BackgroundPolypharmacy is an important safety concern. Medication reviews are recommended for patients affected by polypharmacy, but little is known about how they are conducted, nor how clinicians make sense of them. We used video-reflexive ethnography (VRE) to: illuminate how reviews are conducted; elicit professional dialogue and concerns about polypharmacy; invite new transferable understandings of polypharmacy and its management.MethodsWe conducted 422 hours of fieldwork (participant observation), filmed 18 consultations between clinicians and patients receiving 10 or more regular items of medication (so-called ‘higher risk’ polypharmacy) and played short clips of film footage to 34 participants (general practitioners, nurses, clinical pharmacists, practice managers) in seven audio-recorded reflexive workshops. Our analysis focused on ‘moments of potentiation’ and traced clinicians’ shifting understandings of their practices.ResultsParticipants rarely referenced biomedical aspects of prescribing (eg, drug-drug interactions, ‘Numbers Needed to Treat/Harm’) focussing instead on polypharmacy as an emotional and relational challenge. Clinicians initially denigrated their medication review work as mundane. Through VRE they reframed their work as complex, identifying polypharmacy as a delicate matter to negotiate. In patients with multimorbidity and polypharmacy it was difficult to disentangle medication review from other aspects of patients’ medical care. Such conditions of complexity presented clinicians with competing professional obligations which were difficult to reconcile. Medication review was identified as an ongoing process, rather than a discrete ‘one-off’ activity. Meaningful progress towards tackling polypharmacy was only possible through small, incremental, carefully supported changes in which both patient and clinician negotiated a sharing of responsibility, best supported by continuity of care.ConclusionsSupporting acceptable, feasible and meaningful progress towards addressing problematic polypharmacy may require shifts in how medication reviews are conceptualised. Responsible decision-making under conditions of such complexity and uncertainty depends crucially on the affective or emotional quality of the clinician-patient relationship.
Dementia researchers have persuasively argued for using flexible and creative methods with people with dementia, to ensure their historically marginalised voices are now heard. This article builds on that work, using examples from a study of medicines practices of people with dementia and their informal carers. We have two aims: firstly, we show the ways in which two methods – linguistic ethnography and diary-interview method – can support the inclusion and participation of people with dementia. Secondly, we examine the methodological insights and the dilemmas created by using these methods. Our focus on supporting all means of communication (verbal, non-verbal, drawing, photography and writing) underpinned our choice of methods, which in turn facilitated inclusion and participation. Using a linguistic ethnographic approach supported participants to use material objects to tell their stories; video-recording interactions encompassed non-verbal communication; creative diary-methods made non-linguistic means of knowledge production possible. Moving around the home and neighbourhood and using familiar objects enabled people with dementia to explain their medicines in the context of their lives. Paying attention to sensory data created new insights into the skills and knowledge that family members develop and employ when they provide informal care. The methods were not without challenges. Participants experienced a tension in balancing opportunities for self-expression with the time and effort involved in participatory activities. For the researcher, prioritising the affective quality of respectful research relationships whilst not straying into ‘faked friendship’ created situated ethical dilemmas.
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