Stephen Trumble

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.

The future of the primary medical workforce

Is in jeopardy unless GPs have a more central role in healthcare and develop special skills in areas of unmet need

A growth mindset approach to preparing trainees for medical error

As medical students transition to become trainee doctors, they must confront the potential for making medical errors. In the high stakes environment of medicine, errors can be catastrophic for the patients and for doctors themselves. Doctors have been found to experience guilt, shame, fear, humiliation, loss of confidence, deep concerns about their professional skills and social isolation, effectively becoming the second victim of an error.1 ,2 A number of programmes and practices have been suggested to provide psychological first aid to second victims after an error has occurred.3 Little attention, however, has focused on how medical training can prepare doctors for the inevitability of error, and thus help protect them from potentially severe emotional consequences in the future. The WHO has developed the Patient Safety Curriculum Guide for Medical Schools , which includes training on understanding and learning from mistakes.4 In addition, the case has been made for error management training in which students are encouraged to experience error in safe settings, such as simulation exercises.5 ,6 While these approaches are promising, a more broad-spectrum psychological intervention aimed at changing how students perceive mistakes and cope with setbacks could be advantageous. Research from social psychology suggests a promising intervention that could help assist students in being resilient when encountering difficulties and setbacks. Mindset theory holds that our implicit assumptions about the origins of abilities such as intelligence and talent have a profound impact on how we view mistakes or failure.7 Those with a fixed mindset believe that ability is endowed and static, and thus a failure indicates a lack of ability. Those with a growth mindset view ability as acquired through effort, practice and learning from setbacks, and thus a failure represents an opportunity for development and improvement. A great deal of research …

When I say … phronesis

In Ancient Greece, there existed several different terms for ways of knowing and acting in the world. Commonly referred to as the ‘intellectual virtues’, many of these terms appear in modern English, either as borrowed words, such as nous (intelligence or common sense) and praxis (critical reflective practice [as recently discussed in this series by Ng and Wright]), or by providing roots from which we form words about knowledge and its activities, such as technical/technique (art/skill, from techne), philosophy (love of wisdom, from sophia) and epistemology (from episteme, knowledge/science). Several other related terms remain obscure in everyday English, including gnome (good sense), synesis (understanding) and the subject of this article, phronesis – a form of practical knowing.

The principles of problem-based learning are more important than the method

The Medical Journal of Australia ISSN: 0025729X 4 November 2013 199 9 588-590 ©The Medical Journal of Australia 2013 www.mja.com.au For Debate (Manuscript Invitation Only) behaviourist, cognitivist, huma constructivist perspectives, all o more generic psychological ap outlines of PBL were fundame and Tamblyn, for example, prese i g theory4), it has come to be theories, and most meaningfully proposes that adults make m Active discovery in small groups remains essential to the learning experience