The threatened self: general practitioners’ self-perception in relation to prescribing medicine
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
References (30)
The meaning of medicationsAnother look at compliance
Social Science & Medicine
(1985)- et al.
Physician motivations for nonscientific drug prescribing
Social Science & Medicine
(1989) - et al.
Doctor–patient communication about drugsThe evidence for shared decision making
Social Science & Medicine
(2000) - et al.
Variations in general practitioners’ views of asthma management in four European countries
Social Science & Medicine
(2001) - et al.
A study of general practitioners’ reasons for changing their prescribing behaviour
British Medical Journal
(1996) - et al.
Intentions, strategies and uncertainty inherent in antibiotic prescribing
European Journal of General Practice
(2002) - Bradley, C. P. (1990). A critical incident study of general practitioners’. Discomfort arising from prescribing...
Decision making and prescribing patterns—a literature review
Family Practice
(1991)Factors which influence the decision whether or not to prescribeThe dilemma facing general practitioners
British Journal of General Practice
(1992)Prescribing and the defence of clinical autonomy
Sociology of Health & Ilness
(2001)
Misunderstandings in prescribing decisions in general practiceQualitative study
British Medical Journal
Understanding the culture of prescribingQualitative study of general practitioners’ and patients’ perceptions of antibiotics for sore throats
British Medical Journal
A study of factors associated with cost and variation in prescribing among GPs
Family Practice
Some methodological problems studying consultations in general practice
Journal of the Royal College of General Practitioners
A bitter pill to swallowPlacebo therapy in general practice
The Sociological Review
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