The computer as a ‘third party’ in the consultation

Several authors have introduced the notion of the computer as a ‘third party’ in the consultation, demanding a significant amount of time, and have begun to challenge the notion of the clinical encounter as a communication dyad, preferring instead to refer to the ‘triadic consultation’ (Booth, Kohannejad, &

Robinson 2002a;Chan et al 2008;Margalit et al 2006;Pearce 2007;Pearce, Dwan, Arnold, Phillips, & Trumble 2009;Scott and Purves 1996;Ventres, Kooienga, Vuckovic, Marlin, Nygren, & Stewart 2006).

Scott and Purves introduced a ‘three way interactive DCP model’ in which each

“component” (Doctor, Computer, Patient) is regarded as having an undeniable effect on the relationships between the other two, presenting this as a

“perceptually impossible” triangle and arguing that it is no longer sufficient to analyse the consultation without attending to the third ubiquitous component (Scott et al 1996). Others have drawn attention specifically to the “intrusive”

nature of the computer (Booth et al 2004;Sullivan 1995) or have described the computer as an “interloper” into an environment that was not originally designed for it (Pearce, Walker, & O'Shea 2008).

Booth et al analysed video-recordings of ‘moments of transition’ (when doctors’

attention switched between the patient and the screen) amongst ten experienced GP EPR-users and concluded that the multi-tasking which intensive computer use in the consultation demands is very difficult to achieve (Booth et al 2004). They selected 10 out of 137 consultations for transcription, to reflect a variety of consulting styles and room layouts. Only one of the ten GPs in the study habitually recorded information on the computer as the

51 consultation progressed. The authors analysed the recordings informed by the Calgary Cambridge Guide (Kurtz and Silverman 1996) and identified and classified three styles of doctor behaviour which contributed to the switch of attention. These were: controlling (the GP actively manages the transition, either by directing the patient not to interrupt during computer use or by influencing the flow or dynamic of the dialogue at the transition point);

responsive / opportunistic (the GP makes use of gaps which arise in the consultation, resisting any attempt to interfere with the patient’s interaction);

ignoring (the GP loses rapport whilst engaging with the computer and may not respond at all to interaction from the patient).

Those doctors in the first two groups (controlling or responsive / opportunistic) were found to use specific strategies to manage the transition, namely:

signposting (indicating verbally or non-verbally that they are about to use the computer); chatter or “blather” (general conversation incorporating verbal and non verbal cues to indicate listening, or a running commentary); responding every time (stopping typing and turning to face the patient). The authors mapped these observed strategies to the Calgary-Cambridge Consultation Skills Guide (a consultation skills tool which is widely used in GP training), generated a list of competencies to supplement the guide, and developed a training package aimed at improving rapport whilst using a computer in the consultation, the key message being that clinicians should aim to avoid trying to attend to the patient and the screen at the same time (Booth, Kohannejad, &

Robinson 2002b;Booth et al 2004).

Whereas Booth et al focused their analysis on moments of transition, Ventres et al. conducted an ethnographic study in the United States incorporating participant observation, video-recording and interviews, considering more broadly the relationship between consulting style and EPR use (Ventres, Kooienga, Marlin, Vuckovic, & Stewart 2005;Ventres et al 2006) and developing

“ten tips for patient-centred care” (Ventres, Kooienga, & Marlin 2006). Based on a thematic analysis of the video data, they classified consulting styles as informational, managerial or interpersonal, where these categories represented a spectrum which corresponded with both decreasing time spent looking at the

52 EPR (23% - 43% of consultation time) and with notions of doctor and patient-centred approaches. Doctors tended towards one overall style. Ventres et al.

provide descriptions of the characteristics and conclude that clinician styles determined involvement of the computer in the consultation (Ventres et al 2005;Ventres et al 2006).

Although this resonates with the findings of Booth et al, their classification of

‘style’ (informational, interpersonal, managerial) is one which emerged from the behaviours observed in their own data so their conclusion that consulting style determines computer use is something of a tautology. However, their suggestion that a doctor’s consulting style may be critical for how the EPR comes to be incorporated into the consultation is certainly plausible and raises the interesting possibility that in the context of a ‘patient-centred’ consultation (however we define it) the EPR may open up opportunities to become more patient-centred, whilst in a ‘doctor-centred’ consultation the EPR may contribute to a further shift towards ‘doctor-centredness’. This suggestion is supported in Frankel’s recent longitudinal study, which incorporated video recordings before and after introduction of computers into a US primary care clinic (Frankel, Altschuler, George, Kinsman, Jimison, Robertson, & Hsu 2005). The authors found that clinicians’ baseline communication skills – both positive and negative – judged by observation of them using a paper based medical record are carried forward and amplified with a computer record, suggesting that the technology (be it paper or electronic) does not so much exert specific ‘impacts’

on a consultation but is incorporated by particular clinicians according to a wider range of communication behaviours.

Ventres et al also identified fourteen factors which influenced how the EPR was used in the consultation, grouping these into four categories: spatial, relational, educational, structural – a framework which has since been adapted for use in one small feasibility study of EPR training amongst first year medical students (Morrow, Dobbie, Jenkins, Long, Mihalic, & Wagner 2009). This framework acknowledges that factors relating not only directly to a clinician’s individual style, but to wider institutional and professional concerns also feed into and inform EPR use in the consultation. The authors do not specifically explore the

53 juncture between individual and institutional concerns but this is another interesting possibility for ethnographic study. It is unlikely that there is any simple factor, or collection of factors which ‘determines’ EPR use at all, rather that there is a complex interweaving of practices which shape EPR use, and which are themselves shaped by the EPR. In any study of the EPR in the consultation it seems important to orient both to the moment-by-moment interactional detail of the consultation, whilst remaining aware of the broader institutional and social context within which the interactions take place.

Pearce has made an important recent contribution to this body of literature by seeking to describe the nature of the relationships within the ‘triadic’

consultation (which he calls the “new” consultation) using tagging software to facilitate analysis of videos of 141 patient encounters (Pearce 2007;Pearce et al 2009;Pearce, Trumble, Arnold, Dwan, & Phillips 2008). He criticises previous work for being both under-theorised and primarily ‘doctor-centric’, and for continuing to frame a triadic relationship as a series of dyadic relationships (for example doctor-patient, doctor-computer, computer-patient) (Pearce 2007). He sought to address this limitation, by bringing Goffman’s dramaturgical theories of human interaction to his analysis (Goffman 1974) in what is an explicitly theory-driven approach rather than one which seeks to generate theory from the data. He worked entirely with raw video data rather than with transcripts (Pearce 2007). Pearce considers the computer as a non-human actant, affording it equal analytical attention to the human actors and following the three actants and their “moves” to describe how each contributes to the interaction.

Goffman’s concept of moves invites examination of “talk or its substitutes”

(Goffman 1981b) and Pearce studies talk and bodily conduct to illuminate the triadic nature of the relationship.

Pearce (drawing on Goffman) frames the consultation itself as a ‘play’, the consulting room as the ‘stage’, the objects as ‘props’ – the computer screen itself becoming the ‘face’ of the computer (Goffman 1959b). He regards the arrangements of the setting as an important aspect of the social milieu, and consequential for the interaction, by being broadly patient inclusive or patient exclusive (in terms of how it contributes to a three-way relationship) (Pearce et

54 al 2008). His analysis of the first minute of the consultation revealed that the involvement of the computer often heralded a shift from social conversation to the ‘business’ of the consultation; when all three actors were ‘on the stage’, the play could begin. Openings are described as doctor-openings, patient-openings or computer- openings. The computer is identified as exhibiting agency within a three-way relationship and ‘joining in’ the negotiation, either directly or indirectly (Pearce et al 2008).

Table 2 shows Pearce’s classification framework of actors (human participants) and actant (computer) according to their ‘key’ (overarching theme of beh-aviours, or style exhibited in their relationships) and ‘behaviours’ (discrete actions which can be employed variously within a single consultation, regard-less of the key) (Pearce et al 2009). Pearce proposes that future work on the consultation must acknowledge this agency of the computer and expresses concern that there is a risk that computers may undermine the status of the patient by posing a threat to patient-centredness (Pearce et al 2008).

Pearce shows ways in which information, power and authority shift amongst the three actants throughout a consultation, in what he calls “ever revolving circles”, and calls for further work to be done to examine these issues in more detail – in particular how authority is created dynamically in the consultation. He suggests there are now three agendas to consider, and that the computer vies for attention as a source of authority in its own right, often being acknowledged as such by both doctor and patient, through both their spoken language and their body language. He suggests that the same piece of information may be trusted in one situation but doubted in another, that a doctor may use a piece of information in one setting to empower the patient and in another to bolster the doctor’s own authority (Pearce 2007).

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Table 2. Pearce’s classification framework, showing “keys” and “behaviours” of actors/actant in the consultation. Adapted from Pearce et al. (2009)

Actors /

Physicians Unipolar / bipolar (style exhibited in every consultation)

Unipolar = lower pole of body facing predominantly towards computer Bipolar = switches of focus indicated by lower body shifts

1.Engaging (e.g. turning gaze towards patient or involving them) 2.Disengaging (e.g. shift attention away from patient towards computer)

3.Cogitating (not engaging with either computer or patient)

Patients Dyadic / triadic (stable throughout single consultation)

Dyadic = body orientation suggests interaction with physician is predominant concern

Triadic = happy to deal with computer as integral partner in consultation

1.Screen controlling (patient actively brings computer into play in

consultation)

2.Screen watching (attention focused on screen)

3.Screen ignoring (patient

disregards screen e.g. turning body away from it)

Computer Active / passive (usually both exhibited in each consultation)

Active = reminders / dialogue boxes that pop up during consultation and actively demand attention prompt through its decision support function)

3.Distracting (computer distracts one of the other actors)