1. The issues
Multi-tasking: this is the key issue. Is it possible to do two things at once? More specifically, is it possible to concentrate on two things at once? Can you concentrate on the computer screen without losing rapport with the patient?
One way to think about this is to compare the task with driving a car. Experienced drivers often find that they get to the end of a familiar journey and are unable to remember any details of the journey. They are quite comfortable to drive the car, listen to the radio, talk to their passenger, and probably think about the next meal all at the same time. Get into an unfamiliar situation, such as a busy city centre, and the same driver will turn off the radio, suspend conversation and pay full attention to the road.
We think that it is the same with computer use. We know that the experienced user can put in the background tasks like the mechanical use of keyboard and mouse. It gets more difficult to do this if the computer user has to think about the content on the screen, or is engaged in an interactive programme. It is very difficult, perhaps impossible, to follow two streams of language simultaneously.
How to cope in the consultation: the answer seems to be to adapt your behaviour and structure the consultation so that you are not put in the position of having to pay full attention to both patient and screen at the same time. One important part of this is making sure that the patient knows what is happening. There are different strategies and techniques that can be used to do this: they are explained in this pack and also on the PRODIGY CD ROM. There is no single right way of doing this: the idea is to pick out the strategies and techniques that are useful to you and that you feel comfortable with using.
2. How to transfer attention to the screen
This is covered in sections three and four of the PRODIGY CD ROM. The key point is to stop the patient from saying something important while the GPs attention is on the screen.
There are 3 strategies:
- Signposting: i.e. making sure that the patient knows what you are doing
- Blather: fill the conversation space so that the patient cant talk while you are concentrating on the screen
- Redirect attention to patient every time they speak, or move.
This can be done by verbal and non-verbal means, usually in combination.
Non-verbal: gestures, reaching for mouse, turning away from patient. Verbal: use of phrases that tell the patient what you are doing.
There are several different examples on the video clips. In a group setting the participants can be asked to generate a list; here are some samples:
- Just give me a minute while I look at the computer
- I need to concentrate on the computer for a minute, do you mind?
- Forgive me while I look at the screen
- There is some information about this on the computer, I just need a moment to find it
- Hold on while I do this on the computer
There are lots of variations on these themes. The aim is to get the GP to find one or two that they are happy to use, and then let them practice.
This may be a running commentary on what the GP is doing:
- I just need to get into PRODIGY
- The system is being slow today
- I still need to take my time when Im typing
Alternatively, the GP can prattle about the weather, sport or whatever: most of us can do that on autopilot.
This is illustrated in consultation 3 in the Using the computer in the consultation room section of the PRODIGY CD ROM. When you look at this segment, note how the GP stops typing when the patient speaks and she turns towards him to indicate that he has her full attention. When she has dealt with his question, she signposts verbally her return to the computer screen.
One of the skills here is related to noticing that the patient requires attention: this requires practice. The other skill is handling the return of attention back to the computer screen: again letting the patient know what you are doing.
3. How to read off screen and share information
There are two aspects to this.
First, the GPs attitude to sharing information and being seen to look things up is an important factor. Doctors and patients vary considerably in how much they cling to the idea of doctor as fount of wisdom.
The other is the use of specific skills to manage this effectively in the consultation.
It is probably as well to talk around the attitudinal stuff before embarking on skills training, although some experts think that the best way to change attitudes is by skill-rehearsal.
The key skills are:
- Make sure the patient can see the screen
- Use signposting to let the patient know what is expected
- Dont talk while they are reading
- Give the patient opportunity to ask questions
- Check that the patient has understood the message (ask them to summarise the information, or summarise it yourself and check that they agree with your summary)
Sometimes the GP will want to point out a small piece of information that is on a page full of text. In this case it is important to indicate, by pointing, which bit is being referred to. The GP also needs to make sure that the patient is not distracted by the rest of the page: best to re-establish eye contact before ploughing on.
There are benefits from demonstrating and talking about communication skills, but rehearsal with feedback is much more effective.
You can set up role-plays with a variety of tasks. A simple one is to fill in table that asks a few lifestyle questions (smoking, drinking, exercise habits etc). The GP has to ask the details and then put them onto the computer. This can be done in a trio (GP, patient, observer) and the participants can then rotate roles. This is fairly low-challenge, and need not be facilitated.
More challenging are clinical scenarios in which the patient is primed to ask a question, the answer to which is available on the computer. In a group setting this simulated consultation can be videotaped and reviewed by the group. This is very effective, but it is important that someone with experience of this type of work facilitates the group: there are risks if it is not done properly.