Electronic medical records in diabetes consultations: participants' gaze as an interactional resource.

Two routine consultations in primary care diabetes clinics are compared using extracts from video recordings of interactions between nurses and patients. The consultations were chosen to present different styles of interaction, in which the nurse's gaze was either primarily toward the computer screen or directed more toward the patient. Using conversation analysis, the ways in which nurses shift both gaze and body orientation between the computer screen and patient to influence the style, pace, content, and structure of the consultation were investigated. By examining the effects of different levels of engagement between the electronic medical record and the embodied patient in the consultation room, we argue for the need to consider the contingent nature of the interface of technology and the person in the consultation. Policy initiatives designed to deliver what is considered best-evidenced practice are modified in the micro context of the interactions of the consultation.

What does the use of a computerized checklist mean for patient-centered care? The example of a routine diabetes review.

The authors examine the interaction between nurses and patients with type 2 diabetes during routine consultations in primary care settings in the United Kingdom. Through preconsultation interviews, the authors identified the patients' expectations. The article draws on videotaped consultations with 25 patients with type 2 diabetes. Using conversation analysis, the authors examine the use of a rigid agenda, imposed via a computerized checklist, and consider how far this is able to suppress the patient's agenda. They consider the potential impact for the patient and the factors that might encourage the clinician, and the nurse specifically, to adopt a narrowly task-based approach to the consultation. They identify two potentially conflicting strands within contemporary diabetes care, patient-centered practice and an emphasis on biomedical audit, and suggest that achievement of the former might be compromised by the demands of the latter.

Smuggled tobacco, deprivation and addiction.

OBJECTIVE: To identify the links between smuggled tobacco, deprivation and addiction across one Health Authority in the North East of England and identify the impact on people living in disadvantaged areas. DESIGN: Anonymous postal survey. Sample size 11 443. Multivariate analysis including an 'Ideal Types analysis' examined the probabilities of purchase of smuggled tobacco and associations with population characteristics. SETTING: Sample taken from across the Hull & East Riding Health Authority area in the UK. PARTICIPANTS: Randomly selected from those aged 16 and over, who were registered with a GP in the Health Authority area on the 1 September 2000. RESULTS: The predicted probability of having ever bought smuggled tobacco for a male, employed, heavy smoker living in a deprived area was 0.67. A female with the same characteristics had a probability of 0.49. For the unemployed the probabilities are 0.55 and 0.37 respectively. For respondents living in non-deprived areas the probability of having ever bought smuggled tobacco was much lower. This probability was further reduced for respondents who were unemployed. Respondents living in deprived areas had a 134% higher probability of being heavily addicted to tobacco. Links between addiction and deprivation are confirmed. CONCLUSIONS: This study confirms and extends the findings of previous qualitative studies. The results of this analysis demonstrate that people who have bought smuggled tobacco are heavy smokers with high levels of addiction, living in socially deprived areas, but are more likely to be in employment. They are likely to use smuggled tobacco to save money and sustain their smoking habit.

Achieving multiple topic shifts in primary care medical consultations: a conversation analysis study in UK general practice.

The 'by the way' phenomenon, while commonly described in medical texts on the consultation, has not been systematically explored from an interactional perspective. Starting from a 'noticing' of an example of this phenomenon we studied a collection of over 200 recorded consultations in British general practice. New topics were introduced by both parties, but more commonly by patients, who used two sorts of device to change topic: an announcement, usually at the start of a consultation, but sometimes later, that they had multiple topics, which we have called a 'pre-announcement', and an apparently unexpected sudden change of topic, which we have called an 'in-situ announcement'. These phenomena occurred in about one third of our unselected collection of recorded consultations, drawn from nine doctors, and 27 surgery (office) sessions. We argue that this management of multiple topics is an important and normal part of the consultation, in contrast to its problematic status implied in some medical literature.