PATIENT PRESSURE - AN UNCOMFORTABLE ISSUE FOR SECONDARY CARE PRESCRIBERS?
The influence of patient pressure on the decision to prescribe has
been previously investigated in primary care1. Perception of such pressure
can lead to a prescription that is judged to be inappropriate according
to evidence based medicine and this can often evoke a strong feeling of
discomfort in the prescriber regardless of whether a prescription is issued2.
To date, no studies have explored sources of discomfort in the secondary
care prescriber and the issue of perceived patient pressure to prescribe.
Thirty-two doctors working in various specialties and of varying grades
were purposively selected for interview from four hospitals (two district
general and two teaching hospitals). A further ten doctors were then theoretically
sampled to explore emerging themes from the data. Prior to interview,
participants were requested to remember any instances where they felt
uncomfortable when making a prescribing decision, regardless of whether
a prescription was issued. Focusing on 'uncomfortable decisions', using
a technique known as the 'critical incident technique', made it possible
to avoid general perceptions about what doctors believed influenced their
prescribing. During the interview, the incident(s) were discussed in-depth,
and more general themes emerging from the interviews were also explored.
All interviews were tape-recorded and transcribed verbatim. Data analysis
was approached with a modified grounded theory technique.
Over half of interviewees discussed an uncomfortable prescribing decision
caused by a perceived pressure to prescribe. Doctors working in paediatrics,
intensive care and care of the elderly also reported pressure to prescribe
from patients' relatives. All grades of doctor were affected by this phenomenon.
Patients involved in the incidents were often described as 'well informed'
and 'manipulative'. Interviewees resisted conceding to patient pressure
in approximately half of all incidents. Referral was often the method
of resistance, passing on the problem as opposed to reaching an immediate
resolution. The extent of the discomfort seemed dependant on the grade
of the doctor. This could be attributed to the ease and feasibility for
referring patients, e.g. prescribing decisions made whilst on call. Reasons
given for capitulating to patient's requests included an uncertainty in
diagnosis, maintenance of a good doctor-patient relationship, and to get
rid of the problem. The avoidance of conflict with patients, patient's
relatives and the multi-disciplinary team was also cited as a reason for
Patient and relative pressure to prescribe is a very real phenomenon
within secondary care. Similar to primary care, the doctor's relationship
with the patient was an important factor in whether the doctor capitulated
to the request. However, a theme not reported in primary care was agreeing
to the patient's request in order to minimize disruption within the overall
health care team. The frequent use of emotive language by participants
suggested that opinions of a patient's personality and the formulation
of stereotypes were important in such decisions to prescribe. This study
has highlighted a much underdeveloped area of prescribing influences in
secondary care and raised areas of further study, along with potential
implications for training of secondary care prescribers.
1. Britten N, Jenkins L, Barber N, Bradley C, Stevenson F. Developing
a measure for the appropriateness of prescribing in general practice.
Qual Saf Health Care 2003; 12(4):246-250.
2. Bradley CP. Uncomfortable prescribing decisions: a critical incident
study. BMJ 1992; 304(6822): 294-296.
Presented at the HSRPP Conference 2006, Bath