Volume 7, Issue 1 , Pages 4-15, March 2011
The discomfort caused by patient pressure on the prescribing decisions of hospital prescribers
Article Outline
- Abstract
- Introduction
- Methods
- Results
- Discussion
- Conclusion
- Acknowledgments
- Appendix. Interview schedule
- References
- Copyright
Abstract
Background
The influence of patient expectations and demands on the decisions of prescribers in general practice has been associated with irrational prescribing and lack of evidence-based practice. However, to our knowledge, no one has investigated patient pressure to prescribe in secondary care.
Objectives
To investigate the influences on hospital prescribers' decisions by exploring what they found uncomfortable when prescribing.
Methods
Qualitative interviews with 48 prescribers of varying seniority from 4 hospitals were conducted. Interviews were based on the critical incident technique, and prescribers were asked, before an interview, to remember any uncomfortable prescribing decisions that they had made; these were then discussed in detail during an interview. This approach allowed the interviewer to explore the more general influences on the decision to prescribe. Interviews were tape recorded and transcribed verbatim. A grounded theory approach to data analysis was taken.
Results
Prescribers discussed various factors that could provoke feelings of discomfort when prescribing. Pressure on the prescribing decision from patients, relatives, or carers was a major theme, and more than half of interviewees discussed discomfort caused by such perceived pressure on the prescribing decision. How prescribers dealt with this pressure varied with seniority and the type of relationship that they had fostered with the patient. Nearly half of all incidents of patient pressure resulted in the patient being prescribed the medication they requested. Yet, many of these requests were deemed inappropriate by the prescriber. Their reasons for capitulation varied but included maintaining a good prescriber-patient relationship and avoiding conflict in the wider health care team.
Conclusions
Pressure from patients, relatives, or carers was an uncomfortable influence on these hospital prescribers' prescribing decisions. Increasingly consumer-driven health care will intensify these issues in the future. We advocate further research, focusing on managing patient demands and improving prescribers' coping strategies.
Keywords: Hospital, Prescribing, Patient demand, Qualitative interviews
Introduction
A movement toward patient-centered care (PCC) has been taking place over the last few decades, and the current situation is one in which the medical profession have the philosophy of PCC at its core.1 This mode of practice encompasses several facets; one of these is a patients' right to involvement in decisions about their care and respect for preferences and suggestions.2 Patients in general practice have been found to desire a patient-centered approach,3 and those who experience this approach are likely to feel more satisfied.4 However, despite the perceived benefits of PCC,5 this approach to medicine, along with the general rise in consumerism, may have inadvertently facilitated a rise in public expectations of health care and, hence, patient demand.
Such expectations and demands have been cited as a barrier to evidence-based medicine (EBM) and a perceived cause of irrational prescribing.6, 7, 8 This, in turn, could reduce the quality of patient care, with some patients receiving medications that are inappropriate or that are of no pharmacological benefit but with the potential risk of side effects. Furthermore, the financial implications of irrational prescribing are important to organizations that operate within a limited health care budget. Subsequently, the phenomenon of patient pressure has been explored by many studies in primary care, most of which set out to investigate why prescribing can be irrational or non-evidence-based.9, 10, 11, 12 These studies have highlighted the perceived patient pressure that prescribers experience when prescribing in primary care.
Antibiotic prescribing has been of particular interest to researchers. Butler et al7 found that general practitionersa (GPs) would prescribe antibiotics for a viral sore throat because they perceived that the patient expected them even though the prescribers felt uncomfortable and compromised when doing so. Britten et al13 found that GPs felt “very pressurized” by patients in 3% of consultations. A study that set out to specifically explore both patient expectations and GP's perceptions of them found that patients who expected medication were nearly 3 times more likely to receive medication, and when the GP perceived that the patient expected medication, the patient was 10 times more likely to receive it.14 However, whether or not patient demand has any real effect on the prescribing behavior of GPs is still being debated.10
Nevertheless, the findings of these studies and other similar studies highlight what appears to be an important influence on the decision of whether or not to prescribe in primary care and one that is clearly a cause of discomfort for prescribers.15 To date, however, no one has investigated patient pressure to prescribe within a hospital setting. It is unknown whether hospital prescribers experience similar patient pressure to prescribe as GPs. It could be postulated that they are less exposed to such pressure because patients are usually more acutely unwell and often have much shorter doctor-patient relationships.
The aim of this study was to investigate the influences on hospital prescribers' decisions to prescribe by exploring what they found uncomfortable when prescribing. Discomfort was provoked by various factors, such as multidisciplinary teamwork,16 EBM,17 and the doctor-patient relationship. This article will focus on the prescriber-patient relationship and specifically those incidences of discomfort caused by patient and relative or carer pressure to prescribe.
Methods
Data collection
In-depth interviews, incorporating the critical incident technique (CIT),18 were used to collect the data. The CIT was chosen because it “obtains a record of specific behaviors” and, therefore, avoids general opinion. The CIT enabled the interviewer to prompt reflection by the participant on the prescribing circumstances that made them feel uncomfortable. Prescribers selected to take part were requested before interview to note (on a short proforma if desired) any incidents of uncomfortable prescribing decisions that they experienced during the course of their work. These incidents were explored in detail allowing participants to describe not only factors that could lead to prescribing discomfort but also those factors that would affect prescribing in general. After discussion of the specific incidents, the participants were asked about more general issues associated with discomfort, such as the influence of specific types of medical conditions or groups of patients. This section also served as a means to explore emerging concepts and theories from the ongoing analysis. Overall, this enabled inclusion of wider and more complex prescribing influences in the interview data.
Field notes were taken during each interview to record nonverbal expressions and make a note of initial thoughts of the interviewer and topics to be covered in further interviews.
Study setting and recruitment
The study was set in one Strategic Health Authority and included 2 teaching hospitals and 2 general hospitals. Hospitals were chosen to maximize the potential variation in the characteristics of the organization.
A letter of invitation to participate was sent to all medical prescribers working at each hospital. Snowballing also was used as recruitment strategy because participating prescribers were asked to suggest peers who may be willing to take part. An initial, purposive sampling frame sought 32 medical prescribers of varying experience working within various specialties (a description of the UK medical training structure is given in Table 1). An additional 16 prescribers were then theoretically sampled according to the emerging findings (Table 2).
Table 1. UK medical training structure
| UK training structure |
|---|
| During this study, the initiation of a new training scheme for NHS medical doctors was introduced. This “foundation programme” saw the renaming of the pre-registration house officer (PRHO) year to Foundation Year 1 and the first senior house officer (SHO) year to Foundation Year 2. However, because the prescribers interviewed referred to themselves in the terminology of old training system, we have referred to them in this way ▪PRHO—Pre-registration house officer: medical doctors who have recently graduated from medical school. On completion of the year, the PRHOs are granted full registration with the UK's General Medical Council (GMC) (Similar to the U.S. internship year) ▪SHO—(2-3  y)—Senior house officer: medical doctors who are registered with the GMC and are completing their basic specialist training▪Registrar—(4-6 y): on successful completion of this training, a certificate for the completion of training (CCT) is issued▪Staff grade: medical doctors who do not wish or are unable to complete training for consultant status, or those who do not wish to accept full consultant responsibility ▪Consultant: Holds a CCT (equivalent to a U.S. attending physician) |
Table 2. Number of interviewees and level of seniority
| Grade of prescriber | No. of interviewees |
|---|---|
| Consultant | 16 |
| Staff grade | 2 |
| SpR | 10 |
| SHO | 10 |
| PRHO | 10 |
Approval from a National Health Service (NHS) Research Ethics Committee and management approval was obtained for the study. All data were treated as strictly confidential.
Data analysis
All interviews were tape recorded and transcribed verbatim. Transcripts were checked against the recording to confirm accuracy. Analysis of the data was aided by use of the qualitative data analysis package NVivo 7© (QSR International, Australia) to support the systematic approach to analysis and, hence, its quality.19 Preliminary data analysis began after completion of the first interview. Interview transcripts and field notes were repeatedly read and initially coded. This coding framework was refined as further interviews were conducted, transcribed, reflected on, and coded. Both authors individually read each incident, discussing their interpretations and thoughts until a consensus was achieved. Direct comparison with previous data was enabled confirmation or contrasting with initial findings. Concepts and theories emerging from the ongoing analysis provided a revised focus for subsequent interviews.
Results
In total, prescribers discussed 193 incidents of prescribing discomfort. Patient or patients' relatives' pressure on the prescribing decision was a major theme to emerge early on in the study. Its importance in secondary care was indicated by the extensive discussion of this phenomenon by medical prescribers of all levels of experience and specialties. More than half of interviewees discussed an uncomfortable prescribing decision caused by perceived pressure on the prescribing decision, and many more discussed this more generally.
Controlled drugs, such as morphine, were most frequently associated with patient pressure; antibiotics and sedatives were also frequently mentioned. Yet, it appeared that various medications could be linked to prescribing discomfort. The specialties in which prescribers encountered patient pressure varied. However, those working in Accident and Emergency (A&E) experienced the most frequent pressure to prescribe. This was thought to be most likely because of the walk-in nature of A&E and its similarities to the general practice setting or “a convenience store:”
“People say I want this, and we have people who come in asking for prescriptions of all sorts of stuff and some of them get quite nasty…” A&E consultant (P35)
Those prescribers working in specialties, such as intensive care, pediatrics, and care of the elderly, also reported pressure to prescribe from patients' relatives:
Exertion of patient pressure
Interviewees' accounts of patient pressure to prescribe often described those patients as aggressive, demanding, well educated or well informed, and very often as manipulative. This last behavior appeared to evoke the strongest feeling of discomfort in the interviewee. One drastic example of patient pressure and manipulative behavior was shown in the description of a patient who wanted to be prescribed orlistat, an antiobesity drug, to reduce her weight. The prescriber felt a prescription was inappropriate and denied her request, but his decision was rejected by the patient who, then, continued to manipulate the system in an attempt to receive the prescription:
“…her main concern is that she is overweight. She doesn't look particularly overweight…and so she was coming back to me then asking for orlistat. Whether I'd be willing to prescribe her orlistat, but she doesn't really fit into a category, her BMI [Body Mass Index] isn't high enough and she was pushing for this thing, she'd pay for it privately and all this and… She'd mentioned things like she'd overeaten to get her BMI up so she could take it.” Obs and gyn consultant (P17)
Emotional patients were also felt to be difficult to deal with. Interviewees who discussed situations where patients became overly emotional talked of how this behavior added to the pressure to do something:
“[felt] Just a bit trapped in a difficult… because she was very emotional you know sort of crying a lot and that sort of thing, so sort of a pressure to do something and the thing is with her is if you talk to her you know she gets hysterical basically.” General medicine SHO (P29)
Capitulation to patient pressure
Nearly half of all incidents of patient pressure to prescribe resulted in the patient being prescribed the medication they requested. Of these incidents, two-thirds were deemed by the prescriber to be inappropriate requests because they conflicted with their views of EBM (discussed in more detail elsewhere17). Reasons given for capitulation varied. Some prescribers capitulated simply to get rid of the problem. This would leave them feeling uncomfortable, guilty, and assessing their own performance:
“They [patients] exert a lot of pressure to be given something and I do find myself occasionally buckling and just giving in to, it flies in the face of your clinical exam and the history and you know you shouldn't be doing it but occasionally you give in and you do actually give antibiotics just because it makes your life easier and you can't be arsed with the headache.” A&E registrar (P38)
The same prescriber also felt that he should not be expected to withstand such pressure and conflict:
“It saddens me, but at the end of the day they don't pay me enough to row any more than I do…a very selfish point of view I know.” A&E registrar (P38)
Many prescribers wanted to avoid conflict with the patient and so gave them what they wanted. The senior house officer (SHO) below was asked to see a patient who was demanding opioids. The prescriber acquiesced because he wanted to avoid getting into an argument with the patient:
“I was busy, the nurses were knackered and busy, and there were other patients in the bay who wanted to sleep, and my choices were sit there and get in what would have been a blatantly big fight with him about the whole thing or just give him some morphine and then wait until the consultant ward rounds in the morning and bash it out then. It was more of a tactical prescription I suppose.” SHO (P13)
The quote above illustrates how the prescriber wanted to avoid conflict not only between himself and the patient but also between the nursing team and the patient. Capitulation here was clearly not an easy option but, perhaps, easier than the alternative. This example also highlights the pressure of prescribing on-call and may be typical of the kind of situation junior prescribers are confronted with.
Patients' requests were also capitulated, usually by consultants, to maintain a good doctor-patient relationship. Longer and more enduring relationships were fostered between these prescribers and their patients, mainly because the conditions being treated were often chronic and serious and requiring series of consultations that spanned a number of years. This demonstrated the different relationship that consultants had with patients compared with junior prescribers, one that was more similar to that which a GP develops with his or her patients.
Furthermore, on occasions, patients' requests were yielded too when the prescribing decision was surrounded by uncertainty or what was often termed a “grey area:”
“…you are faced with a child who you are going to send home who's got a temperature or something and who you suspect may have a bacterial infection of the throat, although you are not positive so you would give some antibiotics. I suppose it's safe. It's a bit silly, I suppose, sort of false reassurance.” Pediatrics SHO (P39)
Declining patient requests
There were equal numbers of prescribing decisions where patients exerted pressure to prescribe, but the prescriber declined their requests. It was noticeable that junior prescribers referred those difficult decisions, in which they did not capitulate, to their seniors. Pre-registration house officers (PRHOs) appeared the most ready to refer, whereas SHOs sometimes felt that they should be able to deal with prescribing difficulties themselves and were generally more hesitant to seek the advice of a registrar. This behavior explains the finding that PRHOs did not report capitulating to patient requests and, instead, deferred responsibility for the prescribing decision to their seniors:
“I had a patient the other day that kept, he was in with chest pain, he had a GTN infusion and he kept asking for more and more morphine. I was bit uncomfortable about that, but I phoned the SHO…I feel completely comfortable prescribing things if it's got the SHO's say so, or whatever, but it's when it's just my own prescribing…I feel uncomfortable.” General medicine PRHO (P24)
Some consultants who did not capitulate would discuss their reasons for their actions with the patient; however, they would tell the patient that their GP would have the final decision:
“I said at the end of day it would be up to her and her GP, but I certainly wouldn't recommend it.” Obs and gynae consultant (P17)
Refusal of patients' requests was often quite difficult because of the patients' lack of trust in the prescriber, which was especially apparent in less well-established doctor-patient relationships. One good example of this was an incident where a patient with heart failure asked a cardiology registrar for stem-cell treatment because he had read about this treatment on the Internet. The prescriber explained that this was not suitable and also not available. However, he felt that he still had to refer the patient so that the patient would trust his decision:
“…he gave me this internet thing about stem cells, he wanted to have stem cells…I dealt with it by saying that it was still very experimental…I knew the people that were doing stem cells…and they wrote to the patient because the patient one, didn't qualify to have stem cells anyway and second one is that they actually explained to him that this is all research…he was happy with the explanation that he got because I think at least he got it from authority.” Cardiology registrar (P28)
The transient and fleeting doctor-patient relationships that can often exist in hospital and the subsequent low level of trust from patients often made prescribing decisions difficult. On the other hand, this type of doctor-patient relationship made refusing patient requests easier for junior prescribers and those with one-off consultations, such as A&E:
“I think people come in expecting antibiotics, and I think in some ways it's easier because we don't have an ongoing relationship with them that we go, ‘no I don't give antibiotics’.” A&E registrar (P12)
The lack of relationship with the patient along with situational factors, such as the ability to physically walk away from the patient, made refusal easier:
“I left the ward so I didn't have to deal with him.” ENT SHO (P14)
Not all prescribers who declined inappropriate patient requests passed on the decision or walked away. There were examples of how prescribers, mainly consultants, attempted to discuss the options with the patient. The consultant dermatologist below was often asked to prescribe alternative remedies. Her tactic to deal with this was to state that the patient could take these medications if they wanted, although she herself would not prescribe them, but if the patient did it would not be her responsibility. She used the EBM values to absolve herself from any further discussion with the patient:
“I just come out with my evidence-based medicine line and leave it at that really, but then take the responsibility and on the whole they don't like that because I can now corner them using that. I don't have to do the arguing, give them some facts and some basics and let them decide for themselves…” Dermatology consultant (P37)
Discussion
This is the first study to explore the prescribing discomfort of physicians in a hospital setting. The study provided an important insight into this phenomenon and revealed the importance of patient pressure in this setting. There were, however, some limitations to the study, and it must be reiterated that the study did not set out to focus specifically on patient pressure but on what was uncomfortable about prescribing, more generally. Therefore, there may have been incidents of patient pressure that were encountered and dealt with by prescribers but which were not felt to be uncomfortable. Interviews inevitably rely on self-report, with the subsequent risk of the influence of social norms on data quality. The likely social norms at play here, however, are less likely to be about the quality of their prescribing because the interviews were described to the prescribers as being about uncomfortable prescribing.
It was expected before commencement of the study that patient expectations would play a role in decision making of hospital prescribers because it is one of the many factors influencing prescribing decisions.20 However, the actual magnitude of patient expectations and perceived patient pressure described in the study was unexpected. Most prescribers interviewed had made prescribing decisions in which patients had placed, successfully or unsuccessfully, pressure on the outcome of that decision.
Patient pressure was, however, experienced quite differently depending on the seniority of the prescriber. Senior prescribers faced similar problems to that of GPs and, just like with GPs, these prescribers gave into demands to maintain good relations with patients.11 Junior prescribers often were faced with incidents of strong patient pressure for analgesia and sedatives, but they could usually pass the decision on to a senior prescriber or decline the patient's request without worrying about maintaining good doctor-patient relations. This is in contrast to primary care, where GPs often do not have the option to pass on prescribing decisions to another colleague and risk jeopardizing their relationship with the patient. However, despite junior prescribers' ability to “pass the buck,” these prescribers would still feel uncomfortable and troubled by some patients' demanding behavior. Other studies have reported on the high levels of stress among junior medical doctors caused by demanding, manipulative, violent, or aggressive patients.21
Patient pressure in secondary care did, however, have its own unique problems, such as some patients' lack of trust in the hospital doctor. The length of prescribers' relationships with patients in hospital practice is often, but not always, much shorter than in general practice, making trust much more difficult to foster. This, in turn, may make it difficult for patients to accept these prescribers' decisions to decline their requests.
Considerable discomfort was experienced when the prescribing decision was actually clinically inappropriate because feelings of guilt often ensued. Many prescribers in the study capitulated to patient pressure, and some of their reasons for this were similar to that given by GPs in studies of patient pressure, such as not wanting to jeopardize the doctor-patient relationship.11, 12 GPs have also reported prescribing inappropriately to end a consultation7, 22 and also to maintain the doctor-patient relationship.23 However, reasons for capitulation in these hospital prescribers also stemmed from circumstances particularly relevant (although not exclusively) to secondary care, such as prescribing to avoid conflict in the multidisciplinary team, especially with nurses.
The fact that these prescribers were capitulating to patients' inappropriate requests has much wider consequences for the UK's National Heath Service because often the decision to prescribe in secondary care is continued unquestioningly by the patient's GP in primary care.24 Patient choice in decisions is generally believed to be a good thing. However, in its extreme, it had a negative impact on prescribers, making them uncomfortable and, in some cases, leading to a prescription that was felt to be clinically inappropriate
Not all inappropriate patient requests were agreed to, and some senior prescribers gave examples of ways that they had succeeded in declining requests, such as coming to an agreement about treatment goals. Such “management plans” have been used with some success to alleviate the negative impact of “heart-sink” patients (patients who are difficult to help) in general practice.25 Perhaps, the formulation of such plans should be considered as an option by all prescribers when faced with inappropriate patient demands. Improved communication skills have also been advocated as a means of reducing the stress and discomfort when dealing with difficult patients.21
Conclusion
The phenomenon of patient pressure on secondary care prescribing decisions has gone unreported for some time. However, it was clear from this study that dealing with perceived patient pressure on the prescribing decision challenged many hospital prescribers. Consumer-driven health care, one of the current shifts in approach, will only heighten these issues in the future. Clearly, further research is required, concentrating on both how to manage patient demands and improve prescribers' coping strategies.
Acknowledgments
The authors would like to thank Professor Karen Hassell for her participation in productive discussions regarding the design and analysis of the study.
Appendix. Interview schedule
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- a Primary care physician.
PII: S1551-7411(10)00032-X
doi:10.1016/j.sapharm.2010.02.002
© 2011 Elsevier Inc. All rights reserved.
Volume 7, Issue 1 , Pages 4-15, March 2011
