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Revista Portuguesa de Medicina Geral e Familiar

versão impressa ISSN 2182-5173

Rev Port Med Geral Fam vol.29 no.3 Lisboa maio 2013

 

EDITORIAL

Computers and doctor-patient communication

John Yaphe*

*Associate Professor, Community Health, School of Health Sciences, University of Minho

Endereço para correspondência | Dirección para correspondencia | Correspondence


 

Computers have changed medicine but we are still unsure about the effects of computers on doctor patient communication. This editorial will review relevant literature and speculate on new directions in the light of current challenges.

Recent local discussion has focussed on difficulties family doctors face with computers in the consulting room. Slow servers and long response times with electronic medical records are prolonging consultations. Clinical software is unfriendly. Doctors are burdened with pressure from patients, administrators, and personal issues. How did we get here and where are we going?

Family doctors obtained computers in the 1980s in many countries. Mainframe medical computers had been available thirty years earlier. Doctors with special interests in research were able to study their lists with the help of database programs. Affordable, small machines and practical software for medical record keeping made it possible for doctors to use computers in daily practice. In Portugal, computers arrived in the clinic after 2000. Local record-keeping software permitted statistical analysis of patient lists only three years ago.

A revolution occurred with the development of the Internet and easy access to medical journals, multimedia files and consultant opinions. Patients may adopt new technology faster than doctors. High rates of internet use by patients for health information have positive effects on the doctor-patient relationship for both doctors and patients.1,2 Electronic communication with patients can be used for therapeutic purposes as well as information needs, as was explored here in a recent editorial.3

Technology provokes questions on the effects of computers on personalized medicine. Early evidence suggested that computers increased the length of consultations.4 Patients had concerns regarding the confidentiality of records.5 Critics claimed that all eyes would be on the screen.

Video recordings with a group of family doctors over seven years showed that increased computer time resulted in less eye contact, closed body posture, and less time for patient talk.6

Doctors may spend over 40% of the consultation looking at the screen.7 Focus on the screen and the keyboard can decrease the amount of time spent on psychosocial issues, emotional issues, and patient centeredness.

Perhaps good communicators do not change their habits. Computer-centered doctors may formerly have focussed on paper charts. A study of “the computer-doctor-patient triad” showed how the computer could be used to create a shared reality with patients. By placing the screen at an angle so that it is visible to both the doctor and the patient, the text becomes the property of both. The position of the computer on the desk can help classify doctors as inclusive or exclusive referring to their degree of patient centeredness in the consultation.8

Patients can manipulate the doctor’s gaze to and from the computer screen at different times during a consultation.9 Power, authority and information flow can be shared, with patients directing the action.

High quality computer records may come at the expense of patient centeredness.10 Some doctors may focus solely on the patient and rely on memory to enter data at the end of a visit. Others interrupt the conversation to enter notes as they go. Still others may interrupt only at the end of blocks of time, such as for recording of subjective and objective findings.

Doctors may use the computer to take a “time out” from verbal communication or as a mysterious “black-box” in solving the patient’s problems.11 Many doctors are motivated to change their doctor-computer relationship as a result of observing themselves on video.

Training in communication skills can minimize the adverse effects of the computer in the consulting room. Doctors can maintain verbal, visual and postural communication with patients while using computers and modify the position of the computer on the desk to include patients in the consultation.12

Has desktop medicine replaced bedside medicine or patient-centered care?13 When the computer is used to compute risk scores and determine drug treatment, we need to ask who makes the rules and whose interests are being served.

Computer based decision-making tools add time to the consultation.14 For example, paper-based guidelines for anticoagulation therapy take 21 minutes to complete compared to a computerized guideline tool, which takes 44 minutes. These figures are unworkable in the current reality in general practice.

What can be done? Teachers of medicine need to inform their students of the benefits and harms of computer use in the consultation. Administrators need to listen to doctors and patients to determine their information technology needs. Systems must be rapid and transparent to allow doctors to get on with care. Some clinical software used in Portugal does not allow the opening of multiple windows for data entry during the consultation. Family doctors still have to fight for the software they need to allow them to do their job well. We hope that our readers will pick up the challenge and continue to explore this fascinating area for the benefit of their colleagues and their patients.

 

REFERENCES

1. Giveon S, Yaphe J, Hekselman I, Mahamid S, Hermoni D. The e-patient: a survey of Israeli primary care physicians’ responses to patients’ use of online information during the consultation. Isr Med Assoc J 2009 Sep; 11 (9): 537-41.         [ Links ]

2. Russ H, Giveon SM, Catarivas MG, Yaphe J. The effect of the Internet on the patient-doctor relationship from the patient’s perspective: a survey from primary care. Isr Med Assoc J 2011 Apr; 13 (4): 220-4.         [ Links ]

3. Yaphe, J. Electronic counselling: taking e-mail communication with patients one step further. Rev Port Med Geral Fam 2012 Mai-Jun; 28 (3): 159-60.         [ Links ]

4. Richards HM, Sullivan FM, Mitchell ED, Ross S. Computer use by general practitioners in Scotland. Br J Gen Pract 1998 Aug; 48 (433): 1473-6.         [ Links ]

5. Ridsdale L, Hudd S. Computers in the consultation: the patient’s view. Br J Gen Pract 1994 Aug; 44 (385): 367-9.         [ Links ]

6. Noordman J, Verhaak P, van Beljouw I, van Dulmen S. Consulting room computers and their effect on general practitioner–patient communication Fam Pract 2010 Dec; 27 (6): 644-51.         [ Links ]

7. Margalit RS, Roter D, Dunevant MA, Larson S, Reis S. Electronic medical record use and physician-patient communication: an observational study of Israeli primary care encounters. Patient Educ Couns 2006 Apr; 61 (1): 134-41.         [ Links ]

8. Pearce C, Walker H, O’Shea C. A visual study of computers on doctors’ desks. Inform Prim Care 2008; 16 (2): 111-7.         [ Links ]

9. Pearce C, Arnold M, Phillips C, Trumble S, Dwan K. The patient and the computer in the primary care consultation. J Am Med Inform Assoc 2011 Mar-Apr; 18 (2): 138-42.         [ Links ]

10. Theadom A, de Lusignan S, Wilson E, Chan T. Using three-channel video to evaluate the impact of the use of the computer on the patient-centredness of the general practice consultation. Inform Prim Care 2003; 11 (3): 149-56.         [ Links ]

11. Als AB. The desk-top computer as a magic box: patterns of behaviour connected with the desk-top computer; GPs’ and patients’ perceptions. Fam Pract 1997 Feb; 14 (1): 17-23.         [ Links ]

12. Frankel R, Altschuler A, George S, Kinsman J, Jimison H, Robertson NR, et al. Effects of exam-room computing in clinician-patient communication. J Gen Intern Med 2005 Aug; 20 (8): 677-82.         [ Links ]

13. Karlawish J. Desktop medicine. JAMA 2010 Nov 10; 304 (18): 2061-2.         [ Links ]

14. Kaner E, Heaven B, Rapley T, Murtagh M, Graham R, Thomson R, et al. Medical communication and technology: a video-based process study of the use of decision aids in primary care consultations. BMC Med Inform Decis Mak 2007 Jan 10; 7: 2.         [ Links ]

 

Endereço para correspondência | Dirección para correspondencia | Correspondence

yonahyaphe@hotmail.com

 

Conflict of interest

The author has no conflict of interest in the publication of this editorial.

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