Communicating prescribing decisions v1.4

Communicating prescribing decisions with patients and professional colleagues

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Prescribe - Prescribing Skills

1 Communicating prescribing decisions with patients and professional colleagues

2 Learning objectives

3 Introduction

4 Communicating with patients 1 Why should I take a medicine?

5 Communicating with patients 2 What medicine am I taking?

6 Communicating with patients 3 How should I take this medicine?

7 Knowledge check 1

8 Communicating with patients 4 How will I know the medicine is working?

9 Communicating with patients 5 What are the side effects?

10 Communicating with patients 6 Can I take other tablets OK?

11 Communicating with patients 7 How long should I take the medicine for?

12 Knowledge check 2

13 Barriers to Effective Communication 1 Language & Culture

14 Barriers to Effective Communication 2 Partnership & Control

15 Communicating with Colleagues

16 Knowledge check 3

17 Case Study 1 Scenario

18 Case Study 1 Question 1


20 Case Study 2 Scenario




24 Session Key Points

25 Session Summary

Contents page


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Session Number: CPT 04_05_01

1

Author Sabih Huq

Section Principles of Clinical Pharmacology

Module Prescribing skills

Description

This session discusses what information about prescribed medicines should be shared with both

patients and colleagues. It touches on barriers to effective communication, and potential

strategies to overcome these.


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Learning objectives 2

Learning objectives

By the end of this session you will be able to:•List the important information that patients should be told about their medicines•Explain some of the barriers to effective information exhange and how they can be overcome in practice•Explain how to communicate effectively with other healthcare professionals about prescribing decisions

Prerequisites

Before commencing this session you should have:•An understanding of risks and benefits of drug therapy•Completed the related Prescribe sessions in the module[not sure any are needed]


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“Drugs don’t work in patients who don’t take them.”— C. Everett Koop, Former US Surgeon General

Prescribing a drug is the commonest intervention a physician will make. However, adherence to a drug regimen, or taking medicines as prescribed, is patchy at best. Of those with chronic illness, ⅓ will either take frequent ‘drug holidays’ or not take the medicine at all.1

Non-adherence is costly, in terms of both increased morbidity and increased cost.2 The reasons for non-adherence are complex, but it is more likely when patients lack information about their medications. On the contrary, patients who do get adequate information, and those who feel they are involved in the decision making process, are more likely to take drugs as prescribed.

Therefore how we communicate with patients about prescribing decisions has a direct impact on individual health, and national resource utilisation. It is in all our interests to do it as well as we can.

But what does adequate information mean, and how should it be shared?

Introduction 3

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“Most doctors don’t give you options, they just say this is what you are taking.”1

The vast majority of patients would like a diagnosis, and explanation of their condition prior to making decisions about treatment. Wouldn’t you?

In order to make an informed choice, other possible therapies, both pharmacological and non-pharmacological, should be discussed and their risks and benefits reviewed. Seeking out, and valuing, the patient’s views on the various therapies, involves the patient in the decision making process and is likely to lead to greater adherence to an agreed regimen.

The INDICATION, or why the drug is being taken, should be made clear, preferably in writing.

Unfortunately doctors do not always do this. In one study of observed behaviour of general practitioners and hospital physicians, the reason for taking a medicine was not mentioned in 1 in 8 cases.2


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4Communicating with patients 1 – Why should I take this medicine?

RISK

BENEFIT

commons.wikimedia


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4Communicating with patients 2 – What medicine am I taking?

In one study, 54% of antibiotics prescribed were not actually named1

It may seem obvious, but make sure patients know the actual name of the drug being prescribed. Do not just tell them the type or class of drug, e.g. “antibiotic”.

The GENERIC NAME of the medicine should be made clear, preferably in writing.

An explanation of why the medicine bottle may have two names is useful. Do not rely on just the brand, or trade name, as these may not always be available.

Brand name

Generic name



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4Communicating with patients 3– How should I take this medicine?

In 40-45% of new prescriptions, doctors do not state the number of tablets to take, or how often/

when to take them1

Detailed practical information on exactly how to take medicines is important for the patient. Simple regimens are more likely to be taken than complex ones1. Do not assume that someone else will go through the practicalities, e.g. the dispensing pharmacist.

In up to ⅕ of cases physicians offer no instructions at all on how to take a new medicine.2

Practical information that patients require includes:

‣how many tablets to take

‣when to take the medicine

‣whether to take with food or not

‣what to do if a dose is missed

‣how long the medicine should be taken for


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Knowledge check 1

Select true or false for each of the following statementsSelect true or false for each of the following statementsSelect true or false for each of the following statements

A. ⅕ of patients will take frequent drug holidays or not take the drug at all

TRUE or FALSE?

B. In 9 out of 10 consultations about new medications, physicians offer information about how to take the new medicine

TRUE or FALSE?

C. Medicine bottles often display both a trade name, and a generic name for the medicine.

TRUE or FALSE?

D. The reason for taking the medicine is called the DURATION of the prescription.

TRUE or FALSE?

E. Patients who are involved in the prescribing decision making process are more likely to take adhere to a drug regimen.

TRUE or FALSE?

FeedbackFeedback

A. False. Remarkably ⅓ of patients will take drug holidays at least once a month or not tke the prescribed drug at all.

B. False. Physicians were found to give information about how to take the new medicine only 80% of the time.

C. True. The brand or trade name is a proprietary name the drug company uses to market the drug. the generic name is a standard name for the medicine. The chemical name is sometimes also seen.

D. False. The reason for taking the medicine is called the INDICATION and should be made clear to all patients.

E. True. There is more information about this later in the module.

7


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4Communicating with patients 4 – How will I know the medicine is working?


It is important to discuss how the patient, and the doctor, will know if the medicine is working or not. This means focusing on the indication for therapy and managing the perhaps divergent views of what is achievable with drug therapy.

Where symptom control is involved, personal goals may help. For example, “I would like to be able to play a round of golf without getting angina.”

Where other targets are involved, try to be transparent and explicit: “We will aim for a blood pressure of 140/90 in 4 weeks time.”

Agree an appropriate time to review how well the medicine is working. This may range from a few minutes to a few weeks depending on the specific drug and urgency of the situation.

Write a clear plan for judging how well the medicine is working. Share this with the patient and relevant colleagues.


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4Communicating with patients 5– What are the side effects?

“I find that unless I ask the questions to my doctor, that she doesn’t always come out and tell me..”1

For many patients side effects are the first thing they would like to know about, and many are frustrated about not being given as much information as they would like. This is not surprising given the fact that side effects are directly addressed in only a third of new prescriptions.2

In one survey of 2,500 outpatients, 76% wanted to know about all side effects “no matter how rare”.3. This may seem unreasonable to many healthcare professionals. Do patients really want to know about fine print 1 in a million occurrences?

There is a mismatch between what patients want to know, and what physicians would like to give them. The effects of talking more about side effects are not clear. A strategy of discussing common or severe side effects with more comprehensive written information provides a pragmatic solution.



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4Communicating with patients 6– Can I take other tablets OK?

1 in 50 of all prescriptions in a university hospital contained a drug-drug interaction that increased

bleeding risk. 1

Drug-drug interactions are common and lead to decreased drug effectiveness and increased risk of harm.1 Many drugs have significant interactions with foods, such as grapefruit, or dietary/herbal supplements, or alcohol, as well as other prescribed medicines.

The large number of these interactions makes it difficult, if not impossible, for all these to be memorised. In such circumstances an electronic or web-based prescribing support tool becomes invaluable.

When counselling a patient it is important to review how a new medicine will impact their other medications. Also, let the patient know which common medications they should not use, and remind them to inform other healthcare professionals involved in their care of regimen changes.

wikipedia.com


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4Communicating with patients 7 – How long should I take the medicine for?

It is important to discuss with the patient how long the medicine should be taken for. In other words, what is the duration of therapy.

This is not always obvious, and is related to a clear understanding, for both prescriber and patient, of what the medicine is being taken for. Is it a short course designed to cure a condition? Or is it a preventative measure meant to reduce the chances of complications to be taken for life?

This information should be communicated verbally with the patient and out in the patient record. A place to record duration on the actual prescription chart can also be helpful.


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Knowledge check 2


A. In consultations about new medications, prescribers discuss common side effects most of the time

TRUE or FALSE?

B. Harmful drug interactions do not apply to over the counter preparations.

TRUE or FALSE?

C. Most patients do not want to know about rare side effects

TRUE or FALSE?

D. A time to review how well a medicine is working should be agreed with the patient.

TRUE or FALSE?

E. How long a medicine should be taken for should be recorded in the notes.

TRUE or FALSE?

FeedbackFeedback

A. False. Common side effects are directly addressed in only ⅓ of consultations about new drugs.

B. False. harmful interactions can occur with over the counter medicines, as well as herbal supplements, alcohol and foodstuffs, e.g. grapefruit.

C. False. In surveys, a majority of patients want to know about side effects “no matter how rare”.

D. True. Discussing how long it will take for a medicine to work, and how a patient will know this, is good practice.

E. True. Discussing and recording the duration of therapy helps prevent needless repeat prescription.

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4Barriers to Effective Communication 1 – Language & Culture

just take these slow release anti-anginals

orally

Err... OK

One-fifth of patients cannot characterise the word symptom correctly1

Language is how we express ourselves and is intimately related to how we think. As healthcare professionals we are used to using technical and scientific language that many patients do not understand. For example, in one series, 38% of patients did not understand the word orally, and 56% did not understand the word hypertension.

Using simple language and actively checking for understanding are good habits when discussing medications. Do not use jargon. Providing written information is likely to lead to increasing patient knowledge, satisfaction and compliance and I suggest it should be routine practice when starting new medicines.2

Cultural viewpoints also differ widely, and as professionals we would do well to recognise that values and perspectives far removed from our own are still valid, and not automatically classify them as irrational. It is our job to try to understand the patient’s perspective and work with them to come to a mutually agreed plan of action.

One simple way of improving communication is to present numerical information in an easier to digest format. Use natural frequencies rather than relative risks. 3 So, for example, using the data from the vocabulary study quoted above: 1 in 3 patients did not understand the word orally, and 1 in 2 did not understand the word hypertension.


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4Barriers to Effective Communication 2 – Partnership & Control


Shared decision making is likely to improve care and reduce costs1

There is growing evidence that involving patients in decisions about their own treatment leads to better satisfaction and adherence.2, 3 However, this is not how most consultations happen.4,5

But what does shared decision making mean, and how should we encourage it?

There are several models. Charles, Gafni & Whelan6 suggest:‣ both patient and doctor are involved‣ both parties share information‣ both parties build consensus about preferred treatment‣ both agree on treatment to implement

A combination of increased awareness, training and specific tools is most likely to improve practice.

A Cochrane Review8 found that decision aids helped people making treatment decisions, increasing patient involvement and making informed decisions more likely. However, the effect size of individual aids is variable.

The Ottawa Hospital Research Institute maintains a comprehensive list of current decision aids. Figure 1 A patient decision aid about statin therapy (Stiggelbout A

M et al)

http://decisionaid.ohri.ca/index.html





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In hospital, most prescriptions are not written by the prescribing decision maker.1

As well as the patient, several professionals are often involved in the treatment process. Timely and relevant information makes their job easier and is likely to lead to fewer adverse events and greater efficiency.

Examples in hospitals include communication between senior clinicians, who often lead prescribing decisions, and juniors who actually write the prescriptions. Contextual information helps juniors complete the prescription chart appropriately. Intelligent questions from juniors can help seniors clarify treatment goals, and make the prescribing decision more transparent.

The same information which should be shared and discussed with patients is relevant here. Perhaps of special note are how the effectiveness of the medicine will be measured, and how will potential side effects be monitored. These aspects will often be judged by professionals other than the original prescribing decision lead.

Communication between primary and secondary care is also vital in order to provide accurate treatment information in response to patient queries, to ensure the right monitoring is done, and to prevent harmful interactions occurring as a result of other medicines being inappropriately prescribed.

A clear record of the duration of therapy will help stop medications being taken indefinitely. Which method of communication is best will vary on the urgency of the situation. Talk to the relevant people at the right time, but keep a written record as well.

Fig 1 Legend goes here.

4Communicating with Colleagues


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Knowledge check 3


A. Relative risks are easier to understand than natural frequencies. TRUE or

FALSE?

B. Providing information in writing makes it more likely for patients to understand their condition better.

TRUE or FALSE?

C. In a paternalistic model of decision making, both parties share information and build consensus as to which treatment option to select.

TRUE or FALSE?

D. In hospital, in most cases the person writing the prescriptions chart is the person leading the prescribing decision.

TRUE or FALSE?

E. When communicating with colleagues, a telephone call is a good substitute for written information.

TRUE or FALSE?

FeedbackFeedback

A. False. For most people, natural frequencies are easier to understand than percentages, so 1 in rather rather than 33%

B. True. Giving information in writing allows the patient to digest information at their own pace and helps those with a more visual learning style.

C. False. This is a description of a shared decision making model.

D. False. In hospital, most prescriptions are not written by the prescribing decision maker.

E. False. While a telephone call is often the best way of communicating urgent or complex decisions, a written record should also be made.

7


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A 48 year old man comes to see you about his blood pressure which has averaged 162/94mmHg over the past 3 months with several recordings. He is known to have a raised total cholesterol and is a smoker of 20 cigarettes a day.

His only medical history of note is an appendicectomy at the age of 17. He has no known allergies and is not on any regular medication.

He is 9kg overweight and has a BMI of 28.2.

Now answer the questions associated with this case study.

Case study 1 – Scenario 20


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Case study 1 – Question 1

What would be the most appropriate initial communication strategy?Select one option from the answers below

A. Explain that he would benefit greatly from anti-hypertensive drug therapyB. Ask him what his ideas, concerns & expectations about his condition are.C. Go through the name and dosing regimen of your preferred ACE inhibitor.D. Discuss the side effects of using your preferred ACE inhibitor.

A. Incorrect. Whilst discussing possible benefits of anti-hypertensive medicines might be an important part of the consultation, the discussion needs to be put in the context of both non-drug management, and possible harm. Using the word greatly is unhelpful given individual variability in its meaning.

B. Correct. Finding out what patients know and expect is a form sharing information, the second element of Charles et al’s shared decision making model. It will also will help you talk in a language a particular patient can understand. Addressing their concerns is also likely to improve trust.

C. Incorrect. Discussing the practicalities of any single medicine without agreeing treatment aims is probably premature.

D. Incorrect. Discussing the practicalities of any single medicine without agreeing treatment aims is probably premature.

Feedback

21

A 48 year old man comes to see you about his blood pressure which has averaged 162/94mmHg over the past 3 months with several recordings. He is known to have a raised total cholesterol and is a smoker of 20 cigarettes a day.

His only medical history of note is an appendicectomy at the age of 17. He has no known allergies and is not on any regular medication. He is 9kg overweight and has a BMI of 28.2.

Now answer the questions associated with this case study.


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• How prescribers communicate with patients about treatment affects the quality and cost of healthcare

• Prescribers should involve patients in decisions about treatment and share information about:

‣ what the prescribed medicine is‣ why it should be taken‣ how it should be taken‣ how its effects will be monitored‣ potential side effects and interactions

• Prescribers should use simple language and provide written information

• Patient decision aids improve patient satisfaction and lead to better decisions about treatment

• Communicating with colleagues includes vertical and horizontal pathways

Session key points 24


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Session summary 25

Learning objectives

By the end of this session you will be able to:•List the important information that patients should be told about their medicines•Explain some of the barriers to effective information transfer and how they can be overcome in practice•Explain how to communicate effectively with other healthcare professionals about prescribing decisions

Further reading and activities

Refer to the following texts for additional information:•Tabor, P.A. & Lopez, D.A., 2004. Comply With Us: Improving Medication Adherence. Journal of Pharmacy Practice, 17(3), pp.167–181.•Osterberg, L. et al., 2005. Adherence to medication. New England Journal of Medicine, 353(5), pp.487–497.•Ottawa Hospital Research Institute website




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I am a Clinical Senior Lecturer in Medicine at Newcastle University, currently seconded to the branch campus in Johor, Malaysia. I trained at Cambridge, Barts and the London and UCL and completed training in General (Internal) Medicine and Clinical Pharmacology & Therapeutics (CPT). I have an MD from the University of London.

My current teaching responsibilities include leading clinical modules in the final year and the CPT strand. My current research interests centre on medical education.

I am a Fellow of the Higher Education Academy and a Member of the Royal College of Physicians and the British Pharmacological Society.

Sabih Momenul HuqAUTHOR

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