Misunderstandings in prescribing decisions in general practice: qualitative study
BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7233.484 (Published 19 February 2000) Cite this as: BMJ 2000;320:484
All rapid responses
The article by Britten et al.1 in this week's BMJ has addressed an
area of great importance in primary care. The authors noted that in
particular doctors seemed unaware of the relevance of patients' ideas
about medicines for successful prescribing. Although in the setting of a
psychiatric hospital which may limit its applicability in this context,
Sayre2 has demonstrated that patients may attribute the cause of their
illness to a number of explanations other than that given by the doctor.
Many of these alternative explanations may be valued by patients in
general practice, including attributing causation to personal qualities or
behaviour, a stressful event, retribution for past actions, or a
physiological process. Even when patients attribute their illness to a
physiological process, Sayre found that this was often associated with a
lack of responsibility for maintaining health with a decreased likelihood
of accepting the need for lifestyle changes2.
However, in spite of the differences in the explanation for illness
from the doctor and patient, educational interventions may well have an
impact. In a quantitative study, Lin et al3 have shown that patients who
receive five specific educational messages are more likely to comply
during the first month of antidepressant therapy. This suggests that
adequate explanations can be given in the form of simple and specific
educational messages appropriate for the general practice setting.
1. Nicky Britten, Fiona A Stevenson, Christine A Barry, Nick Barber,
and Colin P Bradley. Misunderstandings in prescribing decisions in general
practice: qualitative study. BMJ 2000; 320: 484-488.
2. Sayre, J. The Patient's Diagnosis: Explanatory Models of Mental
Illness. Qualitative Health Research 2000; 10: 71-83.
3. Lin, E.H.B., Von Korff, M., Katon, W., Bush, T., Simon, G.E.,
Walker, E., Robinson, P. The Role of the Primary Care Physician in
Patients' Adherence to Antidepressant Therapy. Medical Care 1995; 33, 67-
74.
Competing interests: No competing interests
Doctor-patient misunderstandings do not only occur in General Practice
EDITOR - We read with interest the paper by Britten et al on
misunderstandings in prescribing decisions in general practice1. We report
evidence that General Practice is not the only setting where
misunderstandings can occur between patients and doctors. We recently
performed a study questioning women and their obstetrician about the
decision making process for elective caesarean section. We aimed to
investigate the perceptions of both doctor and patient as to who was
making the decision, as well as how much in favour each party was about
the decision.
We asked women to complete a written questionnaire immediately after
the clinic consultation where the decision for caesarean section was
taken. Where possible obstetricians were also asked to complete a similar
questionnaire. As well as a direct question about who had made the
decision for caesarean section, both the woman and obstetrician were asked
to complete a linear analogue scale indicating how much in favour of the
decision they were personally, and how reluctant or in favour they
perceived the other party to be. A score greater than 60% was interpreted
as being in favour of the decision, whilst <_40 indicated="indicated" reluctance.="reluctance." p="p"/> Ninety-six women completed the questionnaire (31% of elective
caesarean sections performed over the study period). Although this was a
small sample, indications for caesarean section were comparable to those
performed in our hospital in 1999. The obstetrician completed a
questionnaire in 31 cases. Analysis of paired samples revealed that
although the women were good at perceiving how the obstetrician felt about
the decision for caesarean section (rs = 0.81), the reverse was not always
true. Correlation between how the woman felt about the decision and how
the obstetrician perceived that she felt was less good, rs = 0.46).
In three of the 31 cases (10%) the obstetrician thought that the woman was
strongly in favour of the decision (65%, 93%, 98%), whereas in reality she
was extremely reluctant (20%, 37%, 30% respectively). Although the
obstetrician in each case indicated that caesarean section had been
his/her advice, all were for relative indications and if the woman's views
had been correctly perceived she may have been allowed to have a trial of
vaginal delivery.
The findings of our study agree with those of Britten et al1 that
misunderstandings are often associated with the patient's lack of
participation in the consultation and are based on inaccurate guesses and
assumptions by the doctor. Although in our study 57% of the women felt
that they had made the decision themselves, patient satisfaction and
understanding may be further improved by exploring their views and
opinions directly.
References:
Britten N, Stevenson FA, Barry CA, Barber N, Bradley CP. Misunderstandings
in prescribing decisions in general practice: qualitative study. BMJ 2000;
320: 484-8.
Nicola Jackson
Clinical Research Fellow
Sara Paterson-Brown
Consultant Obstetrician
Queen Charlottes Hospital, Goldhawk Road, London W6 0XG
Competing interests: No competing interests