Nature and frequency of exchanges on medications during primary care encounters
Introduction
The exchange of information during medical consultations is the main means we have of enabling patients both to give informed consent to a treatment and to learn how to take medication properly. Kessler [1] reminds us that health professionals have the responsibility to ensure the proper use of drugs by their patients by providing them with appropriate patient education. Braddock et al. [2] report that the most common type of decision physicians take during primary care visits are medication decisions which account for 33% of all decisions taken in an outpatient practice and Makoul et al. [3] state that medication decisions are “probably the most common and important decisions in which patients can participate” (p. 1241). Up to now, however, what emerges from the studies that have looked at discussions of medications during medical encounters is cause for concern [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15]. Whether survey or observation methodologies are used, results for the past 25 years tend to concur on the relative poverty of such discussions. Moreover, most studies focus on new prescriptions, which account for only about a third of medications discussed during medical encounters [3], [11].
Thus, according to Svarstad [14], in 20% of cases when medications are prescribed, no verbal instructions are given; in a third of cases the drug is not named, and the patient is given no explicit information about its purpose. Wiederholt et al. [16] indicate that, when new prescriptions are written, from 17 to 30% of physicians give no verbal instructions at all. In a more recent article, Stevenson et al. [13] show that the name of the drug is not mentioned for almost a third of new or changed prescriptions. Still, 79% of new prescriptions are accompanied by information on dosage and timing, but physicians bring up adverse effects a little less than half the time. Finally, Makoul et al. [3] arrive at similar results. They also note that physicians overestimate the proportion of interviews in which they discuss the following subjects with patients: (1) their ability to follow the prescription (49.2% versus 7.9% observed), (2) their opinion of the recommended treatment (48.9% versus 33.9%) and (3) the risks associated with or potential side effects of the prescribed medications (40% versus 33%).
Sleath et al.'s study [11] reveals that the most common queries about medications deal with taking the drug (80%), its effect on the medical condition (56%), the quantity (51%), dosage (41%) and duration (41%) and its adverse effects or the barriers to taking it (27%). Nearly half the patients are not questioned about its effect on their health, and two-thirds are not asked whether they have any side effects or problems taking it.
The above studies concentrated on new prescriptions. In primary care, though, patients may be followed by the same general practitioner for many years and the prescription of a new medication is a relatively less frequent occurrence than is the renewal of a prescription or the mere discussion of an active ongoing drug [17], [18], [19]. We only found one study that specifically compared discussions of new prescriptions with stable medication. Scherwitz et al. [10], in their 1985 study of hypertensive patients followed in primary care, have shown that physicians ask few questions and give few instructions to patients regarding their ongoing medications but doubled the amount of information when initiating a new prescription or changing the medication regimen, indicating that physicians were sensitive to patient information needs and adapted their communication according to these perceived needs.
In the present study, we thought it important to include all medications discussed during the encounter. All of these, theoretically at least, provide the physician with opportunities to check patient medication-taking practices and identify potential or actual problems that could lead to undesirable health outcomes. Thus, our study aims at gaining a more thorough description of medication discussions occurring during primary care encounters by including discussions not only of new prescriptions but of current medications, whether represcribed or not. It also seeks to compare the nature and intensity of discussions of three distinct medication statuses: new, represcribed and current-active medications.
Section snippets
Instrument
The MEDICODE grid is a descriptive tool dedicated to the thematic analysis of discussions about medications during medical consultations developed and validated by the authors assisted by an expert committee that included psychologists, physicians and pharmacists. A detailed description of the structure of the grid and of its psychometric properties are presented elsewhere (see first article of this series [20]).
MEDICODE is well suited to interviews recorded in audio or video format. It does
Physician characteristics
The interviews, conducted in 15 clinics in the area of Greater Montreal in Canada, were divided among 40 experienced physicians in all: 17 women (42.5%) and 23 men (57.5%). There are thus a mean of 11.6 interviews conducted per physician. This was a convenience sample of physicians. The mean age of the physicians was 39.4 years (from 26 to 51 years), and they had been in practice for 14.5 years on average.
Patient characteristics
Patients were recruited in the waiting rooms of participating physicians. All consecutive
Discussion
Some 50% of consultations we analyzed involve a prescription, whether new or renewed. This proportion is similar to that reported by Makoul et al. [3]. Moreover, medications are discussed in 92% of interviews. It must be kept in mind that our patient selection criteria (i.e. adult patients with either a Positive GHQ score or older than 60 years old) were meant to increase the probability of medication discussions. Nevertheless our results, as others before us [17], [18], confirm how important
Acknowledgements
This research benefited from an unrestricted educational grant provided by the Professional Education Office of Aventis, Canada. The authors extend their sincere thanks to Ms. Céline Monette, director of the office at the time this research was conducted. They would also like to thank Mr. Denis Roberge for his contribution to the management of the database and to the statistical analyses.
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