Patient-clinician Interaction Research Articles

Inside the Physician's Black Bag: Critical Ingredients of Brief Alcohol Interventions

ABSTRACT Brief primary care interventions structured around patient workbooks have been shown to be effective in modifying hazardous drinking behavior. However, the critical ingredients of such interventions are not well understood, possibly contributing to their underutilization. Seventeen campus-based clinicians trained in a brief, workbook-based alcohol intervention participated in a qualitative study to identify the most promising clinician-patient interaction components within this shared approach, utilizing a focus group with the clinicians and ranking of the 24 workbook ingredients. Based on the clinicians’ collective experience, consensus emerged around the perceived strength of 5 main components: (1) providing a summary of the patient's drinking level, (2) discussing drinking likes and dislikes, (3) discussing life goals, (4) encouraging a risk-reduction agreement, and (5) asking patients to track their drinking (on cards provided for this purpose). This is the first paper to examine primary care physician perspectives on potentially critical components of effective brief alcohol intervention.

Adherence monitoring in drug delivery

Adherence monitoring is an important issue in inhaled drug delivery. Adherence is commonly found to be low and poor adherence is associated with increased mortality and morbidity and increased use of health services. Improving adherence is essential to maintaining disease and symptom control for patients and decreasing health costs. Feedback on actual adherence has been shown to increase subsequent adherence. In addition, education programs, reminder systems and increased patient–clinician interaction can also improve adherence. However, improved adherence is not sufficient if inhalation devices are being used incorrectly; the emphasis must be on devices being used in accordance with both the prescribed regimen and the instructions for use. As a result of technological advancements, drug delivery devices that both monitor adherence and address poor inhaler technique are now available. These devices combine monitoring systems with various feedback mechanisms in order to ‘coach’ the patient to use the device correctly. Some devices also incorporate connectivity to communicate accurate adherence and inhaler technique data to the clinician. This editorial considers current and future adherence monitoring devices and the impact that such technology could have on improving the patient's adherence and inhaler technique.

Clinician Approaches and Strategies for Engaging Older Men in Depression Care

The aim of this study is to explore primary care physicians' (PCPs) and depression care managers' (DCMs) approaches to diagnosing and treating depression in older men. The authors focus on older men because studies have shown that they are undertreated compared with women and younger groups. The authors contribute to previous research by identifying facilitators of care for older men from the perspective of clinicians. Participants in this study were part of the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) trial, an effectiveness study of collaborative care for late-life depression in 18 diverse primary care practices. Nine PCPs and 11 DCMs were interviewed to collect information on specific roles in caring for depressed patients and their experiences in working with depressed older men. All interviews were tape-recorded, transcribed verbatim, and analyzed thematically in several steps using standard qualitative data analysis techniques. : The authors identified three general approaches to building trust and talking about the depression: 1) an indirect approach ("call it something else"), 2) a gradual approach ("building up to depression"), and 3) a direct approach ("shock and awe"). The authors also found specific strategies that PCPs and DCMs used to manage depression among elderly male patients, such as increased monitoring of mood, treating somatic symptoms first, medicalizing depression, and enlisting the cooperation of family. In our interviews, enlisting family involvement was the most prominent strategy used by clinicians. A variety of approaches and strategies are used by clinicians for diagnosing and treating depressed older men. Clinicians change strategies as a response to a patient's compliance with treatment and the decision about which strategy to pursue is usually made on an "on-the-go" basis throughout the course of clinician-patient interaction. Based on clinicians' experience, depression management requires concerted efforts and persistence, and the family seems to play an important role in how older men receive the diagnosis of depression and adhere to clinicians' prescribed treatment. However, more research is needed to discover the best way of engaging and working with family members to facilitate effective depression care for older adults.

Narrative Reflection in the Family Medicine Clerkship - Cultural Competence in the Third-Year Required Clerkships

OPEN ACCESSMay 25, 2010Narrative Reflection in the Family Medicine Clerkship - Cultural Competence in the Third-Year Required Clerkships Donna Elliott, MD, EdD, Pamela Schaff, MD, Theresa Woehrle, MD, Anne Walsh, PA-C, MMSc, Janet Trial, EdD, CNM Donna Elliott, MD, EdD Keck School of Medicine of the University of Southern California Google Scholar More articles by this author , Pamela Schaff, MD University of Southern California Google Scholar More articles by this author , Theresa Woehrle, MD University of Southern California Google Scholar More articles by this author , Anne Walsh, PA-C, MMSc University of Southern California Google Scholar More articles by this author , Janet Trial, EdD, CNM Keck School of Medicine of the University of So California Google Scholar More articles by this author https://doi.org/10.15766/mep_2374-8265.1153 SectionsAboutAbstract ToolsDownload Citations ShareFacebookTwitterEmail AbstractAbstractThis resource cultivates effective cross-cultural communication skills, which requires an understanding of culture that includes both the physician's and the patient's perspectives. Building on a foundation of cultural awareness, knowledge, and skills students have acquired during the preclinical curriculum, this exercise provides an opportunity for students to continue to refine their narrative reflection skills as they interact with patients in the clinical setting. During the family medicine clerkship, students participate in learning activities that provide the opportunity to explore the rich opportunities of thoughtful reflection and narrative practice. Students also participate in a formative narrative reflection exercise during the clerkship orientation. Each subsequent week of the rotation, the students complete an electronic journal entry based on their clinical encounters that is focuses on the patient/physician interaction. At the end of the clerkship, students demonstrate their ability to reflect on patient care through a final project that is shared with faculty and fellow classmates in a faculty-led wrap-up discussion.A diverse patient population is helpful but not necessary to the success of this experience. Integrating cultural competence into the clinical clerkships allows students to apply cultural competence knowledge gained in the first 2 years of medical education, as well develop clinical skills in caring for patients with a variety of backgrounds. This learning experience has allowed faculty the opportunity to regularly address patient-care experiences that everyone acknowledged were fundamental to patient well-being, but had no particular place in the curriculum. A majority of students find positive educational value in their self-reflections and many comment that the family medicine clerkship has provided the one of the only opportunities they've had during their training for this therapeutic activity. Educational Objectives By the end of this module, learners will be able to: Provide health care to a diverse, multicultural patient population.Recognize the impact of the patient's story on the physician and patient relationship, and management of disease.Think and write reflectively about a patient-clinician interaction, and the feelings and attitudes they experienced as part of that interaction.Demonstrate awareness of personal limits, strengths, weaknesses, vulnerabilities, and ethical choices through the use of self-reflection, self-assessment, and narrative. Sign up for the latest publications from MedEdPORTAL Add your email below FILES INCLUDEDReferencesRelatedDetails FILES INCLUDED Included in this publication: Instructor's Guide.docx Family Medicine Clerkship Handout.doc To view all publication components, extract (i.e., unzip) them from the downloaded .zip file. Download editor’s noteThis publication may contain technology or a display format that is no longer in use. Related Interpretation at the OB/GYN Bedside - Cultural Competence in the Third-Year Clerkships Stereotypes and Bias at the Psychiatric Bedside - Cultural Competence in the Third-Year Required Clerkships Narrative Reflection in the Family Medicine Clerkship - Cultural Competence in the Third-Year Required Clerkships Copyright & Permissions© 2010 Elliott et al. This is an open-access publication distributed under the terms of the Creative Commons Attribution-NonCommercial-Share Alike license.KeywordsHealth Equity ResearchTruth DisclosureClerkshipEthical RelativismTACCT Domain Disclosures None to report. Funding/Support None to report. Prior Presentations Oral presentation at: Western Group on Educational Affairs; 2008. Poster presented at: USC Innovations in Medical Education; 2008. Loading ...

3D printing based on imaging data: review of medical applications

Generation of graspable three-dimensional objects applied for surgical planning, prosthetics and related applications using 3D printing or rapid prototyping is summarized and evaluated. Graspable 3D objects overcome the limitations of 3D visualizations which can only be displayed on flat screens. 3D objects can be produced based on CT or MRI volumetric medical images. Using dedicated post-processing algorithms, a spatial model can be extracted from image data sets and exported to machine-readable data. That spatial model data is utilized by special printers for generating the final rapid prototype model. Patient-clinician interaction, surgical training, medical research and education may require graspable 3D objects. The limitations of rapid prototyping include cost and complexity, as well as the need for specialized equipment and consumables such as photoresist resins. Medical application of rapid prototyping is feasible for specialized surgical planning and prosthetics applications and has significant potential for development of new medical applications.

The impact of limited English proficiency and physician language concordance on reports of clinical interactions among patients with diabetes: The DISTANCE study

Objective To assess the association of limited English proficiency (LEP) and physician language concordance with patient reports of clinical interactions. Methods Cross-sectional survey of 8638 Kaiser Permanente Northern California patients with diabetes. Patient responses were used to define English proficiency and physician language concordance. Quality of clinical interactions was based on 5 questions drawn from validated scales on communication, 2 on trust, and 3 on discrimination. Results Respondents included 8116 English-proficient and 522 LEP patients. Among LEP patients, 210 were language concordant and 153 were language discordant. In fully adjusted models, LEP patients were more likely than English-proficient patients to report suboptimal interactions on 3 out of 10 outcomes, including 1 communication and 2 discrimination items. In separate analyses, LEP-discordant patients were more likely than English-proficient patients to report suboptimal clinician–patient interactions on 7 out of 10 outcomes, including 2 communication, 2 trust, and 3 discrimination items. In contrast, LEP-concordant patients reported similar interactions to English-proficient patients. Conclusions Reports of suboptimal interactions among patients with LEP were more common among those with language-discordant physicians. Practice implications Expanding access to language concordant physicians may improve clinical interactions among patients with LEP. Quality and performance assessments should consider physician–patient language concordance.

Legalism, Countertransference, and Clinical Moral Perception

This target article focuses on dynamics that arise in three typical ethically complex cases in which psychiatric consultations are requested by physicians: a dying patient refuses life-prolonging treatment, an uncooperative patient demands to be allowed to go outside and smoke, and an angry patient demands to be admitted to the hospital. The discussion canvasses what is at stake morally and clinically in each of these cases and explores clinician–patient interactions, dynamics in relationships between consulting physicians and consultant psychiatrists, patient transference, and physician countertransference. The article defines legalism and countertransference and argues that an ethically and clinically important consequence of these phenomena for patients is distortion of clinicians' perceptions of patients' decisions and vulnerabilities. The discussion also describes how legalism and countertransference adversely affect how clinicians treat their psychiatrist colleagues. Finally, the article suggests how the effects of legalism and countertransference can be mitigated.

Consultation Room Design and the Clinical Encounter: The Space and Interaction Randomized Trial

The design of the consultation room remains largely unaltered despite major changes in clinical practice, such as the electronic medical record and patient-centered care. The value of redesigning the consultation room to accommodate these changes and the effect of a redesign on patient-clinician interaction are unclear. The authors randomly allocated 65 patient-physician dyads to consultations in a standard room (n = 30) or in an experimental room designed with a semicircular table around which the clinician and the patient sat, with equal access to the computer screen (n = 35). Participant responses to post-visit surveys, assessing patient experiences in these rooms, were compared in an intention-to-treat fashion. The authors found no differences between the rooms in terms of patient satisfaction with the consultation, mutual respect, or communication quality. Compared to the standard room, patients in the experimental room were better able to interact with the computer monitor (24 [75%] vs. 17 [59%], P = 0.07) and had a greater ability to look at the screen at any time (22 [73%] vs. 8 [28%], P < 0.001); and they reported that clinicians allowed them to review the medical record on the screen (22 [71%] vs. 13 [45%], P = 0.012), shared information on the computer screen (24 [80%] vs. 18 [60%], P = 0.037), and reviewed information on the Internet with the patient (13 [43%] vs. 7 [26%], P = 0.010) more than those in the standard room. The design of the consultation room affects the clinical encounter. In particular, ready access to a computer screen using the electronic medical record and the Internet may enhance information sharing.

Utilisation of laboratory services by health workers in a district hospital in Malawi

Aims:To identify priorities for improving effective use of laboratory services in a district hospital in Malawi.Methods:A prospective observational study of clinician–patient interactions to analyse laboratory test requesting practices and utilisation...

How Improving Practice Relationships Among Clinicians and Nonclinicians Can Improve Quality in Primary Care

Understanding the role of relationships health care organizations (HCOs) offers opportunities for shaping health care delivery. When quality is treated as a property arising from the relationships within HCOs, then different contributors of quality can be investigated and more effective strategies for improvement can be developed. Data were drawn from four large National Institutes of Health (NIH)-funded studies, and an iterative analytic strategy and a grounded theory approach were used to understand the characteristics of relationships within primary care practices. This multimethod approach amassed rich and comparable data sets in all four studies, which were all aimed at primary care practice improvement. The broad range of data included direct observation of practices during work activities and of patient-clinician interactions, in-depth interviews with physicians and other key staff members, surveys, structured checklists of office environments, and chart reviews. Analyses focused on characteristics of relationships in practices that exhibited a range of success in achieving practice improvement. Complex adaptive systems theory informed these analyses. Trust, mindfulness, heedfulness, respectful interaction, diversity, social/task relatedness, and rich/lean communication were identified as important in practice improvement. A model of practice relationships was developed to describe how these characteristics work together and interact with reflection, sensemaking, and learning to influence practice-level quality outcomes. Although this model of practice relationships was developed from data collected in primary care practices, which differ from other HCOs in some important ways, the ideas that quality is emergent and that relationships influence quality of care are universally important for all HCOs and all medical specialties.

Development of an Instrument to Document the 5A's for Smoking Cessation

The widely recommended 5A's strategy for brief smoking cessation includes five tasks: Ask, Advise, Assess, Assist, and Arrange. Assessments of the 5A's have been limited to medical-record review and self-report. Using observational data, an instrument to assess the rate at which the 5A's are accomplished was developed. The 5A's Direct Observation Coding scheme (5A-DOC) was developed using published 5A's guidelines and was refined using observed clinician-patient interactions. The development sample consisted of 46 audio-recorded visits of smokers with their physician (n=5), collected in 2000. The 5A-DOC was next applied to a second sample of 131 visits with 28 physicians between 2005 and 2008. Inter-rater reliability was assessed and frequencies reported. Analyses were completed in 2008. Three observations shaped the development of the 5A-DOC: (1) patients accomplish 5A's tasks; (2) some communication actions accomplish multiple 5A's tasks simultaneously; and (3) sequence is important. Inter-rater agreement for identifying each task was moderate to excellent (kappa=0.58-1.0). When smoking status was established (Ask, n=78), 61% Assessed readiness, and 50% contained Assist. In all, 73% failed to complete the 5A's adequately. Accounting for patient activity in smoking-cessation discussions is essential to accurately capture the degree to which the 5A's have been accomplished. The 5A-DOC can be applied to audio or transcript data to reliably assess which of the 5A's tasks have been accomplished. Clinician performance of the 5A's was modest, and findings suggest that clinician training should focus on Assess and the timing of this task, and alignment with patients' reported readiness.

Transformation of Health Care at the Front Line

CONCERN ABOUT ESCALATING COSTS AND THE quality of health care delivered in the United States continues to mount. This has led to an increasing focus on pay-for-performance, valuedriven health care and public reporting of quality and cost information. However, several authors have questioned the effectiveness of pay for performance and public reporting to improve patients’ outcomes and have highlighted the potential for unintended negative consequences. Currently, frontline clinicians are exposed to disparate pay-for-performance programs that are often uncoordinated and not clearly aligned with producing better outcomes for patients. Evidence is produced at an astonishing rate, but its incorporation into clinical practice is difficult. For patients, the current transparency efforts often have little useful information for decisions regarding a specific disease and selection of clinician or treatment option. However, policy makers and purchasers are faced with an underperforming health care system and untenable cost estimates, so maintaining the status quo is not an option. Recently, 82% of Americans indicated that the health system needs fundamental change or complete restructuring. Health care is now at a critical fork in the road. One option is to continue down a path that too often frustrates clinicians, confuses patients, and fails to align incentives with improving quality and value. The other is to take the path that aligns quality and value efforts with care where it matters, at the front line with clinicians and patients. The Agency for Healthcare Research and Quality (AHRQ) has a role to play in developing the science of measurement, research on quality improvement, and informing how to transform the system successfully, but leadership and collaboration from all stakeholders and a clear vision are needed. The approach described in this Commentary is by no means exhaustive. Each key driver to engage and enable frontline clinicians and their patients to transform care and achieve better outcomes could be the subject of multiple articles, but at the least, a vision must be outlined, the best path and methods to make progress debated, and the focus shifted to the front line of care. Quality Measurement and Payment The multitude of quality organizations (eg, National Quality Forum, National Committee for Quality Assurance, Ambulatory Care Quality Alliance) have each made contributions to the quality enterprise, but there is a need to move beyond simply developing more measures and to focus on developing high-priority measures such as those that influence outcomes on high-prevalence diseases, demonstrate baseline performance variability, and have potential mechanisms to improve results. A mix of process and outcome measures is needed, but measures should increasingly focus on patient-centered outcomes, including appropriate risk adjustment that is improved over time. Occasionally, a given measure may not be appropriate because of patient preference or clinician knowledge of information not captured in claims or electronic data. In these cases, exception reporting should be allowed to minimize “unfair penalization” and the potential unintended consequence of clinicians avoiding complicated cases. However, exception reporting will need to be monitored so it is truly the exception and provides information for requisite refinements. The measurement enterprise needs to be linked to a strategy for capturing high-priority data with minimal workflow disruption. Instead of chart review–based measurement, functional electronic health records (EHRs) are needed, along with patient registries that capture quality measurement data, such as monthly reports, to provide feedback to clinicians. Measurement is the first step in clinicianand practice-based improvement. Current measures often focus on individual patientclinician interactions at a single point in time and, therefore, undervalue teamwork and patient outcomes over time. Measures focused on adherence to process in single interactions, when implemented widely, may have unintended negative consequences for patients. Measures need to focus more on the patients’ outcomes over an episode of care, such as from hip fracture through recovery. If a patient with

How to improve adherence to antipsychotic treatment: Outcomes of the IMproving PAtient outComes in psychiaTry (IMPACT) Berlin 2009 meeting workshop

Objective. To challenge psychiatrists about their practice regarding patients’ treatment adherence in severe mental disease, and make them discuss possible ways to improve this through their relationship with patients. Methods. A total of 423 physicians from 32 countries were assigned across 41 parallel groups during a workshop organised on adherence in severe mental diseases. Factors that influence adherence, and questions and measures to help patient–clinician interaction were discussed and rated. Results. The most important factor influencing adherence to treatment was considered to be insight. The factor over which clinicians felt they had the greatest influence was the therapeutic relationship. The question that most physicians considered the most useful for improving communication with patients was, “Does taking medication cause any problems for you?” Additional areas identified as important in improving adherence included addressing the positive and negative aspects of medication, patient expectations and what patients hoped to gain from seeing their physician. Intervention programmes to improve adherence included patient education, motivational interviewing and cognitive-behavioural therapy. A composite toolkit based on the top-rated questions to improve communication with patients and measures to aid adherence was recommended. Conclusion. Patient-centred practice is fundamental to ensuring adherence in mentally ill patients. Working tools can be successfully developed in interactive workshop settings, through reviewing and challenging current clinical practice.

Teachable moments for health behavior change: A concept analysis

Objective “Teachable moments” have been proposed as events or circumstances which can lead individuals to positive behavior change. However, the essential elements of teachable moments have not been elucidated. Therefore, we undertook a comprehensive review of the literature to uncover common definitions and key elements of this phenomenon. Methods Using databases spanning social science and medical disciplines, all records containing the search term “teachable moment *” were collected. Identified literature was then systematically reviewed and patterns were derived. Results Across disciplines, ‘teachable moment’ has been poorly developed both conceptually and operationally. Usage of the term falls into three categories: (1) “teachable moment” is synonymous with “opportunity” (81%); (2) a context that leads to a higher than expected behavior change is retrospectively labeled a ‘teachable moment’ (17%); (3) a phenomenon that involves a cueing event that prompts specific cognitive and emotional responses (2%). Conclusion The findings suggest that the teachable moment is not necessarily unpredictable or simply a convergence of situational factors that prompt behavior change but suggest the possible creation of a teachable moment through clinician–patient interaction. Practice implications Clinician–patient interaction may be central to the creation of teachable moments for health behavior change.

The Confusion Assessment Method—A Tool for Delirium Detection by the Acute Pain Service

Delirium is an acute fluctuating disturbance in cognitive status, linked to increased morbidity and mortality. The purpose of this pilot study was to assess the feasibility in terms of required time and yield of delirium monitoring by the Acute Pain Service (APS) using the Confusion Assessment Method for Intensive Care Unit instrument. Patients undergoing surgery requiring more than 2 days of hospital stay were recruited. Each patient was assessed daily for 2 days after surgery using the Confusion Assessment Method for Intensive Care Unit. Patients were also assessed for orientation to person, place, and time. Any notes of confusion or delirium made by physicians or nursing staff were gathered. 145 patients were recruited. Each patient encounter required an average 2.3 +/- 0.3 minutes for the assessment (95% CI). The incidence of delirium within 2 days after surgery was 7.6%. Only 18% of the patients diagnosed with delirium by the APS were noted as being confused by the medical or nursing staff. The use of this tool required little training, and only 2 minutes per patient. It detected more patients with delirium than did the standard nursing assessments or other patient-clinician interactions. The use of this instrument by the pain service was feasible in terms of time consumption and most likely would be valuable in its yield. Early detection may help in initiating prompt treatment, eliminating known risk factors and thus reducing morbidity.

Cognitive Expertise, Emotional Development, and Reflective Capacity: Clinical Skills for Improved Pain Care

The overarching goal of medical training is to nurture the growth of knowledgeable, caring, and insightful clinicians guided by the ideals of medical professionalism. Recent definitions of professional competence identify essential clinical skills, including cognitive expertise, emotional competence, and reflective capacity. This modern framework reflects the increasingly complex nature of the patient-clinician interaction, in which the clinician must exchange diagnostic information while supportively engaging the patient on a deeper, affective level. The affective dimension can be particularly potent when pain is the primary symptom, as it is for the majority of medical visits. Unfortunately, however, current models of professionalism, used as an early guide for medical trainees to develop an understanding of the clinical exchange, largely focus on interactions in the cognitive domain. To emphasize the importance of emotions in professional development, we propose the Cognitive and Emotional Preparedness Model, which describes the clinical encounter occurring on two channels, one cognitive and the other emotional, and stresses the importance of multidimensional development in preparing the clinician to (1) communicate clinical information, (2) provide emotional support, and (3) actively reflect on experiences for continued improvement. Together, acquisition of knowledge, emotional development, and reflective skill will improve the clinical interaction. The proficiency of medical trainees in developing clinical skills profoundly shapes patient satisfaction and treatment outcomes. This article reviews the cognitive, emotional, and reflective development of medical trainees and presents a model illustrating how clinical development impacts pain care. For improved efficacy, pain education should be calibrated to students' developmental needs.

Fundamentals of Esthetic Implant Dentistry.

Fundamentals of Esthetic Implant Dentistry.

Virtual Patient Training to Improve Reproductive Health Care for Women With Intellectual Disabilities

A multimedia virtual patient module, involving the case of a young woman with mild intellectual disabilities with a complaint of diffuse abdominal pain, was developed as a clinical training tool for students in health care professions. Primary objectives following use of the module included improved knowledge and reduced perception of difficulty in treating women's health patients with intellectual disabilities. The module was developed using an iterative, collaborative process of a core development team that included medical professionals, multimedia specialists, the parent of a child with intellectual disability, and a disability advocate. Over the course of the module, students were required to identify appropriate and effective clinician-patient interactions in addition to relevant medical and developmental concerns for this patient population. Pilot data from a sample of nursing, physician assistant, and medical students suggest that the module is an effective tool for both improving students' knowledge and reducing their perception of difficulty in providing care to women's health patients with intellectual disabilities.

Traumatic Amputation: A Case of Laotian Indignation and Injustice

Culture is an essential variable of diagnosis and treatment. A cultural perspective draws attention to the social context within which symptoms arise, are given meaning, and are managed. Ethno-cultural work on illness narratives suggests that most people can provide culturally-based explanations for their symptoms. While these explanations are inconsistent with biomedical theory, they relieve patient distress by allowing the patient to create meaning for symptoms. Exploring the characteristics, context, and antecedents of the symptoms enables the patient to convey them to the clinician who may have a divergent explanation of sickness. This case study uses the Outline for Cultural Formulation of the DSM-IV created for clinicians to elicit a narrative account of the illness experience from the patient. Our study examines how the patient, a Laotian used social indignation ("Kwam khem keuang") as an explanatory model for his ailment. He was diagnosed with post-traumatic stress disorder after having undergone a traumatic amputation. In the process of explaining his illness through a cultural idiom, the patient was able to reveal both personal and collective meaning of repressed anger and frustration, expressing them in a context that was acceptable to him. This cultural idiom allowed the patient to reflect upon the structure of the health care system and the specific context in which symptoms and their possible origins are recounted and explored. It also clarified to the treating clinicians some categories of experience and causal explanations that did not fit easily with western biomedical and psychiatric understanding. The case study illustrates how a cultural approach to illness from the patient's perspective offers a reflexive stance on the clinician-patient interaction that allows for better patient care.

Ticking Boxes and Changing the Social World: Data Collection and the New UK General Practice Contract

Abstract The new General Medical Services contract was introduced into general practice in the UK in 2004, and it links pay to performance far more than in the past. As a result, accurate data collection about patients and the care that they receive is now not only important for good patient care but also to prove that targets are being met. The use of electronic records and information technology has thus become much more sophisticated. This article reports the results from an ethnographic study of the early stages of the new contract in two general practices. As expected, electronic data collection had increased in importance in both practices, with consequences both for clinician–patient interactions and for the structures and processes in the practices, as uniform data collection instruments are put in place that privilege ‘hard’ biomedical data that can be easily coded above ‘softer’, more patient‐centred information. Roles and responsibilities had been changed to reflect the needs of the new systems, and new software applications allowed increased surveillance of both doctors’ and nurses’ performance; both of these had an impact on patterns of authority in our study practices. Furthermore, the structural changes that were found acted to embed the new ways of working, ensuring their reproduction in the future. In spite of these effects, we found little opposition to or critical reflection on the changes, and the doctors in our study continued to view their improved computer systems as neutral recording devices. The implication of these findings is discussed.