In a new study, just published in the journal Annals of Family Medicine, researchers interviewed doctors about the barriers that prevent them from being able to decrease excess medications. Doctors called it “swimming against the tide,” citing patient expectations, the medical prescribing culture, and the structure of the medical business as factors making it difficult to deprescribe. This is particularly striking in light of the recent study that found that people who want to decrease their psychiatric medication found their mental health providers unhelpful.
“Adverse drug events and resultant hospital admissions are common in older people, costing health systems billions of dollars every year,” the researchers write. “Up to 10% of hospital admissions result from drug-related problems, two-thirds of which are considered preventable through safer prescribing.”
Particularly for older people, polypharmacy (taking multiple prescribed medications) may lead to dangerous drug interactions and side effects. The researchers write that careful prescription practices—including deprescribing—can help reduce these risks.
However, the authors write that “Despite evidence to guide safe prescribing, high-risk prescribing in older people is common, with 1 in 5 prescriptions potentially inappropriate.”
The researchers were led by Katharine Wallis, at the University of Auckland, New Zealand. They hoped to get an insider’s look into what barriers prevent doctors from feeling confident in deprescribing. As such, they interviewed 24 physicians from a variety of practice settings and years of experience.
According to the doctors interviewed, deprescribing was not rewarded by the medical profession. “The only incentive to deprescribing they identified was the duty to do what was right for the patient.” That is, these doctors effectively considered the safety and benefit of the patient to be at odds with the culture of prescribing enforced in the medical profession.
According to the researchers, doctors “said prescribing was the easy option, while deprescribing was time-consuming and came with inherent risks both for themselves and for patients. They said patients expected there to be ‘a pill for every ill’ and that this expectation was exacerbated by direct-to-consumer advertising of medicines in New Zealand.” The United States is the only other country that allows direct-to-consumer advertising of medications.
The authors also write that “Some physicians, especially the younger and less experienced ones, described a professional etiquette that left them reluctant to stop medicines initiated by others. They felt uncomfortable going against the prescribing of the patient’s usual doctor and of specialists, both of whom they felt knew better than they did.”
Some of the actual quotes from doctors interviewed by the researchers are quite telling about the culture of prescription:
- “I guess it’s easy to keep adding in medications without looking at whether they need all the medications they’re already on.”
- “Prescribing is something that’s taught a lot, you know. Deprescribing isn’t really something that’s been talked about from the get-go. It’s not something that’s come up. As a GP trainee, it’s not something that we’ve had a session on.”
Doctors also discussed the pressures of the medical system as barriers to deprescription:
- “There is no time … [You’ve got] complicated, complex patients and you never have more than 15 minutes and sometimes it’s double booked. There’s never time to spend on this.”
- “Patients are not coming in for a deprescribing conversation; they’re coming in for something else like a repeat or to talk about their aching joints. So the deprescribing conversation is an added thing to the consultation.”
- “With the best will in the world we get really busy, we get distracted and we mean to do things that we don’t do.”
The doctors also mentioned many ideas of how to make deprescription more accessible, including improvements to clinical practice guidelines, scheduled sessions to review medications with patients, better collaboration with patients, and improved training on how to deprescribe.
According to the researchers, the only current reason doctors consider deprescription is their individual judgment of what is best for their patients. The researchers, therefore, encourage policy and research improvements that will help support the primary goals of physicians—to help, rather than harm, their patients.
Wallis, K. A., Andrews, A., & Henderson, M. (2017). Swimming against the tide: Primary care physicians’ views on deprescribing in everyday practice. Annals of Family Medicine, 15(4), 341-346. doi: 10.1370/afm.2094 (LINK)
As a patient, I never went to a doctor wanting pills. I never believed there is a “pill for every ill.” Almost all my conversations with doctors were about wanting to be taken off of drugs, and given alternative therapies, like physical therapy instead.
My experience is that it is the doctors who believe there is a “pill for every ill.” It is doctors who do not want to take patients off drugs, and offer them alternatives instead. And this does seem to be commensurate with their education, according to the doctors you interviewed.
The doctors will eventually wean a person off the drugs, when asking to be taken off the drugs is the only thing you ever discuss with doctors, but even then, it takes years for doctors to do this. Blame the patients, doctors, always, right?
So, I guess that this is why the third leading cause of death for Americans is medical, particularly related to medicines. It’s interesting that it seems like all the considerations for not desprescribing strongly outweigh deprescribing because it’s the right thing and the healthy thing to do for the patient. It’s easier to not have to go through all the time and work that it entails to get people off medicines that they probably shouldn’t be on in the first place.
Exactly, Stephen… with extra stress on “that they probably shouldn’t be on in the first place!” As an iatrogenic illness survivor, it would be interesting to see how the statistic numbers would change adding all of us into the mix, as well. ‘The third leading cause of death for Americans is medical-related,’ however, what about all of us that have been harmed and/or completely disabled by medication?!
this is an awful problem for patients and doctors…the whole system is geared for rapid solutions/quick/fast…….patients are the ones that suffer most…
A timely discussion that we need more of…Should the “culture of prescription” really be considered of more importance than the health of the patient? If we follow the money, we know who is suffering the least.
Thank you, Peter! An important point that was not truly discussed is the fact that so many doctors are given added incentives and perks to over-prescribe… which includes prescribing specific classes of medication to certain groups, such as children and the elderly. But of course, sadly, no other country is probably more guilty of that than the U.S.A.