64
PRESCRIBING IN GENERAL PRACTICE
The medical profession has not quite succumbed to accepting drug companies as principal therapeutic advisors. The traditional sagefuard of' group acceptance ' is being maintained. To date, the profession is still able to act as an umbrella for individual prescribers allowing each to pursue his own idiosyncrasies. The fundamental issue which these suggestions raise for the medical profession is how it can continue to retain legitimation of itself by itself. This issue becomes more pertinent if medical auditing and professional standards review organisations are considered. REFERENCES
Coleman, J., Katz, E. & Menzel, H. (1966). Medical Innovation-a Diffusion Study. Indianapolis: Bobbs-Merrill Company. Hemminki, E. (1975). Review of literature on the factors affecting drug prescribing. Social Science and Medicine, 9, 111-116. Marshall, J. (1972). Aspects of the Sociology ofPrescribing Among General Practitioners. Ph.D. Thesis. University of Wales. Miller, R. R. (1974). Prescribing habits of physicians: a review of studies of prescribing drugs. Drug Intelligence and Clinical Pharmacy, 8, No. 2, 81-91. Report of the Committee of Enquiry into the Relationship of the Pharmaceutical Industry with the National Health Service, 1965-1967 (1967). (Sainsbury Report). London: HMSO. Wilson, C. W. M., Banks, J. A., Maples, R. E. A. & Korte, S. M. T. (1963). Influence of different sources of therapeutic information on prescribing by general practitioners. British Medical Journal, 2, 99-604. Worthen, D. B. (1973). Prescribing Influences: An overview. British Journal of Medical Education, 7, 109-117.
12. GENERAL PRACTITIONERS' VIEWS OF INFORMATION ABOUT DRUGS
GAIL EATON AND PETER PARISH The relationship of the medical profession to the pharmaceutical industry The relationship of the pharmaceutical industry to prescribing doctors has always caused concern to the DHSS. This concern has usually centred on the ever increasing costs of the pharmaceutical services. Both the Hinchliffe Committee (1959) and the Sainsbury Committee (1967) acknowledged the influence of the pharmaceutical industry on the prescribing activities of general practitioners. In a previous paper the findings highlighted the position of the general practitioner between the pharmaceutical industry on the one hand and the DHSS on the other, each competing to influence his prescribing. The findings further suggest the way in which doctors, when uncertain and faced with competing forces, turn to members of their own profession for final legitimation of their actions.
Biased drug information and commercialism. Further answers to the second questionnaire reveal just how uncertain the situation of prescribing doctors can be. Doctors were asked, " Do you feel that you are able to obtain an unbiased assessment of a newly introduced drug? " If they answered no, they were asked to state why not. If yes, they were asked " What source of information would you consult to obtain such an unbiased 'assessment?" Three hundred and eighty-two (84 per cent) of the 453 respondents answered this question. Of these 181 (47 per cent) stated that they were not able to obtain an unbiased assessment. Two hundred and one (53 per cent) said that they could. A majority of the former felt that most drug information was too commercial and therefore biased. Some also considered clinical trials, professional journals, and consultants to be biased in this
PRESCRIBING
65
IN GENERAL PRACTICE
TABLE
1
DOCTORS
WHO STATED THAT THEY WERE NOT ABLE TO GAIN AN UNBIASED ASSESSMENT OF A NEWLY INTRODUCED DRUG
Influences mentioned as contributing to bias Drug company activities Clinical trials Professional journals Lack of own knowledge None mentioned Non-specific Other journals Consultant advice
Total
Number of respondents
%
132 18 9 7 6 5 2 2
72 *9 9 9 5 0 3*9 3*3 2 8 1.1 1.1
181
100 *0O
direction (table 1). Thirty-four complained of the length of time before ' unbiased' information about drugs became available, by which time they considered a drug preparation was no longer new. Of interest was the finding that most doctors mentioned particular sources though they were not necessarily asked to do so. These could be classified into seven main groups (table 1). Lack of information about drugs was not a major complaint, only three respondents referred to this. Different attitudes towards the degree of bias The replies of these doctors about bias were countered by the apparent ability of other respondents to obtain unbiased information. The latter referred to professional sources, particularly the British Medical Journal and Prescribers' Journal. Considerably less popular, but mentioned, were clinical trials, consultants, and colleagues. A small proportion referred to their own ability to make such an assessment (usually through carrying out clinical trials for drug companies). Only 18 doctors specifically referred to commercial sources, three by way of journals sponsored by drug companies, the rest simply by referring to ' industry ', ' drug firms ' or ' reps ' (table 2). These findings suggest differences in attitudes towards the degree of bias of the various sources of drug information, though the one thing both groups of respondents TABLE 2 DOCTORS WHO STATED THAT THEY WERE ABLE TO GAIN AN UNBIASED ASSESSMENT OF A NEWLY INTRODUCED DRUG
Sources of information
Professional journals Non-specific Consultants Clinical trials Drug companies Own assessment
Colleagues Other journals Total
Number of respondents
%
105 30 16 15 15 12 5 3
52 2 14*9 8 0
201
1001
7*5 7 5 6*0 2*5 1*5
66
PRESCRIBING
IN GENERAL PRACTICE
have in common is that very few appear to regard the drug companies as giving information which would enable them to obtain an unbiased assessment of a drug. Only 15 referred directly to them as a source which they would consult in this respect. An important question raised by these responses is why should some doctors consider themselves able to obtain an unbiased assessment, when others feel that they cannot, particularly when they are open to the same influences. It might perhaps suggest that those doctors who state they are not able to obtain an unbiased assessment have a more critical attitude towards the commercialism of the drug companies. In contrast those respondents who stated that they were able to gain an unbiased assessment gave little acknowledgement to the commercial influence of the drug companies, if not on themselves, at least upon other members of the profession to whom they turn for information. And it must be noted that they do not consider their own personal ability to obtain an unbiased assessment of a drug to be of importance (only 12 stated that it was). Suggestions for improving teaching in therapeutics A further question considered the training of doctors in therapeutics. Doctors were told, " We would like you to enter here any suggestions you have about improving undergraduate and postgraduate training in therapeutics ". Two hundred and sixty two (58 per cent) responded to this question, most of whom offered suggestions (90 per cent); seven felt that their training had been adequate and 20 had no suggestions to offer. The majority (257) of respondents answered both this question and the previous one on bias. Fifty-four per cent had said that they were unable to obtain an unbiased assessment of a newly introduced drug and 46 per cent said they were able to do so, 32 per cent of doctors suggested improvements in undergraduate training, 33 per cent (87) suggested improvements in postgraduate teaching and facilities and 25 per cent (66) made suggestions about both. The other ten per cent (27) made various suggestions of which the following are examples. " Nationalise the drug industry." " The very serious problem of people defaulting treatment and trying other people's
drugs should be stressed. Also the placebo way is not put forward strongly enough as a method of treatment which can be used many times every day." " Once qualified most doctors use brand names whereas as undergraduates they are taught approved names only, some sort of integration is required." Types of improvement suggested by doctors Suggested improvements mentioned in the answers could be categorised by the nature of the information desired and the way in which it should be disseminated. These fell broadly into three separate categories: recipe, apprenticeship, and theoretical knowledge. For purposes of analysis a fourth type has been labelled as non-specific where the respondent gave no specific description of the type of information needed. The content of these categories differs slightly depending on whether the respondent referred to undergraduate or postgraduate training though basically their content was as follows:
(1) Recipe This refers to information about particular drug use, e.g. " Emphasis on what to prescribe for minor ailments ", " Teaching what drugs to use in specific disorders ", " Essentials of treatment of common diseases met every day ". In this category also fell those who wished for more written information on the lines ofPrescribers' Journal.
PRESCRIBING
67
IN GENERAL PRACTICE
TABLE 3 TYPE
OF INFORMATION SUGGESTED AS IMPROVING UNDERGRADUATE AND POSTGRADUATE TRAINING IN THERAPEUTICS
Type of information
Undergraduate
Recipe Apprenticeship Theoretical Non-specific
Total (number of respondents)
Postgraduate
Non-specific
10 71 53 3
7-3 51-8 38-7 2*2
30 32 65 8
22-2 23 7 48 1 5*9
4 3 4 0
36-4 27-3 36-4
137
1000
135
99 9
11
100 1
(2) Apprenticeship At both undergraduate and postgraduate level this refers to teaching in clinical general practice or teaching by general practitioners. These answers generally referred to general-practice attachment during undergraduate training and to postgraduate vocational training of some kind e.g. "More about prescribing in general practice ", "Attachments to general practice as well as further courses ", "Proper undergraduate general-practice training by good general practitioners (3) Theoretical knowledge In this category fell that information about subjects traditionally in the hands of departments of pharmacology and therapeutics, e.g. " More formal training in therapeutics", " More emphasis on pharmacology", " There must be proper teaching in therapeutics for final-year medical students and more emphasis laid on therapeutic teaching during pre-registration especially ". As table 3 shows there was a slight shift in the type of information wanted at postgraduate level from that wanted at undergraduate level. At both these levels doctors were specific about the type of information they thought would be an improvement. During undergraduate training they considered that information of the ' apprenticeship ' and 'theoretical' nature would be an improvement. While at postgraduate level, though most respondents still considered that 'theoretical' training would be of most use, there was a change in emphasis from ' apprenticeship ' training to the provision of ' recipe ' type information. The majority indicated that they wished this information to come specifically from the profession (table 4). Only one respondent specifically suggested any further contact with industry during TABLE 4 SOURCE OF 'TRAINING' IN THERAPEUTICS
Undergraduate
Postgraduate
Non-specific
Profession Industry DHSS
136 1 0
99.3 0 *7
130 5 0
96.3 3. 7
7 3 0
700 300
Total (number of respondents)
137
100.0
135
100 0
10
100 0
PRESCRIBING IN GENERAL PRACTICE
68
undergraduate training, five suggested it at the postgraduate level, and a further three suggested that industry should contribute to training in therapeutics without specific reference as to when this should occur. The need for guidance by the medical profession considered that their recommended improvements in undergraduate The majority teaching should be part of the formal teaching curriculum. At postgraduate level they suggested revision courses and lectures. Only two doctors mentioned self-teaching through discussion groups. Twenty-five of the respondents suggested an improvement in professional journals in order to help them. The answers given by these doctors suggest that they feel a need for help in therapeutics when making a judgement in a particular situation e.g. assessing a new drug, and for use in treatment. For some of them the profession is considered to be of help in providing an unbiased assessment of a newly introduced drug, for others no source appears to be helpful. Nevertheless respondents in both groups look for better training in therapeutics, and most felt that this should be provided by the medical profession. Discussion For a considerable time the medical profession has been faced with an increasingly complex technology and so much knowledge has accumulated that no one doctor can claim to know it all. Initially the answer to this has been the separation into different specialties-but specialties joined together by virtue of their basic education. This education involves not just learning the rudiments of medical knowledge and technique, but also the taking on of responsibility and clinical experience (Freidson 1971; Merton et al., 1957). In general practice this increased complexity is exemplified by the expansion in drug therapy during the last three decades. Advances in drug development, treatment, and drug information have come principally from outside the medical professionfrom the drug companies. The role of the profession has been one of having to evaluate drugs and drug information through use. The answers given by our respondents indicate that the role of the drug companies as providers of information about drugs may be met with caution and they expressed a need for improved education in drug use both at the pregraduate and postgraduate levels. The different suggestions indicate that educationalists should not approach general practitioners as an educationally homogenous group with similar requirements. There would appear to be a need for a flexible system catering for the varying needs and preferences of differing groups of practitioners. REFERENCES
Freidson, E. (1971). Professional Dominance. New York: Atherton Press. Merton, R. K., Reader, G. G. & Kendall, P. L. (1957). The Student Physician: Introductory Studies in the Sociology of Medical Education. Cambridge: Harvard University Press for the Commonwealth Fund. Ministry of Health (1959). Final Report of the Committee on Cost of Prescribing (Hinchliffe report). London: HMSO. Report of the Committee of Enquiry into the Relationship of the Pharmaceutical Industry with the National Health Service 1965-1967 (1967). (Sainsbury report). London: HMSO.
PRESCRIBING IN GENERAL PRACTICE
The medical profession has not quite succumbed to accepting drug companies as principal therapeutic advisors. The traditional sagefuard of' group acceptance ' is being maintained. To date, the profession is still able to act as an umbrella for individual prescribers allowing each to pursue his own idiosyncrasies. The fundamental issue which these suggestions raise for the medical profession is how it can continue to retain legitimation of itself by itself. This issue becomes more pertinent if medical auditing and professional standards review organisations are considered. REFERENCES
Coleman, J., Katz, E. & Menzel, H. (1966). Medical Innovation-a Diffusion Study. Indianapolis: Bobbs-Merrill Company. Hemminki, E. (1975). Review of literature on the factors affecting drug prescribing. Social Science and Medicine, 9, 111-116. Marshall, J. (1972). Aspects of the Sociology ofPrescribing Among General Practitioners. Ph.D. Thesis. University of Wales. Miller, R. R. (1974). Prescribing habits of physicians: a review of studies of prescribing drugs. Drug Intelligence and Clinical Pharmacy, 8, No. 2, 81-91. Report of the Committee of Enquiry into the Relationship of the Pharmaceutical Industry with the National Health Service, 1965-1967 (1967). (Sainsbury Report). London: HMSO. Wilson, C. W. M., Banks, J. A., Maples, R. E. A. & Korte, S. M. T. (1963). Influence of different sources of therapeutic information on prescribing by general practitioners. British Medical Journal, 2, 99-604. Worthen, D. B. (1973). Prescribing Influences: An overview. British Journal of Medical Education, 7, 109-117.
12. GENERAL PRACTITIONERS' VIEWS OF INFORMATION ABOUT DRUGS
GAIL EATON AND PETER PARISH The relationship of the medical profession to the pharmaceutical industry The relationship of the pharmaceutical industry to prescribing doctors has always caused concern to the DHSS. This concern has usually centred on the ever increasing costs of the pharmaceutical services. Both the Hinchliffe Committee (1959) and the Sainsbury Committee (1967) acknowledged the influence of the pharmaceutical industry on the prescribing activities of general practitioners. In a previous paper the findings highlighted the position of the general practitioner between the pharmaceutical industry on the one hand and the DHSS on the other, each competing to influence his prescribing. The findings further suggest the way in which doctors, when uncertain and faced with competing forces, turn to members of their own profession for final legitimation of their actions.
Biased drug information and commercialism. Further answers to the second questionnaire reveal just how uncertain the situation of prescribing doctors can be. Doctors were asked, " Do you feel that you are able to obtain an unbiased assessment of a newly introduced drug? " If they answered no, they were asked to state why not. If yes, they were asked " What source of information would you consult to obtain such an unbiased 'assessment?" Three hundred and eighty-two (84 per cent) of the 453 respondents answered this question. Of these 181 (47 per cent) stated that they were not able to obtain an unbiased assessment. Two hundred and one (53 per cent) said that they could. A majority of the former felt that most drug information was too commercial and therefore biased. Some also considered clinical trials, professional journals, and consultants to be biased in this
PRESCRIBING
65
IN GENERAL PRACTICE
TABLE
1
DOCTORS
WHO STATED THAT THEY WERE NOT ABLE TO GAIN AN UNBIASED ASSESSMENT OF A NEWLY INTRODUCED DRUG
Influences mentioned as contributing to bias Drug company activities Clinical trials Professional journals Lack of own knowledge None mentioned Non-specific Other journals Consultant advice
Total
Number of respondents
%
132 18 9 7 6 5 2 2
72 *9 9 9 5 0 3*9 3*3 2 8 1.1 1.1
181
100 *0O
direction (table 1). Thirty-four complained of the length of time before ' unbiased' information about drugs became available, by which time they considered a drug preparation was no longer new. Of interest was the finding that most doctors mentioned particular sources though they were not necessarily asked to do so. These could be classified into seven main groups (table 1). Lack of information about drugs was not a major complaint, only three respondents referred to this. Different attitudes towards the degree of bias The replies of these doctors about bias were countered by the apparent ability of other respondents to obtain unbiased information. The latter referred to professional sources, particularly the British Medical Journal and Prescribers' Journal. Considerably less popular, but mentioned, were clinical trials, consultants, and colleagues. A small proportion referred to their own ability to make such an assessment (usually through carrying out clinical trials for drug companies). Only 18 doctors specifically referred to commercial sources, three by way of journals sponsored by drug companies, the rest simply by referring to ' industry ', ' drug firms ' or ' reps ' (table 2). These findings suggest differences in attitudes towards the degree of bias of the various sources of drug information, though the one thing both groups of respondents TABLE 2 DOCTORS WHO STATED THAT THEY WERE ABLE TO GAIN AN UNBIASED ASSESSMENT OF A NEWLY INTRODUCED DRUG
Sources of information
Professional journals Non-specific Consultants Clinical trials Drug companies Own assessment
Colleagues Other journals Total
Number of respondents
%
105 30 16 15 15 12 5 3
52 2 14*9 8 0
201
1001
7*5 7 5 6*0 2*5 1*5
66
PRESCRIBING
IN GENERAL PRACTICE
have in common is that very few appear to regard the drug companies as giving information which would enable them to obtain an unbiased assessment of a drug. Only 15 referred directly to them as a source which they would consult in this respect. An important question raised by these responses is why should some doctors consider themselves able to obtain an unbiased assessment, when others feel that they cannot, particularly when they are open to the same influences. It might perhaps suggest that those doctors who state they are not able to obtain an unbiased assessment have a more critical attitude towards the commercialism of the drug companies. In contrast those respondents who stated that they were able to gain an unbiased assessment gave little acknowledgement to the commercial influence of the drug companies, if not on themselves, at least upon other members of the profession to whom they turn for information. And it must be noted that they do not consider their own personal ability to obtain an unbiased assessment of a drug to be of importance (only 12 stated that it was). Suggestions for improving teaching in therapeutics A further question considered the training of doctors in therapeutics. Doctors were told, " We would like you to enter here any suggestions you have about improving undergraduate and postgraduate training in therapeutics ". Two hundred and sixty two (58 per cent) responded to this question, most of whom offered suggestions (90 per cent); seven felt that their training had been adequate and 20 had no suggestions to offer. The majority (257) of respondents answered both this question and the previous one on bias. Fifty-four per cent had said that they were unable to obtain an unbiased assessment of a newly introduced drug and 46 per cent said they were able to do so, 32 per cent of doctors suggested improvements in undergraduate training, 33 per cent (87) suggested improvements in postgraduate teaching and facilities and 25 per cent (66) made suggestions about both. The other ten per cent (27) made various suggestions of which the following are examples. " Nationalise the drug industry." " The very serious problem of people defaulting treatment and trying other people's
drugs should be stressed. Also the placebo way is not put forward strongly enough as a method of treatment which can be used many times every day." " Once qualified most doctors use brand names whereas as undergraduates they are taught approved names only, some sort of integration is required." Types of improvement suggested by doctors Suggested improvements mentioned in the answers could be categorised by the nature of the information desired and the way in which it should be disseminated. These fell broadly into three separate categories: recipe, apprenticeship, and theoretical knowledge. For purposes of analysis a fourth type has been labelled as non-specific where the respondent gave no specific description of the type of information needed. The content of these categories differs slightly depending on whether the respondent referred to undergraduate or postgraduate training though basically their content was as follows:
(1) Recipe This refers to information about particular drug use, e.g. " Emphasis on what to prescribe for minor ailments ", " Teaching what drugs to use in specific disorders ", " Essentials of treatment of common diseases met every day ". In this category also fell those who wished for more written information on the lines ofPrescribers' Journal.
PRESCRIBING
67
IN GENERAL PRACTICE
TABLE 3 TYPE
OF INFORMATION SUGGESTED AS IMPROVING UNDERGRADUATE AND POSTGRADUATE TRAINING IN THERAPEUTICS
Type of information
Undergraduate
Recipe Apprenticeship Theoretical Non-specific
Total (number of respondents)
Postgraduate
Non-specific
10 71 53 3
7-3 51-8 38-7 2*2
30 32 65 8
22-2 23 7 48 1 5*9
4 3 4 0
36-4 27-3 36-4
137
1000
135
99 9
11
100 1
(2) Apprenticeship At both undergraduate and postgraduate level this refers to teaching in clinical general practice or teaching by general practitioners. These answers generally referred to general-practice attachment during undergraduate training and to postgraduate vocational training of some kind e.g. "More about prescribing in general practice ", "Attachments to general practice as well as further courses ", "Proper undergraduate general-practice training by good general practitioners (3) Theoretical knowledge In this category fell that information about subjects traditionally in the hands of departments of pharmacology and therapeutics, e.g. " More formal training in therapeutics", " More emphasis on pharmacology", " There must be proper teaching in therapeutics for final-year medical students and more emphasis laid on therapeutic teaching during pre-registration especially ". As table 3 shows there was a slight shift in the type of information wanted at postgraduate level from that wanted at undergraduate level. At both these levels doctors were specific about the type of information they thought would be an improvement. During undergraduate training they considered that information of the ' apprenticeship ' and 'theoretical' nature would be an improvement. While at postgraduate level, though most respondents still considered that 'theoretical' training would be of most use, there was a change in emphasis from ' apprenticeship ' training to the provision of ' recipe ' type information. The majority indicated that they wished this information to come specifically from the profession (table 4). Only one respondent specifically suggested any further contact with industry during TABLE 4 SOURCE OF 'TRAINING' IN THERAPEUTICS
Undergraduate
Postgraduate
Non-specific
Profession Industry DHSS
136 1 0
99.3 0 *7
130 5 0
96.3 3. 7
7 3 0
700 300
Total (number of respondents)
137
100.0
135
100 0
10
100 0
PRESCRIBING IN GENERAL PRACTICE
68
undergraduate training, five suggested it at the postgraduate level, and a further three suggested that industry should contribute to training in therapeutics without specific reference as to when this should occur. The need for guidance by the medical profession considered that their recommended improvements in undergraduate The majority teaching should be part of the formal teaching curriculum. At postgraduate level they suggested revision courses and lectures. Only two doctors mentioned self-teaching through discussion groups. Twenty-five of the respondents suggested an improvement in professional journals in order to help them. The answers given by these doctors suggest that they feel a need for help in therapeutics when making a judgement in a particular situation e.g. assessing a new drug, and for use in treatment. For some of them the profession is considered to be of help in providing an unbiased assessment of a newly introduced drug, for others no source appears to be helpful. Nevertheless respondents in both groups look for better training in therapeutics, and most felt that this should be provided by the medical profession. Discussion For a considerable time the medical profession has been faced with an increasingly complex technology and so much knowledge has accumulated that no one doctor can claim to know it all. Initially the answer to this has been the separation into different specialties-but specialties joined together by virtue of their basic education. This education involves not just learning the rudiments of medical knowledge and technique, but also the taking on of responsibility and clinical experience (Freidson 1971; Merton et al., 1957). In general practice this increased complexity is exemplified by the expansion in drug therapy during the last three decades. Advances in drug development, treatment, and drug information have come principally from outside the medical professionfrom the drug companies. The role of the profession has been one of having to evaluate drugs and drug information through use. The answers given by our respondents indicate that the role of the drug companies as providers of information about drugs may be met with caution and they expressed a need for improved education in drug use both at the pregraduate and postgraduate levels. The different suggestions indicate that educationalists should not approach general practitioners as an educationally homogenous group with similar requirements. There would appear to be a need for a flexible system catering for the varying needs and preferences of differing groups of practitioners. REFERENCES
Freidson, E. (1971). Professional Dominance. New York: Atherton Press. Merton, R. K., Reader, G. G. & Kendall, P. L. (1957). The Student Physician: Introductory Studies in the Sociology of Medical Education. Cambridge: Harvard University Press for the Commonwealth Fund. Ministry of Health (1959). Final Report of the Committee on Cost of Prescribing (Hinchliffe report). London: HMSO. Report of the Committee of Enquiry into the Relationship of the Pharmaceutical Industry with the National Health Service 1965-1967 (1967). (Sainsbury report). London: HMSO.
