PURPOSELittle is known about the effects of the electronic health record (EHR) on physician-patient encounters. The objectives of this study were to identify the factors that infl uence the manner by which physicians use the EHR with patients. METHODSThis ethnographic study included 4 qualitative components: 80 hours of participant observation in 4 primary care offi ces in the Pacifi c Northwest; individual interviews with 52 patients, 12 offi ce staff members, 23 physicians, and 1 nurse-practitioner; videotaped reviews of 29 clinical encounters; and 5 focusgroup interviews with physicians and computer advocates. The main outcome measures were factors that infl uence how physicians use the EHR. Researchers qualitatively derived these factors through serial reviews of data. RESULTSThis study identifi ed 14 factors that infl uence how EHRs are used and perceived in medical practice today. These factors were categorized into 4 thematic domains: (1) spatial-effect of the physical presence and location of EHRs on interactions between physicians and patients; (2) relational-perceptions of physicians and patients about the EHR and how those perceptions affected its use; (3) educational-issues of developing physicians' profi ciency with and improving patients' understandings about EHR use; and (4) structural-institutional and technological forces that infl uence how physicians perceived their use of EHR.CONCLUSIONS This study found that the introduction of EHRs into practice infl uences multiple cognitive and social dimensions of the clinical encounter. It brings into focus important questions that through further inquiry can determine how to make best use of the EHR to enhance therapeutic relationships. INTRODUCTIONT he electronic health record (EHR) is a new technology touted as a standard of practice for American medicine in the 21st century. 1,2 This technology brings the medical record and health information into the examination room through computer hardware and software, patient education materials, and Internet search capabilities. Several authorities endorse the transition to EHRs and promote a technologybased information infrastructure that eliminates handwritten clinical data within 10 years. 3,4 Numerous authors have discussed the theoretical benefi ts of computers in clinical practice, 1,[5][6][7] and differences exist when comparing the use of EHRs with paper charts. 7,8 Although these differences have not been found to affect patient satisfaction, 9-11 little else is known about the effects of this technology on physician-patient encounters.Studies examining clinical encounters with EHRs suggest that physicians using EHRs preferentially structure interviews around data-gathering demands rather than patients' own narratives. 12,13 Recent data, however, suggest that this pattern relates more to physician style than to EHR use alone.14 Physicians using EHRs also engage in a variety of computer-related The purpose of this work was to explore how EHRs affect the encounters between physicians and thei...

Within health professional education around the world, there exists a growing awareness of the professional duty to be socially responsible, being attentive to the needs of all members of communities, regions, and nations, especially those who disproportionately suffer from the adverse influence of social determinants. However, much work still remains to progress beyond such good intentions. Moving from contemplation to action means embracing social accountability as a key guiding principle for change. Social accountability means that health institutions attend to improving the performance of individual practitioners and health systems by directing educational and practice interventions to promote the health of all the public and assessing the systemic effects of these interventions. In this Reflection, the authors (1) review the reasons why health professional schools and their governing bodies should codify, in both curricular and accreditation standards, norms of excellence in social accountability, (2) present four considerations crucial to successfully implementing this codification, and (3) discuss the challenges such changes might entail. The authors conclude by noting that in adopting socially accountable criteria, schools will need to expand their philosophical scope to recognize social accountability as a vitally important part of their institutional professional identity.

Shared presence is a state of being in which physicians and patients enter into a deep sense of trust, respect, and knowing that facilitates healing. Communication between physicians and patients (and, in fact, all providers and recipients of health care) is the medium through which shared presence occurs, regardless of the presenting problem, time available, location of care, or clinical history of the patient. Conceptualizing how communication leads to shared presence has been a challenging task, however. Pathways of this process have been routinely lumped together as the biopsychosocial model or patient, person, and relationship-centered care-all deceptive in their simplicity but, in fact, highly complex-or reduced to descriptive explications of one constituent element (e.g., empathy). In this article, we reconcile these pathways and elements by presenting a graphic image for clinicians and teachers in medical education. This conceptual image serves as a framework to synthesize the vast literature on physicianpatient communication. We place shared presence, the fundamental characteristic of effective clinical communication, at the center of our figure. Around this focal point, we locate four elemental factors that either contribute to or result from shared presence, including interpersonal skills, relational contexts, actions in clinical encounters, and healing outcomes. By visually presenting various known and emergent theories of physician-patient communication, outlining the flow of successful encounters between physicians and patients, and noting how such encounters can improve outcomes, physicians, other health care professionals, and medical educators can better grasp the complexity, richness, and potential for achieving shared presence with their patients.

The era of community-based participatory research (CBPR) began years ago. It may have even started with the American Revolution, when angry colonists rallied under a banner of "taxation without representation" and demanded that their unwelcome despot change his ways. Much more recently, in the early 1990s, disability activists brought the slogan "nothing about us without us" to common usage. With its history of social marginalization, discrimination, and various forms of inhumane treatment, this particular community had had enough. Its members wanted to be included-not just as an afterthought, but also from the "get go"-in the research questions and policy platforms that involved them. Now, many communities are following suit, demanding respect, inclusion, and research methodologies inviting their active participation. An array of advocates supporting indigenous rights and decolonizing perspectives also make similar calls: Methodologies "of the oppressed" promote emancipation of our collective consciousness and instigation of progressive social movements through what has been referred to as "a hermeneutics of love in the postmodern world" (Sandoval, 2000, pp. 10-11).CBPR is steeped in local geography, culture, and relationships-it is community based. CBPR is participatory when partnerships form between community members and researchers to address jointly shared priorities and research agendas. From the inception of the research purpose to the implications of the research endeavor, CBPR participants live up to the intent of mutual collaboration by actively working with researchers for social change. Because CBPR is nested in true-to-life environments, its results-discussions, critiques, and writings about methods, ethics, and outcomes-inform us not only about the health and illness features, but also of the resiliencies and strengths of the natural and built environments where people live, work, and play.Knowing what to ideally expect of CBPR begs the question of how to do it. Qualitative methods are dynamic, as are CBPR methods. To evolve our methods, we write. To keep our methods safe, relevant, and respectful, we write. To encourage representation within our methods, we write. These tasks riddle our written works. In the process, we learn basic lessons about ourselves, regardless of how we entered the research endeavor or what brought about our research collaborations. "Other people don't think like I do!" is perhaps the one common insight born of such collaborative efforts. Idealistic researchers may enter research settings expecting enthusiastic community members to fully "participate," only to discover that even on the basics-what "participation" means, for example-understandings differ, and disappointments can occur. CBPR is thus of necessity both process and product, ongoing over time, a dynamic, engaging, "backand-forth" between researchers and community members that illuminates underlying structural challenges and highlights how humans interact amid those challenges.

The author, a seasoned midcareer family physician, summarizes his personal practice philosophy as it relates to encounters with patients. By focusing on 3 aspects of care-process issues, people issues, and political issues-he explores the unique characteristics of his clinical decision-making process.