Negotiating the polypharmacy paradox: a video-reflexive ethnography study of polypharmacy and its practices in primary care

Workshop discussions often centred on concerns around who is responsible for decision-making in the context of polypharmacy. Participants recognised that decisions about reducing or stopping medicines were complex and potentially involved ‘upsetting the status quo’, acknowledging that ‘it’s often an awful lot easier just to maintain medication than alter it’. As well as the uncertain risk of ‘destabilising’ someone, there was the additional discomfort of stopping medicines prescribed by other clinicians:

One newly appointed clinical pharmacist who had previous experience in an NHS hospital pointed out that she had encountered similar concerns from secondary care clinicians (‘Well, actually the GP knows the patient, we’ll let the GP review it and the GP will stop those.’).

We illustrate this theme by detailing the conceptual shifts that emerged in our final workshop at Site A, thus highlighting more clearly how the VRE methodology encourages a loosening of attachments to existing positions and exploration of alternatives; enabling the emergence of new, transferable understandings.

We shared two clips in this workshop. The first clip (see box 1) showed a GP explaining to a patient: ‘there’s probably nothing I can stop in terms of your heart tablets’. The second clip (see box 2) showed a short extract in which patient and GP negotiate a reduction in furosemide (a medicine which some study participants referred to as a ‘heart tablet’). The first clip illustrated a phenomenon we encountered across our data set, that ‘heart tablets’ prompted particular displays of resistance to change. The second was one of several examples of a patient inviting their GP to consider reducing a medication. Sometimes these invitations were overlooked. In this example the GP takes up the patient’s suggestion. We were curious to know what might emerge in the VRE workshop by juxtaposing these two clips.

Box 1 An account of shifting notions of sharing responsibility

Clip 1 (11 seconds): The general practitioner (GP) looked at his computer, highlighted several drugs on the screen, then turned to the patient: ‘From the point of view, I think, of stopping anything today, there’s probably nothing I can stop in terms of your heart tablets’.

The GP in the clip (Dr Rose) explained that he was looking at different groups of medications with a view to ‘rationalising medications’ (‘this patient is always keen to stop any medications that aren’t indicated’). In the discussion that followed a GP colleague (Dr Green) added: ‘I think, we would feel probably a little bit disempowered changing that, because it is started by the hospital…we don’t have a lot of control’. Participants discussed the special difficulty of reviewing and changing medications prescribed by others (‘I never feel I’m in a position to alter them’).

Dr Green went on: ‘I wonder if it’s easier to contact the consultant and say ‘Is it OK? …I do that occasionally’‘ but a colleague pointed out that often the patient has been discharged from consultant care some time ago and questioned ‘How confident do they feel…do they hit back and say ‘actually you now know more than me about the story, you need to make that decision’’.

Another clinician added:

‘I would get advice from cardiology, speak to them…just run it past them, speak to the on-call cardiologist…just run it past them…that would reassure me’. A discussion ensued about different ways of seeking specialist advice, until Dr Rose reflected:

‘If you think about it, you’re calling an on-call cardiology registrar who might be ST4 or ST5, or just really quite new in the job and because they’ve got this title of being the specialist you’re taking their words as authority…as generalists why don’t we feel the confidence to…(murmurs of agreement). Do we need assent from them?’

This reflection ushered in a ‘turn’ in the discussion towards a recognition that while seeking advice from the specialist enabled them to document ‘spoke to cardiologist’ in the medical record, an alternative approach would be to seek a second opinion from a GP colleague within the practice. A highly experienced GP reflected on the role of medication in older patients: ‘the benefits (of medication) get less and less and less’ and invited his colleagues to consider ‘What is actually going to benefit them?’ He went on to add ‘So having the backing and giving us the authority back again to actually do that (change or stop medications) would be, for me personally, very helpful’ a move which seemed to suggest that current conditions of practice made this difficult. Later in the workshop the same GP referred to ‘too many dangers: political, social, GMC [(General Medical Council])’.

DS invited participants to consider who might be the appropriate specialist for patients affected by polypharmacy. This prompted two responses: the patient (‘sometimes patients stop it themselves’) and the GP (‘I mean we’re certainly expert in the side effects of all these things’). A brief discussion ensued about the paucity of evidence to support clinicians (‘most studies don’t apply to polypharmacy patients (murmurs of agreement) so we have to use our own clinical judgments and we should be using our own clinical judgement’) and recognition of the dual challenge—or paradoxical tangle—that ‘There are no simple answers. Every situation is different. It’s an individual patient situation’ and ‘the big problem is for the last 10 years we’ve been financially incentivised to put people on polypharmacy’.

Box 2 An account of negotiating de-prescribing

Clip 2 (53 seconds):

General practitioner (GP): ‘I suggest we leave the furosemide as it is until next week…until after you’ve had your echo’

Patient: ‘what about wh- should I perhaps reduce it?’ … ‘try to reduce it…see what happens’ (he suggests he half the tablet down a ‘crack’ in the middle of the tablet)

GP: you could try…see if it has an effect on your legs and if you notice a change to this noise you’re hearing, so there’s no harm in doing that.

Patient: I’ll try that

Participants began by reflecting on the patient being ‘in control’ of his pills, ‘testing his own theory’ and the possibility that he wanted to stop furosemide completely, cutting it by half being a reasonable compromise, a ‘negotiation’—a ‘middle ground’. This moved into discussion about the ‘weight of responsibility’ for decision-making with one GP saying they ‘wished’ more patients would ‘take control’ like this, another saying they ‘wished’ more patients would make decisions so that responsibility for decision-making didn’t rest entirely with the GP. This prompted one GP to share a personal story about an illness experience in which they found it surprising to discover that they didn’t want to take on all responsibility as a patient.

Participants drew contrasts between different scenarios (eg, prescribing hormone replacement therapy, prescribing antidepressants) and considered how decision-making is ‘shared’ under different conditions.

Returning to Clip 2, one GP concluded ‘when it’s a shared responsibility it reduces the burden a bit’. His colleagues agreed.

DS and NF invited participants to reflect on points of similarity and difference with the previous clip (seebox 1) in which they had described seeking reassurance from a specialist. This led participants to conclude that a decision shared with a patient offered valid reassurance and— like their discussions with consultants—was a form of shared responsibility that they could document in their records. In concluding reflections on the workshop one GP summarised this discussion:

‘That little insight…of sharing responsibility with the patients actually as being equivalent to the consultant. Very interesting. I found that fascinating. Actually I might try to work that in there. I might try to encourage it’.

Together these extracts show VRE as an intervention capable of prompting profound shifts in how practitioners understand and value their role and their relationship to others within the wider system (eg, consultants, specialists, colleagues, patients). Moreover, the process generated valuable insights regarding the potential that already exists within the therapeutic encounter and within generalists’ capabilities to tackle complex decision-making under conditions of uncertainty. Responsible, incremental change to tackle polypharmacy is within reach and can be approached in ways that are acceptable to both clinician and patient.

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