Talking the talk

I spent the last two days of last week at a Introduction to Qualitative Interviews short course which was run by the Department of General Practice at Melbourne University. It was a welcome break from what is currently my daily slog of attempting to writing up my literature review. 

To assist my literature review I have been reading a lot of academic ‘self-help’ books: How to write a dissertation in fifteen minutes a day (!!), Becoming an academic writer, and How to write a better thesis. As well as this, the graduate research student group in my department have started a weekly thesis writing circle, facilitated by writing guru, which I have so far found incredibly useful – both from a writing perspective but also peer support… (soon I may even start writing! 😉 ).

One of the major messages coming through to me – which has been enormously helpful –  in both the books and the Thesis Writing Circle is along the lines of ‘write in order to clarify thoughts’. Which I like because it challenges my long held (and quite stupid) belief that I must do all reading and write sentences which are delivered in beautifully perfect formed constructions. (Why this is such a long-held and stubborn thought is the subject for another time, dear reader….)

One of the reasons I have been struggling in the shift from industry to research is that I haven’t had to ‘do’ research since (quantitative-based) undergraduate degree (many years ago now). And although I have co-authored a few articles and completed a coursework masters, I massively underestimated the challenges in doing so. I feel like I’m playing the ‘poor victim’ when I admit this, but then, it is what it is…

Which means that the 2 day course was a great way to get an overview of the qualitative field – and helped prompt some critical questions about fundamental things in my research design. However, equally important was the chance to meet and chat with other phd students from different faculties who are at similar stages as me. It helped because I got to understand that their challenges were similar to mine and to bounce ideas about my research on to people who had absolutely no vested interest and no desire or need to judge (whoohoo!). 

The course this week seemed to back up this blog post by the wonderful Pat Thompson on the importance of talking to develop writing. Specifically, (and I particularly like), ‘talking as a deliberate and deliberative way of unpacking the muddle in your head’. This has certainly occured a few times in my supervision meetings, but almost by accident. Maybe I haven’t really understood the real meaning and potential of supervision meetings – seeing it only as an increasingly stressful  ‘are you on track’ check in.

So, here’s to more writing…and more talk! 🙂

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What effect does a computer have on patient-doctor communication?

Computers are so ubiquitous that they may even soon be a kind a retro artifact when compared with the versatility, portability and sheer power of smart phones and tablets. Computers are only a relatively new addition to GP offices, but have been quickly integrated into practice, being driven in large part by incentives from the Department of Health.

In fact, according to the Bettering the Evaluation and Care of Health (BEACH) study of GP activity, only 4.4% of GPs do not use a computer for any clinical purpose (and indeed I’d be concerned if my GP did not use a computer). The most common use of computers by GPs are prescribing, checking drug interactions, to order laboratory tests, and to record notes (the latter was a relatively low proportion of approx. 64%).

As well as the obvious benefit of improving time and accuracy of clinical work, there has been quite a bit of research that has investigated how the GPs use of computer during consultation effects (and has changed) the doctor-patient relationship, suggesting it is now the ‘third actor’ in the relationship. One observational study by Pearce et al (2009)  found that doctors’ orientation tend to be either unipolar (maintaining the lower part of their body facing the computer) or bipolar (alternating between the computer and the patient), while the patients tended to be either dyadic (focusing on the doctor to the exclusion of the computer) or triadic (including the computer in the consultation). Another study by Montague and Asan (2014) looked at eye gaze patterns found that doctors spend a whopping one third of consultations looked at the computer.

So, not surprisingly, they have an impact on posture and eye gaze. But how do computers affect the quality of the doctor-patient relationship (e.g. satisfaction, disclosure, therapeutic alliance) and health outcomes? A systematic review has found mainly neutral or positive effect on patient satisfaction, while a longitudinal study found  doctors report an increase in overall satisfaction and communication with computer use. An identified negative effect is that the demands of the computer system is put ahead of the needs of the patient. Another study found that although doctors felt that it could negatively effect communication, they actively used skills to reduce any negative impact.

Henderson et al (2010) analysed the BEACH data to compare key service quality indicators between GPs who did use computers during consultations and those that did not. She found that there was no evidence to indicate that computers either positively or negatively affected the quality of care GPs provided. A potential limitation of this study is that it looked only at GP-reported indicators such as medications prescribed, GP characteristics, patient risk factors, problems managed, and not patient satisfaction or therapeutic alliance.

So where does that leave us? Perhaps it is more nuanced that previous research suggests – my GP uses both handwritten notes, generally at the start of the consultation when she’s getting information from me (focussing on me as demonstrated by eye gaze and other body language), as well as the computer, generally later in the consultation when checking my history, printing out prescriptions etc. It certainly feels like there are two acts to the consultation (1. GP focuses on me. 2. GP focussing on the tasks that follow on from this – and possibly a 3rd act when GP checks back in with me to make sure we’ve covered everything).

Interestingly, I happened to chat about this yesterday with another phd student who is also a (young) GP. He said that he never uses the computer during a consultation, finding it too disruptive to communicating and establishing a rapport with the patient, and his practice is to write notes and spend time adding notes on the computer after the consultation ends. There is also research that suggests that GPs adapt their use depending on the content of the consultation; the average time GPs spent using their computer in consultations with a significant psychological content was about half that of those without psychological content.

It seems like the extent to which a computer is used is up to the GPs discretion and preference. In addition the patient seems excluded from the computer instead of using it inclusively to engage and educate the patient. Does this just serve to reinforce GP-centred/directed care, instead of the current push for a more collaborative care model?

A major part of my research is developing a tablet (or possibly smart phone) assessment app for young people to complete in the waiting room. The other important part is developing a report that GPs can read before the consultation on their computer. I imagine that GPs will also want to refer to this report on their computer while discussing it with the young person. Given this research, I’m now wondering do I need to actively mitigate against any existing negative impact of the ways in which GPs use the computer? (e.g. providing training/information to GPs prior to the research). That said, perhaps  it more about evaluating how the app affects (and passively mitigates) ‘usual care’…and acknowledging that research isn’t necessarily about controlling and orchestrating ‘ideal’ conditions.