Communicating prescribing decisions v1.4

Communicating prescribing decisions with patients and professional colleagues
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Prescribe - Prescribing Skills
1 Communicating prescribing decisions with patients and professional colleagues
2 Learning objectives
3 Introduction
4 Communicating with patients 1 Why should I take a medicine?
5 Communicating with patients 2 What medicine am I taking?
6 Communicating with patients 3 How should I take this medicine?
7 Knowledge check 1
8 Communicating with patients 4 How will I know the medicine is working?
9 Communicating with patients 5 What are the side effects?
10 Communicating with patients 6 Can I take other tablets OK?
11 Communicating with patients 7 How long should I take the medicine for?
12 Knowledge check 2
13 Barriers to Effective Communication 1 Language & Culture
14 Barriers to Effective Communication 2 Partnership & Control
15 Communicating with Colleagues
16 Knowledge check 3
17 Case Study 1 Scenario
18 Case Study 1 Question 1
20 Case Study 2 Scenario
24 Session Key Points
25 Session Summary
Contents page

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Communicating prescribing decisions with patients and
professional colleagues
Session Number: CPT 04_05_01
1
Author Sabih Huq
Section Principles of Clinical Pharmacology
Module Prescribing skills
Description
This session discusses what information about prescribed medicines should be shared with both
patients and colleagues. It touches on barriers to effective communication, and potential
strategies to overcome these.

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Learning objectives 2
Learning objectives
By the end of this session you will be able to:
•List the important information that patients should be
told about their medicines
•Explain some of the barriers to effective information
exhange and how they can be overcome in practice
•Explain how to communicate effectively with other
healthcare professionals about prescribing decisions
Prerequisites
Before commencing this session you should have:
•An understanding of risks and beneﬁts of drug therapy
•Completed the related Prescribe sessions in the module
[not sure any are needed]

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“Drugs don’t work in patients who don’t take them.”— C.
Everett Koop, Former US Surgeon General
Prescribing a drug is the commonest intervention a physician
will make. However, adherence to a drug regimen, or taking
medicines as prescribed, is patchy at best. Of those with
chronic illness, ⅓ will either take frequent ‘drug holidays’ or
not take the medicine at all.1
Non-adherence is costly, in terms of both increased morbidity
and increased cost.2 The reasons for non-adherence are
complex, but it is more likely when patients lack information
about their medications. On the contrary, patients who do get
adequate information, and those who feel they are involved in
the decision making process, are more likely to take drugs as
prescribed.
Therefore how we communicate with patients about
prescribing decisions has a direct impact on individual health,
and national resource utilisation. It is in all our interests to do
it as well as we can.
But what does adequate information mean, and how should it
be shared?
Introduction 3
[I don’t have permission to use this image]

“Most doctors don’t give you options, they just say
this is what you are taking.”1
The vast majority of patients would like a diagnosis,
and explanation of their condition prior to making
decisions about treatment. Wouldn’t you?
In order to make an informed choice, other possible
therapies, both pharmacological and non-
pharmacological, should be discussed and their
risks and beneﬁts reviewed. Seeking out, and
valuing, the patient’s views on the various therapies,
involves the patient in the decision making process
and is likely to lead to greater adherence to an
agreed regimen.
The INDICATION, or why the drug is being taken,
should be made clear, preferably in writing.
Unfortunately doctors do not always do this. In one
study of observed behaviour of general practitioners
and hospital physicians, the reason for taking a
medicine was not mentioned in 1 in 8 cases.2
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4Communicating with patients 1 – Why should I take this medicine?
RISK
BENEFIT
commons.wikimedia

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4Communicating with patients 2 – What medicine am I taking?
In one study, 54% of antibiotics prescribed
were not actually named1
It may seem obvious, but make sure patients know
the actual name of the drug being prescribed. Do
not just tell them the type or class of drug, e.g.
“antibiotic”.
The GENERIC NAME of the medicine should be
made clear, preferably in writing.
An explanation of why the medicine bottle may have
two names is useful. Do not rely on just the brand,
or trade name, as these may not always be
available.
Brand name
Generic name

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4Communicating with patients 3– How should I take this medicine?
In 40-45% of new prescriptions, doctors do not
state the number of tablets to take, or how often/
when to take them1
Detailed practical information on exactly how to
take medicines is important for the patient. Simple
regimens are more likely to be taken than complex
ones1. Do not assume that someone else will go
through the practicalities, e.g. the dispensing
pharmacist.
In up to ⅕ of cases physicians offer no instructions
at all on how to take a new medicine.2
Practical information that patients require includes:
‣how many tablets to take
‣when to take the medicine
‣whether to take with food or not
‣what to do if a dose is missed
‣how long the medicine should be taken for

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Knowledge check 1
Select true or false for each of the following statementsSelect true or false for each of the following statementsSelect true or false for each of the following statements
A. ⅕ of patients will take frequent drug
holidays or not take the drug at all
TRUE or
FALSE?
B. In 9 out of 10 consultations about new
medications, physicians offer information
about how to take the new medicine
TRUE or
FALSE?
C. Medicine bottles often display both a
trade name, and a generic name for the
medicine.
TRUE or
FALSE?
D. The reason for taking the medicine is
called the DURATION of the prescription.
TRUE or
FALSE?
E. Patients who are involved in the
prescribing decision making process are
more likely to take adhere to a drug
regimen.
TRUE or
FALSE?
FeedbackFeedback
A. False. Remarkably ⅓ of patients will take drug
holidays at least once a month or not tke the
prescribed drug at all.
B. False. Physicians were found to give information
about how to take the new medicine only 80% of
the time.
C. True. The brand or trade name is a proprietary
name the drug company uses to market the drug.
the generic name is a standard name for the
medicine. The chemical name is sometimes also
seen.
D. False. The reason for taking the medicine is called
the INDICATION and should be made clear to all
patients.
E. True. There is more information about this later in
the module.
7

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4Communicating with patients 4 – How will I know the medicine is working?
It is important to discuss how the patient, and the
doctor, will know if the medicine is working or not.
This means focusing on the indication for therapy
and managing the perhaps divergent views of what
is achievable with drug therapy.
Where symptom control is involved, personal goals
may help. For example, “I would like to be able to
play a round of golf without getting angina.”
Where other targets are involved, try to be
transparent and explicit: “We will aim for a blood
pressure of 140/90 in 4 weeks time.”
Agree an appropriate time to review how well the
medicine is working. This may range from a few
minutes to a few weeks depending on the speciﬁc
drug and urgency of the situation.
Write a clear plan for judging how well the
medicine is working. Share this with the patient
and relevant colleagues.

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4Communicating with patients 5– What are the side effects?
“I find that unless I ask the questions to my doctor,
that she doesn’t always come out and tell me..”1
For many patients side effects are the first thing
they would like to know about, and many are
frustrated about not being given as much
information as they would like. This is not
surprising given the fact that side effects are
directly addressed in only a third of new
prescriptions.2
In one survey of 2,500 outpatients, 76% wanted to
know about all side effects “no matter how rare”.3.
This may seem unreasonable to many healthcare
professionals. Do patients really want to know about
fine print 1 in a million occurrences?
There is a mismatch between what patients want to
know, and what physicians would like to give them.
The effects of talking more about side effects are
not clear. A strategy of discussing common or
severe side effects with more comprehensive written
information provides a pragmatic solution.

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4Communicating with patients 6– Can I take other tablets OK?
1 in 50 of all prescriptions in a university hospital
contained a drug-drug interaction that increased
bleeding risk. 1
Drug-drug interactions are common and lead to
decreased drug effectiveness and increased risk of
harm.1 Many drugs have signiﬁcant interactions with
foods, such as grapefruit, or dietary/herbal
supplements, or alcohol, as well as other prescribed
medicines.
The large number of these interactions makes it
difficult, if not impossible, for all these to be
memorised. In such circumstances an electronic or
web-based prescribing support tool becomes
invaluable.
When counselling a patient it is important to review
how a new medicine will impact their other
medications. Also, let the patient know which
common medications they should not use, and
remind them to inform other healthcare
professionals involved in their care of regimen
changes.
wikipedia.com

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4Communicating with patients 7 – How long should I take the medicine for?
It is important to discuss with the patient how
long the medicine should be taken for. In other
words, what is the duration of therapy.
This is not always obvious, and is related to a clear
understanding, for both prescriber and patient, of
what the medicine is being taken for. Is it a short
course designed to cure a condition? Or is it a
preventative measure meant to reduce the chances
of complications to be taken for life?
This information should be communicated verbally
with the patient and out in the patient record. A
place to record duration on the actual prescription
chart can also be helpful.

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Knowledge check 2
A. In consultations about new medications,
prescribers discuss common side effects
most of the time
TRUE or
FALSE?
B. Harmful drug interactions do not apply to
over the counter preparations.
TRUE or
FALSE?
C. Most patients do not want to know about
rare side effects
TRUE or
FALSE?
D. A time to review how well a medicine is
working should be agreed with the
patient.
TRUE or
FALSE?
E. How long a medicine should be taken for
should be recorded in the notes.
TRUE or
FALSE?
FeedbackFeedback
A. False. Common side effects are directly addressed
in only ⅓ of consultations about new drugs.
B. False. harmful interactions can occur with over the
counter medicines, as well as herbal supplements,
alcohol and foodstuffs, e.g. grapefruit.
C. False. In surveys, a majority of patients want to
know about side effects “no matter how rare”.
D. True. Discussing how long it will take for a
medicine to work, and how a patient will know
this, is good practice.
E. True. Discussing and recording the duration of
therapy helps prevent needless repeat
prescription.
7

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4Barriers to Effective Communication 1 – Language & Culture
just take these slow
release anti-anginals
orally
Err... OK
One-ﬁfth of patients cannot characterise
the word symptom correctly1
Language is how we express ourselves and is intimately related
to how we think.As healthcare professionals we are used to
using technical and scientiﬁc language that many patients do
not understand. For example, in one series, 38% of patients did
not understand the word orally, and 56% did not understand
the word hypertension.
Using simple language and actively checking for understanding
are good habits when discussing medications. Do not use
jargon. Providing written information is likely to lead to
increasing patient knowledge, satisfaction and compliance and I
suggest it should be routine practice when starting new
medicines.2
Cultural viewpoints also differ widely, and as professionals we
would do well to recognise that values and perspectives far
removed from our own are still valid, and not automatically
classify them as irrational. It is our job to try to understand the
patient’s perspective and work with them to come to a
mutually agreed plan of action.
One simple way of improving communication is to present
numerical information in an easier to digest format. Use natural
frequencies rather than relative risks. 3 So, for example, using
the data from the vocabulary study quoted above: 1 in 3
patients did not understand the word orally, and 1 in 2 did not
understand the word hypertension.

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4Barriers to Effective Communication 2 – Partnership & Control
Shared decision making is likely to improve care and reduce
costs1
There is growing evidence that involving patients in
decisions about their own treatment leads to better
satisfaction and adherence.2, 3 However, this is not how most
consultations happen.4,5
But what does shared decision making mean, and how
should we encourage it?
There are several models. Charles, Gafni & Whelan6
suggest:
‣ both patient and doctor are involved
‣ both parties share information
‣ both parties build consensus about preferred treatment
‣ both agree on treatment to implement
A combination of increased awareness, training and speciﬁc
tools is most likely to improve practice.
A Cochrane Review8 found that decision aids helped people
making treatment decisions, increasing patient involvement
and making informed decisions more likely. However, the
effect size of individual aids is variable.
The Ottawa Hospital Research Institute maintains a
comprehensive list of current decision aids.
Figure 1 A patient decision aid about statin therapy (Stiggelbout A
M et al)

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In hospital, most prescriptions are not written by the prescribing
decision maker.1
As well as the patient, several professionals are often involved in the
treatment process.Timely and relevant information makes their job
easier and is likely to lead to fewer adverse events and greater
efﬁciency.
Examples in hospitals include communication between senior
clinicians, who often lead prescribing decisions, and juniors who
actually write the prescriptions. Contextual information helps juniors
complete the prescription chart appropriately. Intelligent questions
from juniors can help seniors clarify treatment goals, and make the
prescribing decision more transparent.
The same information which should be shared and discussed with
patients is relevant here. Perhaps of special note are how the
effectiveness of the medicine will be measured, and how will potential
side effects be monitored.These aspects will often be judged by
professionals other than the original prescribing decision lead.
Communication between primary and secondary care is also vital in
order to provide accurate treatment information in response to
patient queries, to ensure the right monitoring is done, and to prevent
harmful interactions occurring as a result of other medicines being
inappropriately prescribed.
A clear record of the duration of therapy will help stop medications
being taken indeﬁnitely.Which method of communication is best will
vary on the urgency of the situation.Talk to the relevant people at the
right time, but keep a written record as well.
Fig 1 Legend goes here.
4Communicating with Colleagues

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Knowledge check 3
A. Relative risks are easier to understand
than natural frequencies.
TRUE or
FALSE?
B. Providing information in writing makes it
more likely for patients to understand
their condition better.
TRUE or
FALSE?
C. In a paternalistic model of decision
making, both parties share information
and build consensus as to which
treatment option to select.
TRUE or
FALSE?
D. In hospital, in most cases the person
writing the prescriptions chart is the
person leading the prescribing decision.
TRUE or
FALSE?
E. When communicating with colleagues, a
telephone call is a good substitute for
written information.
TRUE or
FALSE?
FeedbackFeedback
A. False. For most people, natural frequencies are
easier to understand than percentages, so 1 in
rather rather than 33%
B. True. Giving information in writing allows the
patient to digest information at their own pace and
helps those with a more visual learning style.
C. False. This is a description of a shared decision
making model.
D. False. In hospital, most prescriptions are not
written by the prescribing decision maker.
E. False. While a telephone call is often the best way
of communicating urgent or complex decisions, a
written record should also be made.
7

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A 48 year old man comes to see you about his blood
pressure which has averaged 162/94mmHg over the past 3
months with several recordings. He is known to have a
raised total cholesterol and is a smoker of 20 cigarettes a
day.
His only medical history of note is an appendicectomy at
the age of 17. He has no known allergies and is not on any
regular medication.
He is 9kg overweight and has a BMI of 28.2.
Now answer the questions associated with this case study.
Case study 1 – Scenario 20

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Case study 1 – Question 1
What would be the most appropriate initial communication
strategy?
Select one option from the answers below
A. Explain that he would beneﬁt greatly from anti-
hypertensive drug therapy
B. Ask him what his ideas, concerns & expectations about his
condition are.
C. Go through the name and dosing regimen of your preferred
ACE inhibitor.
D. Discuss the side effects of using your preferred ACE
inhibitor.
A. Incorrect. Whilst discussing possible beneﬁts of
anti-hypertensive medicines might be an important
part of the consultation, the discussion needs to be
put in the context of both non-drug management,
and possible harm. Using the word greatly is
unhelpful given individual variability in its meaning.
B. Correct. Finding out what patients know and expect
is a form sharing information, the second element of
Charles et al’s shared decision making model. It will
also will help you talk in a language a particular
patient can understand. Addressing their concerns is
also likely to improve trust.
C. Incorrect. Discussing the practicalities of any single
medicine without agreeing treatment aims is
probably premature.
D. Incorrect. Discussing the practicalities of any single
medicine without agreeing treatment aims is
probably premature.
Feedback
21
A 48 year old man comes to see you about his blood
pressure which has averaged 162/94mmHg over the
past 3 months with several recordings. He is known to
have a raised total cholesterol and is a smoker of 20
cigarettes a day.
His only medical history of note is an appendicectomy at
the age of 17. He has no known allergies and is not on
any regular medication. He is 9kg overweight and has a
BMI of 28.2.
Now answer the questions associated with this case
study.

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• How prescribers communicate with patients about treatment
affects the quality and cost of healthcare
• Prescribers should involve patients in decisions about
treatment and share information about:
‣ what the prescribed medicine is
‣ why it should be taken
‣ how it should be taken
‣ how its effects will be monitored
‣ potential side effects and interactions
• Prescribers should use simple language and provide written
information
• Patient decision aids improve patient satisfaction and lead to
better decisions about treatment
• Communicating with colleagues includes vertical and
horizontal pathways
Session key points 24

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Session summary 25
Learning objectives
By the end of this session you will be able to:
•List the important information that patients should be
told about their medicines
•Explain some of the barriers to effective information
transfer and how they can be overcome in practice
•Explain how to communicate effectively with other
healthcare professionals about prescribing decisions
Further reading and activities
Refer to the following texts for additional information:
•Tabor, P.A. & Lopez, D.A., 2004. Comply With Us:
Improving Medication Adherence. Journal of Pharmacy
Practice, 17(3), pp.167–181.
•Osterberg, L. et al., 2005. Adherence to medication. New
England Journal of Medicine, 353(5), pp.487–497.
•Ottawa Hospital Research Institute website

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I am a Clinical Senior Lecturer in Medicine at
Newcastle University, currently seconded to the
branch campus in Johor, Malaysia. I trained at
Cambridge, Barts and the London and UCL and
completed training in General (Internal) Medicine
and Clinical Pharmacology & Therapeutics (CPT). I
have an MD from the University of London.
My current teaching responsibilities include leading
clinical modules in the ﬁnal year and the CPT
strand. My current research interests centre on
medical education.
I am a Fellow of the Higher Education Academy and
a Member of the Royal College of Physicians and
the British Pharmacological Society.
Sabih Momenul Huq
AUTHOR
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