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Perturbations in the ergonomics of primary care

This article originally appeared in BMJ USA

At a recent meeting, the chief of psychiatry at my institution was explaining why it is difficult to get primary care physicians to screen their patients for depression. One of the reasons, he said, is that it creates a "perturbation in the ergonomics of the primary care visit." Primary care physicians have 16 to 18 minutes for the average patient encounter. Asking the patient a question designed to screen for depressioneg, "Have you been bothered recently by feeling down, depressed, or hopeless?"may elicit a lengthy response, or it may reveal a serious psychosocial problem demanding the physician's attention, which then disrupts the clinic schedule. So, the easiest approach in the midst of a harried day at the office is to avoid posing the question.

One way to screen for depression without perturbing the doctor-patient encounter is for office staff to administer a screening questionnaire. Gilbody and colleagues performed a systematic review of randomized controlled trials of the administration of psychiatric screening questionnaires and the feedback of results to clinicians in non-psychiatric settings (BMJ USA p 179). Results were not encouraging. Feedback of scores for all patients did not increase the overall rate of recognition of mental disorders. Recognition of depression did increase in two studies of selective feedback for high scorers ("high-risk patients"), but there was no impact on the rate of intervention. The authors note that feedback is most effective when accompanied by an educational program and an outside referral agency that assumes responsibility for management.

Will informatics improve the ergonomics of primary care? Mitchell and Sullivan conducted a systematic review of studies evaluating the impact of computers on primary care (BMJ USA p 195). They found that computing systems can improve immunization rates and delivery of other preventive services, increase prescribing of generic drugs, and reduce ordering of unnecessary tests. Thornett, however, argues in a rapid response that computer use has "significant detrimental effects" on the doctor-patient encountereg, increasing consultation time and preventing doctors from developing an empathic relationship with patients (BMJ USA p 199).

The ergonomics of clinical practice are thoroughly degraded when doctors find themselves spending more time with insurers and auditors than with patients. A news article in this issue reports on MERFAthe Medicare Education and Regulatory Fairness Act of 2001which, if passed by Congress, will provide some relief to physicians from the 130 000 pages of laws and regulations dealing with Medicare (BMJ USA p 209).

Finally, in a paper from the BMJ 's Christmas issue, Norton reports how the Gungan inhabitants of the planet Naboo, depicted in Star Wars Episode 1: The Phantom Menace, appear to have the fungal infection tinea imbricata (BMJ USA p 205). This is evidence, he says, of extraterrestrial visitations to earth.

Psychiatric screening questionnaires (BMJ USA p 179) http://bmj.com/cgi/content/abstract/322/7283/406

Computers in primary care (BMJ USA p 195) http://bmj.com/cgi/content/abstract/322/7281/279

Rapid responses (to paper by Mitchell & Sullivan) (BMJ USA p 199) http://bmj.com/cgi/doi/10.1136/bmjusa.01040006

Medicare (BMJ USA p 209) http://bmj.com/cgi/content/full/322/7287/638

Tinea on Naboo (BMJ USA p 205) http://bmj.com/cgi/content/abstract/321/7276/1619