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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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Models based on the competitive queuing (CQ) approach can explain many of the effects on dysgraphic patients' spelling attributed to disruption of the "graphemic output buffer". Situating such a model in the wider spelling system, however, raises the question of what happens when input to the buffer (e.g., from a semantic system) is degraded while the buffer remains intact. We present a preliminary exploration of predictions following from the CQ approach. We show that the CQ account of the graphemic buffer predicts and explains the finding that deep dysgraphic patients generally show features of graphemic buffer disorder, as disrupted input from a damaged semantic system has an inevitable effect upon the functioning of the buffer. The approach also explains the most salient differences between the two syndromes, which are seen as consequences of the difference between an intact sequence generation system operating on degraded input versus a damaged sequencing system operating on intact input.