Unintended consequences of patient online access to health records: a qualitative study in UK primary care

BackgroundHealth systems around the world are seeking to harness digital tools to promote patient autonomy and increase the efficiency of care. One example of this policy in England is online patient access to full medical records in primary care. Since April 2019, all NHS England patients have had the right to access their full medical record prospectively, and full record access has been the “default position” since April 2020.AimTo identify and understand the unintended consequences of online patient access their medical record.Design and SettingQualitative interview study in 10 general practices in South West and North West England.MethodSemi-structured individual interviews with 13 patients and 16 general practice staff with experience of patient online access to health records.ResultsOnline access generated unintended consequences that negatively impacted patients’ understanding of their health care, for example patients discovering surprising information or information that was difficult to interpret. Online access impacted GPs’ documentation practices, such as when GPs pre-emptively attempted to minimise potential misunderstandings to aid patient understanding of their health care, in other cases, negatively impacting the quality of the records and patient safety when GPs avoided documenting their speculations or concerns. Contrary to assumptions that practice workload would be reduced, online access introduced extra work, such as managing and monitoring access and taking measures to prevent possible harm to patients.ConclusionThe unintended consequences described by both staff and patients show that to achieve the intended consequences set out in NHS policy additional work is necessary to prepare records for sharing and prepare patients about what to expect. It is crucial that practices are adequately supported and resourced to manage the unintended consequences of online access now that it is the default position.

Starting the Conversation

Helping boys stand against sexual violence is not a one-time event and requires a sustained conversation. Chapter 4 identifies some key complications that boys may face once they decide to share their voices so that caretakers can be prepared to help them through the process of adopting anti-violent perspectives. Particular emphasis is given to questioning the popular notion of defending alleged Black perpetrators as a default position for Black boys. Standing against violence is definitively pro-Black, as this chapter explains. The chapter also identifies the social justice ideologies held by many Black boys as a potential resiliency factor that can help them to adopt anti-violence perspectives.

Buddhist Nominalism

This chapter examines the Buddhist rejection of universals. Nominalism is the default position for Buddhist philosophers because real universals would be permanent, and Buddhists claim all existents are momentary. The difficulty they encountered was to explain why conceptualization should prove efficacious if concepts fail to capture real resemblances among things in the world. Dignāga and Dharmakīrti responded with the theory of apoha or exclusion, according to which the extension of the concept blue is all those things that are not in the exclusion class non-blue. Since not being non-blue is an absence, and as such something with no claim to being ultimately real, it was thought to follow that this was a safe way to secure a truly radical nominalism. Various difficulties with this program are discussed, and a possible work-around for the most challenging is explored.

John Philpot – Archdeacon of Winchester and Martyr (1515–1555)

This is the most comprehensive account yet of the life of John Philpot, archdeacon of Winchester cathedral and martyr, burned at the stake in 1555. Included is an outline of his trial from which it is shown that he was promised the position of archdeacon by the ultra conservative bishop of Winchester, Stephen Gardiner. Evidence is also provided from the trial and from his family, contrary to the opinion of Muriel St. Clare Byrne, that he was not related to Clement Philpot who was executed in 1540. A transcript translation of his father's will is provided giving a good indication of his family circumstances. This will was drawn up in 1540 at a pivotal point in English law when, in order to overcome the default position of inheritance through primogeniture, the rules of will writing were altered. This will was written to abide by the rules that existed before the new Statute of Wills was passed by Parliament, and, also, to abide by the new rules set out in the Statute. From this will and other evidence a new genealogy of the Philpot family down to the 1650s is provided. The authenticity of the so-called portrait of John Philpot held at Winchester cathedral is also discussed.

Post-Crisis Reckoning: Making Sense of Early 21st-Century Civilizational Ruptures

As the world is struggling with the Covid crisis and its numerous aftereffects, it is easy to forget that the present pandemic is only the latest of a whole series of paradigm-changing 21st-century crises. Indeed, the word “crisis” has become one of the key concepts for the understanding of the early 21st century. Thus, crisis seems very much to be the default position of the 21st century, the new norm. In this paper, I argue that the 21st century has a recognizably different cultural logic from what the previous one had: most of our social, ideological, political, financial, and ecological paradigms are either changing or will (or must) change soon. As most of our critical concepts, intellectual tools, and ideological frameworks were made during the boom years of the late 20th century, they are clearly outdated and inadequate today. Thus, in this paper, through taking account of these shifting intellectual and artistic paradigms, I attempt to indicate how the present crisis of knowledge and sense-making may be turned into a process of knowing and making sense of crisis, and thus help us meet the challenges of the new century. It is often through these fault-lines, breakdowns, and inconsistencies of our narratives that one may recognize those pre-crisis assumptions that we have to critically re-evaluate and update in order to understand the new century.1

Armstrong's Resource-Egalitarianism Theory and Attachment

The paper analyses the interrelationship between Armstrong’s egalitarian theory and his treatment of the ‘attachment theory’ of resources, which is the dominant rival theory of resources that his theory is pitched against. On Armstrong’s theory, egalitarianism operates as a default position, from which special claims would need to be justified, but he also claims to be able to incorporate 'attachment' into his theory. The general question explored in the paper is the extent to which ‘attachment’ claims can be ‘married’ to an egalitarian theory. The more specific argument is that a properly constrained attachment theory is more plausible than Armstrong’s egalitarian theory. It also criticizes attachment and improvement accounts as justifying permanent sovereignty over resources. The paper argues that neither of those arguments aim to justify the international doctrine of permanent sovereignty.

The clinical significance of anomalous experience in the explanation of monothematic delusions

Monothematic delusions involve a single theme, and often occur in the absence of a more general delusional belief system. They are cognitively atypical insofar as they are said to be held in the absence of evidence, are resistant to correction, and have bizarre contents. Empiricism about delusions has it that anomalous experience is causally implicated in their formation, whilst rationalism has it that delusions result from top down malfunctions from which anomalous experiences can follow. Within empiricism, two approaches to the nature of the abnormality/abnormalities involved have been touted by philosophers and psychologists. One-factor approaches have it that monothematic delusions are a normal response to anomalous experiences whilst two-factor approaches seek to identify a clinically abnormal pattern of reasoning in addition to anomalous experience to explain the resultant delusion. In this paper we defend a one-factor approach. We begin by making clear what we mean by atypical, abnormal, and factor. We then identify the phenomenon of interest (monothematic delusion) and overview one and two-factor empiricism about its formation. We critically evaluate the cases for various second factors, and find them all wanting. In light of this we turn to our one-factor account, identifying two ways in which ‘normal response’ may be understood, and how this bears on the discussion of one-factor theories up until this point. We then conjecture that what is at stake is a certain view about the epistemic responsibility of subjects with delusions, and the role of experience, in the context of familiar psychodynamic features. After responding to two objections, we conclude that the onus is on two-factor theorists to show that the one-factor account is inadequate. Until then, the one-factor account ought to be understood as the default position for explaining monothematic delusion formation and retention. We don’t rule out the possibility that, for particular subjects with delusions there may be a second factor at work causally implicated in their delusory beliefs but, until the case for the inadequacy of the single factor is made, the second factor is redundant and fails to pick out the minimum necessary for a monothematic delusion to be present.

Communities and the individual: Beyond the liberal–communitarian divide

Liberalism believes that individuals are endowed a priori with reason or at least agency and it is up to that reason and agency to make choices, commitments and so on. Communitarianism criticizes liberalism’s explicit and deliberate neglect of the self and insists that we attain a self and identity only through the effective recognition of significant others. However, personal autonomy does not seem to be a default position, neither reason nor community is going to provide it inevitably. Therefore, it is so important to go beyond the liberal–communitarian divide. This article is analysing various proposals in this direction, asks about the place of communities and the individual in times of populism and the pandemic and provides a global perspective on the liberal–communitarian debate.