Tackling Polypharmacy in Practice: Too little evidence or too much emotion? A video-reflexive ethnography study in general practice.

Problem

The World Health Organisation identifies polypharmacy as a global safety issue. Polypharmacy is primarily the domain of generalists whose expertise includes caring for patients with multiple long term conditions. It is a ‘wicked’ problem: difficult to define (what really is the trouble?); difficult to locate (where in the complex system does the trouble really lie?); and characterised by a troubling gap between ‘what is’ and ‘what ought to be’. So what are GPs to do?

Approach

We present findings from seven Video-Reflexive Ethnography (VRE) workshops, conducted in three UK general practices, involving 34 participants. We showed short clips, selected from 18 video-recorded consultations to VRE participants (some of whom also featured in the selected clips). The videos focused on processes of medication review involving older patients prescribed 10+ items of medication. The video extracts were a catalyst for inter-professional conversations about polypharmacy, prompting an opportunity to reflect collectively on the nature of the polypharmacy problem as clinicians experience it ‘on the ground’.VRE is based on four principles: exnovation (foregrounds the accomplishment and complexity of taken-for-granted care practices); collaboration (participatory co-creation); reflexivity (participants re-view and re-imagine their practices); care (creating a safe space for participants).

Findings

Clinicians articulated many different ways of conceptualising and re-defining polypharmacy and expressed a wide range of concerns relating to how to conduct a medication review in a zone of such uncertainty. Medication review, described by one participant at the outset as ‘just a medication review’ was re-imagined for its complexity and inherent challenge. Clinicians’ conversations focused primarily on matters of emotion and relationships (both clinician-patient and inter-professional) rather than on technical matters of science and evidence. Medicines were constructed as objects with deeply embedded social attachments, and the medication review an occasion when fear, courage, hope, despair, trust and mistrust played out as clinicians and patients sought to navigate competing priorities in a situation of ‘not knowing’.

Consequences

Clinicians who seek to tackle polypharmacy find themselves stranded in an evidence desert with few landmarks and no useful map to guide their actions. The boundary between ‘appropriate’ and ‘problematic’ polypharmacy is fuzzy, and the business of changing complex medication regimens is fraught with uncertainty and emotional labour. VRE is a productive methodology for revealing what is unseen, uncovering assumptions, and enabling professionals to discover afresh the complexity of their ‘ordinary’ everyday practice. Our findings casts doubt on the capacity for polypharmacy interventions that focus solely or primarily on technical evidence to translate into meaningful changes to practice. Medicines ‘adherence’, it turns out, is not just a challenge for patients who are taking medicines. Medicines are sticky things for professionals to remove, even in the context of ‘high risk’ polypharmacy.