Pollock Kristian, Grime Janet
Department of Medicines Management, Keele University, Keele, Staffordshire, ST5 5BG, UK.
Eur J Gen Pract. 2003 Dec;9(4):126-33, 140. doi: 10.3109/13814780309160421.
Evidence-based medicine (EBM) has stimulated a proliferation of clinical guidelines and prescribing protocols which aim to increase quality and improve equity of healthcare through the standardisation of treatment and access to resources. The containment of rising prescribing costs is a major concern of European healthcare systems, which has led to a more overt rationing of resources. However, prescribing guidelines and cost-containment strategies reduce the capacity of health professionals to involve patients in discussion and choice of treatment and consequently work against the objectives of patient-centred medicine (PCM), which are a priority of current UK healthcare policy. Little is known about the impact of prescribing guidelines or cost-containment strategies on the practice of medicine in the primary care sector, their effect on relations between doctors and patients, and the ways in which laymen and professionals evaluate and respond to strategies for more 'rational' prescribing.
This paper considers the responses of general practitioners (GPs) in the UK to the conflicting commitments of meeting the clinical needs of individual patients and dealing with the situational constraints of the consultation, while also achieving a reduction in prescribing rates (and costs) of proton pump inhibitors (PPIs) in the treatment of gastric disorders.
Qualitative interview-based research involving 26 GPs.
Most doctors considered that they were making an effort to achieve a reduction in PPI prescribing, and none regarded his current prescribing of PPIs to be inappropriate. However, the raised prescribing thresholds for PPIs, which were a consequence of applying a cost-containment policy, conflicted with the GPs' stated commitment to provide the best and most appropriate treatment for individual patients. In addition, the aim to reduce PPI prescribing was often subverted by the situational constraints of the consultation, and doctors' desire to protect their relationship with patients.
An outcome of the conflicting pressures to which the doctors were subject in their efforts to meet clinical need while also reducing the cost of PPIs was the reinforcement of widespread assumptions and negative patient stereotypes relating to a 'mythology' of PPI prescribing. The prevalence of such stereotypes inhibits the reflexivity in medical practice, which is required for doctors to perceive and respond more constructively to patient perspectives of illness and treatment. Such typifications also function to justify the rationing of treatment on the basis of inappropriate judgements about the deservingness or moral worth of patients. The study illustrates the adverse impact on medical practice of GPs' responses to the competing pressures of meeting patient needs while complying with prescribing incentives and guidelines. It highlights the incompatibility of different policies relating to cost containment and patient-centred medicine and may help to explain the systematic inertia which appears to have hindered the development of genuinely patient-centred medicine over the last few decades.
循证医学（EBM）促使临床指南和处方规范大量涌现，其目的是通过治疗标准化和资源获取标准化来提高医疗质量并改善医疗公平性。控制不断上涨的处方成本是欧洲医疗体系的一个主要关注点，这导致了对资源更明显的配给。然而，处方指南和成本控制策略降低了医疗专业人员让患者参与治疗讨论和选择的能力，因此与以患者为中心的医学（PCM）的目标背道而驰，而PCM是当前英国医疗政策的优先事项。关于处方指南或成本控制策略对初级医疗部门医疗实践的影响、它们对医患关系的作用，以及外行人与专业人员评估和应对更“合理”处方策略的方式，我们所知甚少。
本文探讨了英国全科医生（GPs）在应对满足个体患者临床需求和处理诊疗情境限制这两个相互冲突的要求时的反应，同时还探讨了在治疗胃部疾病时如何降低质子泵抑制剂（PPIs）的处方率（及成本）。
基于26名全科医生的定性访谈研究。
大多数医生认为他们正在努力降低PPIs的处方量，且没有人认为自己目前开具PPIs的处方是不合适的。然而，由于实施成本控制政策导致PPIs的处方阈值提高，这与全科医生宣称的为个体患者提供最佳和最合适治疗的承诺相冲突。此外，降低PPIs处方量的目标常常被诊疗情境的限制以及医生保护医患关系的愿望所破坏。
医生在努力满足临床需求同时降低PPIs成本时所面临的相互冲突的压力，其结果是强化了与PPIs处方“神话”相关的普遍假设和负面患者刻板印象。这种刻板印象的盛行抑制了医疗实践中的反思性，而反思性是医生理解并更建设性地回应患者对疾病和治疗看法所必需的。这种类型化也起到了作用，即基于对患者应得性或道德价值的不当判断来为治疗配给提供正当理由。该研究说明了全科医生在应对满足患者需求与遵守处方激励措施和指南这两种相互竞争压力时，对医疗实践产生的不利影响。它凸显了与成本控制和以患者为中心的医学相关的不同政策之间的不相容性，并且可能有助于解释在过去几十年中似乎阻碍了真正以患者为中心的医学发展的系统性惰性。
