Results
Sample characteristics
Twenty-three GPs who had previously
indicated their willingness to receive video-feedback, were asked to
participate in the reflective practice intervention. Of these
23, two GPs refused to participate
and one GP could not participate due to a long lasting disease. Table 1 shows
the characteristics of the 20 GPs and of their selected visits. Two-thirds of
the GPs were male; half of them worked in a group practice. In the 40 visits
which were selected for reflective practice, the GPs prescribed a total of 57
medications.
Medication characteristics
Type of
medication According to the GPs, the elaborateness of their medication
communication is largely determined by the type of medication they prescribe,
being either medication for chronic diseases or for acute complaints. Apart
from this, they consider the purpose of the medication as being relevant. Most
GPs specifically stress the importance of educating patients about a correct
use of chronic medication.
When a patient is starting with
chronic medication, it is important to prepare him well, mention the side
effects. Normally I use more than one visit for this. Otherwise the patient
will quit his treatment.
When the primary goal of the
treatment is a reduction of relatively harmless physical complaints, when
prescribing for example analgetics, there is less need to discuss adherence
according to most GPs. After all, most of these medications are to be used on
demand only.
Sometimes it is not necessary to
prescribe medication, for example when it is only for painkilling or relieve of
complaints. Non-adherence is less of a problem in such cases.
When more than one treatment option
is available as is the case with prescribing psychotropics versus psychotherapy
for treating a major depression, GPs consider it important to provide extra
information, to enable the patient to make a well-founded decision
Medication name Most GPs do
not always mention the name of the medication. They give several reasons for this:
Due to generic prescribing,
sometimes patients receive a different medication at the pharmacy. To avoid
confusion, I often do not mention the name of the prescription.
I am wondering what the value of
naming the medication is. Often the names are complicated, I do not believe the
patients will remember it well.
Side effects Whether or not a
GP mentions possible side effects when prescribing medication depends on their
prevalence and severity and on certain characteristics of the patient. GPs sometimes
withhold information out of fear of eliciting exactly these side effects in
their patients.
When prescribing, I ask my
patients not to read the leaflet, it contains too much information. Instead I
explain to them the most common side effects, so they know what to expect.
Actively mentioning side effects
runs the risk of developing them. Too many patients report side effect from
statins.
Other GPs feel they should prepare
the patients for possible side effects.
Important and hindering side effects
I always mention, so the patient is prepared for them.
Antidepressants always cause side
effects in the beginning, so I always mention those.
First prescription versus refill The
interviews revealed that GPs accommodate their talk also to the type of
medication being a first prescription or a refill.
They furthermore consider it
important to provide the patient with clear information before the start of the
treatment, to take away possible worries and to emphasize the importance of
correct medication use. In the process of medication use monitoring comes into
play by asking whether the patient has any questions and checking if there are
intake problems.
Medication literacy A lot of
GPs believe that patients do not want to know everything, and certainly can not
remember everything that is said. For this reason, GPs sometimes restrict the
amount of information about medication:
I was educated to communicate a
maximum of four messages per visit. You can not achieve everything.
Another GP indicates that the
pharmacist also provides patients with a lot of information. So he himself can
inform less. Sometimes patients already have knowledge or experience with
medication, for example when they have a medical background themselves. In such
a situation, some GPs are inclined to explain less to the patient, although
this can also be a pitfall:
When patients are working in the
medical sector themselves, you assume their knowledge is more extensive. But
still you should try to explain everything.
Responsibility Rights and
duties of patients and caregivers are legally anchored in the Dutch Medical
Treatment Act (1995). Following this Act, the patient should make the final
decision about a treatment. However, some GPs feel that not every patient is up
to that task:
I tend to display some dominance
during my visits. However, my practice population consists mainly of elderly
people, letting them participate is difficult.
Other GPs like their patients to be
equal partners with whom responsibility can be shared and put extra effort in
creating such a situation:
I try to inform my patients as
much as possible, also using leaflets and brochures. This way a more equal
situation is created, by decreasing the gap in knowledge. Only then the patient
is really capable in sharing responsibility.
Acquaintance with a patient As
Dutch GPs have fixed patient lists, they usually maintain a long-term
relationship with their patients. A lot of GPs consider this an advantage which
for example pharmacists do not have. Nonetheless they acknowledge that it can also
be a pitfall, because they have developed assumptions about their patients
which they do not always check. One of them says:
After a while you know which
patients take their medication and which do not.
Another GP, talking about patients
he has been treating for 30 years:
I am certain that these patients
always take their medication as they should, I do not have to check that, it is
so obvious. I would bet on it.
On the other hand, they do recognise
their personal assumptions and realise these can be incorrect:
It depends on the patient which
side effects I mention. I do realise that I may be prejudiced.
Treatment goal The GPs in
this study differ regarding the treatment goals they have. Often the goal is
considered to be curing the patients from his complaints, to end the episode.
Adherence is not seen as a goal in itself.
I am not able to check whether a
patient takes his medication. When they do not return to my practice, I assume
the episode is finished. When they return later for another complaint, I will
not check the medication of the former episode.
Most GPs are having trouble keeping
control of the medication use and adherence of the patients. They feel that,
what happens in the patients’ own homes after they exit the GP practice, is out
of their hands.
To what extent should you
interfere? Calling after three days to ask how things are going makes you a
very paternalistic GP. I think my patients would feel very patronized.
Often the GPs indicate that it is
difficult to deal with patients who do not share their opinion. For example
regarding the necessity to prescribe medication:
In a conflicting situation when
the patient prefers another treatment, sometimes I just give in, even if I do
not agree. It takes too much energy to convince the patient.
Views Most GPs in this study
know how important adherence and medication use in general are. Nonetheless
some do believe that their patients think differently.
I am wondering whether my
patients also have such a high non-adherence rate.
The interviewed GPs do not all
believe they can influence their patients. Their views determine the extent to
which they give attention to correct medication use. Some approach their
patients in a positive way being aware of the power of their words and of using
communication as a therapeutic instrument:
The patient can be influenced by
the way you promote a prescription. Raising positive expectations works by
creating a placebo effect
Others have less faith in such
therapeutic effects:
Even if you explain everything
correctly, people sometimes still forget.
Visit characteristics
Limited time The GPs
unanimously mention limited time as one of the most salient factors determining
the content and elaborateness of communication about proper medication use and
adherence. They consider the average duration of ten minutes per visit too
short to fulfil all their duties, like adhering to clinical guidelines and
performing all kinds of administrative tasks. One of the GPs clearly states:
If we have to fulfil everything
they like us to do, ten minutes is not enough. If we would have 20 minutes, I
would bring up the topic of medication more often.
Others explain the way in which time
pressure affects their communication:
I could give the patient more
information on side effects, but it would be at the expense of another topic.
Because of the lack of time, GPs
feel they need to prioritize:
Medication adherence has no high
priority. Time pressure forces you to make choices. Discovering the necessity
for treatment is more important.
When you experience time
pressure, you can skip the social talk. Just treat the complaint, and send the
patient off. But working like that makes my work less enjoyable. The downside
is causing delay.
Due to time pressure GPs sometimes
refrain from asking more questions, this way countering possible extensive
reactions from their patients which might cause even more delay in their
visits. One GP mentions:
Asking more questions about
complaints and why the patient wants treatment brings along the risk of extra
stories and questions from patient’s side, causing delay. So sometimes, you
just do not ask questions.
Phasing of the visit
Prescription are usually handed out at the end of the visit, when time pressure
is felt most. A lot of GPs indicate that this affects their communication.
Giving extra information about the medication might elicit subsequent questions
or stories in the patient for which the GP does not have enough time.
At the end of the visit, it takes
a lot of time to enter a new discussion concerning the medication. So you skip
that.
According to one of the GPs, a lack
of time forces one to prioritize:
Prescriptions are usually given
at the end of the visit: so schedule for this. If the topic is important, give
it enough time in your visit.
Organizational characteristics
Guidelines Guidelines
stimulate the prescription of preferred medication for particular diseases,
like simvastatin for high cholesterol levels. One GP mentions difficulties in
communicating guidelines and choices to the patient, especially when he does
not support them.
You are better able to sell
something you support.
A lot of GPs adapt their
communication to the individual patient with his/her specific complaints and
needs. Like one of them argues:
I am convinced I do not always
act according to the guidelines, but general practice can not be performed like
cooking instructions. You have to use the ingredients, but you should also be
able to deviate when necessary. I will always motivate such a deviation.
Cooperation Apart from GPs,
also practice nurses and pharmacists take care of patients with chronic
diseases. Several GPs mention the importance of accommodating the different
caregivers’ instructions to the patient.
Providing patients with
information is partly delegated to the pharmacist. I believe they explain more
than we are aware of.
Within Dutch Pharmaco Therapeutic
Assemblies the different caregivers try to reach agreement on
medication-related issues. For example regarding the instruction of inhalation
medication, which often takes place at the pharmacy, while the patient also has
regular control visits with the practice nurse and once a year with the GP. GPs
have strong opinions regarding this situation, which affect their
communication:
The pharmacist informs me when a
patient is overdue picking up a refill medication. This makes it easier for me
to discuss this during a control visit.
Some GPs more actively participate
in this process than others:
GPs and practice nurses should
cooperate in taking care for chronic patients, with GPs taking the lead.
Pharmacists can support them. But in the end, the patient decides.
Others do not want to dominate the
relationship:
Regarding the issue of adherence,
I believe GPs have a signaling function. Still, I do not want to patronize,
there should be a shared responsibility between GP and patient.
Discussion
The aim of this study was to gain
insight into the determinants of the content and process of GP communication
concerning medication use and adherence with their patients. The results of the
study increase our knowledge about the underlying mechanisms concerning
adherence communication. Using reflective practice, GPs displayed many thought
processes and motives for talking to their patients in the way they do. These
determinants could be categorised in different groups referring to medication,
patient, GP, visit and organisation characteristics. Because of this apparent
multi-layered process of more or less intentionally choosing a particular
communication strategy, there is not one straightforward strategy for
increasing GP talk about medication use. Some determinants, such as the
relatively short duration of a medical visit, ask for changes in health care
policy, which may fall short because of cost containment. Other determinants,
such as the priority GPs assign to discussing medication use and adherence,
might be influenced by giving GPs as well as practice nurses and pharmacists
more information about the effects their communication can have on medication
adherence and other patient behaviours. Alternatively, given the shortage of
time related to the discussion of medication use, Tarn and colleagues have
recommended to redesign time-compressed office visits “to promote improved
provider-patient communication about new medications.” [29] Another solution
put forward by the GPs that participated in this study is to transfer the
responsibility for a proper medication talk (partly) to the pharmacist. As patient
education has recently become an integral part of Dutch pharmacists’ competence
profile, this might become more common practice in the short run, provided,
again, that pharmacists have enough time to spend on patient education and
instruction [31]. Still, according to the GPs in this study, motivating the
patient to take their medication as prescribed should remain the exclusive task
of GP and practice nurse. In addition, continuous evaluation and monitoring of
the delineation of communicative tasks among all the different caregivers seems
warranted to prevent the classical risk of no one taking responsibility as a
result of the division of duties. Another solution might be to come to an
agreement with the pharmacist to be informed about patients being structurally
non-adherent and direct adherence communication primarily to the non-adherent
patients. This will become more easy with the full implementation of the
electronic medical record. Lastly, in medical education, more attention could
be given to the importance and preferred content of communication about proper
medication use and adherence.
Methodological reflections
The reflective practice interviews
helped to elicit GPs‘ reasons for talking about medication use in the way they
do. A limitation of this study was the long recall period. Sometimes this was
as long as 1.5 years. This long period resulted from the fact that first all
808 visits videotaped as part of the parent study had to be analysed, which is
a time-consuming process. However, despite the fact that the video-recordings
were made some time ago, the GPs reported no problems remembering the visits.
Some of them even noted that reflection was even better because of the longer
time span.
Conclusion
Regular reflective practice can help
GPs to remain conscious of their own attitudes and motives to act in a given
way. According to most GPs participating in this study, communication about
adherence should be tailor made by not thoughtlessly applying guidelines but by
paying attention to patient’s needs. In this study, patients’ perspective is
lacking. Their opinion is, however, equally important in order to safeguard
shared control and decision making in the medical visit, key components of
patient-centered care. [32] As a part of standard prescribing practice, GPs
could for instance ask whether or not a patient wants to be informed about all
side effects or only about the most salient ones, or if the patient wants to
know the exact name of the medication. By doing so, communication about
medication use can become more tailored to patients’ needs and attitudes.
Acknowledgements
The study was financed by Platform
PI, see http://www.platformpi.nl/platformpi/welcome_to_the_platform_pi_website.
We thank the GPs who participated in the study.
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