Doctor, patient and computer—A framework for the new consultation
Introduction
Computerisation of the family practice space is now almost complete in Australia, with 93% of doctors using a computer on their desktop for prescribing [1], due to a combination of government initiatives and doctor driven demand for computer prescribing [2]. This has come about rapidly, increasing from 60% reporting the same level of computing five years ago [3], and it represents the most significant computerisation of the clinical encounter since the mass computerisation of the United Kingdom's National Health Service in the 1980s. Computers are now used in all facets of the consultation—prescribing (98%), recall systems (78%), progress notes (64%) and decision support (20%) [1].
While it appears that computerisation improves clinical practice [4] and, by implication, clinical outcomes, surprisingly little literature exists on the direct effects of computerisation on the physician–patient relationship itself [4]. Evidence suggests that different technologies and their methods of implementation have a tremendous effect on if technology is accepted, how it is used and, consequently, how it affects users [5], [6]. It is tempting to assume that any shift in focus of the physician and patient from each other would signal a lessening of the physician–patient relationship. Nevertheless, if we accept the clinical benefits that emerge from computer use, it behooves us to explore the ways in which computers can be incorporated into, and even benefit, the existing relationship.
The Australian general practitioner (GP) ushers the patient into the room at the start of the consultation, and sits at a desk on which a computer screen resides. The patient is seated beside the desk, or less commonly across the desk. Physical examinations take place on the other side of the room, on a couch provided for that purpose. Any printed material generated as a result of the consultation is usually produced by the physician in the room while the patient is present. Australian GPs have expressed concern that the presence of computers may have a detrimental effect on the physician–patient dyad [3]. For this reason we explore the interaction between physician and patient, and identify the ways in which the computer can be understood to influence that interaction.
Emphasis on the physician–patient relationship has undergone a renaissance over the past fifty years, as the deficiencies of the predominant biomedical model became apparent. In 1956 Michael Balint began his work exploring the importance of the relationship as a therapeutic entity in its own right [7]. Thomas Szasz [8] at the same time characterised several different models of the relationship embodied in the interaction. Similar emphases on the relationship were significant in the development of the “biopsychosocial” model of care [9], with its expanded view of the domains of illness and healing. Today, these models have evolved into the concept of “Patient Centered Medicine” (PCM) [10]. The application of PCM in the consultation, or more correctly consultations that can be described as “patient-centred”, are held to produce better patient satisfaction and improve outcomes [11]. Consequent to this conceptualisation, most of the research, and much of the teaching of PCM, has assumed that the relationship is a dyadic one, that is, it exists only between the physician and the patient. However, evidence that the computer may well play a larger role than is currently appreciated is accumulating, with doctors changing their interactions according to the nature of the consultation [12]. The relationship is now being described as a triadic one [13].
The introduction of a computerised decision support system in the UK called “Prodigy”, prompted Ian Purves to propose a new clinical method; one which considers computer support an integral part of the consultation [14]. He positioned the computer as a source of timely, relevant information for both the physician and the patient. Thus asserting that the computer is a significant part of the consultation, and that the three actors (physician, patient and computer) enter into a “triadic” relationship [13]. Margalit et al. have echoed this view more recently, in their study on Israeli family physician consultations. In their discussion, they comment: “The computer has become a ‘party’ in the visit that demanded a significant portion of visit time” [15]. These works posit that the computer plays a more significant part of the consultation than has been understood previously, and that social science methods must be used to describe this role.
Other research has attempted to describe some of the elements of this triadic relationship, by describing classes of behaviours. Fitter [16] for instance, divided physicians into two groups: block, and conversationalist. Ventres et al. [17] divided physicians into informational, managerial and interpersonal styles. So too have Als [18] and Booth et al. [19] provided classifications of behaviours witnessed in the consultation. Als for instance, observed how patients exhibited “looking” behaviour, and described two physician behaviours, “magic box” and “explanation”. Booth et al. similarly described controlling and ignoring behaviours in physicians.
Our study builds on this previous work by seeking to identify and classify the influence of computers on the physician–patient dyad. It also extends the existing literature in the area by drawing on social theory to frame analysis. The theory provides a starting point for analysis while our hermeneutic approach ensures that the consultation is explored in its entirety, not merely as a collection of theoretically interesting concepts.
Section snippets
Method
Theoretical work on the medical consultation is thin [20]; nevertheless, theory has much to offer our understanding of these quintessentially human interactions. We have chosen Ervin Goffman's dramaturgical theories of human interaction to help us explore the phenomenon [21]. Goffman views social interactions as one would a theatrical play; humans interact with each other according to perceived roles and accepted rules of behaviour, much as one performs a scripted play. For Goffman, the
Results
Both the actors (human participants) in the interaction and the actant (computer) were classified according to their “key” or style; a term derived from Goffman that describes the attributes of each actor/actant which influence the flow of the interaction, akin to a musical key signature [21]. A further classification was made on the basis of the “behaviours” or observable actions that have identifiable meanings within the context of the interaction. The typology developed from analysis is
The keys
Keys describe overarching themes of the behaviours exhibited by the actors in their relationships. For physicians, their key was the style they exhibited in every consultation. Patients were only seen for one consultation, so that observation cannot be made, but the patient's key was stable throughout their consultation. Unlike physicians and patients, computers could, and usually did, exhibit both of their keys within a single consultation. Repeated viewings of the video-taped consultations
Discussion
This study builds on a growing body of work that examines the physician–patient relationship in the context of increasing computerisation [13], [14]. It follows a line of research that describes the relationship as a triadic one, in which the three actors are given equal attention. Equal does not mean that they are the same, nor does it mean that the physician–patient relationship should cease to be viewed as a dyad. But that such a framework has been posited means that it must also be tested.
Conclusion
All new technologies carry risks and benefits. The computerisation of the health space is only going to continue apace, and with it the presence, and therefore influence, of the computer on human interactions is going to increase. There is risk that computers will dehumanise the consultation. There is also risk if we exclude the computer on the basis that it will dehumanise the consultation. If the dynamics of the consultation are to be understood both now and in the future, when computers will
Acknowledgements
Dr. Pearce was supported by a National Health and Medical Research Council Fellowship, and the research was supported by a Royal Australian College of General Practitioners Informatics Scholarship. Neither had any role in the decision to submit this manuscript. Author contributions: The study was undertaken by CP as part of a Ph.D. study. He developed the initial framework, which was critically reviewed and modified by the other authors. First draft of the paper was prepared by CP and the other
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