March 1997, Volume 47, Issue 3


Patient Management: Conflicts in Decision and Rationality

Inayat H. Thaver  ( G-3, Jiwani Resort, 163-C Block III, P.E.C.H.S., Karachi. )

Patient management by health care providers includes history taking, physical examination, writingprescriptions(or dispensing medicines), ordering diaynostic tests, advice and follow-up or referral suggestions1. These are the most important and frequently performed activities (i.e., curative care) expected from a health care provider, specially a physician who is either working in public sector or has a private practice2. Recently the quality of care as offered by health care providers has become the focus for researchers because of the need to have cost-effective and cost-efficient services3. These studies have revealed mixed findings especially of poor prescribing practices and “irrational use of drug4-7. Lack of knowledge has always been thought to be the major cause and “training” has been suggested as the panacea for improving prescribing practices8-10. . However, before prescribing, it is necessary to know and understand other dimensions, rationally and decisions taken by physicians for managing their patients. The main problem in patient management is the knowledge-practice gap11,12 and merely incrcasing the knowledge by “training” may not be the only solution13.  Besides, a number of psychological and social factors interact with clinical consideration of physicians for treatment and management of patients; some of which include time pressure, uncertainty and patient characteristics13. The time pressure has to do with profit motive of physicians, commonly observed in private practice14,17. The result of this pressure is to tenninate the consultation process by either prescribing, referring or getting diagnostic tests done. The uncertainty may be due to lack of knowledge or physician’s difficulty in distinguishing personal ignorance from limitations in medical knowledge18. In addition, the uncertainty also relates to patient’s social and psychological characteristics, their expectations and lack of trust. These lead to decision conflicts and sometimes patients’ expectations rather than drug toxicity becomes a prime reason of a prescription19.
In addition, them are a number of motivational forees which influence physicians’ prescribing style. Physicians are concerned with preservation of their mle as a healer and prescriber20. They are used to automated decision without using any recent knowledge as they feel that their previous experience of treating the disease by particular medicines have been encouraging21. Thus one can imagine that prescribing decisions do require a great deal of thought and eonsidemtions. A prescriber has to struggle to balance the disparate conditions. There is a rationale in it though it is just not pharmacological19. So how could this dilemma be addressed? One of the important actors inthisprocess hasbeen the patients or clients, but, traditionally clients had been passive and dependent and following experts’ instructions ma compliant fashion. Thus, though physicians perceive that increased medicines are patients’ demands, patients have not been actually involved in that decision making22. Besides, it has been observed that physicians have been insensitive to their patients intentions; patient would like to have a doctor who would listen and sort out their problem23. Physician’s insensitivity reflects their bias to see the function of consultation in terms of medical treatment24. There is a conflict as according to patients this is a lower priority than is the receipt of information or support. There prevails a medical dominance expressed in doctor-patient relationship by poor communication, reluctance to give/share information and use of medical jargons25. Therefore, patient management can be impmved by “client-centered” approach by the physicians. Patients do not want paternalism and negotiate trtatment with their physicians, rather than following “doctors orders26. Improving communication, both between doctor and patient27,28 and educating people and community about medications29 can hopefully resolve the conflict currently inherent inpatient management decisions.


1. Ugalde, A., Homedes, N. and Urena, J.C. Do patients understand their physicians? Prescription compliance in a rural area of the Dominican Republic. Health Policy Plan., l986;1 :250-259.
2. Naylor, C.D,Private medicine and privatization of health care in South Africa. Soc. Sci. Med., 1988;27:1153-1170.
3. Thaver, l.H. ‘Quality’ in medical care; A conceptual framework. J. Pak. Med. Assoc., 1995;45:53-54.
4. Greenhalgh, T. Drug prescription and self medication in India: An exploratory study. Soc. Sci.Med., I 987;25 :307-318.
5. Naja, S.A., Idris, M.Z. and Khan, A. Drug coat more at primary health clinic: An experience from Libya. Ftealth Policy Plan., I 988;3 :69-73.
6. Tomson, G., Diwan, V. and Angunawela, I. Paediatric prescribing in out-patient care: An example from Srj Lanka. Eur. J. Clin. Pharmacol., 14 990;39:469-473.
7. Thaver, l.H. Preacribing pattcrna of primary care providers in squatter areas of Karachi. 3. Pak. Med. Assoc., 1995;45:301-302.
8. Stein, L.S. The effectiveness of continuing medical education: Eight research report. J. Med. Educ., 1980;56:103-110.
9. Magruder-Habib, K., Zung, W.W.K. and Feussner, JR. Improving physicians’ recognition and treatment ofdepression in general medical care: Results from a randomized clinical trial. Med. Care, 1990;28:239-250.
10. Gutierrez, G., Guiscafre, H.,Bronfman, M et al. Changing physician prescribing patterns: Evaluation of an educational strategy for acute diarrhoea in Mexico city. Med. Care, 1 994;32:436-446~
11. lgun, U.A. The knowledge-practice gap: An empirical example from prescription for diarrhoea in Nigeria. 3. Diarrhoeal Dia. Fez., 1994; 12:65-69.
12. Ofori-Adjei, D. and Arhinful, K. Effect of training on the clinical management ofmalaria by medical aaaiatants in Ghana. Soc. Sci. Med., I 996:42:1169-1176.
13. Caccavo, A. D. and Reid, F Decisional conflict in general practice: Strategies of patient management. Soc. Sci. Med., 1 995;41 :347-353.
14.  Barros, F.C., Vaughan, J:P. and Victors, C.G. Why so many caesarean sections? The need for a further policy change in Brazil. Health Policy Plan., 1 986;1 19-29,
15.  Liu, Z.X. and Wang, J.L. An introduction to China’s health caresystem. J. Public Health Policy, 1991;12:104-1 16.
16.  Qureshi, A.F. and Shepard, D.S. Health Expenditure and services utilization in a squatter settlement. Takemi Research paper, Harvard School of Public Health, 1988.
17. World Bank. Financing health services in developing countries: An agenda for Reform. Washington. The World Bank, 1987.
18. Rizzo, J.A. Physician uncertainty and the art of persuasion. Soc. Sci. Med., 1993;37:1451-1459.
19. Bradley, C.P. Uncomfortable prescnbing decisions: A critical incidentstudy. Br. Med. J., 1992;304:294-296.
20. Paredes, P., La-Pena, M.D., Flores-Guerra, E. et al. Factors influencing physicians prescribing behaviour in the treatment of childhood diarrhoea: Knowledge may not be the clue. Soc. Sci: Med., 1 996;42: 1141-1153.
21.  Schwartz, R.K., Soumerai, S.B. and Avom, J. Physician motivations for non-scientific drug prescribing. Soc. Sci. Med., 1989;28:577-582.
22.  Chewning, B. and Sleath, B. Medication decision-making and management: A client-centered model. Soc. Sci. Med., 1996;42:389- 398.
23.  Boland, M. What do people expect from their doctors? World Health Forum, 1995;16:221 -226.
24.  Salmon, P., Sharma, N., Valori, R. and Bellenger,. N. Patient’s intentions in primary care: Relationship to physical and psychological symptoms and their perceptions by general practitioners. Soc. Sci. Med., 1 994;38 :585-592.
25.  Phillips, D. Medical professional dpminance and clientdissatisfaction. Soc. Sci. Med., 1996;42:141 9-1425.
26.  Fabb, W. A reliable explainer, round table on what do people expect from their doctors? World Health Forum, 1995; 16:241-244.
27.  Hall, J.A., Roter, DL. and Katz, N.R. Task versus socio- emotional behaviours in physicians. Med. Care, 1987,25:399.
28.  Ong. LML., deHaes, J.C.J.M.. Hoos, A.M et al. Doctor-patient communication: A review of the literature. Soc. Sci. Med., I 995;40:903-918. 8.
29.  Block, L., Ranspach, SW., Gans, K. et al. Impact of public education and continuing medical education on physician attitudes and behaviour concerning cholesterol. Am,J. Prey. Med., 1988;4:255-260.

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