Are we too quick to push the prescribing button?

I was at a meeting recently with leading figures from various disciplines, both clinical and administrative, within the health service. A very lively, useful and excellent gathering it was too. Most of us, though carrying out vastly different roles, found common ground and shared similar aims and goals, ie. delivering the best possible healthcare to as many as possible despite fewer resources. One comment, however from one of the group rather astonished me: “GPs almost always end a consultation by writing a prescription”. 

There was no space within this high-powered meeting for me to do much more than express my astonishment at such a statement and look suitably appalled and disgruntled. But was this intended slur on our specialty completely off the mark? I have no absolute evidential proof that it is wrong, although my own anecdotal (but not audited) experience suggests that it is not accurate. I have made a lifetime informal study on how to end consultations without writing a (new) prescription.

If almost all GP visits in Ireland result in the writing of a new prescription, that would mean a horrifying 17,000,000 or so scripts being presented to pharmacies each year! 

Working in a deprived urban area places me in a community with much early and multiple morbidity, and most folk visiting the practice are genuinely ill with chronic diseases with comorbidity and (hospital-generated) polypharmacy. Some of my patients are already on 15 items prescribed by various non-communicating hospital specialties for goodness sake!

Here are just a few of the strategies which allow me to end a consultation without prescribing a new medication:

• Stand up, take their coat or hat and help them on with it

• Suggest a referral to the physiotherapist

• Arrange a counselling psychology referral

• Explain that antibiotics are not indicated and give them a leaflet about best treatment for URTIs

• Review the patient’s repeat prescription list and remove a non-essential drug (to the patient’s relief)

• Ask them to phone or call back if the ‘no drug option’ does not work

• Emphasise non-prescription treatments such as paracetamol, fluids and TLC for kids with colds

• Suggest acupuncture

• Stand up to the pressure from ‘benzo’ seekers and don’t ‘give in’ – be willing to have a stand-up row!

• Ditto for seekers of nutritional supplements

• Write an ‘in case prescription’ for antibiotics and fold it as many times as possible

• Never prescribe sleeping tablets for more than one week

• Lance an abscess rather than prescribe an antibiotic 

• Lance and evacuate a thrombosed external pile. 

It is a mistake to think that people always want a prescription when they visit a GP. Many just want someone to communicate their fears to and (hopefully) reduce them. It has also been shown in at least one study that very long consultations are not any more satisfying for the patient and indeed, short but focused visits may be very rewarding for patient and doctor alike.

In the last week I carried out a brief survey during a morning surgery when I saw 13 patients. Many of these were people with long repeat prescription lists due to two or more chronic conditions. I prescribed new items for six people, two were skin creams, two were additional hypoglycaemic agents for patients whose diabetes was poorly controlled and two were antibiotics. I suggested Calpol for a child with a fever and paracetamol for at least two adults with pain. I stopped one repeat medication for a victim of polypharmacy. A number of patients did leave the room with unchanged repeat prescriptions – all in all, quite a lot of prescribing activity.

I will be the first to admit to being sometimes quite quick to push the prescribing button, particularly when seeing patients out-of-hours where time is very limited and the patient is not known to me. In the same way, I am not surprised when I receive reports from my patients seen out-of-hours with seemingly unnecessary antibiotic treatment. 

I must finish now and attend to 21 repeat GMS prescriptions, which have been requested for today; the largest of these contains 20 items, all of which originated in hospital clinics. Perhaps the allied health professional at the high-powered meeting was not too far off the mark; however the most voluminous (and expensive) prescriptions emanate  originally from secondary and tertiary care.