Christine Phillips

Doctor, patient and computer—A framework for the new consultation

PURPOSE The use of a computer during general/family practice consultations is on the rise across the world, yet little is known about the effect the use of a computer may have on the all important physician-patient relationship. This paper provides a framework for further analysis of computers influence on physician-patient interactions during general practice consultations. METHODS This is an observational qualitative study informed by hermeneutics and the phenomenological tradition of Irving Goffman, based in Australian general practice. A single digital video recording of 141 patient encounters over 6 months was made and imported into a tagging software program to facilitate analysis. Through an iterative process several keys and behaviours were described for doctors, patients and the computers in the interaction. RESULTS Physicians tended to fall into two categories; unipolar-those who tend to maintain the lower pole of their body facing the computer except were examination of the patient or some other action demands otherwise, and bipolar-those physicians who repeatedly alternate the orientation of their lower pole between the computer and the patient. Patients tended to demonstrate behaviours that focused on the physician to the exclusion of the computer (dyadic) and included the computer in the consultation (triadic). The computer was also seen to influence the physician-patient interaction passively or actively. CONCLUSION In describing and categorising the behaviours of the computer, in addition to the humans in the consultation, a framework is provided for further analytical work on the impact of computers in general practice.

Computers in the new consultation: within the first minute

BACKGROUND Computers are now commonplace in the general practice consultation in many countries and literature is beginning to appear that describes the effects of this presence on the doctor-patient relationship. Concepts such as patient centredness emphasize the importance of this relationship to patient outcomes, yet the presence of the computer has introduced another partner to that relationship. OBJECTIVE To describe the patient-doctor-computer relationship during the opening period of the consultation. METHODS Twenty GPs provided 141 consultations for direct observation, using digital video. Consultations were analysed according to Goffmans dramaturgical methodology. RESULTS Openings could be described as doctor, patient or computer openings, according to the source of initial influence on the consultation. Specific behaviours can be described within those three categories. CONCLUSIONS The presence of the computer has changed the beginning of the consultation. Where once only two actors needed to perform their roles, now three interact in differing ways. Information comes from many sources, and behaviour responds accordingly. Future studies of the consultation need to take into account the impact of the computer in shaping how the consultation flows and the information needs of all participants.

Low vitamin B12 levels among newly-arrived refugees from Bhutan, Iran and Afghanistan: a multicentre Australian study

Background Vitamin B12 deficiency is prevalent in many countries of origin of refugees. Using a threshold of 5% above which a prevalence of low Vitamin B12 is indicative of a population health problem, we hypothesised that Vitamin B12 deficiency exceeds this threshold among newly-arrived refugees resettling in Australia, and is higher among women due to their increased risk of food insecurity. This paper reports Vitamin B12 levels in a large cohort of newly arrived refugees in five Australian states and territories. Methods In a cross-sectional descriptive study, we collected Vitamin B12, folate and haematological indices on all refugees (n = 916; response rate 94% of eligible population) who had been in Australia for less than one year, and attended one of the collaborating health services between July 2010 and July 2011. Results 16.5% of participants had Vitamin B12 deficiency (<150 pmol/L). One-third of participants from Iran and Bhutan, and one-quarter of participants from Afghanistan had Vitamin B12 deficiency. Contrary to our hypothesis, low Vitamin B12 levels were more prevalent in males than females. A higher prevalence of low Vitamin B12 was also reported in older age groups in some countries. The sensitivity of macrocytosis in detecting Vitamin B12 deficiency was only 4.6%. Conclusion Vitamin B12 deficiency is an important population health issue in newly-arrived refugees from many countries. All newly-arrived refugees should be tested for Vitamin B12 deficiency. Ongoing research should investigate causes, treatment, and ways to mitigate food insecurity, and the contribution of such measures to enhancing the health of the refugee communities.

Following the funding trail: Financing, nurses and teamwork in Australian General Practice.

BackgroundAcross the globe the emphasis on roles and responsibilities of primary care teams is under scrutiny. This paper begins with a review of general practice financing in Australia, and how nurses are currently funded. We then examine the influence on funding structures on the role of the nurse. We set out three dilemmas for policy-makers in this area: lack of an evidence base for incentives, possible untoward impacts on interdisciplinary functioning, and the substitution/enhancement debate.MethodsThis three year, multimethod study undertook rapid appraisal of 25 general practices and year-long studies in seven practices where a change was introduced to the role of the nurse. Data collected included interviews with nurses (n = 36), doctors (n = 24), and managers (n = 22), structured observation of the practice nurse (51 hours of observation), and detailed case studies of the change process in the seven year-long studies.ResultsDespite specific fee-for-service funding being available, only 6% of nurse activities generated such a fee. Yet the influence of the funding was to focus nurse activity on areas that they perceived were peripheral to their roles within the practice.ConclusionsInterprofessional relationships and organisational climate in general practices are highly influential in terms of nursing role and the ability of practices to respond to and utilise funding mechanisms. These factors need to be considered, and the development of optimal teamwork supported in the design and implementation of further initiatives that financially support nursing in general practice.

General Practice and Pandemic Influenza: A Framework for Planning and Comparison of Plans in Five Countries

Background Although primary health care, and in particular, general practice will be at the frontline in the response to pandemic influenza, there are no frameworks to guide systematic planning for this task or to appraise available plans for their relevance to general practice. We aimed to develop a framework that will facilitate planning for general practice, and used it to appraise pandemic plans from Australia, England, USA, New Zealand and Canada. Methodology/Principal Findings We adapted the Haddon matrix to develop the framework, populating its cells through a multi-method study that incorporated the peer-reviewed and grey literature, interviews with general practitioners, practice nurses and senior decision-makers, and desktop simulation exercises. We used the framework to analyse 89 publicly-available jurisdictional plans at similar managerial levels in the five countries. The framework identifies four functional domains: clinical care for influenza and other needs, public health responsibilities, the internal environment and the macro-environment of general practice. No plan addressed all four domains. Most plans either ignored or were sketchy about non-influenza clinical needs, and about the contribution of general practice to public health beyond surveillance. Collaborations between general practices were addressed in few plans, and inter-relationships with the broader health system, even less frequently. Conclusions This is the first study to provide a framework to guide general practice planning for pandemic influenza. The framework helped identify critical shortcomings in available plans. Engaging general practice effectively in planning is challenging, particularly where governance structures for primary health care are weak. We identify implications for practice and for research.

Low levels of uptake of free interpreters by Australian doctors in private practice: secondary analysis of national data

BACKGROUND One in thirty-five Australians has poor proficiency in English, and may need language support in health consultations. Australia has the worlds most extensive system of fee-free provision of interpreters for doctors, but the degree of uptake relative to need is unknown. OBJECTIVE To assess the current unmet and projected future needs for interpreters in Australia in Medicare-funded medical consultations. METHOD Secondary analysis of Australian Census, Medicare and Translating and Interpreting Service (TIS) datasets. Age-specific rates of non-Indigenous populations who had self-reported poor proficiency in English were applied to age-specific attendances to general practitioners (GPs) and private specialists to estimate the need for language-assisted consultations in 2006-07. The proportion of services where language assistance was used when needed was estimated through aggregate data from the Medicare and TIS datasets. RESULTS We estimate that interpreters from the national fee-free service were used for patients with poor proficiency in English is less than 1 in 100 (0.97%) Medicare-funded consultations. The need for interpreters will escalate in future, particularly among those over 85 years. DISCUSSION Doctors currently underuse interpreters. Increasing the use of interpreters requires education and incentives, but also sustained investment in systems, infrastructure and interpreters to meet the escalation in demand as the population ages.

Reporting a research project on the potential of aged care nurse practitioners in the Australian Capital Territory

AIM This paper reports a project investigating the potential role of the nurse practitioner in aged care across residential, community and acute care venues in the Australian Capital Territory. BACKGROUND Australia, like many other countries, faces unprecedented challenges in the provision of health care. Escalating health care costs, an ageing population, increasing prevalence of comorbidities and chronic illnesses, inefficient health care delivery, changing models of health care and shifting professional role boundaries are factors that have contributed to the development of advanced practice roles for nursing. DESIGN This was a mixed methods study using multiple data sources. METHODS Student aged care nurse practitioners were examined across the continuum of care in the acute, community and residential aged care settings. The potential role of the nurse practitioner in these areas was evaluated qualitatively and quantitatively to identify a model of care to enhance the delivery of efficient and effective health care. RESULTS The project findings have demonstrated that there is potential for significant improvement in client outcomes arising from a transboundary aged care nurse practitioner model. The improved outcomes are associated with a decrease in acute hospital admissions for residential care clients, timely intervention for a range of common conditions and strengthened multidisciplinary approaches to care provision for older people. CONCLUSIONS Overall the project findings strongly support the potential of a transboundary aged care nurse practitioner role. This role would focus on skilled assessment, timely assessment and intervention, brokering around access to care and clinical leadership and education for nurses. RELEVANCE TO CLINICAL PRACTICE This paper offers further evidence of support for the role of nurse practitioners in complementing existing health services and improving delivery of care.

Student portfolios and the hidden curriculum on gender: mapping exclusion

Context  The hidden curriculum – the norms, values and practices that are transmitted to students through modelling by preceptors and teachers, and decisions about curricular exclusions and inclusions – can be profoundly important in the socialising of trainee doctors. However, tracking the hidden curriculum as it evolves can be challenging for medical schools.

Time to talk, time to see: changing microeconomies of professional practice among nurses and doctors in Australian general practice

In Australia, more nurses are entering general practice, and nurses– work is being funded in increasingly complex ways through Medicare. Little research has explored the ways doctors and nurses realign their priorities and activities when working together in general practice. We undertook rapid, intensive multimethod studies of 25 general practices to explore the ways in which the labour of nurses and doctors was structured, and the implicit decisions made by both professions about the values placed on different ways of working and on their time. Data collected included photographs, floor-plans, interviews with 37 nurses, 24 doctors and 22 practice managers, and 50 hours of structured observation. Nursing time was constructed by both nurses and doctors as being fluid and non-contingent; they were regarded as being ‘available’ to patients in a way that doctors were not. Compared to medical time, nursing time could be disposed more flexibly, underpinning a valorized attribute of nursing: deep clinical and personal contact with patients. The location of practice nurses’ desks in areas of traffic, such as administrative stations, or in the treatment room, underpinned this valuable unstructured contact with patients. Changes to the practice nurse role through direct fee-for-service items for nurses may lead to greater congruence between the microeconomies of nursing and medicine in general practice. In a time of pressure upon a primary care workforce, this is likely to lead to more independent clinical work by nurses, but may also lead to a decrease in flexible contact with patients.

When policy meets the personal: general practice nurses in Australia.

Objective A significant focus of current health policy in Australia is to expand both the number and role of general practice nurses. Multiple new payment incentives have been instituted to encourage the use of practice nurses. This study explored the way these policies have framed their work. Methods Multimethod research using observation, workspace photographs and interviews with nurses, doctors and managers collected through rapid appraisal in 25 practices in two states, followed by case studies of the role of nurses in seven practices over one year. Results Many respondents reported unanticipated benefits in general practice functioning and teamwork as a result of employing a nurse, though this had not been a policy aim. Within funding constraints, nurses created new roles and manipulated old roles to fit their personal understanding of patient care. Policy initiatives targeting practice nurses are often based around tasks and system issues, rather than the personal creation of care and quality that patients require and nurses seek. Incentives in this study were targeted at both the uptake of nurses and specific nursing activities. Conclusion Policy development and funding structures would benefit from better understanding of nurses as agents of connectivity (rather than simply as performers of tasks) as well as the nature of teamwork in practices.