Letters

RAPID RESPONSES FROM BMJ.COM Two e-letters posted on bmj.com in response to the paper by Mitchell and Sullivan are reproduced (after minor editing) below.Editor

The negative effects of computers in the doctor-patient encounter

Primary care skills and computing

The negative effects of computers in the doctor-patient encounter

This article originally appeared in BMJ USA

EDITORIn their review, Mitchell and Sullivan found no evidence that computer use during the doctor-patient encounter resulted in negative effects on patient outcomes, and they concluded that doctors and patients were generally positive about use of computers.

Computers in the general practice consultation can improve the quality of medical care in some cases.¹ Benefits have been shown in disease prevention with an improvement in immunization rates by up to 18% and other preventive services by up to 50%,² in disease management with more appropriate dosing for drugs with a narrow therapeutic range,³ and in the management of chronic physical illness when there is a clear consensus regarding treatment protocols. ^{4 5}

However, their use is also associated with significant detrimental effects on the encounter. Consultation time is increased by their use, and there is no appreciable benefit for patient satisfaction.² Both practitioners' conduct and disclosure of information by the patient are adversely affected,³ and many patients are concerned about confidentiality.⁴ The current computer systems are not well suited to the wide variety of undifferentiated problems that present in general practice, and their use may prevent the doctor from developing an empathic relationship with patients. This makes evaluating the impact of computers on doctor-patient interactions particularly important.⁵

Work is still needed to ensure that computerization of the doctor-patient encounter is not detrimental to the quality of the relationship between the doctor and patient.

Andrew Martyn Thornett, clinical research fellow. 
University of Southampton, UK eanador{at}soton.ac.uk

Primary care skills and computing

EDITORMitchell and Sullivan's comprehensive review of primary care computing raised the issue that practitioners perceive their training in computer use as being poor. They also noted that computer literacy should be made a component of ongoing medical education.

While agreeing with this statement, we feel that there is more to this issue than just being comfortable using a computer. There is little doubt that most practitioners have some basic knowledge of computing, but are they information literatecan they search Medline efficiently, negotiate the Cochrane database, navigate a reliable health portal, and evaluate useful content on behalf of their patients?

A study of general practitioners' use of evidence databases showed that 22% were aware of the Cochrane database, 6% had access to it, and only 4% had ever used it.¹ Another study found that only 26% of family physicians had computers in their offices and that the majority turned to books when faced with questions about patient care.² Hence, research suggests that general practitioners may be reluctant to embrace information technology. Perhaps the reasons for this reluctance relate more to technical issues than practitioners' skills.

There is no consensus on the best method for retrieving information from the web. Graber and colleagues³ found that medicine-specific search engines on the web fare poorly in answering clinical questions when compared with general search engines.

Furthermore, a review by Hersh and Hickman⁴ suggests that current information retrieval systems are too slow to allow busy clinicians to address the myriad questions that arise in clinical practice. Hence, how can one integrate computers into clinical practice if the tools we use are worn and dated?

The younger generation of medical practitioners and medical students seems to have more confidence and skill in computer use and medical informatics.⁵ With advances in user-friendly technology, perhaps the problem of information illiteracy will no longer exist for future generations.

Bartosz Szkandera, . 
Wayne Lee, medical students. 
University of New South Wales, Australia