Abstract
Background
The ways in which patients’ requests for antidepressants affect physicians’ prescribing behavior are poorly understood.
Objective
To describe physicians’ affective and cognitive responses to standardized patients’ (SPs) requests for antidepressants, as well as the attitudinal and contextual factors influencing prescribing behavior.
Design
Focus group interviews and brief demographic questionnaires.
Participants
Twenty-two primary care physicians in 6 focus groups; all had participated in a prior RCT of the influence of patients’ requests on physicians’ prescribing.
Measurements
Iterative review of interview transcripts, involving qualitative coding and thematic analysis.
Results
Physicians participating in the focus groups were frequently unaware of and denied the degree to which their thinking was biased by patient requests, but were able to recognize such biases after facilitated reflection. Common affective responses included annoyance and empathy. Common cognitive reactions resulted in further diagnostic inquiry or in acquiescing to the patient’s demands to save time or build the patient–clinician relationship. Patients’ requests for medication prompted the participants to err on the side of overtreating versus careful review of clinical indications. Lack of time and participants’ attitudes—toward the role of the patient and the pharmaceutical ads—also influenced their responses, prompting them to interpret patient requests as diagnostic clues or opportunities for efficiency.
Conclusions
This study provides a taxonomy of affective and cognitive responses to patients’ requests for medications and the underlying attitudes and contextual factors influencing them. Improved capacity for moment-to-moment self-awareness during clinical reasoning processes may increase the appropriateness of prescribing.
Similar content being viewed by others
References
Hollon M. Direct to consumer advertising: a haphazard approach to health promotion. JAMA. 2005;293:2030–3.
Holmer AF. Direct-to-consumer prescription drug advertising builds bridges between patient and physicians. JAMA. 1999;281:380–2.
Lipsky MS, Taylor CA. The opinions and experiences of family physicians regarding direct-to-consumer advertising. J Fam Pract. 1997;45:495–9.
Young D. Studies show drug ads influence prescription decisions, drug costs. Am J Health Syst Pharm. 2002;59:14, 16.
Almasi EA, Stafford RS, Kravitz RL, Mansfield PR. What are the public health effects of direct-to-consumer drug advertising? PLoS Med. 2006;3:e145.
Bell RA, Wilkes MS, Kravitz RL. The educational value of consumer-targeted prescription drug print advertising. J Fam Pract. 2000;49:1092–8.
Hoffman JR, Wilkes MS. Direct to consumer advertising of prescription drugs: an idea whose time should not come [editorial]. BMJ. 1999;318:1301–2.
Weissman JS, Blumenthal D, Silk AJ, et al. Physicians report on patient encounters involving direct-to-consumer-advertising. Health Aff (Millwood). 2004;Suppl Web Exclusives:W4-219–33.
Wilkes MS, Bell RA, Kravitz RL. Direct-to-consumer prescription drug advertising: trends, impact, and implications. Health Aff. 2000;19(2):110–28.
Woloshin S, Schwartz LM, Tremmel J, Welch HG. Direct-to-consumer advertisements for prescription drugs: what are Americans being sold? Lancet. 2001;358:1141–6.
Young HN, Paterniti DA, Bell RA, Kravitz RL. Do prescription drug advertisements educate the public? The consumer answers. Drug Inf J. 2005;39:25–33.
Feldman MD, Franks P, Epstein RM, Franz CE, Kravitz RL. Do patient requests for antidepressants enhance or hinder physicians’ evaluation of depression? A randomized controlled trial. Med Care. 2006;44:1107–13.
Kravitz RL, Epstein RM, Feldman MD, et al. Influence of patients’ requests for direct-to-consumer advertised antidepressants: a randomized controlled trial. JAMA. 293(16);2005:1995–2002.
Mintzes B, Barer ML, Kravitz RL, et al. How does direct-to-consumer advertising (DTCA) affect prescribing? A survey in primary care environments with and without legal DTCA. Can Med Assoc J. 2003;169(5):405–12.
Gemperli MP. Rethinking the role of the learned intermediary: the effect of direct-to-consumer advertising on litigation. JAMA. 2000;284:2241.
Glazer BG, Strauss A. The Discovery of Grounded Theory. New York: Aldine; 1967.
Miller WL, Crabtree BF. Qualitative analysis: how to begin making sense. Fam Pract Res J. 1994;14(3):289–97.
Morgan DL, Krueger RA. The Focus Group Kit. Beverly Hills: Sage; 1998.
Morse JM. The significance of saturation (editorial). Qual Health Res. 5(2);1995:147–9.
Kaplan SH, Greenfield S, Ware JE, Jr. Assessing the effects of physician–patient interactions on the outcomes of chronic disease. Med Care. 1989a;27:S110–27.
Kaplan SH, Greenfield S, Ware JE, Jr. Impact of the doctor–patient relationship on the outcomes of chronic disease. In: Stewart M, Roter D, eds. Communicating with Patients in Medical Practice. Beverly Hills: Sage; 1989b:228–45.
Roter DL. Patient participation in the patient–provider interaction: the effects of patient question asking on the quality of interaction, satisfaction and compliance. Health Educ Monogr. 1997;5:281–315.
Butow P, Devine R, Boyer M, Pendlebury S, Jackson M, Tattersall MH. Cancer consultation preparation package: changing patients but not physicians is not enough. J Clin Oncol. 2004;22:4401–9.
Mangione-Smith R, McGlynn EA, Elliott MN, Krogstad P, Brook RH. The relationship between perceived parental expectations and pediatrician antimicrobial prescribing behavior. Pediatrics. 1999;103:711–8.
Deyo RA, Diehl AK. Patient satisfaction with medical care for low-back pain. Spine. 1986;11:28–30.
Kahneman D, Tversky A. On the psychology of prediction. Psychol Rev. 1973;80:237–51.
Damasio AR. Descartes’ Error: Emotion, Reason, and the Human Brain. New York: Putnam; 1994.
Damasio AR. The Feeling of What Happens: Body and Emotion in the Making of Consciousness. New York: Harcourt Brace Jovanovich; 1999.
Dreyfus HL. On the Internet (Thinking in Action). New York: Routledge; 2001.
Stanovich KE. West RF. Individual differences in reasoning: implications for the rationality debate? Behav Brain Sci. 2000;23(5):645–65; discussion 665–726.
Kahneman D. A perspective on judgement and choice: mapping bounded rationality. Am Psychol. 2003;58(9):697–720.
Bordage G. Why did I miss the diagnosis? Some cognitive explanations and educational implications. Acad Med. 1999;74(10 Suppl):S138–43.
Chang RW, Bordage G, Connell KJ. The importance of early problem representation during case presentations. Acad Med. 1998;73(10 Suppl):S109–11.
Charlin B, Roy L, Brailovsky C, Goulet F, Van Der Vleuten C. The script concordance test: a tool to assess the reflective clinician. Teach Learn Med. 2000;12(4):189–95.
Pauker SG, Kassirer JP. The threshold approach to clinical decision making. N Engl J Med. 1980;302(20):1109–17.
Reyna VF, Lloyd FJ. Physician decision making and cardiac risk: effects of knowledge, risk perception, risk tolerance, and fuzzy processing. J Exp Psychol Appl. 2006;12(3):179–95.
Bauchner H, Simpson L, Chessare J. Changing physician behaviour. Arch Dis Child. 2001;84:459–62.
Epstein RM. Mindful practice. JAMA. 1999;282:833–9.
Wilson TD, Centerbar DB, Brekke N. Mental contamination and the debiasing problem. In: Gilovich T, Griffin D, Kahneman D, eds. Heuristics and Biases: The Psychology of Intuitive Judgment. New York, NY: Cambridge; 2002:185–200.
Acknowledgements
The authors would like to express their gratitude to Camille S. Cipri and Judy Lardner for their assistance with recruitment and project coordination, and to all the physicians who took the time out of their schedules to participate in these focus groups.
This research was funded by the National Institute of Mental Health 5 R01 MH064683-03, RL Kravitz, PI.
Conflict of Interest
None disclosed.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Tentler, A., Silberman, J., Paterniti, D.A. et al. Factors Affecting Physicians’ Responses to Patients’ Requests for Antidepressants: Focus Group Study. J GEN INTERN MED 23, 51–57 (2008). https://doi.org/10.1007/s11606-007-0441-8
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11606-007-0441-8