Objectives To evaluate the potential effect of computer support on general practitioners' management of familial breast and ovarian cancer, and to compare the effectiveness of two different types of computer program. Design Crossover experiment with balanced block design. Participants Of a random sample of 100 general practitioners from Buckinghamshire who were invited, 41 agreed to participate. From these, 36 were selected for a fully balanced study. Interventions Doctors managed 18 simulated cases: 6 with computerised decision support system Risk Assessment in Genetics (RAGs), 6 with Cyrillic (an established pedigree drawing program designed for clinical geneticists), and 6 with pen and paper. Main outcome measures Number of appropriate management decisions made (maximum 6), mean time taken to reach a decision, number of pedigrees accurately drawn (maximum 6). Secondary measures were method of support preferred for particular aspects of managing family histories of cancer; importance of specific information on cancer genetics that might be provided by an "ideal computer program." Results RAGs resulted in significantly more appropriate management decisions (median 6) than either Cyrillic (median 3) or pen and paper (median 3); median difference between RAGs and Cyrillic 2.5 (95% confidence interval 2.0 to 3.0; P < 0.0001). RAGs also resulted in significantly more accurate pedigrees (median 5) than both Cyrillic (median 3.5) and pen and paper (median 2); median difference between RAGs and Cyrillic 1.5 (1.0 to 2.0; P < 0.0001). The time taken to use RAGs (median 178 seconds) was 51 seconds longer per case (95% confidence interval 36 to 65; P < 0.0001) than pen and paper (median 124 seconds) but was less than Cyrillic (median 203 seconds; difference 23. (5 to 43; P = 0.02)). 33 doctors (92% (78% to 98%)) preferred using RAGs overall. The most important elements of an "ideal computer program" for genetic advice in primary care were referral advice, the capacity to create pedigrees, and provision of evidence and explanations to support advice. Conclusions RAGs could enable general practitioners to be more effective gatekeepers to genetics services, empowering them to reassure the majority of patients with a family history of breast and ovarian cancer who are not at increased genetic risk.

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Summary Objectives: To assist general practitioners in evaluating patients’ genetic risk of cancer on the basis of family history data. Methods: A new computer application, RAGs (Risk Assessment in Genetics), has been developed to help doctors create graphical family trees and assess the genetic risk of breast and colorectal cancer. RAGs possesses two features that distinguish it from similar software: (i) a user-centred design, which takes into account the requirements of the doctor-patient encounter; (ii) effective and accessible risk reporting by employing qualitative evidence for or against increased risk, which is more easily understood than numerical probabilities. The system allows any rule-based genetic risk guideline to be implemented, and may be readily modified to cater for the varying degrees of information required by different specialists. Results: RAGs permits fast, accurate data entry, and results in more appropriate management decisions than those made via other techniques. In addition, RAGs enables both the clinician and the patient to understand how it arrives at its conclusions, since the use of qualitative evidence allows the program to provide explanations for its reasoning. Conclusions: The RAGs system promises to help practitioners be more effective gatekeepers to genetic services. It may empower doctors both to make an informed choice when deciding to refer patients who are at increased genetic risk of breast or colorectal cancer, and to reassure those who are at low risk.

As evidenced by many of the chapters in this book, the concept of motivational style can account for an impressively large array of human experience and behavior. At the same time, however, there would appear to be many everyday feelings that cannot be adequately described by simple reference to the metamotivational modes and their accompanying variables such as hedonic tone or felt arousal. The fascination of toys, the excitement of watching sport, the "magic" associated with special times of the year such as Christmas and Halloween, the delight of art and music, the enjoyment of humor-all these are instantly recognizable as paratelic phenomena. Yet to consider them as little more than different types of paratelic pleasure would detract severely from the unique qualities associated with each. In a similar manner, although feelings such as homesickness, disappointment, sorrow, and embarrassment are manifestly telic in nature, the essential character of these experiences is lost if one describes them as merely different forms of telic anxiety.To capture the distinctive qualities of the feelings listed above, it is necessary to invoke another reversal theory concept known as cognitiwe synergy (hereafter synergy). Unlike metamotivation, which applies to the experience of one's motivation, synergy relates to the experience of identities, such as particular people, objects, places, events, situations, statements, or even oneself. Synergy is thus conceptually distinct from metamotivation, although, as will be seen, it is intimately connected with the telic and paratelic states.This chapter provides an overview of the fundamental nature of synergy, the ways in which it underlies many common experiences, its mechanism, and its close interactions with metamotivational mode. The main concepts, definitions, and distinctions here are those provided by ApterThe material for this chapter was researched and prepared while the author was at the

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