services in China and similar cultural contexts.

1. Introduction

Traditional Chinese Medicine (TCM), with a history of over two thousand years, is deeply shaped by classical Chinese philosophies. ¹ In recent decades, it has gained increasing global recognition as a complementary medical approach. ² Its diagnostic framework comprising wàng (望, observation), wén (闻, auscultation), wèn (问, inquiry), and qiè (切, palpation) requires comprehensive patient engagement to establish connections between physical symptoms, environmental factors, and personal experiences. ² This holistic approach emphasizes personalized care and emotional connection, ³ yet faces specific challenges.

A key challenge in TCM consultations is patient resistance, defined as patients’ non-deference to the actions expected by doctors. ⁴ In China, where Western medicine (WM) predominates, ⁵ patients influenced by WM’s epistemological and cultural foundations often perceive the philosophy of TCM as unfamiliar. This unfamiliarity may lead to resistance toward statements based on TCM principles. Such initial resistance may escalate into demands aligned with WM, for example, rapid biomedical solutions rather than acceptance of holistic lifestyle interventions.^6,7 Investigating how TCM doctors respond to patient resistance provides important insights into treatment adherence and the broader tension between traditional and modern medical paradigms. However, limited research has focused on this topic, especially studies based on authentic TCM consultations.

While these challenges have long existed in face-to-face encounters, the growing digitalization of healthcare adds new layers of complexity. Driven by advances in information and communication technology (ICT), online medical consultations (OMCs) emerge and reshape doctor-patient dynamics. TCM’s traditional four-step method is often reduced to text-based inquiry. This digital setting magnifies certain challenges, including patient resistance to small talk that may appear trivial but is, in fact, essential for TCM diagnosis in OMCs. ⁸ In addition, features of online platforms such as marketized healthcare, anonymity, and performance-based rating systems can empower patients, sometimes leading them to resist more actively. ⁸ However, systematic research remains limited regarding how TCM doctors manage patient resistance within digitally mediated consultations.

Based on that, the present study applies rhetorical ethos theory to examine how patient resistance is managed in TCM OMCs. Ethos refers to the construction of the speaker’s images through discourse, encompassing both self-representation and alignment with community values.^9,10 It comprises phronesis (sound sense), arête (good character), and eunoia (good will), ⁹ and has been shown to help doctors reconcile differing patient perspectives in medical contexts.^11,12 Based on this theory, using mixed methods combining interactional discourse analysis (IDA) and multiple correspondence analysis (MCA), this study explores how doctors manage epistemological and cultural challenges unique to TCM, offering insights often overlooked in existing research on resistance management. Theoretically, this study links classical rhetorical theory with contemporary digital practice by showing how ethos is enacted in OMCs, particularly in underexplored TCM contexts. Practically, it identifies communication strategies that balance traditional diagnostic approaches with the expectations of patients accustomed to technologically mediated care. These strategies not only support treatment adherence in telehealth but also provide culturally grounded guidance for developing trust-building frameworks in the design of ICT systems.

1.1. Patient Resistance, and Its Management in Online Medical Consultations

Patient resistance plays a critical role in shaping doctor-patient interactions, As a longstanding topic in health communication research, the study of patient resistance and its management has gained renewed attention with the development of OMCs. Recent research has drawn heavily on examples from OMCs involving WM doctors.^{8,13-15, 1}

Traditionally, patient resistance in offline contexts takes two forms: passive and active. Passive resistance includes non-verbal cues such as silence, nervous laughter, or the minimal verbal responses.^16-19 In OMCs, because communication is mainly text-based, the use of non-verbal cues is limited, making active resistance the dominant form. Active resistance typically involves patients challenging doctors’ statements by referencing personal experiences or perceived symptom severity. Patients may also invoke practical barriers to adherence.^8,13-15 As noted, resistance in OMCs is further shaped by patient empowerment.^8,20 Patients increasingly challenge diagnoses by self-interpreting offline test results. New forms of resistance have also emerged, including emotion-oriented resistance which relies on patients’ explicit expression of feelings such as frustration, anxiety, or fear to challenge the doctors’ authority by framing medical advice as insufficiently attentive to patients’ emotional needs.^13,15

Existing research has identified that WM doctors in OMCs adopt multiple strategies to manage patient resistance in relation to epistemic and deontic authority. ²¹ In the epistemic domain, when patients resist, WM doctors most commonly employ interpretive strategies, providing evidence-based explanations, such as laboratory results or physical examination findings, to justify their statements. These explanations are typically framed in biomedical terms, emphasizing measurable outcomes to promote patient acceptance.^8,13-15 At the same time, patients are recognized as holding epistemic authority over their own illness experiences.^17,21 When patients disclose first-hand knowledge about their symptoms, discomfort, or prior medication experiences, doctors often display flexibility to revising their initial assessments.^15,22

In the deontic domain, while WM doctors traditionally hold the authority to prescribe biomedical treatments and expect patient compliance, this authority has become more fragile in OMCs due to the rise of patient empowerment.^14,15 The transformation has incentivized e-doctors to adopt supportives that explicitly address patients’ emotional needs to maintain satisfaction and protect professional reputation.^14,22 However, when patients persistently resist and directly challenge doctors’ deontic authority, WM doctors tend to reassert their professional roles by adopting imperatives that balance authority with their ethical responsibility to safeguard patient safety, a principle long recognized as central to medical consultations. ²³ In such cases, they may guide decision-making by presenting structured choices or issuing direct instructions.^13,14,22

Overall, existing research suggests that WM doctors in OMCs frequently employ three types of strategies, namely, interpretives, supportives, and imperatives, although with different frequencies: interpretives (53.79%) serve as a means of leveraging epistemic authority, supportives (26.49%) have gained prominence in response to patient empowerment in the digital context, and imperatives (19.78%) are used as a resort to maintain deontic authority. ¹³

Despite the global growth of TCM, research on how doctors manage patient resistance in this context remains limited. This gap is particularly significant given the fundamental epistemological differences between TCM and WM. WM is shaped by its dualistic assumptions of mind-body and human-nature separation, ²⁴ grounded in standardized, positivist approaches, where diagnoses often depend on quantitative test results that are considered self-explanatory. In contrast, TCM draws on holistic, experience-based knowledge and treats patient narratives as central to diagnosis.^25-27 These epistemological differences may shape how resistance is expressed and managed in TCM settings. Furthermore, as WM remains the dominant medical system in China, ⁵ patients are often socialized into its epistemological frameworks. Hence, they may evaluate TCM through a WM lens, resulting in skepticism toward its unique diagnostic reasoning, its slower-acting treatments, and ultimately, different forms of resistance. ⁶ In response, TCM doctors may develop distinct strategies to manage such resistance. Yet, few studies specifically address the unique epistemological perspectives of TCM.

Additionally, in OMCs, the absence of conventional TCM diagnostic methods due to the limited use of non-verbal communication compels doctors to rely exclusively on inquiry. This reliance may itself provoke resistance, as patients question the relevance of such information-gathering practices. ⁸ Thus, beyond epistemological challenges, TCM doctors must also navigate the tension between maintaining traditional practices and adapting to ICT-driven medical environments. ²⁸ These challenges highlight the need for further research into how TCM doctors adjust their communication strategies in digital contexts.

1.2. TCM Consultations and Rhetorical Ethos

TCM consultations serve not only to diagnose and treat illness but also to foster patients’ understanding and acceptance of a holistic view of health that emphasizes an individualized and dynamic diagnostic approach. ²⁶ Grounded in a holistic understanding of the interdependence between the human body and its broader environment,^5,29 TCM emphasizes relational balance and dynamic adjustment, commonly articulated through frameworks such as Yin-Yang balance ³⁰ and the Five Elements theory. ³¹ Together, these principles direct doctors to move beyond the immediate symptoms and instead to regard each patient as a unique whole, inseparable from the surrounding lifeworld. ⁵

Yet, given the dominance of WM, many patients are oriented toward observable symptoms and standardized treatments, a tendency that they may resist statements that do not appear directly relevant to their immediate conditions. ⁸ This tension challenges TCM doctors, who aim to reframe health as a lived, dynamic experience. ⁶ In TCM clinical practice, doctors tend to draw on multiple rationales to guide patients to keep openness to holistic diagnosis, and sustain long-term engagement. Some use the rationale grounded in TCM theory.^5,32 For instance, in a study of TCM consultations, doctors’ use of questioning embracing TCM philosophies enables patients to internalize a more holistic self-understanding in terms of balance and interdependence. ² Additionally, some TCM doctors employ the rationale based on personalized guidance, integrating patients’ medical histories, and lived experiences in their explanations. ³³ Doctors may also employ consensus-based rationales that appeal to jointly negotiated health norms or shared understandings,^32,34 as well as procedural rationales that clarify step-by-step treatment pathways, thereby making the therapeutic process more transparent. ³³ In certain contexts, doctors draw on imperatives that invoke professional authority to reinforce compliance.^26,35 These findings suggest that TCM consultations are not merely informational or relational but constitute purposeful rhetorical practices. Through discourse, doctors shape patients’ understandings of their conditions, thereby facilitating acceptance and engagement.^2,8 This interpretive orientation aligns with rhetoric’s core conception of persuasion as symbolic action. ³⁶ Although prior studies have examined features of TCM consultations,^2,37 systematic rhetorical analyses of how doctors manage patient resistance through diverse rationales remain limited.

This study adopts rhetorical ethos theory as an analytical lens for analysis. Positioned at the intersection of sociology, psychology, pragmatics, and rhetoric, ³⁸ ethos has been theorized in diverse ways. ³⁹ This study adopts a rhetorical approach, defining ethos as the strategic enactment of self-images through discourse within communicative contexts, ⁹ rather than as an inherent moral character or personal psychology. ⁴⁰ Importantly, ethos also encompasses cultural alignment. As Killingsworth ¹⁰ contended, speakers represent both themselves and the collective values of the communities to which they belong. From this perspective, ethos is as much a reflection of cultural worldviews as it is of individual identity.

Ethos consists of three dimensions: phronesis (sound sense), arête (good character), and eunoia (good will). Phronesis refers to the ability to discern the most appropriate course of action in a given context. It requires not only deep subject-matter expertise, ⁴¹ but also sensitivity to the audience’s expectations and the situational nuances involved. ⁴² This dual awareness enables speakers to manage conflicting circumstances. ⁴³ Arête denotes the moral virtue of character. ⁴⁴ Ethos is also demonstrated when speakers embody the values they promote, communicating with integrity and aligning themselves with culturally defined ideals of virtues. ⁹ Such virtues are determined by cultural norms rather than individual preferences ⁴² . By exhibiting traits that are culturally valued, such as courage, temperance, and justice, speakers strengthen their persuasive effectiveness. ⁴³ Eunoia reflects a speaker’s genuine concern for the audience’s well-being. Aristotle ⁹ linked this quality to friendship, suggesting that effective persuasion requires a shared sense of values.

Aristotle ⁹ identified ethos as the most powerful mode of persuasion, particularly in contexts marked by uncertainty or disagreement. In medical encounters, when patients resist doctors’ statements, it is often the doctor’s ability to construct a credible and contextually appropriate ethos that determines whether trust is established, authority is accepted, and treatment is followed.^11,12 Reflecting its significance, rhetorical ethos theory has been increasingly applied to analyze persuasive strategies in health communication.^45-48 However, most existing research has focused on WM encounters, emphasizing the use of scientific evidence in constructing ethos to promote patient compliance. Less attention has been paid to how ethos functions in other medical paradigms, such as TCM, where epistemological frameworks differ considerably.^27,49,50

Moreover, previous investigations have revealed that patient resistance management in doctor-patient interactions is not merely the transmission of medical information, but a socially situated practice shaped by broader sociocultural contexts.^19,51 For instance, WM doctors in Nigerian clinical encounters may invoke religious expressions (e.g., “by God’s grace”) to avoid giving definitive answers, thereby mitigating potential conflict. Such strategies function to emphasize shared community values, highlighting humility in the face of uncertainty. ⁵¹ TCM has its distinct cultural norms, ethical principles, and communicative conventions that are rooted in traditional Chinese philosophies and that guide TCM doctors’ clinical practices and interactions with patients. ²⁶

Precisely because medical communication is culturally embedded, ethos, which encompasses both individual credibility and broader cultural orientations, offers a useful lens for examining how TCM doctors manage patient resistance and construct credibility. Importantly, the adoption of Aristotelian ethos in this study does not override indigenous TCM norms; rather, it serves as an analytical framework for exploring how credibility is discursively constructed within these practices. Accordingly, the three dimensions of ethos, namely phronesis, arête, and eunoia, correspond closely to what communication research conceptualizes as source credibility, which has been widely theorized and empirically validated as a key determinant of persuasive effectiveness across cultural contexts.^52,53 This suggests that the evaluations of speakers in terms of sound sense, good character, and good will reflect broadly shared mechanisms of social interactions. While their realization is shaped by culturally specific value systems, ethos can be understood as a general communicative mechanism through which credibility is constructed and negotiated in discourse. ⁵⁴ In this sense, Aristotelian ethos operates at the level of general social cognition and interactional evaluation, which supports its cross-cultural applicability as an analytical framework rather than a culturally imposed normative system.

In TCM consultations, ethos is realized through culturally specific moral frameworks. Phronesis, often conceptualized as adaptive expertise, can be understood as a form of context-sensitive practical reasoning, which is realized in TCM through distinct but complementary intellectual traditions, particularly Daoism and Confucianism. Daoist philosophy, characterized by principles such as tiānrénhéyī (天人合一, the unity of humans and nature), provides an important cosmological and epistemological framework for TCM. Within this orientation, concepts such as Yin-Yang, a foundational principle in classical Chinese thought, emphasize dynamic balance and continuous transformation within an interconnected system. Together, these principles foreground alignment with natural processes and responsiveness to changing conditions. ⁵⁵ In this respect, Daoist thought supports a form of context-sensitive reasoning that aligns with the notion of phronesis, by fostering attentiveness to situational variation and adaptive responses in clinical practice. Accordingly, Daoist philosophy informs TCM’s understanding of health, disease, and the human body in relation to the natural world. By contrast, Confucianism centers on human relationships, social ethics, and appropriate conduct, and thus more directly informs the ethical dimension of phronesis. The Confucian ideal of hé (和, harmony) emphasizes the coordination of multiple perspectives and provides normative guidance for how doctors engage with patients. This orientation aligns with the holistic nature of TCM, where patients’ experiences and contextual conditions are treated as integral to diagnosis and treatment. ⁵⁶ In this respect, Confucian ethics supports the enactment of phronesis through moral responsibility, sensitivity to context, and appropriate interpersonal conduct in doctor-patient interaction. The pursuit of arête in TCM is closely associated with Confucian virtues. Traditionally, TCM practitioners have been expected to cherish life, relieve suffering, and act sincerely, combining clinical competence with moral integrity. ¹ In particular, the principle of zhōngyōng (中庸, doctrine of the mean) reflects a cultivated moral disposition characterized by balance, moderation, and the avoidance of excess and deficiency. Zhōngyōng embodies a stable ethical orientation through which doctors regulate their conduct in a consistent and appropriate manner. In clinical practice, this is reflected in a tendency to avoid overly aggressive intervention while maintaining a sustained commitment to patients’ long-term physical and psychological well-being. ⁵⁷ Acting sincerely further emphasizes chéng (诚, sincerity), namely, the physician’s moral character and relational commitment.^58,59 Moreover, eunoia in TCM is linked to Confucian ideals of rén (仁, benevolence) and lǐ (礼, ritual propriety), which foster trust and rapport through practices such as personalized guidance, compassion, and fairness. ¹ Furthermore, except Daoism and Confucianism, TCM has also been shaped by other intellectual traditions, including Legalism and Buddhism, which have contributed to respectively institutional regulation of medical practice and ethical reflections on suffering and compassion in healing traditions.^60,61 However, Daoism, Legalism and Buddhism operate at the level of separately cosmological, institutional, or spiritual reflection rather than providing fine-grained, interaction-oriented concepts that can be directly applied to the coding of discourse in doctor-patient communication. The present study examines ethos construction in doctor-patient communication, which is an interpersonal and relational process. Given that Confucian ethical concepts such as hé, zhōngyōng, chéng, rén, and lǐ emphasize moral cultivation, relational responsibility, and respectful interpersonal conduct, and have long been regarded as central to social practice,^62,63 these dimensions are particularly relevant for analyzing interactional practices in this study. Moreover, in medical consultations, these values are not merely abstract philosophical commitments but can function as interactional resources. Doctors enact these values through discourse practices such as conflict avoidance, empathy displays, relational alignment, and face-sensitive guidance.^64,65 This becomes especially important in OMCs where verbal expressions of empathy and sincerity help compensate for the lack of physical presence and embodied trust. ⁸ These culturally embedded moral orientations therefore provide an important cultural and ethical foundation for understanding ethos construction in TCM doctor-patient communication.

Furthermore, TCM has long undergone institutional and policy reforms, demonstrating a strong ability to adapt to changing social, scientific, and regulatory environments. ²⁸ For instance, given the dominance of WM in China and its clinical advantages, research shows that TCM practice increasingly moves toward an “organic integration” of WM epistemologies to leverage the strengths of both systems. ⁶⁶ As healthcare digitalization accelerates, with OMCs becoming an important way of medical service delivery, ⁶⁷ TCM is also undergoing adaptation within digital contexts. ²⁸ In these OMCs, where communication is text-based and patients often reference external biomedical information,^14,15 TCM doctors face a dilemma: they must preserve TCM’s holistic, body-oriented paradigm while engaging with the data-driven logic of digital healthcare. ²⁸ Some doctors continue to rely solely on traditional TCM epistemology. Others incorporate WM diagnostic tools and data to compensate for the loss of embodied interaction in online encounters, creating one mode of digital adaptation. ²⁸ Still others pursue deep theoretical and practical integration of TCM and WM knowledge systems, ⁶⁸ forming another mode of digital adaptation. These adaptations are particularly salient in digitally mediated interactions, as the online environment reshapes both informational access and interactional dynamics. Consequently, digital adaptations shape diagnostic and patient engagement practices in TCM and influence how doctors construct ethos in online consultations, highlighting the interplay among ethos, rationales, cultural ethics, and digital adaptation examined in this study.

The present study aims to investigate how TCM doctors construct ethos in managing patient resistance during OMCs by addressing the following research questions.

RQ1: What types of ethos-based strategies do TCM doctors employ to manage patient resistance in Chinese OMCs?

RQ2: How do these ethos-based strategies constructed (associated with rationales, cultural ethics, and digital adaptation) to assist TCM doctors in managing patient resistance?

2. Methods

2.1. Data Collection

Data for this study were obtained from Chunyu Doctor, a leading Chinese OMC platform. Chunyu Doctor offers several advantages for analyzing digitally mediated TCM doctor-patient interactions. It provides complete, publicly accessible consultation records, enabling systematic discourse analysis of naturally occurring interactions. The platform mainly supports text-based consultations, which allow precise sequential analysis of patient resistance and physician responses, whereas platforms relying on video or audio (e.g., Haodaifu Online) may not provide such detailed textual data. ⁶⁹ In addition, Chunyu Doctor hosts a geographically and institutionally diverse cohort of TCM practitioners, ensuring that the sample is representative of different hospital levels and regions.

On this platform, doctors who serve as offline health professionals in hospitals publicly disclose basic information such as their authentic names, specializations, professional affiliations, and titles to verify themselves as licensed medical practitioners. In contrast, patients can opt for anonymity to protect their privacy. The platform enables patients to engage in asynchronous text-based consultations with doctors, subject to a 48-hour time limit or a maximum of 30 doctor responses.

Because the total number of doctors available on the platform is not publicly disclosed, we followed the sampling procedure described by Zhang et al ⁶⁹ and applied doctor-level inclusion criteria. The inclusion criteria were as follows: (1) doctors who had conducted at least 30 completed text-based consultations on the platform; (2) doctors whose consultation records included interactions with a minimum of four conversational turns, consistent with established interactivity standards for interactional discourse analysis ⁷⁰ ; and (3) doctors whose specialization was clearly identified as TCM. To ensure the recency of the dataset, ⁷⁰ only doctors with consultations initiated after January 2023 were considered. Based on these criteria, a sampling frame was constructed on 5 August 2025 using the system-generated default list of eligible TCM doctors. From the first 100 doctors who met the criteria, 20 doctors were randomly selected using Excel’s randomization function. For each selected doctor, the 20 most recent consultation records were retrieved in chronological order using Octopus, a Chinese web-crawler tool. At the consultation level, the exclusion criteria were as follows: (1) duplicate consultation records and (2) consultations that were incomplete or contained only administrative or non-clinical content. After applying these criteria, the final dataset comprised 395 consultations totaling 307,414 Chinese characters.

The consultations on Chunyu Doctor are publicly available with the consent of both doctors and patients. ¹⁵ Although patients cannot be contacted for explicit consent due to their anonymized status, there is an implicit understanding that their shared interactions may be viewed and used for research purposes. ⁷¹ Following established practices in research using publicly accessible, anonymized medical data,^14,15 formal consent statements and ethical committee approval were not required for this study. Nonetheless, any information that could potentially reveal a participant’s identity was redacted. ⁷² Each participant was assigned a numerical code, with “D” denoting doctors and “P” patients in all examples.

2.2. Data Analysis

This study employed a mixed methods design. We used IDA to examine doctor-patient interactions at the micro level and MCA to identify broader patterns in the coded data. Together, these approaches supported cross-validation of the findings.

2.2.1. IDA and Ethos Coding

First, using IDA and following the procedures outlined by Muntigl, ⁷³ the first two authors independently annotated patient resistance units through turn-by-turn analysis. Although Muntigl’s work was originally developed in the context of couple therapy, its core analytical logic focuses on the sequential organization of resistance and how speakers respond to each other’s prior actions in naturally occurring interactions. This emphasis on interactional sequencing has been successfully applied to research on OMCs, where patterns of patient resistance and doctors’ management strategies are examined within turn-by-turn interaction structures, ¹³ demonstrating the framework’s applicability beyond marital counseling. In adapting this framework to TCM consultations, we retained its focus on action-response sequences while redefining the core interactional components for medical talk. Each resistance unit was defined to include the following components: (1) the doctor’s question, suggestion, or diagnosis; (2) the patient’s resistant response; (3) the doctor’s resistance management strategy; and (4) the patient’s follow-up. Specifically, patient responses were identified as resistance following Kent’s⁴ interactional definition, in which a response that does not align with the expected course of action is treated as a dispreferred or non-deferential response to the prior action, for example, by delaying, questioning, or avoiding the expected contribution. This interactional concept of resistance has been widely applied in conversation analytic studies of institutional talk, including medical consultations. ⁷⁴ Inter-annotator reliability for the discourse segmentation of resistance units was high (Krippendorff’s α = .938). ⁷⁵ Any discrepancies between coders were resolved through discussion.

Second, doctors’ responses to patient resistance were analyzed using the rhetorical theory of ethos. ⁹ Each resistance unit was treated as a single instance of analysis. Although the three dimensions of ethos may co-occur, we identified a primary dimension ⁷⁶ based on which dimension was most interactionally salient in responding to the patient’s resistance. Drawing on conversation analytic principles of action formation and sequential organization, coders assessed: (1) the doctor’s main communicative objective in the turn ⁷⁷ ; (2) the relative prominence and density of linguistic cues for each ethos dimension^9,76; and (3) the sequential function of the response within the consultation. ⁷⁷ The dimension that played the most central role in advancing the doctor’s response to resistance was coded as primary. Language use was analyzed in light of Aristotle’s⁹ definitions and interpreted within the clinical context of TCM consultations. Phronesis was evidenced through context-sensitive clinical judgments (e.g., “Your pulse shows liver fire rising”), where phronesis refers to practical wisdom or sound judgment in specific situations. Arête was reflected in ethical care (e.g., “This herb comes from authentic Dao-di sources”), where arête denotes excellence of character and professional virtue; reference to Dao-di indicates authentic, high-quality medicinal sources and reflects the doctor’s commitment to providing safe and effective treatment. Eunoia emerged through empathetic engagement (e.g., “I understand your feeling”), where eunoia denotes benevolent goodwill toward the patient that fosters trust and positive interaction. The first two authors independently coded the data to identify the dominant ethos type in each unit, achieving high inter-coder reliability (Cohen’s κ = .919). ⁷⁸ Any discrepancies were resolved through discussion.

To capture variations in ethos construction, the first two authors further identified subtypes of ethos through an iterative process based on Owen’s ⁷⁹ criteria: (a) recurrence of the implicitly related concepts; (b) repetition of keywords, phrases or sentences; and (c) forcefulness of the underlining of words and phrases, the increased size of print or use of colored marks circling or otherwise focusing on passages in the written reports. To ensure the reliability of the coded results, constant comparative analysis ⁸⁰ was conducted to verify established themes. ⁸¹ We reviewed each other’s transcripts to check the data anainst the emergent themes.

To minimize experimenter bias, two researchers specializing in interpretive investigations conducted expert checks. Using Miles and Huberman’s formula for confidence = Consensus/(Consensus + Disagreement), we calculated an average coding reliability of 97.3% for patient resistance, 95.5% for identifying the ethos types in doctor persuasion, and 96.5% for the ethos subtypes. A confidence level higher than 90% indicates reliable coding. ⁸² All discrepancies were discussed with the third author, a licensed TCM doctor, until agreement was reached.

2.2.2. MCA and Variable Selection and Coding

Following the IDA, we conducted an MCA to examine how the identified ethos strategies were constructed in TCM doctors’ management of patient resistance. MCA is a multivariate technique used for the analysis of multiple categorical variables, extending correspondence analysis to more than two nominal variables and representing their relationships in a common geometric space. In this framework, the raw data are structured as an indicator matrix of categorical variables, making it necessary that the analytical variables be specified as categorical indicators prior to analysis. ⁸³ Accordingly, the variables were defined based on the theoretical framework established in the literature review.^1,9,28,33 The operational definitions were developed through a two-step process combining theoretical grounding and empirical refinement.

We adopted a top-down deductive coding framework because our analysis aims to systematically link theoretically specified ethos construction (phronesis, arête, and eunoia) and the dimensions of rationales, cultural ethics, and digital adaptation to actual discourse practices. A deductive approach is appropriate when coding is guided by pre-existing theoretical constructs and research questions, as it applies predefined categories to examine how these constructs are manifested in the data through MCA. Such an approach is commonly used when theory-driven variables are required to operationalize constructs for quantitative analysis, rather than when exploring entirely emergent themes. Moreover, given the heterogeneity and subtlety of online discourse, all cases were first jointly reviewed by all authors and two researchers specializing in interpretive analysis. Through iterative discussions, recurrent and theoretically meaningful patterns were incorporated into the coding scheme. This process involved iterative rounds of pilot coding and refinement to ensure consistency and conceptual clarity. Four categorical variables were included in the MCA (Table 1).

(1) Dominant_Ethos refers to the primary ethos dimension enacted by doctors when managing resistance. Drawing on classical rhetorical theory, ethos was operationalized through its three widely recognized components: phronesis, arête, and eunoia. ⁹ These dimensions have been widely used to examine how speakers establish credibility in persuasive communication.^45-48 In clinical contexts, ethos is reflected in how doctors present adaptive expertise, moral integrity, and concern for patients during interactions. Each resistance unit was coded according to the most salient ethos dimension expressed in the doctor’s response.

(2) Rationale_of_Managing_Statements captures the persuasive rationales underpinning doctors’ management strategies.^6,32,33 Instead of relying solely on lexical markers, coding focused on the functional rationale through which doctors justified their recommendations. The categories include reasoning grounded in TCM principles, patient-specific explanations, consensus-oriented reasoning, procedural rationale, and imperative reasoning. This functional operationalization enables the analysis to capture the underlying persuasive logic of doctors’ statements rather than isolated linguistic forms.

(3) Cultural_Ethics represents culturally embedded moral orientations grounded mainly in Confucian philosophy.^1,56 These ethical concepts were first identified through prior literature on Confucian ethics and Chinese medical practice. Confucian moral principles such as rén, lǐ, hé, zhōngyōng, and chéng have long shaped expectations of doctors’ moral conduct and relational responsibilities in Chinese medical traditions.^64,65 These concepts were selected because they represent core relational virtues in Confucian medical ethics and are relevant to doctor-patient interaction in consultation discourse. The operational definitions were developed through a combination of literature review and data-based refinement. During the annotation process, these concepts were further refined through joint review and discussion among the research team and two specialized researchers. The coding definitions were refined to capture recurring discourse patterns rather than the full philosophical scope of the concepts. For example, lǐ was coded as maintaining professional propriety and respectful conduct toward patients, reflecting how ritual propriety is enacted in clinical interactions. While lǐ encompasses broader philosophical meanings, this study focuses on its most interactionally relevant manifestation in clinical discourse. This operationalization was justified through its recurrent manifestation in the data rather than assumed a priori. In this study, these culturally grounded orientations are treated as interactional resources through which doctors construct credibility, goodwill, and professional authority in managing patient resistance, consistent with a discourse-analytic perspective that treats cultural values as enacted through recurring communicative practices rather than as static philosophical constructs.

(4) Digital_Adaptation concerns discourse adaptation in digital clinical encounters.^28,66 OMCs differ from traditional face-to-face visits in that patients often access health information through digital platforms and communicate with doctors through text-based or asynchronous interfaces, which can reshape the informational environment and interactional dynamics of consultations. While such strategies may also occur in offline consultations, they become particularly salient in digitally mediated encounters where patients commonly introduce externally sourced biomedical information into the interaction.^13-15 In online contexts, doctors frequently encounter patients who reference externally obtained biomedical information or digital diagnostic resources. The coding scheme therefore focuses on how doctors position WM knowledge within their responses: NON (no reference to WM), INS (instrumental use of WM tools or information), and EPI (epistemological integration of WM and TCM knowledge sources). These categories do not assume that such strategies occur exclusively in digital consultations; rather, they operationalize how physicians adapt their discourse to the communicative conditions of online environments where patients’ access to external medical knowledge becomes a salient interactional resource.

Table 1.

Coding Scheme of Doctors’ Management Strategies

Variables	Features	Coding	Cohen’s κ
Dominant_Ethos	Phronesis	PHR	.919
	Arête	ARE
	Eunoia	EUN
Rationale_of_Managing_Statements	Reasoning grounded in TCM principles	TCM	.970
	Personalized rationale integrating statements with patient-specific situations	PAT
	Consensus-oriented rationale appealing to shared norms or goals	CON
	Procedural rationale that prioritizes action progression	PRO
	Imperative rationale based on authoritative persuasion	DIR
Cultural_Ethics	Promoting relational harmony and restoring balance	He	.966
	Projecting moral sincerity and trustworthiness	Cheng
	Balancing firmness and flexibility through moderation	Zhong Yong
	Expressing benevolence and empathetic concern	Ren
	Maintaining professional propriety and respectful conduct	Li
Digital_Adaptation	No reference to WM	NON	.932
	Instrumental use of WM tools	INS
	Epistemological integration of WM and TCM	EPI

The four variables were manually annotated on the identified patient resistance units. Each unit was treated as one observation. The first two authors independently applied the finalized scheme in coding, achieving high intercoder reliability in four aspects (Table 1, Cohen’s κ = .919-.970), ⁷⁸ with all disagreements resolved through consensus. Some responses did not clearly correspond to any category or simultaneously reflected multiple dimensions. These cases were coded as OTHER and excluded from the MCA. The remaining data were transformed into an indicator matrix in Python (version 3.13), and the MCA was conducted using the prince package. This study followed the STROBE Statement reporting guideline for observational studies to ensure transparency in reporting the study design, data collection, and analysis.

3. Results

Across the 395 OMC cases, 217 instances of patient resistance were identified. TCM doctors addressed these instances using ethos in 209 cases, while the remaining 8 cases involved other responses, including non-answers, and topic shifts. A chi-square goodness-of-fit test was conducted. The observed frequencies were 80 for phronesis (36.9%), 58 for arête (26.7%), and 71 for eunoia (32.7%). The results indicated no significant differences across the three categories (χ ² (2, n = 209) = 3.55, p = .17), suggesting that these strategies were employed at comparable rates.

3.1. MCA Results

The scree plot shows that the percentage of total inertia explained declines sharply after the second dimension (Figure 1), with the corresponding eigenvalue dropping by 56.3% from Dimension 2 to Dimension 3. The first two dimensions together accounted for 48.4% of the total inertia. Following the approach recommended by Sourial et al ⁸⁴ for MCA, we adopted a two-dimensional solution because it offers greater clarity and interpretability of the underlying category structure.

Figure 1.

Scree plot

To investigate how ethos was constructed to support doctors in managing patient resistance, we plotted 95% confidence ellipses around the mean coordinates of each Dominant_Ethos category in the MCA space. The distribution in Figure 2 reveals three distinct clusters, each defined by a specific configuration of ethos types, rationales, cultural ethics, and digital adaptation. These clusters illustrate how TCM doctors strategically construct different ethos associated with these variables to manage patient resistance.

Figure 2.

MCA joint plot-variable relationships

The phronesis cluster (lower left, red) is associated with PAT- and TCM-based rationales as well as the cultural ethic of hé. This pattern shows that practical wisdom emerges from personalized reasoning and integrates traditional TCM theory. Here, hé represents the coordination of internal and external forces and the balance among individual, social, and natural relationships, ⁵⁶ and this orientation guides doctors in helping patients interpret their conditions in a more integrated way. The arête cluster (right, green) links CON-based rationales with digital adaptation, including the instrumental use of INS and EPI, alongside the Confucian principles of chéng and zhōngyōng. This configuration reflects that, when enacting professional virtue, doctors strategically combine evidence and theoretical knowledge from both WM and TCM, while maintaining transparent communication grounded in moral integrity and emphasizing consensus of balanced in treatments. ⁵⁷ The eunoia cluster (upper center, purple) is associated with PRO rationales and the Confucian values of rén and lǐ, showing that patient-centeredness is realized through step-by-step guidance shaped by care ethics and proper relational conduct.

Notably, DIR (n = 7) and NON (n = 154) are located near the center of the plot, separate from all three ethos clusters. The scarcity of DIR (3.23%) reflects the infrequent use of imperatives by TCM doctors in managing patient resistance, whereas the prevalence of NON (70.97%) suggests that these strategies function as general communicative resources rather than distinctive markers of ethos.

3.2. IDA Results

IDA was conducted to identify the specific subtypes of ethos: (1) phronesis through dynamic diagnosis or recommendation adjustment and integration of theory with experience; (2) arête through transparency in limitations and patient-safety prioritization; and (3) eunoia through affective alignment, and empowerment via education.

3.2.1. Phronesis

Two types of phronesis, namely dynamic diagnosis or recommendation adjustment and integration of theory with experience. The former reflects sensitivity to context and audience, while the latter applies expertise through experiential insight.^41,42

3.2.1.1. Dynamic Diagnosis or Recommendation Adjustment

Hauser ⁸⁵ defined phronesis as making specific choices about what is beneficial in a given situation. In OMCs, TCM doctors often constructed their ethos by iteratively refining diagnostic hypotheses and treatment recommendations in response to patients’ evolving input on clinical cues, thereby suggesting an active engagement with patients’ symptoms, health conditions, and lifestyles. Such iterative engagement reflects a Confucian orientation toward hé, in which doctors adjust their responses to coordinate differing perspectives and maintain a harmonious interaction.

Excerpt 1 is drawn from an OMC in which a patient reported breast discomfort prior to menstruation. In Turn 01, the doctor explained that mild premenstrual breast pain was common due to hormonal fluctuations and suggested diagnostic testing to rule out any pathological causes with the softened and indirect expression of “It’s best ...,” which avoided imposing and made space for patient autonomy. Realizing this “patient-centered” direction, in Turn 02, the patient clarified that she had not experienced breast distension and that the pain had subsided once menstruation began, implicitly questioning the necessity of further testing. Rather than insisting on additional tests, the doctor pivoted in Turn 03, demonstrating flexibility that aligns with the Confucian ideal of balancing different viewpoints to achieve relational harmony. The doctor provided a low-intervention solution by suggesting two classic formulas to relieve her premenstrual discomfort. By addressing the patient’s specific concerns and avoiding unnecessary interventions, the doctor helped to reduce resistance and reinforce trust. This led to the patient’s explicit agreement in Turn 04, marking the success of the doctor’s adjusted recommendation.

Excerpt 1 Dynamic diagnosis or recommendation adjustment.

3.2.1.2. Integration of Theory With Experience

TCM doctors also frequently integrated traditional medical theories with clinical experience as an expression of phronesis in managing patient resistance. These interactions involved applying core TCM principles while tailoring explanations to specific symptoms, demonstrating clinical expertise. ⁴¹

Excerpt 2 Integration of theory with experience.

Excerpt 2 is drawn from an OMC case in which a patient presented with urinary frequency and urgency. In Turn 01, the doctor ruled out a damp-heat pattern and instead attributed the condition to heat binding in the bladder, identifying liver qi stagnation and spleen deficiency as the underlying causes. Rather than aligning with the diagnosis, the patient in Turn 02 foregrounded superficial sensations such as scrotal dampness and occasional coolness, which appeared more indicative of damp-heat or cold-damp patterns. This misalignment introduced a tension between the patient’s embodied experience and the doctor’s initial diagnostic reasoning, prompting the need for further elaboration.

Recognizing that these localized bodily sensations might be interpreted under a Western-medical paradigm as signs of discrete pathology, in Turn 03 the doctor reframed them within a holistic TCM framework by invoking the Five Elements theory. ³¹ He explained that spleen qi deficiency had generated dampness, which subsequently impeded the liver’s dispersing function, leading to liver qi stagnation. This diagnostic rationale drew on the classical principle “earth overburdens, wood stagnates,” linking spleen earth dysfunction to liver wood pathology. By integrating the patient’s experiential account into core TCM epistemology, ²⁷ the doctor validated the patient’s concerns and reinforced the theoretical coherence of his diagnosis. In the Confucian philosophical tradition, harmony involves balancing diverse perspectives and integrating them into a coherent understanding of the situation, which resonates with the doctor’s effort to reconcile the patient’s experiential sensations with TCM theory. The patient’s minimal acknowledgement token “Uh-huh” in Turn 04, functioning as a listener signal of understanding and tentative agreement, ⁸⁶ suggests movement toward acceptance.

Taken together, exchanges in this category reveal doctors’ flexibility toward patients’ narratives, as they adjust treatment plans based on patients’ reported experiences. Doctors also invoke TCM theories to explain diagnoses, offer suggestions, and guide inquiries, emphasizing a relational coordination among individual experience, diagnostic theory, and ongoing interaction that reflects the Confucian understanding of hé. ⁵⁶ Rather than applying theory rigidly, they respond dynamically to emerging resistance and provide tailored explanations that attend to patients’ concerns. These practices embody TCM’s holistic principle of adapting treatment to the individual, time, and environment. ⁸⁷ In line with the MCA results, this pattern indicates that phronesis is associated with PAT- and TCM-based rationales and the cultural ethic of hé. Together, they guide doctors to integrate TCM theoretical knowledge with patients’ evolving conditions in a holistic manner when managing resistance.

3.2.2. Arête

Arête refers to acting in line with culturally valued virtues. ⁹ When addressing patient resistance, TCM doctors enacted arête by prioritizing patient safety and maintaining transparency about clinical limitations. As ethical agents, they acknowledged the boundaries of TCM, supplemented their decisions with WM theories or tools when necessary, and refrained from recommending treatments driven by financial gain if those treatments conflicted with their professional judgment. Through these actions, doctors upheld professional integrity and strengthened their credibility, reflecting broader cultural ideals of virtue in medical practice.^42,43

3.2.2.1. Transparency in Limitations

Arête entails demonstrating moral character by presenting issues clearly and engaging fairly with differing views. ⁹ In TCM OMCs, this was seen in doctors’ transparency in limitations when addressing patient resistance. Some explicitly acknowledged the scope of TCM, such as the slower effects of herbal treatments, or the limitation of the four-step method in OMCs.

Excerpt 3 Transparency in limitations.

Excerpt 3 comes from an OMC where a patient asked about abdominal discomfort and unusual stool shape. In Turn 01, the doctor asked whether the patient previously had a colonoscopy. Although the patient answered, he also expressed implicit skepticism in Turn 02, questioning why a TCM doctor would request biomedical test results, signaling doubting the doctor’s approach or identity. This doubt reflects a common assumption: that TCM doctors rely on the traditional four-step method and typically do not use modern medical data. ⁸⁸ To manage this doubt, in Turn 03, the doctor acknowledged the patient’s resistance and responded by reaffirming his identity as a TCM practitioner. At the same time, he stressed the importance of detailed information for accurate diagnosis. He explained that without in-person interaction, biomedical reports like colonoscopy findings become essential. This clear and honest explanation addressed the patient’s skepticism and highlighted the practical limits of online TCM consultations. It reasserted the doctor’s professional legitimacy while also bridging the gap between TCM epistemology and online constraints. After that, the doctor redirected the conversation by asking “Have you taken any medication?,” to an area where the doctor’s clinical experience and treatment reasoning can resume. ¹⁷ This finally led to the patient’s expression of deeper concerns in Turn 04.

3.2.2.2. Patient-Safety Prioritization

Aristotle ⁹ defined virtue, grounded in arête, as action guided by concern for others. In TCM, this is reflected in physicians’ commitment to patient well-being, such as devoting extra time to ensure safety. ⁸⁹ This study identified patient-safety prioritization as a strategy, where doctors responded to resistance by emphasizing that their inquiries and recommendations stemmed from genuine concern for patients’ health.

Excerpt 4 Patient-safety prioritization.

Excerpt 4 is taken from an OMC in which a patient inquired about treatment for chronic atrophic gastritis with erosion. In Turn 01, the patient asked whether two TCM formulas, Weifuchun and Moluodan, could be taken concurrently. This reflects a common misconception among patients that combining multiple medications will necessarily enhance therapeutic effectiveness. In Turn 02, the doctor responded with a firm rejection, stating “No, they can’t,” employing high-modality language that reinforces clinical authority and prescribing expertise ⁹⁰ to prevent unsupervised medication combinations. However, this authoritative stance elicited resistance in Turn 03, as the patient questioned the rationale behind the prohibition, prompting the doctor to justify their authority. Recognizing the patient’s resistance, the doctor adjusted his expression in Turn 04 by employing the rhetorical strategy of patient-safety prioritization to construct his ethos as a responsible practitioner. He began by affirming the evidence-based effectiveness of Weifuchun as a consensus, ³² and then explained that combining different formulas could reduce its efficacy or cause unpredictable interactions, emphasizing the importance of avoiding excessive or aggressive interventions. By framing his decision around patient safety with rather than financial interest or authoritative control, the doctor presented his recommendation as guided by the patient’s well-being. However, this approach still encountered resistance in Turn 05.

Overall, in this category, TCM doctors aimed to uphold professional credibility while managing patient resistance. They acknowledged the limitations of TCM, incorporated WM tools or theories when necessary, and refrained from recommending excessive interventions that conflicted with clinical judgment and consensus. These actions are in line with the MCA results showing that arête is connected with chéng, indicating that doctors communicated with sincerity and adhered to moral integrity. Additionally, they are also consistent with MCA findings that arête closely links to CON-based rationales, digital adaptations such as INS and EPI, and the cultural ethic of zhōngyōng, which values moderation over rapid but potentially aggressive treatments. ⁵⁷

3.2.3. Eunoia

TCM doctors also construct ethos through eunoia by acknowledging patients’ concerns and identifying with their experiences. ⁹ As a marker of trustworthiness, eunoia reflects understanding, empathy, and responsiveness. ⁹¹ Understanding involves recognizing patients’ needs and perspectives, empathy entails emotional attunement, and responsiveness acknowledges patients’ communicative efforts.

In OMCs, TCM doctors expressed eunoia through tailoring responses to individual concerns, aligning emotionally with patients’ struggles, and empowering them through education. This not only affirms patient autonomy but also positions them as active participants in the healing process.

3.2.3.1. Affective Alignment

Affective alignment, grounded in eunoia, is a strategy whereby TCM doctors address patient resistance by empathetically engaging with patients’ emotions. By validating patients’ feelings, doctors foster a therapeutic environment that promotes compliance and deepens understanding of clinical conditions. ²

Excerpt 5 Affective Alignment

Excerpt 5 is drawn from an OMC in which a patient sought advice for severe hair loss. In Turn 01, the doctor recommended a TCM formula. The use of the expression “Would it be convenient to...” introduces the option with low imposition. In Turn 02, the patient expressed past treatment failure and accompanying emotional fatigue, softening the compliant with the emoji . This response reflects emotional resistance, ¹⁵ revealing a complex emotional state: openness to new help, but hesitancy rooted in disillusionment, which demands emotional sensitivity in response. To manage patient resistance, in Turn 03, the doctor employed the strategy of affective alignment by using a tentative, collaborative invitation, “Well, let’s give it a shot. What do you think?” This reframes the recommendation as a joint decision, thereby reducing perceived pressure. To further ease the patient’s emotional burden, the doctor introduced the metaphor, “Seeing a doctor sometimes depends on fate.” Drawn from Confucian traditions, the concept of yuánfèn (缘分, predestined affinity) ⁹² reframed the patient’s previous treatment failures not as clinical shortcomings, but as mismatches in doctor-patient fit. This rhetorical move subtly redirects the patient’s focus ⁹³ toward the possibility of renewed compatibility and trust, rather than medical efficacy alone. The inclusion of the non-verbal cue further conveyed warmth, helping to reduce emotional tension, and ultimately facilitated agreement in Turn 04.

3.2.3.2. Empowerment Through Education

TCM doctors demonstrated responsiveness to patients’ communicative goals by employing the strategy of empowerment through education, a form of eunoia-based ethos used to address patient resistance. This strategy involved offering actionable knowledge aligned with TCM principles, particularly through tiáolǐ (调理, holistic self-regulation practices that encompass dietary guidance, lifestyle adjustment, emotional balance, and the observation of bodily changes over time). ³⁷ By integrating tiáolǐ into their consultations, doctors provided patients with concrete, culturally grounded methods to participate actively in their own care. This approach not only supports patient autonomy but also transforms compliance into informed, sustained engagement.

Excerpt 6 Empowerment Through Education

Excerpt 6 is from an OMC in which a patient sought treatment for chronic prostatitis. In Turn 01, the doctor recommended initiating treatment with a three-dose course of TCM. In Turn 02, the patient expressed skepticism about the short duration and questioned its adequacy. This response reflects the influence of WM on the patient’s expectations, particularly the belief that efficacy increases proportionally with dosage and duration, a model known as the linear dose-response relationship. ⁹⁴ By contrast, TCM operates under a nonlinear and individualized framework that begins with small, syndrome-specific trial doses. ⁹⁵ Although the doctor initially reiterated his recommendation in Turn 03, he soon recognized that the patient’s underlying communicative aim was a need for more detailed explanations on guidance and reassurance. In Turn 05, the doctor directly addressed this resistance by clarifying that the short-term prescription served as an initial trial to observe the body’s response, with the treatment duration to be adjusted based on subsequent stability. This explanation exemplifies TCM’s adaptive, individualized approach. The doctor further empowered the patient by providing specific guidance for self-monitoring: he outlined possible side effects such as loose stools, normalized these as part of the therapeutic process, and offered practical solutions for more severe symptoms like frequent or watery stools. This interaction illustrates the strategy of empowerment through education, whereby the doctor fosters patient agency and reinforces mutual trust through detailed, anticipatory guidance. The patient’s response in Turn 06 indicates acknowledgment of the guidance provided, reflecting receptivity to the doctor’s explanation.

Taken together, in this category, TCM doctors addressed patients’ emotional resistance by acknowledging feelings, restoring hope, and fostering a sense of shared journey in treatment. They empowered patients through education, provided stepwise guidance, and complemented prescriptions with tiáolǐ, such as holistic advice on diet, lifestyle, and self-monitoring, demonstrating responsiveness and supporting patient understanding and agency. These practices exemplify eunoia by reflecting patient-centered care and relational attentiveness. These actions correspond to the MCA results, which show that eunoia is closely associated with PRO-based rationales and the Confucian values of rén and lǐ. Specifically, doctors’ stepwise guidance and emphasis on patient participation align with PRO-based rationales, while relational attentiveness, empathy, and moral care reflect the ethical orientation of rén and the proper relational conduct of lǐ.

4. Discussion

Using mixed methods combining IDA and MCA, this study investigated ethos-based strategies employed by TCM doctors in OMCs and how these strategies help manage patient resistance. Across 217 patient resistance instances, TCM doctors employed phronesis, arête, and eunoia in relatively balanced ways. Phronesis includes the subtypes of dynamic diagnosis or recommendation adjustment and integration of theory with experience, co-occurring with PAT- and TCM-based rationale, alongside the value of hé, reflecting the realization of it through flexibility and holistic interpretation to navigate clinical uncertainty. Arête involved transparency in limitations and patient-safety prioritization, linked CON-based rationale with INS, EPI, and the values of chéng and zhōngyōng, indicating its realization through integration of WM tools or theories while maintaining moral integrity. Eunoia emphasized affective alignment and empowerment through education, associated with PRO and the values of rén and lǐ, reflecting its realization through sensitivity to patients’ emotional and physical suffering, and demonstrated responsiveness to foster patient agency. Notably, DIR was rarely used. NON appeared frequently near the plot center, indicating that it functioned as general resources.

TCM doctors demonstrated flexibility in adjusting diagnoses and treatment recommendations as an expression of phronesis, similar to WM doctors’ willingness to revise clinical assessments.^15,22 Extending prior research on epistemic authority in WM,^17,21 our findings show that TCM doctors also recognize patients’ epistemic authority by valuing their experiential knowledge in OMCs. These practices reflect a shared orientation toward collaborative decision-making in digital contexts.

However, distinct from WM doctors who differentially rely on interpretives, supportives, and imperatives to assert epistemic or deontic authority, ¹³ TCM doctors exhibited a relatively balanced use of ethos-based strategies. Ethos construction in TCM consultations draws on interpretive reasoning (phronesis) and relational engagement (eunoia and arête), while DIR were uncommon (3.23% in TCM vs. 19.78% in WM OMCs). ¹³ This pattern also contrasts with findings from offline TCM settings, where imperatives are reportedly frequent. ³⁵ These differences may reflect the distinct epistemological foundations of the two medical systems. WM is grounded in a positivist biomedical paradigm emphasizing standardization, and objectivity.^25-27 Evidence-based justifications such as laboratory and physical examination results position doctors as authoritative controllers of physiological conditions.^13,14 This reflects a reductionist view of the body as discrete, measurable parts subject to control and predictability, ²⁴ which in turn legitimizes the use of imperatives. Although the patient-empowering nature of OMCs may lessen explicit directiveness, the communicative orientation of WM largely persists, as e-patients can provide standardized evidence from offline visits, ²² sustaining a directive logic in online encounters.

In contrast, TCM is grounded in a holistic worldview that integrates relationality, lived experience, and intuitive judgment.^5,29 MCA results show that phronesis co-occurs with PAT and TCM-based rationales and with the value of hé. This suggests that TCM doctors’ reasoning involves individualized understanding, theoretical integration, and cultural ethics that coordinate diverse experiential and diagnostic perspectives rather than imposing uniformity, reflecting the Confucian ideal of harmony. ⁵⁶ In offline settings, the four-step method provides comprehensive diagnostic cues, which allow doctors to confidently assert authority through imperatives. However, in OMCs, the absence of pulse-taking and the distortion of tongue or facial indicators due to device and lighting limitations heighten diagnostic uncertainty. Hence, doctors tend to rely more on tailored explanatory reasoning guided by the value of hé to persuade patients rather than directly issuing imperatives. Language functions as relational guidance instead of a mechanism of control. ⁸ This study demonstrates that TCM in OMCs embodies a form of negotiated authority that builds trust through education, empathy, and holistic coordination. This perspective extends Aristotelian ethos by embedding it in a relational and holistic moral framework, where credibility derives not only from expertise but also from the coordination of different perspectives and the pursuit of relational harmony represented by hé. ⁵⁶

Having shown that TCM doctors use fewer DIRs when constructing ethos in OMCs, this section turns to a related issue: how patient safety is communicated. Patient safety is a shared concern across medical systems, grounded in the principle of non-maleficence and reinforced by professional norms. ²³ However, the ways safety is communicated differ. In WM OMCs, safety is commonly maintained through directive language and constrained-choice formats that foreground deontic authority and promote adherence to standardized protocols.^13,14 By contrast, TCM doctors tend to safeguard safety by softening authority. Arête-based strategies, often co-occurring with CON-based rationales and zhōngyōng, favor minimal yet sufficient intervention and emphasize consensus. These strategies frame recommendations in terms of harm reduction and necessary intervention, thereby conveying concern for patients’ well-being rather than control. This approach is particularly salient in online settings, where diagnostic uncertainty is higher. In OMCs, zhōngyōng thus functions as a practical guide for balancing explanation and guidance: doctors neither enforce compliance through imperatives nor shift full responsibility to patients under conditions of limited knowledge.

Beyond balancing authority, TCM OMCs placed patient empowerment within a moral and relational framework. Strategies based on eunoia showed sensitivity to patient suffering, similar to emotion-oriented approaches in WM OMCs.^13,15 More importantly, they also reflected culturally rooted ideas. ⁹² For instance, treatment failure was sometimes explained not as a sign of professional fault but as a temporary misalignment of fate in the patient’s life course. This explanation helped doctors maintain credibility and encouraged patients to stay resilient. In TCM, empowerment was not simply used to make patients follow instructions but developed as a shared process, linking PRO-based reasoning with empathy and care shaped by rén and lǐ. Rén emphasizes compassion and understanding of others’ suffering, while lǐ highlights respect and appropriate conduct in interpersonal interactions. ¹ Together, these virtues help doctors communicate with moral concern and maintain respectful relationships. Drawing on these values, TCM doctors often acted as companions who focused on patients’ individual needs rather than mere standardized procedures. They offered advice that combined diagnostic reasoning with everyday experience and guided patients on how to tiáolǐ, to adjust diet, lifestyle, and self-care to maintain balance and prevent illness. ³⁷ This relational approach reflects a broader shift in digital health communication from treating disease to addressing emotional and personal dimensions of illness.^13,15

Crucially, moral sincerity further reinforces this culturally embedded approach. In practice, this virtue is manifested when TCM doctors openly acknowledged the limitations of their practice in online contexts (e.g., the absence of embodied diagnostic methods), consistent with MCA results of the co-occurrence of arête-based strategies and Confucian virtue of chéng. In Confucian philosophy, chéng signifies the cultivation of authentic moral character, aligning one’s inner intentions with outward actions, and sustaining integrity in all forms of human interactions. Rather than reducing credibility to mere procedural transparency or technical accuracy, chéng stresses the physician’s commitment to moral self-cultivation and the genuine alignment of words, attitudes, and conducts.^58,59 This emphasis is particularly salient in OMCs, where diagnostic uncertainties and contextual constraints may easily undermine trust. By embodying chéng, TCM doctors managed uncertainty and setbacks not by denying or disguising them, but by openly acknowledging limitations and reaffirming their commitment to the patient’s well-being. Taken together, these findings demonstrate that TCM OMCs are culturally embedded practices that actively translate Confucian ethics into communicative strategies. This perspective enriches understanding of resistance management by revealing how cultural resonance can foster trust and alliance in digital healthcare.^49,50

Moreover, the Confucian virtue of chéng encourages TCM doctors to acknowledge the boundaries of TCM and the limitations imposed by online consultation, while still engaging in adaptive responses. The MCA results showed that this concept tended to co-occur with INS and EPI, indicating that sincerity enables doctors to incorporate modern WM tools and theories, such as laboratory results, while preserving TCM’s core principles and professional identity. Through this process, TCM and WM are presented as complementary systems rather than conflicting sources of “cross-dimensional ambivalence”.^28,67 In digital contexts, such synthesis mitigates epistemic and technological constraints, including patients’ concerns about scientific validity, and sustains cultural authenticity. It also represents a pragmatic mode of problem-solving that aligns with TCM’s historical evolution through institutional reforms. ²⁸ The frequent use of NON strategies, positioned near the plot center, further suggests that these communicative resources operate as flexible tools. This pattern indicates that TCM doctors primarily rely on TCM frameworks while supplementing them with WM elements when needed. As a result, modernization in TCM communication is not a process of passive Westernization but a form of active identity negotiation that maintains fidelity to tradition and responds to contemporary demands. This finding has important implications for TCM’s role in global health, as its future vitality may hinge on developing hybrid identities that integrate traditional values with modern technologies and evidence-based practices.

5. Conclusion

This study examined how TCM doctors managed patient resistance in OMCs. Our findings showed that TCM doctors constructed ethos through three key dimensions in a balanced manner. In phronesis, they demonstrated dynamic diagnosis or recommendation adjustment and integration of theory with experience. In arête, they emphasized transparency in limitations and patient-safety prioritization. In eunoia, they offered patients affective alignment, and empowerment through education.

Theoretically, this study shows how TCM doctors manage patient resistance by combining medical tradition, cultural ethics, and digital adaptation in OMCs. It extends existing ethos research that centers on evidence-based WM by demonstrating how TCM’s holistic reasoning shapes credibility and persuasion. TCM doctors integrate Confucian values in patient resistance management procedures. In doing so, they turn OMCs into settings where authority is built through culturally meaningful trust rather than imperative control. The findings also show that digital environments do not weaken this ethical approach but support its adaptation, as TCM doctors use modern diagnostic resources to enhance credibility while keeping cultural principles intact. This combination of cultural tradition and technology offers a new way to understand ethos in OMCs and broadens existing views of credibility, trust, and persuasion by including culturally grounded practices of sincerity, relationship-building, and shared agency.

Practically, findings provide several insights for improving healthcare practices. First, TCM doctors’ holistic approaches illustrate that patient resistance can be reframed as constructive resources in interpretations, offering feedback that strengthens trust and fosters sustained engagement rather than being treated solely as non-compliance. Second, TCM doctors’ transparent integration of WM diagnostic data within a TCM framework demonstrates a pragmatic pathway toward more holistic and credible assessments in telemedicine. Third, acknowledging the cultural foundations of TCM can inform the design of culturally attuned health interventions, including ICT systems tailored to TCM practice, which respect local epistemologies while enhancing user trust. These insights can support policymakers, platform developers, and practitioners in creating digital health ecosystems that are both culturally resonant and clinically effective.

This study has some limitations. It focuses on a single OMC platform, which may not capture the full range of resistance patterns across online, offline, or cross-cultural settings. Future studies should examine a broader variety of platforms and clinical environments. In addition, the exclusive use of publicly available text-based consultations omits non-verbal cues, such as tongue inspection, which are central to TCM diagnosis and doctor-patient rapport. This may oversimplify how ethos is constructed, particularly in offline contexts. Future research could include multimodal data from private or face-to-face interactions to better understand resistance management across communication modes. Finally, this study adopts an etic perspective based on IDA and MCA. While these approaches highlight discursive patterns, it does not fully reflect how patients interpret doctors’ strategies. Future work could apply methods that include an emic perspective to examine both doctors’ and patients’ views, offering a more comprehensive understanding of ethos in OMCs and its role in managing resistance.