General Practitioner's use of online resources during medical visits: managing the boundary between inside and outside the clinic

"You become a slightly better doctor": Doctors adopting integrated medical expertise through interactions with E-patients

The accessibility of information via the internet has radically altered the doctor-patient relationship. By means of in-depth interviews with Israeli physicians from four different specialties, this study explored how physicians cope with internet-informed patients, referred to as e-patients, and examined how they make sense of their new professional roles. Findings show that three types of boundaries in the doctor-patient relationship have been blurred by the emergence of the e-patient: the boundaries between doctors' and patients' knowledge, between doctors' authority and patients' autonomy, and between positivistic knowledge and humanistic knowledge. Each of these is a boundary between liberal and non-liberal values. Only the combination of all these components produces, according to the participants, a good doctor. I call this new phenomenon integrated medical expertise and explain how it diverges from previous notions of 'good doctoring'.

Power, paradox and pessimism: On the unintended consequences of digital health technologies in primary care

We consider what might be learned from the unintended, apparently unanticipated, consequences of the use of digital health (including alternatives to face to face consultations, electronic medical records, use of apps and online monitoring) in primary care. We chose a conceptual literature review method, to seek a higher order understanding of the nuanced patterning of unintended consequences of digital health technologies (for people, relationships, organisations and ways of working) which are rarely simply positive or negative. The approach is informed by realist review, which recognises that experiences and outcomes of interventions work (or fail) in different ways in particular contexts. We present three higher order themes to illuminate underpinning mechanisms for unintended consequences in digital health technologies in primary care. These themes are illustrated by case examples, with particular focus on those that have been little discussed in the literature. Following Merton's (1936) differentiation between consequences for the actor(s) and others, which are mediated through the culture and social structure, we discuss consequences that i) disrupt power relations between patients and health professionals or between different groups of health professions, ii) contribute to paradoxical outcomes and iii) result in a potentially corrosive sub-culture of pessimism about digital health. We conclude that when implementing or evaluating digital technologies in primary care, it is wise to consider the 'dark logic' of the intervention (Bonell et al., 2015). Attention to issues of power relations, the potential for paradoxical outcomes, and impacts on the expectations of staff in relation to digital innovation are particularly salient in relation to the dramatic changes in primary care delivery initiated during the Covid-19 pandemic. Fostering a sense of ownership and interest in monitoring the effects that matter to the organisation will likely help counter pessimism and renew interest in deploying those digital innovations that show promise.

Digital mediation of candidacy in maternity care: Managing boundaries between physiology and pathology

This paper brings together scholarship across sociology, media and communication, and human computer interaction to explore the intersection of digital health and the maternity care system. We draw on data (including interviews, focus groups, observations, and analyses of digital media content) from 19 studies involving over 400 women to explore women's experiences of using different forms of digital support such as the Internet, mobile technologies (apps and text messaging), social media, and remote monitoring devices in their reproductive journeys. We use a best fit approach to analysis, mapping our findings to the candidacy framework and notions of trajectory work to understand how women engage in digital health practices to negotiate boundaries between physiology and pathology and to enter dialogue with maternity services during conception, pregnancy and the postnatal period. We propose an integrated revised conceptual framework which explicates intersections between digital and care practices, and micro-level negotiations between women and professionals in the maternal health context. Our revised framework retains the dimensions of candidacy, but it introduces a precursor to the identification of candidacy in the form of 'understanding normality'. It identifies distinct forms of digital work (e.g. information work, navigation work, machine work) which operate across the candidacy dimensions that women (and partners at times) engage in to negotiate legitimacy when entering into encounters with the maternity care system. Operating conditions (norms around expert motherhood; neoliberal discourses around health optimisation, risk and responsibilisation) provide a broader macro-level context, influencing the micro-level dialogic processes between women and healthcare professionals. Our synthesis highlights digital mediation as a useful filter to understand care systems, distribution of lay/professional responsibilities, relational practices and the (dis)enablement of candidacy.

Patients' use of the internet to negotiate about treatment

The internet provides access to a huge variety of information, including health information. There is, however, a dearth of evidence as to how, and to what ends, patients raise prior use of the internet during medical visits. Analysis is based on the Harnessing Resources from the Internet study. Drawing on data from 281 video-recorded primary care consultations, we use conversation analysis (CA) to systematically inspect the data for instances in which patients reveal that they have accessed publicly available online resources regarding their illness, symptoms, or treatment concerns. Patients invoke the internet to support three types of action: to (i) justify concerns about a serious illness; (ii) provide a warrant for treatment where they have been unable to find a solution; and (iii) advocate in relation to treatment. Although invoking the internet risks potential encroachment into the doctor's domain of authority, patients carefully design their turns when raising the internet so as to orientate to the final decision about treatment as residing firmly within the doctor's domain of authority. The work demonstrates how detailed interactional analysis can be used to illuminate the local work that patients and doctors engage in to manage the rise in availability of information from the internet.

Platform encounters: A study of digitised patient follow-up in HIV care

Digital technologies are increasingly embedded in clinical encounters, reconfiguring the basis on which health care is delivered. Thereby, the delivery of care shifts from territorial locations in clinics and temporal modes of co-presence towards digital platforms. Drawing on a sociotechnical evaluation of digitised patient follow-up in HIV care, this paper argues that the forms of interactivity practised in platform encounters cannot be adequately understood through traditional interaction frameworks such as Erving Goffman's interaction order. To conceptualise the new informational space and temporal mode of 'response presence' within which platform encounters are conducted, the paper draws on theoretical advances made by Karin Knorr Cetina who further developed Goffman's interaction order to describe interactions augmented by 'scopic media'. A comprehensive framework is presented to elaborate the distinct qualities of interactions occurring in face-to-face, tele-interaction and platform encounters and to analyse their affordances based on doctor and patient experiences. This framework is intended to stimulate further research on how new interactional forms between doctors and patients will reconfigure roles and responsibilities as well as wider structures of digital society. Furthermore, it can also support practical guidance of when and how different forms of clinical encounters may be integrated in care pathways.

Becoming a diagnostic agent: A collated ethnography of digital-sensory work in caregiving intra-actions

Sociological contributions on digital health have acknowledged the enduring significance of sensory work in diagnosis and practices of care. Previous explorations of these digital and sensory entanglements have focused separately on healthcare providers or patients/caregivers, rarely bringing these worlds together. Our analysis, based on the collation of ethnographic fieldwork in clinics, medical schools, and homes in Australia, offers rare insights into caregiver and practitioner perspectives. We interrogate the work involved in digital-sensory becoming, as caregivers (in our case parents) learn to assign diagnostic meaning to potential childhood disease. Working with Karen Barad's concept of 'intra-action', we demonstrate how diagnostic knowing is enacted between practitioners, parents, senses, and devices. We identify seven aspects of digital-sensory learning: attention to the change from normal; testing/searching for signs and symptoms; confirmation and direction from more experienced others; mimicry; analogy/metaphor; digital archiving; and reference to validated digitised signs. We found that this learning does not take place discretely in the clinic or at home. Doctors and parents both do digital-sensory work to register, co-witness, and mutually enact disease by interpreting signs and symptoms together in their caregiving intra-actions. Our article also champions collated ethnography as a methodological approach for making sense of complex assemblages in healthcare.

Combining patient talk about internet use during primary care consultations with retrospective accounts. A qualitative analysis of interactional and interview data

Despite widespread acknowledgement of internet use for information about health, patients report not disclosing use of online health information in consultations. This paper compares patients' reported use of the internet with matched video recordings of consultations. The concepts of doctorability and epistemics are employed to consider similarities and differences between patients’ reports in interviews and actions in the consultation. Data are drawn from the Harnessing Resources from the Internet study conducted in the UK. The data set consists of 281 video-recorded general practice consultations, with pre-consultation questionnaires completed by all patients, interviews with all 10 participating doctors and 28 selected patients. We focus on the 28 patient interviews and associated consultation recordings. A conversation analytic (CA) approach is used to systematically inspect both the interview and consultation data. In interviews patients presented use of the internet as associated with appropriate self-management and help-seeking. In consultations patients skilfully translated what they had found on the internet in order to provide grounds for the actions they sought. We conclude that patients translate and utilise what they have found on the internet to assert the doctorability of their presenting problems. Furthermore, patients design their talk in both interviews and consultations to accord with their understanding of the epistemic rights of both doctors and patients. Patients search the internet so they are informed about their medical problem, however they carefully manage disclosure of information to avoid disrupting the smooth running of medical interactions.

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Patients seek information from the internet to support decisions to consult.

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Patients seek information from the internet to support appropriate self-management.

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Patients skilfully translate what they find on the internet to support requests.

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Patients skilfully use the internet to invite action from their doctors.

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Patients do not openly challenge the epistemic authority of the doctor.