The threatened self: general practitioners’ self-perception in relation to prescribing medicine

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Abstract

Insufficient understanding of the variation in GP's medicine prescribing behaviour and ineffective interventions call for an investigation of the GPs’ own perspective. This article describes the GP's self-perception as it emerged in 20 semi-structured interviews that explored the GP's perspective on their own prescribing. Data collection and analysis was largely inspired by grounded theory. The GPs described a constantly active process in which they prescribed, experienced an emotional reaction to their prescribing, evaluated themselves, redefined themselves for the better or worse, defined the new prescribing situation, prescribed and so forth. The GPs felt disappointed with themselves when their prescribing conflicted with their human or scientific ideals, and when they did not live up to their image of themselves, as GPs and as persons. They experienced discomfort when they were exposed to pressure as well as when they gave in to it. These negative emotions demanded a redefinition of the GPs’ selves. The GPs applied both preventive and coping strategies to protect themselves from redefining themselves negatively. They strived to live up to their ideals, lowered their ideals, convinced themselves of the appropriateness of their prescribing and sought inspiration and self-development. This study demonstrates that self-perception is fundamental to how GPs prescribe medicines. Future interventions in quality development that aim to improve GPs’ prescribing practices should therefore include considerations of the GPs’ self-perception and facilitate autonomous self-development.

Introduction

Research on prescribing has predominately focused on prescribing patterns, the relationship between prescribing and practice, GP characteristics, and attempts to influence the wide variation and ‘irrationality’ of prescribing patterns (Bradley, 1991). These studies yield only sparse understanding of why GPs prescribe the way they do. Consequently, interventions aimed at quality development have had little or no effect (Oxman, Thomson, Davis, & Haynes, 1995).

Several studies have striven to understand ‘irrational’ prescribing and variation and low impact of interventions related to prescribing by exploring the GPs’ perspective on their medicine prescribing practices (Armstrong, Reyburn, & Jones, 1996; Bjørnsdottir & Hansen, 2002; Carthy, Harvey, Brawn, & Watkins, 2000; Freeman & Sweeney, 2001; Jaye & Tilyard, 2002; Wahlström et al., 2001; Weiss & Scott, 1997). These articles suggest that GPs’ prescribing is influenced by many sources. These sources include patients (Bjørnsdottir & Hansen, 2002; Jaye & Tilyard, 2002; Stevenson, Greenfield, Jones, Nayak, & Bradley, 1999), peers (Carthy et al., 2000), the problem and solutions at hand (Damestoy, Collin, & Lalande, 1999), trends in society like deprofessionalisation and proletarianisation (Britten, 2001), as well as practice and GPs themselves (Weiss & Scott, 1997). GPs prescribe to cope with the influences (Weiss & Scott, 1997) and to reconcile professional norms with clinical realities (Comaroff, 1976).

How GPs as persons influence their prescribing and vice versa have not been explored. Some articles on the GP perspective have vaguely implied that GPs’ perceptions of themselves are associated with their prescribing. According to these studies GPs have expectations of themselves about how to use medicines and how to handle patients (Bradley, 1992; Jaye & Tilyard, 2002). GPs sometimes fail to live up to their expectations (Bradley, 1990) or can feel that their autonomy has been compromised (Butler, Rollnick, Pill, Maggs-Rapport, & Stott, 1998; Dybwad, Kjølsrød, Eskerud, & Laerum, 1997; McKegney, 1988). The GPs may become disappointed with themselves (Bradley, 1992), and sometimes prescribe to maintain their self-esteem (Schwartz, Soumerai, & Avorn, 1989) and to gain confidence (Comaroff, 1976).

GPs can be viewed as one kind of users and thus the GPs’ perspective seen as parallel to the user perspective developed within research on medicine use. Interestingly, established researchers within the user perspective tradition also focus on GPs’ perspectives in their research (Bjørnsdottir & Hansen, 2002; Britten, Stevenson, Barry, Barber, & Bradley, 2000). Research on the user perspective emphasizes the users’ subjective experiences (Hansen (1988), Hansen (1992); Hansen & Launsø, 1988). Early research illustrated that users self-regulate their use of medicines according to demands in their daily lives (Conrad, 1985; Larsen & Hansen, 1985). As described above, the same applies to GPs. Research on the user perspective has also demonstrated that medicine use is closely related to changes in the users’ self-concepts (Karp, 1993; Knudsen, Hansen, Traulsen, & Eskildsen, 2002). The lack of research that explores how GPs view themselves and how this affects their prescribing and vice versa is evident.

This study sought to gain a deeper understanding of the GPs’ perspective on prescribing medicine. The article reports from a systematic examination of the GPs’ self-perception in relation to their prescribing behaviour as it emerged in semi-structured interviews with GPs from the County of West Zealand,1 Denmark.2

Section snippets

Methods

Grounded theory significantly inspired the methods applied in this study due to the emphasis on process and interaction, as well as the techniques for preserving openness, reflection, exploration and grounding in data (Strauss & Corbin, 1996).

Results

The GPs reported being pressured by exterior sources and interior characteristics within themselves to prescribe in a way that threatened their self-image. They expressed being in a constant state of readiness to handle these pressures and directed their prescribing according to the perceived need of self-protection. The consequences for the GPs’ self-perception from giving in to threats and their strategies for handling them will be depicted in the following.

The results presented should be

Discussion

This study demonstrated that there was a reciprocal influence between the GPs’ self-perception and their prescribing behaviour. The GPs experienced both satisfaction and dissatisfaction in relation to prescribing. These feelings made the GPs constantly evaluate their own actions in relation to prescribing and redefine themselves accordingly. They explained their dissatisfaction as a consequence of not living up to their ideals, having their autonomy compromised and hence experiencing threats to

Acknowledgements

First and foremost we want to thank the informants who took part in the study for their willingness to share their daily lives. This study was conducted as part of a Ph.D. project sponsored by The Danish University of Pharmaceutical Sciences, Copenhagen. We gratefully acknowledge the assistance of Erik Knudsen and Thorsten Kruse from the local health authorities in the County of West Zealand, also affiliated with FKL—The Research Centre for Quality in Medicine Use, for developing the sampling

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