Family Practice Vol. 17, No. 6, 480-483
© Oxford University Press 2000
‘Strong medicine’: an analysis of pharmacist consultations in primary care
Lewisham Primary Care Research Consortium, Rushey Green Group Practice, 410 Lewisham High Street, London SE13 6LL and
a GKT Department of General Practice and Primary Care, 5 Lambeth Walk, London SE11 6SP, UK.
Chen J and Britten N. ‘Strong medicine’: an analysis of pharmacist consultations in primary care. Family Practice 2000; 17: 480–483.
Received 7 September 1999; Revised 11 April 2000; Accepted 17 July 2000.
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Abstract |
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Background. Patients often find it difficult to discuss their medications fully with their prescribing doctor. Little is known about what might be said about medications to another professional within the primary health care team (PHCT). Pharmacists are seeking to extend their role within primary care and are ideally placed to provide independent medication advice.
Objective. Our aim was to test the feasibility of using primary care pharmacists as medication counsellors, and to analyse the content of their consultations using qualitative methods.
Method. Some patients were referred by their doctors, some self-referred and others were invited by the pharmacists for medication reviews. Pharmacist–patient consultations took place within GP surgeries and in patients' homes, and were audiotaped, transcribed and analysed qualitatively. The study sample consisted of 25 consultations with three primary care pharmacists conducted over a 3-month period.
Results. Referrals from the doctors were slow and there were no referrals from nurses. The pharmacists, who all had clinical backgrounds and were not dispensing pharmacists, experienced few problems with the consultations. Patients were willing to discuss their medications in detail with the pharmacists. A theme emerged regarding the perceived potency of medications, and this seemed to have an effect on the experience of side effects and the perceived efficacy of the medications.
Conclusions. From this small study, it would seem that pharmacist consultations within primary care are a feasible extension of their current role as prescribing budget advisors. The richness of the consultations reflects the acceptability to patients. Feedback of information to other members of the PHCT, given patient consent, would be very useful for a better understanding of the patient's perspective, which in turn would facilitate concordance in the negotiation of the patient's management.
Keywords. Medication concordance, medication counsellors, patient health beliefs, pharmacist consultations.
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Introduction |
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Pharmacists, although receiving intensive training in the area of medications, are still on the fringes of the primary health care team (PHCT), and are often seen more as shopkeepers than health professionals. They have limited opportunities to see patients in a primary care setting as part of a practice team. Direct contact with patients is brief and impromptu, with little scope for detailed, private consultation. Most consultations last 1–3 minutes, and having a private consulting area in the pharmacy does not increase the number of consultations, although their length is increased slightly.1
Prescribing and discussions about medications occur mostly in doctor consultations, and yet evidence points to the passivity of the patient during these consultations and the low levels of information exchanged regarding risks, benefits and side effects.2,3 Makoul et al. found that 67.5% of consultations involving the prescription of new drugs in a large primary care study in the UK had no mention at all about side effects, risks or precautions.2 Similarly, Cockburn et al.'s study in Australia found that side effects were mentioned in only 10% of 201 consultations involving the prescription of antibiotics.3
From the social science literature, it is clear that patients continually test out, form impressions and adjust their medicine taking according to their own set of health beliefs, and do not merely follow ‘doctor's orders's. These beliefs may not be expressed in a doctor's consultation. Tuckett et al. suggested that consultations became tense if patients expressed their views more openly.4 As the literature on consultations regarding medications has focused on doctor–patient consultations, it is not known if patients would divulge more to another health professional.2,3
Here we describe a study in which patients were given the opportunity to talk about their medications, within a consultation setting, with a health professional other than their prescribing doctor. Pharmacists were chosen for this study because their training gives them the potential for a more defined role in medication advice than other members of the PHCT.
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Methods |
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Recruitment and collection of data
Three practice-based pharmacists were involved in the study. The pharmacists were all clinical pharmacists (i.e. they were not dispensing community pharmacists) and had backgrounds as advisors in the hospital, Community Trust or Health Authority. They were recruited following recommendations from The Royal Pharmaceutical Society, as pharmacists already working in general practice surgeries.
Patients could be referred from any member of the PHCT or be self-referred. Most consultations were at the surgeries, but three were in patients's homes. All patients who gave consent were included. Twenty-five pharmacist consultations were audiotaped and transcribed.
Analysis
Transcribed consultations were analysed manually using charting methods as described by Ritchie and Spencer,5 looking for factors influencing the taking of medicines. Emerging categories were coded on the transcripts, summarized into constructs and charted to look for linking themes. When new categories were added, the transcripts were read again to look for data suitable for the new categories. Themes generated were then checked with the original transcripts to make sure they were grounded in the data. Particular attention was paid to divergent views expressed on the same topic. The analysis was carried out by the first author and supervised by the second author. In presenting the results, patients are identified by codes which signify the pharmacist they saw (A, B or C) and their own identification number (e.g. C1; see Table 1
).
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Results |
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Characteristics of the consultations with the pharmacists
The duration of the consultations ranged from 15 to 90 minutes. Although these practices had agreed to participate in the study and were given guidelines on appropriate referrals, the doctors had difficulty referring patients despite frequent telephone and written reminders from the first author. There were no referrals from practice nurses. Two refusals included one who was very nervous of the audiotape recorder and another in a hurry.
The pharmacists did not experience any difficulties with their greater exposure to patients. Two of the pharmacists reported that at times it had been difficult to stop patients talking. There were no follow-up sessions with any of the patients within the study period.
An analysis of the pharmacist consultations illustrated the richness of these contacts. In the next section, a brief summary of the themes is presented. In particular, a central theme, which emerged from the data was how these patients perceived the potency of their medications and how this related to their experience of side effects and their perceptions about the efficacy of the medications.
A qualitative analysis of the pharmacist consultations
The following constructs (see Fig. 1), which partly depended on individual experiences and knowledge, seemed to be important in determining how these patients perceived the potency of a drug.
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In several cases, these perceptions directly shaped the experience of side effects, making them either acceptable or not. There were four possible scenarios.
- If a drug was thought to be strong and effective and had acceptable side effects, this was the ideal for these patients and they were more likely to adhere to their medications. In fact, it would become difficult for changes to be made.
- However, if a drug was thought to be strong and had unwanted side effects, the patient would most probably stop the medication even if it was effective.
- For other patients, although the drug was felt to be weak, this was preferable as the side effects were acceptable and it was perceived to be causing less harm. These patients also showed a preference for herbal medicines.
- When a drug was no longer effective, and was perceived to be a strong drug, this caused anxiety as the patient struggled with a deteriorating condition. Weaker drugs losing their efficacy caused less anxiety. Some patients felt that their medication had become less efficacious because they had been on it for a long time.
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Discussion |
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Referrals to the pharmacists from the clinicians were slow. The doctors and nurses were not interviewed about their experience of this study or their attitudes about practice pharmacists. However, other studies have shown doctors's reservations about pharmacists having direct consulting responsibilities with their patients.6 The pharmacists in this study did not have dispensing responsibilities and the data indicated that their advice was largely appropriate.
This study is limited by small numbers and the relatively short time scale. Patients's accounts of past actions may be coloured by subsequent events, but are likely to represent their current thinking. The themes arising regarding perceived potency, efficacy and side effects will have to be substantiated further in another study involving more direct questioning in these areas. However, patients's theories linking efficacy and side effects, and the notion of drugs being powerful chemicals which may cause harm, are consistent with previous studies.7–9
The pharmacists in this study have shown the possibilities of providing independent medication advice within primary care, in an unhurried, private, accessible and credible environment. The acceptability to patients has been highlighted by the richness of these consultations. As part of the PHCT, the pharmacist could provide feedback on how patients use their medications and whether there are important patient beliefs which affect adherence (given patient consent to share information). Pharmacists employed by general practices have already been shown to be cost effective in producing savings in prescribing budgets, and medication counselling would simply be an extension of their current role.
Whether patients would divulge similar information to another member of the PHCT, given the same conditions, is not known. The magnitude of non-adherence in itself reflects a mismatch of doctors's interpretations of patients's views about their medications. It may be that doctors are not eliciting patients's views sufficiently, or that patients are unwilling to discuss their views with doctors.
We propose that providing patients with the opportunity to discuss their medicines with another health professional is one step towards medication concordance, because it is a move towards greater understanding of patients's beliefs about what medicine taking means to them.
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Acknowledgments |
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The authors would like to thank the practices and pharmacists involved in this study who gave up their time very generously. This paper is based on a project completed as part of the first author's MSc in General Practice at the United Medical and Dental School of Guy's and St Thomas's Hospitals. This study was funded by a small grant from the Royal College of General Practitioner's Scientific Board.
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References |
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1 Smith FJ, Salkind MR. Factors influencing the extent of the pharmacist's advisory role in Greater London. Pharmaceut J 1990; 17 February: R4–R7.
2 Makoul G, Arnston P, Schofield T. Health promotion in primary care: physician–patient communication and decision making about prescription medications. Soc Sci Med 1995; 41: 1241–1254.
3 Cockburn J, Reid A, Sanson-Fisher R. The process and content of general practice consultations that involve prescription of antibiotic agents. Med J Aust 1987; 147: 321–324.[Web of Science][Medline]
4 Tuckett D, Boulton M, Olson C, Williams A. Meeting Between Experts: An Approach to Sharing Ideas in a Medical Consultation. London: Tavistock, 1985.
5 Ritchie J, Spencer L. Qualitative data analysis for applied policy research. In Bryman A, Burgess R (eds). Analysing Qualitative Data. New York: Routledge, 1994: 173–194.
6 Spencer JA, Edwards C. Pharmacy beyond the dispensary: general practitioners's views. Br Med J 1992; 304: 1670–1672.
7 Fallsberg M. Reflections on medicine and medication: a qualitative analysis among people on long-term drug regimens. Sweden: Linkoping University, 1991.
8 Arluke A. Judging drugs: patients's conceptions of therapeutic efficacy in the treatment of arthritis. Hum Organisation 1980; 39: 84–88.
9 Morgan MA, Watkins CJ. Managing hypertension: beliefs and responses to medication among cultural groups. Sociol Health Illness 1988; 10: 561–578.
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