Facing complexity

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The wonderful Jan Radford (you should follow her on twitter)  drew my attention to Garth et al’s excellent study on repeat prescription management in general practice. I enjoyed the approach, a  feel good experience. On reflection I think this paper is avoiding complexity and seeing it as a problem for the consumer. Is that fair?

Why do people take medications that are of marginal benefit or doing them harm? Why do so many patients attend and ask for their scripts without any concern for their health and the continuing relevance of these medicines?

My introduction to the study of repeat prescribing was Michael Balint’s excellent research work with a group of GPs entitled “Treatment or Diagnosis: research into repeat prescribing in general practice” published in the 1970s. Although this predates many pharmaceutical treatments for chronic disease, it raises critical issues with regard to human behaviour and receiving medications as a surrogate for care. These are perhaps more relevant today. What does taking the medication mean for that person? Did it start when their mother died, perhaps their child or spouse? Is it the one remaining legacy of a doctor that helped them a great deal and is missed terribly? Does it avoid conversation and inquiry and keep the doctor happy?

A friend told me how he turned up for a script for his epileptic medicine for years after he stopped taking it, just to keep the doctor happy – he was too scared to say he had stopped it. Many people are afraid to stop taking something that affects them negatively for fear of something worse – the wrath of relatives or doctor? The fear of withdrawal effects?

We are the source of repeat prescribing and if we expect people to be organised 99% of the time, then a few people will run short unexpectedly every day. Should we blame them? The amounts vary – 28 or 30 tablets for some things – 25 or 50 tablets for others – 5 or 2 repeats. How do they manage at all? Is the list of medications in their file an “all time list” or an up-to-date managed list. Do you actually know what they are taking?

Then we have the narcotic repeat prescriptions – perhaps 100,000 medical addicts who cannot be late or they feel sick. When will we doctors learn that narcotics do not work for chronic pain, in fact they clearly exacerbate the problem. And Endone should be banned (along with its long acting preparations). What are we doing to people? A pain clinic referral is unlikely to help as the return letters  only seems to justify the damage or at least ease the conscience of the GP.

Finally, we can insist on people waiting for an appointment if they urgently need a script but have been reviewed recently, as a punishment and monetary tactic. This enables the doctor to be seen and the fee to be subsidised or bulk billed.  Is this a reasonable use of public money and is there any measurable benefit?

Repeat prescribing is truly complicated, involving issues of compliance, funding, safety, quality and motivation. Difficulties cannot be seen solely as a problem patients bring on themselves.  The doctor’s statement “Your lack of organisation doesn’t constitute our emergency” could be reflected as “Your complexity, dependency inducement and chaos causes our emergency”. Whatever your point of view, repeat prescribing illustrates the complexity of modern general practice.

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