‘Now let’s see what the problem is’
They are the first contact with anyone who is ill in the wider community. Not only do patients see ‘Family Doctors’ as their personal healers but they also trust them implicitly to do the best for them.
It is in this light that Family Physician Prof. Leela De Alwis Karunaratne who is Founder-Professor of Family Medicine at the Sri Jayewardenepura University’s Faculty of Medical Sciences and a Past President of the College of General Practitioners of Sri Lanka spoke on the very important subject of ‘Prescribing with care’ at the Symposium on ‘Prescribing in Family Practice’ at a recent international conference.
One of the most roles of a doctor is to 'prescribe with care"
This was the South Asian Regional Conference of the World Organization of National Colleges and Academies (WONCA) of General Practitioners/Family Physicians. It was hosted by the College of General Practitioners of Sri Lanka.
Quoting James Spence that “the essential unit of medical practice is the occasion on which, in the intimacy of the consultation room or sick room, a person who is ill or believes himself to be ill, seeks the advice of a doctor whom he trusts. This is the ‘consultation’ and all else in the practice of medicine derives from it”, Dr. De Alwis Karunaratne spoke of how care for people who seek help at the primary care of health care could be enhanced.
This is a description of the scenario in which people receive care from a family doctor and it is the most intimate of doctor-patient interactions. Ideally, at a consultation in family practice, the patient is already known to the doctor and the patient’s personal and health related data are on record.
A consultation usually begins with a greeting of welcome to the patient. When the patient presents the problem, the doctor should respond by listening attentively and then ask relevant open-ended questions. Listening and careful observation are important and may reveal the views and expectations of the patient and perhaps the reason for consulting at that moment of time.
At a consultation in family practice the nature of the problem presented is often apparent, but the doctor should not rush to ask a few questions and hand over a prescription with the intention of ending the consultation quickly. A caring family doctor should, in an unhurried manner, allow the patient to relate the story of the presenting problem, its onset and progress and find out whether self-care has been tried. With a calm and reassuring manner, the doctor should proceed to do a relevant clinical examination and request any laboratory investigation only if useful, for making a diagnosis or for management.
Health problems presented to a family doctor could be managed in the patient’s home environment, with the exception of a few. A small percentage may be emergencies or problems needing referral to specialists in medical disciplines of the higher levels of health care, for their opinion and/or services.
Management of a patient in family practice, however, should not be limited to the problem presented. The family doctor should enquire for any other problems, especially co-morbidity and manage the patient holistically. If health screening is indicated it should be included in the plan of management. When a plan is made to manage a patient in the home environment there are several factors that the doctor must consider.
They are: Home and family background; lifestyle; and beliefs and expectations. A family doctor should always make the plan of management in collaboration with the patient or carer, after a thorough discussion. If the doctor lays down the plan authoritatively without discussion and negotiation, patient compliance cannot be expected.
Patient management in family practice almost always includes prescribing. This has been a tradition in family practice, patients expect a prescription and it is no secret that the physician derives satisfaction. What does prescribing mean? To provide clear, explicit and authoritative directions or guidance to those who are supposed to follow it, according to Business Directory.com.
A family doctor’s prescription usually includes one or more pharmacological preparations and other therapeutic measures. The pharmacological preparations will be to prevent disease, promote and maintain health, relieve symptoms, cure specific conditions, control the progress of non-communicable diseases (NCDs) and as replacement therapy. The non-pharmacological therapy will be rest, physical exercise, diet, lifestyle modification, physiotherapy (specific/non-specific) and counselling.
It is, therefore, a great responsibility for the doctor, especially when a patient presents with symptoms/signs of undifferentiated illness, with no diagnosis in sight, to prescribe with care.
What is Care? It is the process of protecting someone and providing what that person needs, according to Cambridge Dictionary online. What does ‘prescribing with care’ mean to a family doctor? What should the doctor do? The doctor should be rational, the prescribing should be appropriate for the individual, it should be effective but safe, the side/adverse effects should be minimal and it must be economical.
A family doctor should prescribe rationally. Medication that is prescribed should be appropriate for the nature of the problem. If it is for a self-limiting condition, only symptom relief may be necessary, while a specific condition may need anti-inflammatory medication or antibiotics.
The dose of medication and the frequency should meet the individual patient’s requirements and should be prescribed for an adequate period of time. The form of the medication prescribed should be suitable for the individual patient. For example, a very young child or a bedridden patient may not be able to swallow tablets; and there are inherent dangers too.
When prescribing pharmacological drugs, the patient’s age and physical condition must be taken into consideration, not forgetting pregnant women, breastfeeding mothers, neonates and patients on concurrent medication or chemotherapy. The World Health Organization has reported that four small children died by choking on albendazole tablets during a de-worming campaign in Ethiopia in 2007.
A family doctor must also look for social factors in the person’s background and find out the reason why that person has come in for a consultation at that moment of time. Social factors are bound to influence a doctor’s decision and these may include factors such as a university student sitting the final examination, a business executive due to travel overseas that night, someone who is marrying the next day or a five-year-old with a sibling hospitalized with pneumonia.
All pharmaceutical preparations used should be effective and safe. Selecting drugs that have minimal side/adverse effects will allow patients to be comfortable during therapy and prevent non-compliance. A family doctor should be guided by national and international drug information publications and use one’s own experience and that of colleagues when making a choice when prescribing.
It is also very important that the doctor’s prescription is economical for the patient. It would not only avoid waste but also prevent the possibility of effective medication turning out to be inefficient in the patient’s hands. This could happen when a patient faces financial constraints and is unable to meet the cost of the doctor’s expensive taste and lavish prescribing. In such circumstances, a patient may decide not to purchase all the items or buy less quantity or even depend on the pharmacist to change the prescription and dispense cheaper alternatives which may be substandard.
Sometimes, a patient may even forego supportive nutritional needs during an illness to buy the drugs prescribed in the overloaded prescription. Prescribing in a sensible manner with care and concern for the patient is not easy. Sometimes family doctors may deviate to satisfy patients or to relieve their own anxiety. But a family doctor must be prudent and take the responsibility for prescribing with care, seriously and be guided by principles. Principles for prescribing could be formulated by self-direction through experience and by peer group interaction.
The guidelines for prescribing are:
- Prescribe only when positively indicated.
- Prescribe effective medication known to be safe.
- Select drugs with least side/adverse effects.
- Avoid poly-pharmacy.
- Prescribe appropriately for the problem and the person.
- Do not prescribe to please the patient or save consultation time.
- Write a prescription legibly.
- Use a standard format for prescribing.
- Give clear instructions and information to patient/carer.
- Reveal the plan of review.
A family doctor should prescribe only when positively indicated. A careful clinical assessment would help the doctor to decide whether it is necessary to prescribe pharmacological drugs. In many instances the patient may need only advice for self-care, but it must be convincing and given with words of reassurance
Medication prescribed by a doctor should be effective and known to be safe. A wise family doctor should rely on a compendium of time-tested pharmacological preparations and refrain from indulging in a multiplicity of new drugs that are much advertised.
It is an obligation for a family doctor to select drugs with the least side/adverse effects and not add to the discomfort of an already ailing patient.
Poly-pharmacy should be avoided and it should not be a problem for a family doctor who provides primary medical care to prescribe only a very limited number of items. A lengthy prescription will be confusing to the patient, who will find it difficult to follow multiple directions.
It is a wrong assumption that a long list on a prescription would enhance the doctor’s image.
Paediatrician Dr. Stanley De Silva, our teacher in the late 1950s, once said, “You should not use machine guns to kill mosquitoes.”
Prescribing should be for the problem and the person. When a prescription is given for relief of symptoms such as pain or fever, simple analgesics or antipyretics should be used. When it is necessary to cure an infection, first-line antibiotics are the most appropriate to begin with, in primary medical care. Although these have been deemed ineffective by those who prescribe irrationally, they are effective in the hands of rational prescribers.
Trying out each new antibiotic which is produced by the pharmaceutical industry is a dangerous game for a family doctor to play. If these valuable drugs are used irrationally, drug-resistant microorganisms could emerge and render them ineffective.
When prescribing the dose, frequency and duration for a pharmacological drug the doctor must follow recommendations given in reliable drug information publications. Prescribing a higher dose or increasing the frequency will only add to side/adverse effects.
A family doctor should not prescribe to please the patient. Most patients do expect a prescription when they consult, but it is the moral and ethical duty of the doctor to manage correctly and take trouble to explain and educate
Handing a prescription to a patient is the finale to a consultation, but should not be used to end it abruptly. Even when a patient is difficult, a more courteous strategy could be adopted, to save consultation time.
A doctor’s prescription should be legible. The purpose of the prescription is lost unless it is readable. The patient will not be aware of what has been prescribed and the pharmacist could make a mistake. Even the doctor may need time to read it at the next consultation. Typing may be a solution.
A standard format for prescribing should include:
n Name, address and telephone no of the practice
n Date of prescribing
n Name and age of patient
n Pharmacological drugs prescribed by generic name and a brand stated when preferred
n Dose, frequency and duration for each drug and any relation to meals
n Quantity to be dispensed
n An instruction when repeating is required
n Name and signature of prescriber
This standard format should be used by a doctor when prescribing. Every single item I have shown is important enough to be included in a prescription form which should be a hallmark of the doctor’s professionalism.
Clear instruction and information about all that is prescribed must be given verbally to a patient/carer who should also be encouraged to read the prescription. The patient/carer should be made aware of the effects of the pharmacological drugs prescribed.
A patient has a right to know the good effects as well as the side/adverse effects which may be experienced. It is not correct to assume these would be imagined and not tell the patient. It would all depend on how the doctor communicates with the patient.
A patient should be informed, about the form of the medication that would be dispensed, and whether it is for oral intake parenteral administration or topical use. If any medication dispensed needs to be reconstituted before use, clear instructions must be given, and a method of storage advised. The doctor should also make sure that the patient knows to measure liquid preparations accurately
A family doctor should remember that reviewing a patient is necessary to monitor progress; the patient’s response to therapy; adverse effects; compliance; and the need to continue or change. A family doctor, however, should discuss the plan for review with the patient and make it acceptable, instead of laying it down authoritatively.
Let me tell you why a family doctor should manage patients with care and concern specially in prescribing.
When a family doctor interacts with a patient, showing interest and giving time, the care and concern shown by the doctor is comforting and has a positive therapeutic effect on the patient.