Compliance and concordance during domiciliary medication review involving pharmacists and older people

Authors


Address for correspondence: Charlotte Salter, School of Medicine, Health Policy and Practice, University of East Anglia, Chancellor’s Drive, Norwich NR4 7TJ
e-mail:c.salter@uea.ac.uk

Abstract

Medication review is an advanced service registered pharmacists can now offer patients in the UK. This in-depth study of pharmacist-older patient communication during domiciliary medication review encounters examines how the interactions are constructed by participants and the influence of the compliance paradigm on the interaction. Twenty-nine observed, taped and transcribed consultations were analysed using discourse analysis. Ethnographic-style interviews in the field with pharmacists, follow-up interviews with patients and feedback workshops with pharmacists allowed interpretations to be tested and strengthened. The findings presented here use discourse analysis to look at the task-driven nature of the medication review encounters. The analysis explores the interactional format of three over-lapping phases of the consultations: (i) introductions and agenda setting; (ii) screening and testing patients’ ability to comply; and, (iii) investigating over-the-counter medicines. Analysis suggests that a dominant compliance paradigm encourages pharmacist-led encounters with patients failing to engage in the medication review process. Little evidence of two-way reciprocated discussion or concordance was evident. The strategic nature of the discourse of compliance heard in these medication review encounters and its effect on older patients are discussed. The paper concludes with a consideration of the implications for pharmacy practice and policy development.

Introduction

Medication review (MR) is a feature of the new general medical services contract in the UK and is categorised as an advanced service that registered pharmacists can offer as part of the new pharmacy contract (NHS Confederation, accessed 2007). Described as the cornerstone of modern medicines management (Shaw et al. 2002), MR is a public health initiative whose explicit purpose is stated as (i) to increase compliance to prescribed medication regimen through the improvement of patients’ knowledge and use of their drugs and (ii) to reduce waste through improved clinical and cost effectiveness. The focus is on gaining and improving compliance (NHS 2004, 2005).

‘Compliance’ within the medical frame is the extent to which patients’ behaviour coincides with medical or health advice. It assumes patients should and will do as healthcare professionals tell them and symbolises the traditional paternalistic relationship in which healthcare professionals are in authority and decide what action is in the patients’ best interest. In terms of medicine taking, assumptions about compliance can put patients’ wishes or preferences at odds with those of the healthcare team (Donovan 1995, Lerner 1997, Lask 2002).

More than 10,000 inconclusive scientific papers have been produced on ‘medical compliance’ since the 1970s (Donovan 1995, McGavock 1996). The focus has been on why patients do not take their medicines as prescribed. Non-compliance is reported in the literature as a serious public health problem with up to 50 per cent of older people not taking their medicines as ‘intended’ and £100m ‘wasted’ on ‘unwanted’ medicines annually (Royal Pharmaceutical Society of Great Britain 1997, McGavock, 1996, DoH 2001 and Lowe 2002).

The notion of concordance has developed in the policy and practice literature only over the last decade. It has been interpreted as a patient-centred decision-making approach to medicine taking and prescribing. The original definition assumes both healthcare professional and patient play an equal part in the relationship and that agreement can be met only after informed negotiation (RPSGB 1997). However, the concept of concordance remains ambiguous and ill defined. When used in policy and practice guidance, it frequently lacks an operational definition and is therefore hard to pin down and measure as a construct. Cribb and Barber distinguish between concordant prescribing involving ‘an agreement’ and concordant medicine-taking involving ‘a process’ (Cribb and Barber 2005). This process does not necessarily equate with the synchronisation of patient and healthcare beliefs and wishes, and remains normative involving ‘very real ethical judgements’ of right and wrong in medicine taking (Crib and Barber 2005). It does however allow for the logical result of concordant practice that some people may decide not to take potentially beneficial treatment options as prescribed or at all (Dickinson et al. 1999).

This in-depth study of pharmacist-older patient communication during domiciliary MR encounters will consider the influence of the compliance paradigm on the interactions, and will look for evidence of concordant discussion. Using discourse analysis, it will look at the way in which the interactions are constructed by participants, and will analyse the formats that develop. The paper will begin by situating MR in the socio-political context by considering (1) older people as long-term users of medicines and (2) pharmacists’ extended roles and ‘drug counselling’.

Older people as long-term users of medicines

Everyday medicine taking is essentially self-medication and forms a part of many older peoples’ daily healthcare routines. Medicine taking in the home is a personal activity that is undertaken in a private spatio-temporal world where the ebb and flow of everyday life takes place and where habits, routines and personal preferences are juxtaposed and distanced from the formal world of service provision, hospital or clinic (Twigg 2000). Domiciliary MR brings pharmacists into the novel environment of patients’ own homes, possibly for the first time.

MR services were recommended as a new preventative healthcare initiative for older people by the national service framework and the National Health Service Plan (DoH 2001a, 2001b). Research suggests up to 30 per cent of hospital admissions for older people can be blamed on adverse drug reactions, and whilst in hospital between six and 17 per cent of older people are reported to experience adverse drug reactions (DoH 2001a, 2001b, Cromarty et al. 2001). However, MR is a complex area of healthcare policy and practice that was introduced, at least in part, to help abate the rising panic reported in the literature in relation to medicine taking and older people. (Holland et al. 2005, Dolinsky 1995, Lowe 2002). Older people in society are commonly depicted as forgetting to take their medicines and as passive and vulnerable (over) users of medicines (Lumme-Sandt and Virtanen 2002).

Pharmacist’s extended roles and ‘drug counselling’

The role of the modern pharmacist is still evolving and their responsibilities for patient care are at times unclear (Edmunds and Calnan 2001, Mays 1994, Hibbert et al. 2002). As dispensers of prescriptions scripted by doctors their role has traditionally been to activate the doctor’s treatment plan through the safe dispensing of medicines. The extension of the traditional pharmacy role over and beyond the correct and safe dispensing of medicines, with its codes of practice embodied in a technical and procedural discourse, has taken them away from the rational and largely predetermined world of the dispensary to the everyday social world in which people live and experience their health and illness. Despite ‘reprofessionalisation’ there is a conflict in the minds of the public produced by pharmacists’ status as independent practitioners and retailers. This has added to their tangential position and subsequent marginal status in the healthcare system (Harding and Taylor 1997). In terms of pharmacist-patient consultations, international research has shown pharmacists to be unsure about their new relationship with patients, including their ‘drug counselling’ role: pharmacists tend to focus on safer topics such as storage, dosage and other technical handling issues rather than on providing personalised advice and counselling (Pronk et al. 2002, Kansanaho et al. 2002, Skoglund et al. 2003, Williams 2007).

Pharmacists have traditionally remained shielded from direct or sole responsibility for patient care. By extending their roles they are currently being pulled politically to align themselves with the healthcare system whilst also being seen as ideally placed to bridge the gap or middle ground between lay and professional networks (Blaxter and Britten 1997). Research suggests that a tension still exists between a traditionally dominant ‘technical paradigm’ of pharmacy practice and a less sophisticated paradigm of pharmacist as ‘patient advocate and caring professional’ (Morgall and Almarsdóttir 1999).

Method

These study data form part of the author’s post-doctoral research whose overarching aims were to examine how the MR was constructed through talk by participants; and, in what ways the MR supported older people as long-term users of medicines. The analysis and findings presented in this paper focus particularly on the way in which the interactions were constructed by participants and the influence and effect of the compliance paradigm on the interactions.

The study was a qualitative sub-study of a large randomised trial based in Norfolk and Suffolk in the UK. The trial was set up to evaluate the effectiveness of domiciliary MR for patients over 80 years of age who had suffered an emergency admission to hospital and were ready to be discharged home (Holland et al. 2005). Criteria for eligibility included being on two or more medicines. The intervention consisted of two visits from a trained pharmacist, six weeks apart, in order to carry out MR.

The author adopted a three-pronged approach to data collection for the sub-study to increase trustworthiness of the data and enhance the subsequent analysis. This included non-participant observation, tape-recording and transcription of 29 tape-recorded MR encounters; in-depth ethnographic style interviews in the field with pharmacists; and, revisits to participants to collect data on their perceptions of the encounter. In addition to regular supervision, two feedback evenings were held with pharmacists to discuss findings and verify interpretations. It is not known what effect, if any, the presence of the researcher might have had during observation of the consultations but it is possible, at least initially, that pharmacists felt more conscious of the MR process.

Sampling

Patients, recruited to the intervention arm of the parent trial on discharge home from hospital following an emergency admission, would receive a MR from a trained pharmacist. Between October and December 2002, a sample of participants was invited to take part in this additional study. Twenty nine out of a total 437 eligible participants able to give informed written consent were recruited and visited this way.

Final sample selection of the older people from the parent trial was essentially pragmatic and dependent on the combined availability of the pharmacists, the researcher and consenting participants during the designated fieldwork period. In the event, only one patient declined to participate in the sub-study. Study participants were representative of the parent trial including baseline diagnosis; mean age (83.3 and 85.5 respectively); and were taking an almost identical number of prescribed medicines (mean 6.7 and 6.3 respectively). Ethical approval was obtained.

All 22 pharmacists recruited to the parent trial were invited to take part. Eleven expressed an interest and seven took part. The participants and pharmacists were not known to each other. However, the pharmacists all worked as community pharmacists and were paid on an ad hoc basis to provide the MR. Pharmacists had a minimum of 15 years’ experience (range 15–40) and at least one postgraduate qualification. They received a two-day training course on adverse drug reactions and prescribing to older people, with the second day focusing on improving concordance and communication skills. This included consultation skills practice involving role-play with simulated patients.

Pharmacists recruited to this study were broadly representative of the parent trial with a mean age of 43.4 and 41.8 respectively. However, whilst all but one of the sub-study pharmacists were female, 60 per cent of the trial pharmacists were female. Sample saturation was judged to have been reached when no new styles of consultation were witnessed and when all seven pharmacists had done a minimum of three consultations each.

Analysis

The author transcribed and analysed the tapes and field notes by hand on a turn-by-turn basis. The transcription conventions adopted were based on those of Jefferson (Coupland and Coupland, 1991). Principles of discourse analysis were applied whereby characteristic forms of talk or activity types were searched for. Fine-grained sociolinguistic analysis of the conversational properties of the consultation enabled critical or delicate moments to be identified (Sarangi 2000). These were moments where disruptions to the flow of the interaction occurred and the communication between participants was most under pressure (Pilnick 2003). The development of the analytical framework was an iterative process and involved movement between literature and data and constant discussion with participants. Intense fieldwork, manual transcription, re-listening and in-depth analysis of the 29 tape-recorded and observed encounters enabled the author to become very familiar with the process and content of MR. In-depth interviews with one third of the patient participants and formal feedback meetings with the pharmacists involving focus group style discussion enabled initial findings and hunches to be explored and followed up.

The transcripts presented have been selected for their representative nature, and identifiers have been removed.

Findings

Pharmacists invested considerable time and energy in preparing for the MR encounter. Using basic discharge documents (but no patient records), they researched drug details and considered potential issues for each patient in advance. The interactions themselves often lasted nearly an hour (55 minute average). Contrary to the author’s initial expectation that the older participants would have much they wanted to talk to the pharmacists about, they were at times awkward and convoluted encounters with participants at first glance appearing to take a back seat. The findings presented here look at the essentially task-driven nature of the MR encounters and at the influence of the compliance paradigm on the structure and content of the interactions. The analysis will explore the interactional format of three over-lapping yet identifiably distinct phases to the consultations:

  • 1Introductions and agenda setting;
  • 2Screening and testing patient’s ability to comply; and,
  • 3Investigating over-the-counter medicines.

Introductions and agenda setting

The encounters were introduced and set up by the pharmacists and a clear agenda was presented that oriented to the eradication of any obstacles to compliance. The pharmacists took the role of interviewer. Participants did not seem to expect anything else and rarely formally challenged this interactional order. The only patient who did greet the pharmacist with a concern relating to his diagnosis stopped abruptly after a few minutes and apologised saying ‘sorry I am leading you astray’ (Pt: 02) suggesting he did not expect to impose an agenda of his own. In follow-up interviews with the researcher, participants often described the encounter as one-way and greeted pharmacists with comments such as ‘I don’t know what you can do for me’ (Pt: 23). One gentleman described it as a test saying ‘she ask (sic) all the questions and I just give her what she wanted’ (Pt: 09). Extract 1 illustrates a typical problem-focused opening with the pharmacist stating her agenda and effectively taking or being given control early on in the interaction and leading the discussion.

Extract 1 (Ph:01/Pt:10) [Pharmacist = Ph; Patient = Pt]

 1. Ph:Okay (0.3) hhm (0.3) so (0.3) what I’d like to do is go through your medicines with
 2.  you (0.3) and just see what sort of understanding you have of them like you’ve just
 3.  told me about your (0.2) dipyridamole
 4. Pt:Yeah
 5. Ph:And check (0.3) to make sure that (0.3) what you’ve actually got (0.3) is (0.2) what
 6.  you should have according to the (0.2) hospital list
 7. Pt:Yeah
 8. Ph:And to see whether anything’s changed (0.3) hh (0.3) and the reason for that is
 9.  because sometimes we do have instances when people (0.2) come out from hospital
10. (0.3) on (0.2) a list of medicines (0.2) and when they get home they’ve got a different
11. list (0.2) from the doctor’s
12.Pt:Yeah

The pharmacist’s turns appear to invite only the minimal response token ‘yeah’ providing little for the pharmacist to base the participant’s interest or understanding on (Pilnick 2003, Dyck et al. 2005). The interaction continues in this vein for a further 12 lines (see Extract 6 below). One of the most evident effects of the pharmacist’s interactional lead that continued throughout encounters was the absence of topic initiation or questions from participants. Participants were almost never heard to ask questions or initiate topic changes. One consequence of restricting what is relevant by the use of this sort of problem-oriented approach could be to limit participants’ potential involvement in the MR process.

In the second opening sequence in Extract 2, the lady was articulate and, despite being partially sighted, knew the names of all her medicines and was aware of changes that had been made during her recently lengthy hospital stay. After an initial greeting, the pharmacist announces her intention to change and fix a new topic by saying ‘well onto these new medicines’ (see line 1).

Extract 2 (Ph:04/Pt:05)

 1. Ph:=Well onto these new medicines (0.4) let’s just find out what you know about your
 2.  medicines then because (0.2) if they’ve all been changes I just want to be sure that
 3.  you you know what you’re taking and and a little bit about why (0.1) and that taking
 4.  you’re happy with what you’re=
 5. Pt:=Well I know hh I’m I’m taking (0.1) a digoxin=
 6. Ph:=digoxin yes
 7. Pt:Yes that’s for the heart isn’t it
 8. Ph:That’s the heart one yes
 9. Pt:And I know I’m taking hh=
10.Ph:=And how often do you think you take that
11.Pt:I take it once a day
12.Ph:Right so after digoxin I’ve got on my list we’ll go through my list if I
13. ask then you can tell me
14. (0.3)
15.Ph::calci-chew d34
16.Pt:Yes
17.Ph:Do you know why you take those
18.Pt:Hh strengthen your bones
19.Ph:(impressed noise) That’s right
20.Ph:Do you have any problem with those (0.2) or are they easy enough to chew

Whether meaning to or not, the effect of stating ‘let’s find out what you know (and) I just want to be sure that you know’ (see lines 1 to 4) was to implicitly set-up the ensuing questioning sequence as an assessment of the patient’s correct knowledge and understanding. Older people, especially those recently discharged home from hospital after an emergency admission, may have a lot at stake in terms of being seen as competent and autonomous individuals. Typical of this data set, the patient was knowledgeable about her medication and responded immediately, saying at lines 5 and 7 ‘I know I’m taking digoxin … for the heart’. However, when the patient tried to continue with her response at line 9 she was interrupted by the pharmacist who had not finished her agenda. The pharmacist needed to know further precise details of what the lady knows about taking her heart medicine. Interestingly, at lines 12–13 the pharmacist’s turn appears to remove further initiative from the patient when she says ‘we’ll go through my list if I ask then you can tell me’. The consequence of the pharmacist’s need to get precise systematic information appears to further remove the possibility that the process will be a shared one.

One of the most strikingly consistent aspects of the MR encounter was that even when explicitly asked, participants rarely appeared to have any spontaneous questions or concerns they wanted to raise with the pharmacist. A notable example of this was when asked about side-effects. In all but one observed encounter, pharmacists received a no-problem response typical of Extract 3.

Extract 3 (Ph:06/Pt:08)

1.Ph:Is there anything else that you want to discuss about your medicines whether you get
2. any side-effects (0.2) or (0.2) what ever
3.Pt:No not really hh=
4.Ph:=Quite happy
5.Pt:Yes

Pharmacists were expected to ask whether the patient thought they were suffering from any side-effects from their medicines. During discussion at two feedback evenings pharmacists spoke about difficulties they experienced in knowing how to elicit concerns from participants about side-effects. In particular they spoke both about being apprehensive about creating anxiety in their patients and conscious of ‘the power of suggestion’ when it came to knowing how to ask. However, Extract 4 is the exception. On this single occasion the pharmacist chooses to follow-up her initial question with the information that ‘codeine can sometimes cause constipation’ (line 5). At this point the patient expands saying she does suffer from constipation and discussion follows about the lady’s high fibre diet (not shown) and the outcome for pharmacist and patient appeared unproblematic.

Extract 4 (Ph:03/Pt:24)

1.Ph:Do you hhm (0.2) think you suffer any side-effects from that one
2.Pt:No
3.Ph:No
4.Pt:No
5.Ph:Codeine can sometimes cause constipation
6. (0.3)
7.Pt:Well that that is a bit with me I’ll agree
8.Ph:Yes
9.Pt:You know I am a bit constipated

Screening and testing patients’ ability to comply

The compliance paradigm brings with it an asymmetrical relationship between healthcare professionals and patients that conveys assumptions about competence, problematic behaviour and ‘deviancy’ (Lerner 1997, Fogarty 1997). These relationships can be found embodied in these interactions at the micro-sociolinguistic level. Analysis found that the majority of the MR encounters were structured around an assessment of the older participants’ intellectual, physical and mental capacities. However, the implications of these assessments were frequently resisted by the older patients and can be heard as disruptions to the flow of the interactions.

A test of physical competence

Part of the assessment was of the older participants’ ability to physically manipulate their medicine bottles and packets. Hearing, swallowing and sight were all included in the examination. Pharmacists would take a circuitous route to ascertain non-intentional non-compliance caused by physical incapacity. This was possibly due to an awareness of the sensitive nature of asking directly about patients’ physical competence but was not raised by pharmacists during discussions. Props and mini-tests were used with different pill packets, lids, bottle tops and small-print labels to assess physical competence. In reality people invariably had developed sophisticated routines and procedures for decanting and administering their medicines. Despite attempts to veil their assessment of the patients’ physical capacity, suggestions of incapacity were met with dismissal, no-problem responses and even disdain from participants, and comments such as ‘I don’t think there’s much trouble with that’ (Pt:03/Ph04) and ‘I ain’t that far gone yet’ (Pt:09/Ph02) were common.

The sequence in Extract 5 demonstrates a patient’s anger and rejection of the pharmacist’s suggestion that his competence was threatened by his physical status.

Extract 5 (Ph:10/Pt:02)

 1.Ph:Right okay so you’ve got no problem reading=
 2.Pt:[No I’m very lucky
 3.Ph:[=Labels and things like [that
 4.Pt:[No=
 5.Pt:=None at all
 6.Ph:(0.1) Now your tablets hhm you haven’t got any problem opening bottles have you at
 7. all=
 8.Pt:=None at all I mean I’ve got arthritis (rising intonation) but I can still hold a golf club
 9. reasonably well which is the important thing
10.Ph:Yeah and okay and swallowing any problems with swallowing=
11.Pt:=None at all

The pharmacist can be heard to be running through her agenda of physical competences (see lines 1 and 6–7). The patient, a brisk and dapper ex-army officer, although apparently not initially affronted by the series of questions the pharmacist asks him, does react strongly at lines 8–9 when he is asked if he has any problems opening bottles. He replied in a defensive tone ‘none at all I mean I’ve got arthritis but I can still hold a golf club reasonably well which is the important thing’. The older gentleman is emphatic and dismissive of the question and a note of irritation can be discerned at line 8. It is possible the 86-year-old gentleman was reacting to a perceived threat to his physical competence. He went on to talk at length of his fitness regime.

The fact that participants did not raise any issues concerning their medicine-taking may not necessarily indicate that participants never found packaging awkward or medicines difficult to use or unpleasant to take. But it does suggest this form of questioning and its implicit assumptions can restrict the interaction.

A test of mental competence

No patient was exempt from being asked how they remembered to take their medicines. This included a retired pharmacist with a detailed ledger as a log of every dose she had taken for two years who was asked ‘how confident (she was) about remembering to take the tablets’ (Ph:07/Pt:13). Extract 6 is a continuation of Extract 1 involving minimal response tokens from the gentleman until line 25 where a critical moment occurs.

Extract 6 (Ph:01/Pt:10)

13.Ph:Sometimes there’s a little [bit of=
14.Pt:[This happens
15.Ph:=A little bit of muddle so
16.Pt:Yeah
17.Ph:I really wanna (0.2) check and make sure that that’s okay and the only way I can do
18. that is by a (0.2) talking to you and hh (0.2) having a look at (0.2) the actual
19. medicines that you’ve got
20.Pt:Yeah
21.Ph:And the labels on the boxes to make sure that everything’s (0.3) perfectly correct
22. (0.5) so that’s what I’ll (0.2) I’ll do in a minute (0.3) hhm just a little bit about taking
23. your medicines then (0.3) hhm (0.4) how how do you remind yourself to take
24. medicines hh=
25.Pt:=Well hh (0.4) I’m eighty-one (0.3) my knees may be bloody wore up but (0.3) my
26. canister up here (pointing to head) is alright (0.2) I’ve got a good memory
27.Ph:Right

Having built up an explanation of why she has come to visit in the opening moments of the encounter, and missed the patient’s first attempt to speak at line 14 a disruption occurs at line 22–24 where she switches topic somewhat unexpectedly and asks ‘how do you remind yourself to take medicines’. The gentleman’s response is immediate: ‘well I’m eighty-one my knees may be bloody wore up (sic) but my canister up here is alright I’ve got a good memory’ (see line 25–26). The gentleman is affronted at the suggestion in the question that he should not be able to remember and the pharmacist is noticeably taken by surprise and remains unsettled for some time.

In sum, whether due to pharmacists’ inexperience, but almost certainly linked to the imperative of the MR agenda and a pre-occupation with non-compliance and proof of competence, questioning sequences were often constructed and perceived as a test of capability or independence and therefore created interactional difficulties for the patient and pharmacist in turn. In addition, the environment created by the dominating compliance paradigm of testing, assessing and cross-examining competence served to further increase interactional imbalance between pharmacist and patient, leading to communication that was often one-sided and tactical in nature.

Investigating over-the-counter (OCT) medicines

Medical talk frequently displays institutional properties capable of creating an imbalance in patient-healthcare professional communication (Silverman 1987). Institutional properties can be identified through ordinary conversational phenomena including misunderstandings or interruptions. In the context of healthcare communication, however, these ordinary conversational phenomena can have significant implications for the success of the interaction and the relationship between participants (Drew and Heritage 1992).

The MR required the pharmacist to identify possible contraindicated OTC drugs. This section will demonstrate how pharmacists’ communication became increasingly under pressure as they appeared to try and conceal this task, meaning that participants frequently had no way of knowing why a pharmacist was pursuing a particular line of questioning. The configuration of MR as a strategic and rational task driven by a pre-existent systemic imperative to know and be certain, meant pharmacists were only satisfied if they felt they had been successful in eliminating all possible contraindicated drugs. During feedback discussions pharmacists talked about not feeling they had got ‘the truth’ from patients regarding their OTC medicines (Ph: 08) and of other undisclosed medicines ‘hiding in cupboards and drawers’ (Ph: 04). There was a sense of unease among a majority of the pharmacists relating to a perception that their job of ensuring safety in medicine taking might have been incomplete.

In Extract 7 the pharmacist is looking for precise answers. Her concern is with what other OTC medicines the patient has purchased; particularly what other analgesics are being taken. Although she asks the patient whether he ever buys anything else from the chemist her reasons for wanting to know remain submerged.

Extract 7 (Ph:03/Pt:16)

 1.Ph:Suppose you had a sore arm or a sore leg would you take some hh them (paracetamol)
 2.Pt:Yeah yeah yeah
 3.Ph:What about hhm do you ever buy anything or does your niece buy anything
 4. from the chemist for you for any reason
 5.Pt:No not really I have brought the occasional aspirin but apart from that no=
 6.Ph:=No but is that the strength of aspirin you have bought from the chemist
 7.Pt:Yeah yeah
 8.Ph:The little one because that’s not the pain killing one
 9.Pt:No no no no
10.Ph:Right hhm and suppose you you have any indigestion or anything like that I
11. know you’ve got well normally your protium but do you ever take anything
12. else do you have a liquid medicine
13.Pt:Not these days not recently since my stomach got better
14.Ph:So you just take that
15.Pt:Just take that
16.Ph:The protium that seems to work and you don’t have anything from the chemist
17.Pt:No no no no don’t need it no
18.Ph:No settlers no rennies (0.2)
19.Pt:(shakes head)
20.Ph:No oh that’s very good then (0.3) what about constipation or diarrhoea
21.Pt:No I don’t have any problems
22.Ph:That’s good do you drink a lot of fluid then
23.Pt:Only beer
24.Ph:What about water

The nature of the questions at lines 1, 6 and 8 are an attempt to single out or specify the patient’s medicine-taking behaviour. However, the first question is greeted with an unspecific response. At line 3 the pharmacist attempts a broader questioning tactic by asking whether the patient or his niece ever buy ‘anything from the chemist (for) any reason’. At line 5 the patient answers with ‘the occasional aspirin’. In spite of this she is still attempting to pin down a more specific response with her questioning technique but is not offering her rationale (or indeed time) before, at line 6 she cuts in again with a secondary question on the precise nature of the patient’s use of aspirin. The extract continues in a closed-question-answer interview-style format (Frankel 1990). At line 14 she reiterates her need for accuracy with ‘so you just take that’ which she appears to repeat at line 16 when she says ‘you don’t have anything from the chemist’ and at line 18 with ‘no settlers no rennies’. When at line 23 the older gentleman answers ‘only beer’ to the pharmacist’s question about his fluid intake, this might be heard as an attempt by the patient to shift the interactional control in some way. He is making a reference to his lifeworld, however obliquely. In the event the pharmacist does not follow up the patient’s statement and simply asks at line 24 ‘what about water’ thus keeping the rest of the sequence (not shown) on schedule.

In the second example of a pharmacist looking for certainty and rationality in relation to purchased OTC medicines (Extract 8), the patient’s contextually and historically-bound experience of medicine taking and self-healthcare routines appear to be juxtaposed with the pharmacist’s world of scientific exactitude and search for truth.

Extract 8 (Ph:02/Pt:19)

 1.Ph:Do you take them (paracetamol) for anything else would you take them if you got
 2. headache or would you take them (0.4) if you’ve got any (0.2) you know would you
 3. use those paracetamol for anything else
 4.Pt:I know (0.2) I used to take paracetamol (0.3) before all this happened but
 5. only (0.4) if I was desperate (0.2) I’m not one for taking a lot of pills (0.3) not till now
 6. (0.4) now I’ve got plenty ((laughter)) far too many (0.2) no I didn’t take (0.4) I didn’t
 7. take many (0.2) unless I had a cold (0.2) or (0.3) something else
 8.Ph:And if you had a cold what would you have taken
 9.Pt:Just paracetamol
10.Ph:Did you buy anything from the chemist
11.Pt:Just paracetamol ((laughs))
12.Ph:But have you (0.2) so so since hospital or even before would you be tempted to use
13. anything from the chemist (0.2) to help make yourself go
14.Pt:Hh no (0.2) as I say its just that liquid paraffin I had on prescription (0.3) and hh (0.2)
15. prune juice
16.Ph:Indigestion (0.3) how is your tummy normally just as a general state of affairs (0.2) is
17. that alright
18.Pt:It seems to be alright (0.2) yes=
19.Ph:=But you don’t (0.2) do you have any (0.5) indigestion mixtures or anything in the
20. house
21.Pt:No I don’t think I have

The pharmacist has embarked on a sequence of interrogative-style questions designed to elicit what OTC medicines the older lady might have in the home. The lady has just explained that she does still take a paracetamol tablet at night because she has a large pressure sore on her ankle. She has already stressed earlier as she stresses again at line 5 that she is not ‘one for taking a lot of pills’ and regards herself as now having ‘far too many’ medicines (see line 6). The pharmacist is very emphatic in her questioning. She can be heard repeatedly to ask essentially the same question in different guises about what else the patient might have bought from the chemist but without saying why (see in particular line 1–3, 8, 10, 12–13, and 19–20).

The tone and energy of the voice of the patient and the voice of the pharmacist are thrown into contrast during the sequence in Extract 8. The pharmacist is repetitive and persistent in her search for OTC products. The older lady is polite and at ease. When she answers ‘no I don’t think I have’ (at line 21) in response to the pharmacist’s insistent question ‘do you have anything in the house’ (see lines 19–20) her answer is not clear-cut. She does not think she has, but neither does she volunteer to check. She might have. Who after all knows exactly what might be at the back of their bathroom cabinet? The pharmacist is confounded in her search for definitive answers and leaves the encounter concerned that she had not been able to remove all counter-indicated indigestion medicine. Interestingly, this lady subsequently declined her scheduled re-visit on the grounds that she was ‘fine with her medicines’.

Extract 9 represents an exception to the rule where the pharmacist does explain the purpose of her line of questioning. Initially the pharmacist asks simply if she can ‘check’ whether, when they pick up their prescriptions, they buy ‘anything over-the-counter’ (not shown). At line 2 the gentleman says he and his wife buy things for colds and the wife clarifies that she is careful not to get sugary preparations. At lines 6 to 8 the pharmacist embarks on an explanation of why she is asking. This explanation is unique to the data set. It comes after the patient (and carer) have demonstrated knowledge and understanding.

Extract 9 (Ph:07/Pt:23) [Wf = wife]

 1.Ph:What kind of stuff would you (0.2) would you get (from the chemist)
 2.Pt:Out to do with colds
 3.Wf:Little bit of cough mixture for me not for him
 4.Pt:Not for me
 5.Wf:Because (0.2) being diabetic that’s sugar ain’t it
 6.Ph:Yeah some of them you can take I mean the reason for asking is not just because I’m
 7. I’m nosey but (laughs) but (0.2) I just want to check if there is anything you are
 8. taking that might interact with the medication
 9.Pt:No I don’t take nothing nothing bar that (pointing at bag of prescription medicines)
10.Ph:If he does get a cough and a cold there are some products he can use over the counter
11. so long as you just let the pharmacist know what medicines you are on
12.Pt:Well generally if I get a cold if I get a chesty cold (0.2) she phones up Dr (name) up
13. and asks if I can have a weeks (0.2) ’biotics
14.Ph:Oh right ’cause sometimes you don’t need them [but ’cause of your
15.Pt:[’Cause I’m a bron=
16. =chial kind of person
17.Wf:Well we don’t ask until his phlegm changes colour

One interpretation of this exception is that the couple’s claim to knowledge at line 5 gave the pharmacist interactional space to explain. What is even more interesting is the continuing exchange of knowledge in this sequence which culminates in the patient and his wife explaining their own routine for dealing with coughs. This is a routine which is sanctioned by validity claims to the doctor who offers antibiotics on demand when the ‘phlegm (changes) colour’.

The communicative strategies that pharmacists used to find out about participants’ OTC medicines often left meanings submerged or hidden. This created and perpetuated interactional confusion and misunderstanding, making the process more difficult and the tasks of MR unreciprocated. Pharmacists frequently worked diligently but ‘silently’ and in isolation from the patient to try to calculate safety, contra-indications and interactions. Participants were not told and may have not realised the purpose of the pharmacists’ line of questioning. The concealed nature of the meaning of the pharmacists’ discourse meant there were very few occasions where the ‘validity claims’ of the dominant medical compliance paradigm were opened up for challenge by participants (Greenhalgh et al. 2006). The consensual environment necessary for more concordant discussion was rarely present.

Discussion and conclusion

In-depth analysis on a turn-by-turn basis demonstrated the complex and difficult nature of these interactions. The task-driven nature of the MR encounters inevitably focused on participants’ ability to comply with prescribed medication routines. In addition, pharmacists’ concern with safety in medicine taking frequently shaped the interactions leading to misunderstandings and conversational misalignment. Little evidence of two-way reciprocated discussion or concordance was evident. Although the model of MR under study in this paper is not the only model, it is not unlike the government’s newly sponsored medicines use review (MUR) service. MR services to date are informed by assumptions and beliefs that stem from the dominant medical paradigm of compliance. Unfortunately and perhaps counterintuitively, the parent RCT set up to evaluate the effectiveness of domiciliary MR intervention eventually produced negative results, including a significantly higher rate of hospital admissions and no significant improvement in quality of life or reduction in deaths (Holland et al. 2005). Although these results were not known at the time of this data collection and analysis, they perhaps came as less of a surprise to the author. The findings of this study, alongside the results of the RCT, although limited to older people, suggest that domiciliary MR in its current form poses several challenges for pharmacists, older people and policy makers as well as for notions of concordance. These will be discussed in turn below.

The first area of challenge relates to the extension of pharmacists’ roles towards more intimate patient care and the related issues of communication skills, professional roles, responsibilities and boundaries. Overwhelmingly, the pharmacists in this study reported high levels of satisfaction with their MR role and the new environment, intellectual challenges and unique patient contact. However, they also admitted to areas of anxiety in relation to their intimate communication with patients and their role. Previous research on pharmacist-patient communication has suggested that pharmacists have a tendency to adopt a protocol-driven discourse involving eliminative questioning that can be technical, perfunctory and impersonal in nature (Norris and Rowsell 2003, Skoglund et al. 2003, Morrow et al. 1993). Pharmacists have traditionally inhabited a rule-bound community of practice involving set-questions when advising about and administering OTC and prescription medicines. This study shows that when coupled with the compliance paradigm of an emergent public health initiative such as MR, the inherently constraining nature of the ‘technical-rational’ pharmacy discourse risks being magnified via an agenda-driven problem-focused interrogation exclusively concerned with medical compliance (Williams 2007).

Although communication has not traditionally been an area in which pharmacists were trained, modern pre- and post-registration pharmacy syllabi include reference to effective communication. Students must be able to select and provide appropriate information and to counsel patients. This study reinforces the importance of the pharmacy profession addressing the communicative competencies required in practice that can take into account the unique interactional dynamics of intimate consultations (Pilnick 2001). Counselling involving information and advice giving in healthcare contexts is complex and has been shown in previous in-depth sociolinguistic analysis to place considerable demands on healthcare practitioners’ communicative competencies in general and in pharmacist-patient interactions in particular (Heritage and Sefi 1992, Pilnick 1999, Salter et al. 2007).

Despite being there to support participants in their medicine taking, pharmacists’ status and position in the older peoples’ healthcare networks was diffuse and ambiguous. Knowledge boundaries were often unclear as the participants were frequently well informed and experienced long-term users of medicines with sophisticated yet everyday routines and reminder systems. The pharmacists’ tangential position in this study was compounded by their not being attached to the participants' own general practitioner. Pharmacists were concerned not to cause any unease or anxiety for participants in relation to prescribed medicines. These concerns related to issues of ongoing responsibility and management and led to aspects of the review process being covert. If the process of concordance begins at the prescribing stage and pharmacists remain relatively powerless to enact change then it is hard to see how MR can be much more than a form of arms-length checking or surveillance.

The second set of challenges relates to the participants’ perception of the MR. It was interesting that participants reported having gathered little new knowledge in relation to the management of their medicines during the MR. They were also heard to react strongly to perceived threats to their autonomy. In addition, the domiciliary site of this healthcare encounter was quite unique. Interactions in clinical environments have a tendency to strip patients of identity and certain rights to privacy. In the home, the balance shifted back and forth. Despite the scrutinising nature of the MR that could involve examining every cupboard and kitchen drawer, the older participants appeared to retain the right to limit access and therefore limit the pharmacists’ jurisdiction. However, they were also exposed to the gaze of authority and perhaps therefore more vulnerable to suggestions of not coping. The older people in this study, having recently returned home from hospital, were required to prove their competence to comply with their medication regimen and may have felt vulnerable under scrutiny of the MR process. The traditional compliance paradigm assumes that most non-compliance in medical care is due to mistakes and ignorance on behalf of patients rather than choice or personal preference. Constant defence of competence can weaken peoples’ autonomy by threatening knowledge, self-efficacy and undermining taken-for-granted notions of competence. If compliance is a proxy measure for competence during MR then the participants had even more reason to prove they were compliant.

The final area of challenge concerns the nature of MR as an emergent public health initiative. Safety and waste reduction may be legitimate drivers for implementation of MR services but there are many complex factors concerning the way in which older people choose to use and modify their medicine regimes in their everyday lives. These everyday nuances are at risk of being lost by services that predominantly reflect the concerns of policy makers and practitioners and do not adequately address the needs of the intended population (Donovan 1995, Bytheway et al. 2000). They may be resisted or underutilised by those for whom they were intended or possibly have adverse consequences (Ballinger and Payne 2002). Non-compliance is frequently blamed on poor patient understanding, lack of information or on general incompetence by a public health epistemology that assumes it can be rectified by instruction from a healthcare professional. This presupposition is at odds with any definition of concordance in medicine taking and is a hard task to hand pharmacists through MR.

Acknowledgements

I would like to thank Norfolk Health and NHS Pharmacy Practice Unit at UEA who funded the studentship, the pharmacists and older people who took part, and Clive Seale and the anonymous reviewers who made such helpful comments and suggestions.

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