"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