Doctors and drugs : how Swedish emergency and family physicians understand drug prescribing

Background: Drug prescribing is increasing, making prescribing one of the most common interventions in healthcare. The beneficial effects of drugs are manifold, but drug use also involves risks of drug-drug interaction (DDI), side effects and other drug-related problems. Despite research, a gap remains in our knowledge about the variation in physicians understanding of drug prescribing. Knowledge of how physicians think about and understand drug prescribing might make it possible to influence their behaviour, and thus improve drug treatment.

Aims: The overall aim of this thesis is to explore how physicians understand drug prescribing. Two groups of physicians were studied: emergency room physicians (ERs) and general practitioners (GPs). The specific aims were to (I) identify ERs perception of possibilities and obstacles in the implementation of a computerised prescribing support system; (II) explore how ERs view their work with patient drug treatment; (III) identify ways of understanding drug prescribing among GPs; and (IV) explore GPs understandings of who bears responsibility for a patient s drug list and how this responsibility is managed.

Methods: An inductive qualitative approach was used in order to gain deeper knowledge about physicians experiences. Data were collected by means of semi-structured face-toface interviews (Studies I, III-IV) and focus group discussions (Study II). Thematic (Studies I-II) and phenomenographic methods (Studies III-IV) were used in analysing data.

Findings: Variations were found between ERs and GPs in their views of drug prescribing, as well as within the group of GPs. The ERs expressed a need for more pharmacological training and support in working with patients drug treatment. They wanted access to current patient drug lists in order to make the diagnosis safely and quickly. A lack of follow-up appointments forces ERs to refrain from making changes to a patient s drug regime. ERs perform their work in the here and now . The GPs demonstrated how they understood drug prescribing in five ways, each of which had different foci: the biomedical aspects, the patient and society. Each GP had access to more than one view, but none included all five ways. The GPs also demonstrated a variation in understanding about responsibility for patient drug lists, and in particular about how they use different strategies to manage this responsibility. These strategies were described in five ways: imposed responsibility; responsibility for own prescriptions; responsibility for all drugs; different but shared responsibility; and patient responsibility for transferring drug information between healthcare providers.

Implications: The question of responsibility for current patient drug lists and communication between settings is of utmost importance. In Sweden, a new law was passed in 2008 allowing the sharing of patient-specific information between databases. In this thesis, we see how ERs and GPs understand the responsibility for current patient drug lists in different ways. These different ways indicate that information sharing between healthcare providers is insufficient to remove potential hazards in prescribing. In order to support physicians in moving towards a comprehensive approach to prescribing, there is a need for a parallel development in: 1) physicians competence in drug prescribing; 2) patients understandings of drug use; and 3) technological solutions to facilitate a shared understanding between different physicians and patients in drug prescribing/drug therapy.

List of scientific papers

I. Bastholm Rahmner P, Andersén-Karlsson E, Arnhjort T, Eliasson M, Gustafsson LL, Jacobsson L, Ovesjö ML, Rosenqvist U, Sjöviker S, Tomson G, Holmström I (2004). "Physicians perceptions of possibilities and obstacles prior to implementing a computerised drug prescribing support system." Int J Health Care Qual Assur Inc Leadersh Health Serv 17(4-5): 173-9
https://pubmed.ncbi.nlm.nih.gov/15481682

II. Bastholm Rahmner P, Gustafsson LL, Rosenqvist U, Tomson G, Holmström I (2008). " Limit work to here and now A focus group study on how emergency physicians view their work in relation to patients drug treatment." International Journal of Qualitative Studies on Health and Well-being 3(3): 155-164

III. Rahmner PB, Gustafsson LL, Larsson J, Rosenqvist U, Tomson G, Holmström I (2008). "Variations in understanding the drug-prescribing process: a qualitative study among Swedish GPs." Fam Pract Dec 22: Epub ahead of print
https://pubmed.ncbi.nlm.nih.gov/19103613

IV. Bastholm Rahmner P, Gustafsson LL, Holmström I, Rosenqvist U, Tomson G (2008). " Whose job is it anyway Swedish general practitioners perception of their responsibility for the patients drug list." (Submitted)