"It's just a medication review" - how do GPs do medication reviews?

By Nina Fudge

General Practitioners (GPs) find themselves in a very challenging position. On the one hand they are encouraged to treat people with medicines. On the other hand they are expected to limit the harms that polypharmacy (taking many medicines) can bring. Medication reviews are an opportunity for patients to discuss their medicines with a GP, nurse or pharmacist, who will if needed change the prescription. While medication reviews are recommended by the NHS, we don’t know much about what happens in a medication review or what GPs think about them. As part of the APOLLO-MM project, we studied medication reviews in practice.

We video-recorded 18 medication review appointments in three general practices. The appointments we filmed involved older patients who were prescribed ten or more medicines. Most of the appointments were led by GPs and a few were led by a pharmacist. We then held reflective workshops with healthcare professionals from each general practice. In the workshops, we showed short clips or extracts from the filmed appointments. The healthcare professionals reflected on what they saw in the clips and what they thought about their work. We recorded and analysed this discussion which offered insights into how GPs and practice pharmacists make sense of their work.

What is a medication review?

When the GPs watched the footage and described what they saw, they often began with comments like: “It’s just a medication review” or “I’m just reviewing the medicines.” This suggests that GPs thought of their work as rather uninteresting and mundane. But, as they spent more time watching the video clips they came to see how complex medication reviews are. We noticed that GPs talked about the emotional aspects of discussing medicines with patients. For example, they talked about the  fear of stopping a medicine and destabilising a patient or upsetting a patient’s balance. This contrasts with many professional documents with advice about starting and stopping medicines. In these documents the focus is on the technical aspects of medicines, such as how drugs interact or the side effects they cause. 

During the workshops GPs shifted their thinking about what a medication review is. They recognised that when patients have many medications it’s impossible to review them all in a one-off appointment. It is made harder when that appointment is only ten minutes long. The GPs came to realise that doing a medication review cannot be a one-off activity. Reviewing medicines is part of an ongoing collaborative process characterised by small, incremental changes. Reducing the harms of many medications can only happen through small, incremental and carefully supported changes.

"People are trying to do like a super-complex bit of work within 10 to 15 minutes."

General Practitioner, GP Practice C

"It just made me realise how complex the whole polypharmacy is. There’s so many different factors, both for me and for the patients. And actually, I’m someone who likes to think systematically about things, and it’s very difficult to think systematically about something that is this complex… just an awareness of that is helpful."

General Practitioner, GP Practice B
Organising the medication review
Healthcare professionals in the workshops noticed that the computer played a big role in the medication review. The medicine list on the computer screen dictated how GPs organised the review. For example, the videos showed GPs going down the list of medicines instead of asking the patient which medicines they wanted to talk about. In the workshops, clinicians considered the pros and cons of inviting patients to look at this computer list with them. In one of our workshops, we showed a clip of a patient who brought their medicines to their consultation and laid them out on the desk. GPs saw potential in this as a way of organising the medication review. Seeing the medicines on the desk helped the GP and the patient be sure they were both talking about the same thing. Often GPs and patients have different ways of talking about medicines. GPs know about medicines by their chemical or brand name. Patients tend to know about their medicines by the colour, size, or the time of day they take it. Having the medicines in the consulting room made it easier to put the patient’s concerns first. The medicines acted as a useful reminder for the patient about what they wanted to ask the doctor.
Who makes the decisions about medicines?
Tackling the problems of polypharmacy requires decision-making under conditions of complexity and uncertainty.  Early on in the workshops GPs said they didn’t feel confident about stopping medicines without speaking to a hospital specialist first. But reviewing the video clips in the workshops helped GPs realise that the expertise required to stop a medicine was already in the consultation room. It is the GP, other practice staff (other GPs, pharmacists) and the patient together who can decide when and how to stop a medicine that is no longer needed or not working well for the patient. But for this to work, patients need to see the same GP so they can work together over time. And GPs need opportunities (like the reflective  workshops) to discuss with their colleagues the challenges of looking after patients who are taking many medicines and the best way to address these challenges.
 Want to know more?
Our research is published in BMJ Quality and Safety. You can read the full research paper here Swinglehurst D, Hogger L, Fudge N. Negotiating the polypharmacy paradox: a video-reflexive ethnography study of polypharmacy and its practices in primary care. BMJ Quality & Safety 2023;32:150-159.

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