Papers Commentary

Does a prescribed treatment match a patient's priorities?

BMJ 2003; 327 doi: (Published 09 October 2003) Cite this as: BMJ 2003;327:840
  1. Nicky Britten, professor (nicky.britten{at}
  1. 1 Institute of Clinical Education, Peninsula Medical School, Universities of Exeter and Plymouth, St Luke's Campus, Exeter EX1 2LU

    Within the past 10 years several studies carried out in different settings have investigated patients' perceptions of prescribed drugs. Most of these studies have been qualitative and relatively small scale. They have all revealed considerable ambivalence about drug taking. This study by Townsend and colleagues confirms the validity of these findings for a community based sample of middle aged people in Scotland with multiple morbidities and provides a rich description of the different aspects of this ambivalence. Most prescribed drugs are taken by elderly people with chronic conditions.

    This study also helps to explain quantitative research that has identified core beliefs about the perceived necessity of taking prescribed drugs as well as concerns about potential harms.1 It shows the futility of labelling patients as “compliers” or “non-compliers,” as the same person may take one drug regularly while altering the dose or frequency of another. The paper shows the ambiguous yet powerful impact of drug taking on people's identity and the efforts that people make to fulfil their family and social obligations. Above all, the paper reveals the centrality of the notion of self regulation of prescribed drugs, in which patients organise their drug taking around their own priorities.

    Patients' priorities may therefore be very different from prescribers' priorities, or indeed from the priorities that prescribers assume their patients to have. This paper shows clearly that patients' moral concerns and the demands of their social roles are often more important for them than the alleviation of symptoms or the cure of disease. For people struggling to retain their social identity, the issue of compliance may not be high on their agenda. Clinicians who are trying to give their patients the best evidence about treatment options and to present balanced information about risks and benefits may find it difficult to take this on board.

    Clinicians need to engage with patients' priorities in order to understand how prescribed drugs will actually be used once patients have left the consulting room. Researchers developing interventions to improve adherence to treatment may not always engage with patients' priorities,2 but clinicians have immediate access to patients' perspectives. The integration, within the consultation, of best evidence and the patients' priorities is at the heart of concordance.3

    Prescribed drugs may be only one element of an individual's strategy of self care. This paper shows that patients used a range of resources in managing their chronic ill health. They used a minimum-maximum strategy—minimal use of drugs and maximal use of other ways of managing their illnesses. The question for prescribers is not “How can this person use this drug most effectively?” but “How does this drug contribute to this person's self management and the attainment of his or her goals?”


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