Stimulus for change (David Gibson)

I was recently discussing with a friend, who is a GP, how doctors start prescribing new medicines. I am always a bit nervous about prescribing a drug for the first time. She referred me to an article published in the BMJ a few years ago (1996;312:949), which described the reasons for changing prescribing behaviour in a group of GPs. They described three models of change that influenced prescribing decisions:

• Accumulation — the prescriber accumulates a weight of evidence for a drug which motivates the change. This may come from various sources including articles, talks, discussions with colleagues and meetings with “drug reps”. The extent to which each source influences behaviour depends upon its relative authority
• Challenge — change stimulated by a challenge to behaviour. For instance a pharmacist intervention, “clinical disaster” or an unexpected success
• Continuity — the first two models suggest some resistance; however in certain instances there is a preparedness to change. This tends to follow congruence between possible change and a clinical need

In general it was found that GPs “tried out new prescriptions tentatively while looking for reinforcement”.

This made me reflect upon how I prescribe a medicine for the first time. In general I would subscribe to all three models of change. I am reticent to start prescribing a new drug without fully investigating the literature that supports it.

I find it useful to discuss the medicine with senior medical colleagues to determine their views on how it might be used in practice. Only after I am fully confident will I start prescribing a new drug. These first experiences will often influence my perception of that drug in the future. This is only natural. However, I am aware of this and try not to let first impressions cloud my judgement long term.

The discovery of a new treatment option can influence my practice. For instance I recently started prescribing lidocaine patches for herpetic neuralgia in elderly patients prone to falls. I had encountered a few patients previously who had experienced side effects with oral therapies — and this filled a gap in my prescribing armoury. Cost may be another stimulus. The availability of a cheaper alternative (eg, generic simvastatin a few years ago) can quickly stimulate changes in prescribing.

On several occasions I have had medical colleagues question a prescribing decision, which has then made me reconsider my practice. Clearly, “challenge” does also influence my prescribing.

 

David Gibson is senior clinical pharmacist (medical admissions) at Darlington Memorial Hospital