Developing the Medication Change Questionnaire.

OBJECTIVE: People who seek non-pharmaceutical interventions are often motivated by a desire to avoid or reduce orthodox medication. Effectiveness research in these areas needs to measure change in medication as an outcome. We set out to develop a data collection tool that is sensitive to changes in individual drug use over time. METHOD: A multi-disciplinary team designed, piloted, and revised the Medication Change Questionnaire (MCQ) on two occasions, and used qualitative interviews to understand the patient's perspective and ensure that the final product accurately reflected the medication that patients were taking. Thirty patients in one general practice completed the questionnaire on two occasions and a purposive sample of 14 were interviewed. The design sought to enable patients to record all their ingested medication accurately, both prescription and over-the-counter drugs, over a period of 7 days. It was designed to be administered face-to face on the first occasion, and to be self-completed on subsequent occasions. RESULTS: In considering in detail what medication was taken each day, the interview data fully correlated with the MCQ data in only one of the five people who were interviewed after completing the first draft of the questionnaire, but in eight of the nine people who completed the second draft. Of these eight people all but one had made some change to their medication, either by stopping or starting a drug, varying the dose of a drug or always taking one or more drugs in varying doses. The interviews demonstrated the complex and individual ways that people took their medicines, and the disparity between what was prescribed and what was actually taken. The qualitative data were also useful for reflecting on the potential advantages and disadvantages of other data collection methods, such as single medication questions and pill counts. CONCLUSION: By involving patients at every level of research, we have developed a questionnaire that enables people to record their medication use accurately over a 7-day period, and to demonstrate changes in medication over time. Further work is required to assess its acceptability by different patient populations and its feasibility in terms of completion rates over longer periods of repeated use. We believe the MCQ to be an improvement over the variety of ad-hoc tools used in the past and it is freely available from the authors.

Treating dyspepsia with acupuncture and homeopathy: reflections on a pilot study by researchers, practitioners and participants.

OBJECTIVES: For people with dyspepsia who are receiving orthodox general practice care, what is the effect on outcome and on NHS costs of adding treatment by a choice of acupuncture or homeopathy? This paper describes and reflects upon a pilot study with user involvement. DESIGN: A randomised pilot study. Patients chose between acupuncture and homeopathy and were then randomised to this preference or to the control group of normal GP care. SETTING AND PARTICIPANTS: Sixty people with dyspepsia (>/=2 weeks) presenting in one UK general practice were recruited in consultations and by letter to those on repeat prescriptions. There were few exclusion criteria. The homeopath and the acupuncturist treated the patient individually according to their normal practice for up to 6 months. After the trial there was a focus group for participants. OUTCOME MEASURES: SF-36 health survey, Measure Yourself Medical Outcome Profile (MYMOP), and General Well-being Index (GWBI). Counts of prescriptions, consultations and referrals from practice computer records. RESULTS: No trend or significant difference between the groups for clinical outcome or NHS costs. Major costs for the 6 months, mean (S.D.) cost per patient, were general practitioner consultations pound 8 (18), prescriptions pound 64 (73), acupuncture pound 175 (52), homeopathy pound 105 (33). Participants gave insights and suggestions which will inform the full trial design. CONCLUSIONS: Reflection on the pilot study data and experience by participants, treating practitioners and researchers led to modifications in the design and a sample size calculation. How to demonstrate individual responses to treatment remains a problem.

Giving voice to the lifeworld. More humane, more effective medical care? A qualitative study of doctor-patient communication in general practice.

Mishler (The discourse of medicine. The dialectics of medical interviews. Norwood, NJ: Ablex), applying Habermas's theory of Communicative Action to medical encounters. showed how the struggle between the voice of medicine and the voice of the lifeworld fragmented and suppressed patients' multi-faceted, contextualised and meaningful accounts. This paper investigates and critiques Mishler's premise that this results in inhumane, ineffective medical care. Using a more complex data collection strategy, comprising patient interviews, doctor interviews and transcribed consultations we show more complex relations than emerged from Mishler's analysis. We found four communication patterns across 35 general practice case studies. When doctor and patient both used the voice of medicine exclusively (acute physical complaints) this worked for simple unitary problems (Strictly Medicine). When both doctor and patient engaged with the lifeworld, more of the agenda was voiced (Mutual Lifeworld) and patients were recognised as unique human beings (psychological plus physical problems). Poorest outcomes occurred where patients used the voice of the lifeworld but were ignored (Lifeworld Ignored) or blocked (Lifeworld Blocked) by doctors' use of voice of medicine (chronic physical complaints). The analysis supports the premise that increased use of the lifeworld makes for better outcomes and more humane treatment of patients as unique human beings. Some doctors switched communication strategies in different consultations, which suggests that their behaviour might be open to change. If doctors could be sensitised to the importance of dealing with the concerns of the lifeworld for patients with chronic physical conditions as well as psychological conditions, it might be possible to obtain better care for patients. This would require attention to structural aspects of the healthcare system to enable doctors to work fully within the patient-centred model.