Family Practice Vol. 17, No. 2, 119-123
© Oxford University Press 2000
GPs' recognition of, and response to, influences on patients' medicine taking: the implications for communication
Department of General Practice and Primary Care, Guy's King's and St Thomas' School of Medicine, 5 Lambeth Walk, London SE11 6SP,
a School of Health and Community Studies, University of Derby, Kingsway House, Kingsway, Derby DE22 3HL and
b School of Education and Social Science, University of Derby, Mickleover, Derby DE2 5GX, UK.
Stevenson FA, Gerrett D, Rivers P and Wallace G. GPs' recognition of, and response to, influences on patients' medicine taking: the implications for communication. Family Practice 2000; 17: 119–123.
Received 26 July 1999; Accepted 26 October 1999.
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Abstract |
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Background. Research evidence suggests that patients' beliefs about medicines influence medicine taking. Therefore, it is important that GPs are able to both identify and take account of such beliefs in the consultation.
Objectives. The purpose of this study was to explore GPs' awareness of asthma patients' beliefs about medicine, and of the ways in which friends and family, television programmes and the Campaign for Asthma may influence these beliefs. We also wanted to consider how GPs believe they would feel, and their likely behaviour, when a patient refers to these influences in the consultation.
Method. Four events, drawn from 17 semi-structured interviews previously conducted with patients recently prescribed oral steroids (prednisolone), were used to compose a narrative account of a hypothetical patient's behaviour. The narrative described a series of scenarios to which GPs were asked to respond. It was sent to all GPs in Derbyshire (n = 476).
Results. The response rate was 69%. Half judged that the scenarios which presented the patients' beliefs about medicine, the influence of friends and family and the television were not ‘realistic’. GPs also reported feeling more ‘supportive’ and ‘sympathetic’ towards the Campaign for Asthma as a source of patient information than they were towards opinions based on advice given by patients' family and friends.
Conclusion. Developing ‘common ground’ in the consultation will be problematic if GPs are not aware of, and sympathetic towards, the ways in which patients use information from a range of sources to formulate beliefs that then affect their medicine-taking behaviour. GPs should be encouraged to open up their discussions with patients so as to encourage the development of a partnership in which each party is aware of, and respects, the other's point of view.
Keywords. Asthma, beliefs about medicine, doctor–patient communication, information sources, oral steroids.
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Introduction |
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Ten years ago, Weston and Brown1 argued that doctors needed to understand patients' experiences so that they can develop common ground in the consultation. More recently, Britten2 noted the importance of establishing a patient's general orientation to medicine and the potential implications for adherence if this is not achieved. These ideas have been developed further by a multi-disciplinary working party set up to enquire into failures of compliance in medicine taking. The working party concluded that if a real difference is to be made in effective medicine taking, then it will be necessary to develop a different model of the relationship between patients and prescribers. This would involve an open exchange of views and information about medicines by both patients and health care professionals.3 They called this new model concordance.
This study explores GPs' recognition and response to patients' beliefs about the use of oral steroids for asthma. It presents the results of a survey of all GPs in Derbyshire (n = 476). The first objective was to explore GPs' awareness of asthma patients' beliefs about medicines, with explicit reference to the continuing effects of three influences: family and friends; the television; and the Campaign for Asthma support group. The second objective was to ascertain how GPs feel, and their likely behaviour, when a patient mentions any of these influences in the consultation.
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Methods |
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The behaviour of a hypothetical, 58-year-old woman recently diagnosed with asthma (Mrs X), was presented as a narrative broken down into a number of incidents. The narrative drew on a thematic analysis of 17 in-depth interviews previously conducted with patients prescribed prednisolone in the month prior to interview.4 The interview data indicated that patients' medicine-taking behaviour was influenced in four main ways: by their own beliefs; by the opinions of family and friends; by television; and by a support group run under the auspices of the Campaign for Asthma. Mrs X's behaviour was presented in ways that introduced each of these influences into a fictional account of consultations with the GP. Questions, specific to each incident, asked GPs to judge whether they thought the scenarios were ‘realistic’, and then to express how they felt about the way Mrs X had behaved according to a list of emotions which ranged from ‘supportive’ and ‘sympathetic’ through to ‘frustrated’ and ‘I have failed’ (see Appendix).
The vignette was piloted in two practices and sent out in the summer of 1995. Analysis was conducted using SPSS for Windows version 6.1.
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Results |
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A 69% response rate, which included approximately equal proportions of men (247/358) and women (81/117), was achieved after two mailings. Seventy per cent of respondents worked in group practices (309/439) and 54% in single-handed practices (20/37). The GPs who responded had, in general, been in practice for a shorter time than those who did not respond (16 years versus 18 years, mean difference = 2 years). The results are based on the numbers who responded to each question. This may be lower than the total response rate due to the inclusion of incomplete questionnaires.
The narrative began with background information about Mrs X. GPs were told that she recently had been diagnosed with asthma and that her condition was deteriorating and so they had taken the decision to prescribe oral steroids. They were also informed that this was her first prescription for this medicine, and that they had told her that the prescription was for oral steroids.
Eighty-three per cent (283/341) indicated that as this was Mrs X's first prescription for oral steroids they would ask her if she knew anything about the medicine. Sixty-five per cent (181/279) of these agreed that Mrs X's response that she had heard ‘good’ and ‘bad’ things about oral steroids would influence the way in which they might describe the side effects to her. Of those GPs who said they would not ask Mrs X if she had any prior knowledge about oral steroids, 69% (40/57) indicated that if she volunteered existing knowledge about oral steroids, then this would make a difference to the way in which they might describe any side effects. This does, however, mean that 
30% of GPs who said they would not ask Mrs X if she had any prior knowledge also indicated they would not attempt to take account of such knowledge, even if it was volunteered.
The narrative continued by introducing the idea that Mrs X had had an adverse reaction to an antibiotic prescribed a year previously. Sixty-one per cent (205/335) thought this might affect her attitude to oral steroids, while the remainder believed it would not.
The hypothetical patient then requested a home visit because the tablets were not working. She said that she had not been taking them as prescribed because she thought the dose was ‘a bit high’. Her daughter and her neighbour had reinforced this belief when she discussed it with them, and she had reduced the number of tablets she was taking. Just under half (166/335) of the GPs found the patient's belief about the size of the dosage to be ‘realistic’, while rather more, 61% (205/335), agreed that it was likely that she had consulted her daughter and her neighbour about the dose. Only 57% (191/333) agreed that a television programme about the side effects of oral steroids could cause serious concerns. In contrast, 93% (314/336) believed that Mrs X's request to discuss information she had obtained from the Campaign for Asthma was ‘realistic’ (see Table 1
).
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GPs were asked to indicate their feelings about each of the above scenarios on a scale ranging from ‘supportive’ to feelings of failure. The results should be interpreted with caution as missing values ranged from 37 to 47%. There was a particularly low response to five of the emotions listed (‘resigned’, ‘frustrated’, ‘betrayed’, ‘angry’, ‘that you had failed’). Nevertheless, it is worth noting that those GPs who responded felt most supportive and sympathetic towards the influence of the Campaign for Asthma. This influence was judged to be worthy of support by 80%, and of sympathy by 97%, of those GPs who responded. The influence judged to be the least worthy of support and sympathy related to the scenario in which Mrs X consulted her daughter and neighbour. The results were 53 and 54%, respectively.
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Discussion |
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It is worth recalling that all the scenarios in the composite narrative were drawn from interviews with patients in which they reported their experiences of taking prescribed oral steroids. Furthermore, as the results are based on GPs' self-perceptions, the responses are likely to over-estimate the extent to which they would recognize these influences in practice.5
The high proportion (83%) of GPs who said they would ask Mrs X what she knew about oral steroids when prescribing them for the first time suggests a general awareness of the importance of encouraging patients to share their knowledge about medicines. If GPs do not ask, then they have to rely on patients volunteering prior knowledge. This may be problematic if patients do not feel sufficiently comfortable in the consultation to volunteer their own views.
Over half of the GPs did not believe the reason Mrs X gave for not taking the prescribed dose to be ‘realistic’ (‘the dose seemed a bit high’), and only marginally more than half accepted that patients could be seriously worried by a television programme. This suggests that a high proportion of GPs lack an awareness of the effect of factors outside the consultation that influence patients' perceptions and decisions about medicine taking. Interestingly, the scenario describing the way in which Mrs X turned to her daughter and her neighbour for advice and support was recognizably ‘realistic’ to almost two-thirds of the respondents; yet GPs indicated that their feelings about such an influence were the least supportive and sympathetic of all. If patients sense disapproval when they raise opinions that have come out of discussions with family and friends, then they may be unlikely to share their concerns. This is likely to reduce opportunities for doctors and patients to develop a common understanding about medicines. These results may be contrasted with the findings on GPs' views of the Campaign for Asthma. The medical profession in Derbyshire has input into the local support group so it is possible that GPs were more likely to perceive this as a legitimate source of information.
Although this study focused on a prescription for oral steroids for asthma, the findings may be applicable to other medicines and treatments. Medical knowledge is now a burgeoning industry,6 and patients and carers actively seek information from sources other than the medical consultation. Newspapers and magazines feature health topics and exhort their readers to be proactive in raising issues of concern with their doctors. In addition, the information available on the Internet about health topics has increased substantially in recent years. Since the Internet was not raised as a source of information during the semi-structured interviews, it was not included in this study. With the advent of digital television, the Internet is likely to become an increasingly important source of information. There is scope for additional research focusing on patients' access to information about medicines and the effect of this on the doctor–patient relationship. GPs need to be aware of the influence of patients' knowledge and beliefs on adherence. More specifically, GPs should be encouraged to open up their discussions with their patients about beliefs about medicines, in keeping with ideas contained within the model of concordance.3 The aim is to develop a partnership in which each party is aware of, and respects, the other's point of view, with the ultimate aim being to improve medicine taking.
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Appendix |
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TopAbstractIntroductionMethodsResultsDiscussionAppendixReferences |
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The vignette
PLEASE READ THE CASE STUDY AS IT DEVELOPS IN THE SHADED BOXES BELOW. AFTER READING EACH PART, PLEASE ANSWER THE ASSOCIATED QUESTIONS (Q) IN THE MANNER INDICATED.
| Mrs X, aged 58, has been on the practice list for five years, however, you have never treated her before. She has recently been diagnosed as an asthmatic and her condition is deteriorating. In your opinion, she now requires a week long course of oral steroids. You have no record of her having had this medication before. She is already using both a salbutamol inhaler and a steroid inhaler. You tell her that the prescription is for oral steroids.
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(Please circle your answer)
Q1 As it is Mrs X's first prescription for oral steroids, would you ask her whether she knows anything about oral steroids?
No Yes
| She says that she has heard both ‘good’ and ‘bad’ things about steroids.
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Q2 Would the fact that she already has some idea about the effects of oral steroids influence the way you might describe any side effects to her?
No Yes
| On further examination of her records, you notice that she was prescribed an antibiotic a year ago. She suffered an adverse reaction which she attributed to the medication.
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Q3 Do you believe this experience is likely to make her wary of the oral steroids that you have prescribed?
No Yes
| She calls you out two days later and tells you that the tablets are not working. You discover that she thought the dose prescribed ‘sounded’ a bit high and that she has not taken them as prescribed.
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Q4 How you would feel in this situation:
(Please circle your answer for each category)
supportive? No Yes
sympathetic? No Yes
resigned? No Yes
frustrated? No Yes
betrayed? No Yes
angry? No Yes
that you had failed? No Yes
Q5 Do you believe her explanation for her decision not to take the medication is realistic?
No Yes
| As the conversation develops, Mrs X tells you that she had also spoken to both her daughter and her neighbour and asked them what they thought about the dose that you had prescribed. They agreed with her that it ‘sounded’ a bit high.
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Q6 How you would feel in this situation:
(Please circle your answer for each category)
supportive? No Yes
sympathetic? No Yes
resigned? No Yes
frustrated? No Yes
betrayed? No Yes
angry? No Yes
that you had failed? No Yes
Q7 Do you believe Mrs X's action in seeking the advice of friends and family is realistic?
No Yes
| You explain the necessity of taking the medication at that dose. She appears convinced and says that she will follow the instructions you have given. She telephones the surgery a week later and says that she has seen a television programme about the side effects of oral steroids. She is upset and worried about the fact that she has taken them.
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Q8 How you would feel in this situation.
(Please circle your answer for each category)
supportive? No Yes
sympathetic? No Yes
resigned? No Yes
frustrated? No Yes
betrayed? No Yes
angry? No Yes
that you had failed? No Yes
Q9 Do you expect to be able to reassure her sufficiently of the safety of short term oral steroid medication, so that she would be happy to take oral steroids in the future?
No Yes
Q10 Do you believe that Mrs X's concern about her medication as a result of a television programme is realistic?
No Yes
| A fortnight later Mrs X comes to the surgery and tells you that she has joined the Campaign for Asthma and has received some written information about the use of steroids in asthma. She has come to the surgery to discuss what she has learnt.
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Q11 How you would feel in this situation:
(Please circle your response for each category)
supportive? No Yes
sympathetic? No Yes
resigned? No Yes
frustrated? No Yes
betrayed? No Yes
angry? No Yes
that you had failed? No Yes
Q12 Do you believe that Mrs X's wish to discuss with you what she has learnt is realistic?
No Yes
Q13 I would like to visit a sample of General Medical Practitioners to discuss the issues raised by this case study. This will not involve a discussion of your specific answers. Would you be prepared to take part?
No Yes
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Acknowledgments |
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The authors would like to thank Dr Nicky Britten for her helpful comments on a draft of this paper and also acknowledge the constructive comments of two anonymous referees. This research was conducted while FA Stevenson was a Research Student at the Medicines Research Unit, University of Derby.
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References |
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TopAbstractIntroductionMethodsResultsDiscussionAppendixReferences |
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1 Weston WW, Brown JB. The importance of patient's beliefs. In Stewart M, Roter D (eds). Communicating with Medical Patients. London: Sage Publications, 1989; 77–85.
2 Britten N. Patients' ideas about medicines: a qualitative study in a general practice population. Br J Gen Pract 1994; 44: 465–468.[Web of Science][Medline]
3 Royal Pharmaceutical Society of Great Britain. From Compliance to Concordance: Towards Shared Goals in Medicine Taking. London: Royal Pharmaceutical Society, 1997.
4 Stevenson FA, Wallace G, Rivers P, Gerrett D. ‘It's the best of two evils': a study of patients' perceived information needs about oral steroids for asthma. Health Expectations 1999; 2: 185–194.[Medline]
5 Makoul G, Arntson P, Schofield T. Health promotion in primary care: physician–patient communication and decision making about prescription medications. Social Sci Med 1995; 41: 1241–1254.
6 Taylor RCR. Alternative medicine and the medical encounter in Britain and the United States. In Salmon JW (ed.). Alternative Medicines. London: Tavistock, 1984.
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