Hindawi Publishing Corporation
International Journal of Family Medicine
Volume 2012, Article ID 612572, 6 pages
ClinicalGazeinRisk-Factor Haze: SwedishGPs’ Perceptionsof
PrescribingCardiovascular Preventive Drugs
1˚ Aby Health Care Centre, County Council of¨Osterg¨ otland, Department of Medical and Health Sciences, General Practice,
Faculty of Health Sciences, Link¨ oping University, 581 85 Link¨ oping, Sweden
2Institute of Community Medicine, University of Tromsoe, Tromsoe, Norway
3Research Unit of Kalmar County Council, Kalmar, Sweden
Correspondence should be addressed to Josabeth Hultberg, firstname.lastname@example.org
Received 14 August 2012; Accepted 14 October 2012
Academic Editor: Ruth Kalda
Copyright © 2012 J. Hultberg and C. E. Rudebeck. This is an open access article distributed under the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
drugs. Methods. Qualitative content analysis of transcribed group interviews with 14 participants from two primary health care
centres in the southeast of Sweden. Results. GPs’ prescribing of cardiovascular preventive drugs, from their own descriptions,
involved “the patient as calculated” and “the inclination to prescribe,” which were negotiated in the interaction with “the patient
in front of me.” In situations with high cardiovascular risk, the GPs reported a tendency to adopt a directive consultation style.
In situations with low cardiovascular risk and great uncertainty about the net benefit of preventive drugs, the GPs described
a preference for an informed patient choice. Conclusions. Our findings suggest that GPs mainly involve patients at low and
uncertain risk of cardiovascular disease in treatment decisions, whereas patient involvement tends to decrease when GPs judge
the cardiovascular risk as high. Our findings may serve as a memento for clinicians, and we suggest them to be considered in
training in communication skills.
General practitioners are heavily involved in considering and
prescribing cardiovascular preventive drugs and maintaining
their increasing use . Numerous trials have shown indis-
putable effects of cardiovascular preventive drugs . How
to apply these findings in clinical medicine remains an issue
of controversy. Proponents of increased drug use calculate
on reduced cardiovascular mortality whereas sceptics fear a
threat to public health and to the sustainability of health
care by introducing preventive drug treatment to large
proportions of healthy populations [3, 4]. A Swedish survey
showed that between 1980 and 2000, the number of people
who stated that they had a chronic disease almost doubled.
inferring that people comprehend the preventive medication
as a treatment for disease .
tion in health-care decisions in practice and in the legislation
of many countries including Sweden . Governments,
health-care organisations and insurance companies have a
common interest in public health and costeffectiveness in
prescribing. Guidelines aim to implement evidence-based
prescribing  and rational drug use  but are supported
by drug trials largely sponsored by the pharmaceutical
Demands on GPs’ prescribing are thus numerous, multi-
tion constitutes the basis for the subsequent drug utilisation
in the population. Most previous qualitative studies of how
GPs prescribe cardiovascular preventive drugs have focused
on barriers to a desirable implementation of guidelines
[12, 13]. For a broader understanding of cardiovascular
2International Journal of Family Medicine
Table 1: Characteristics of participants.
GenderYears of work experience
Primary health care centre 1
Primary health care centre 2
preventive drug prescribing, it needs to be investigated
with different approaches, and from GPs’ own professional
perspectives, with no defined preferences regarding their
We aimed to explore GPs’ descriptions of their thoughts and
actions when prescribing cardiovascular preventive drugs.
3.1. Interviews. We chose group interviews with GPs prac-
tising together to collect data that would capture individual
and collective professional experience. Fourteen GPs from
two primary health care centres in south-eastern Sweden
participated, see Table 1. One is situated in a suburb near
a fairly large city and is the first author’s workplace. The
other is in the centre of a small city. They serve urban,
suburban, and rural populations. The interviews were held
at the participants’ workplaces, the first in 2004 and led by
the second author, the second in 2007 and led by the first
author. Audio recordings were transcribed verbatim shortly
after each interview.
vascular preventive drugs, was held in focus with minimal
guidance and occasional use of a checklist, Table 2. Quieter
participants were encouraged to express their thoughts. The
participants expressed conflicting opinions and views with
little or no hesitance and the material proved to be rich in
content relevant to the research question.
3.2. Analysis. Qualitative content analysis was considered
appropriate to the aim . The first interview was analysed
before the second was planned. After the second interview,
Table 2: Interview checklist.
How do you do when you prescribe a new medication for
Can you recall a recent case when you prescribed medication to
prevent cardiovascular disease?
Areas for further probing
Descriptions of routine, rules of thumb, phrasing, information
Specifics of preventive treatment: the concept of risk, life long
Consideration of patients’ responses, attitudes, adherence.
the material from both interviews was analysed. The tran-
scripts were thoroughly read and then slightly condensed.
Meaning units were identified and assigned codes. Codes
were grouped into subcategories and subcategories into
main categories, resulting in a stepwise abstraction from
the original text. Internal homogeneity and external het-
erogeneity between categories were sought. At each step,
the results were checked against the original material and
adjusted according to it, similarly to the model of constant
above were discussed and negotiated between the authors
until agreement was reached. Table 3 exemplifies each level
of abstraction. Quotations were selected to illustrate the
3.3. Ethics. Oral and written information to participants
stated that their participation was voluntary and that they
were free to withdraw at any time without explanation.
The original audio recordings and transcripts have been
handled by the authors only. In all presentations of this
study, quotations have been slightly altered when necessary
to retain participants’ anonymity.
4.1. The Patient as Calculated
4.1.1. Measurability. When describing their assessments of
patients, the GPs considered a number of risk factors for
cardiovascular disease, and different aspects of them. Among
the qualities of the risk factors discussed, measurability
was crucial for decision making on prescribing. Separate
threshold values for blood pressure and cholesterol or
estimates of total risk of future disease, based on more
“These are treatments ruled by guidelines with
firm levels for decision, 140/80 and diabetes, that’s
Also those who regarded a comprehensive risk calcula-
tion as the proper basis for decision making reported refer-
ring to thresholds in guidelines when motivating decisions
International Journal of Family Medicine3
Table 3: Example of the derivation of a main category.
“I am waiting for the day, and probably won’t
experience it during my career, when we are able
to define who is really at risk.”
Cardiovascular risk for the individual patient is
Solidity of knowledge
The patient as calculated
to patients. There were elaborate descriptions of followup of
prescriptions with specific reference to measurable factors.
4.1.2. Solidity of Knowledge. It was recognised that there
is an inherent uncertainty in probabilistic reasoning and
application of epidemiological data to individuals.
“I’m waiting for the day, and probably won’t
experience it during my career, when we are able
to define who is really at risk.”
Lack of agreement and consensus about preventive treat-
“This issue of cholesterol—there are different
opinions about it.”
Not-readily-measurable factors such as stressful life
events and other psychosocial factors were considered but
were felt to be more difficult to base prescribing decisions
on. Various degrees of personal limitation were perceived
regarding knowledge, access to relevant information in the
prescribing situation, and ability to convey such information
“I’d like to have the risk figures in front of me, not
just at the back of my head.”
4.2. Inclination to Prescribe. Each doctor entered the pre-
scribing situation with a set of attitudes that taken together
contributed to a general inclination to prescribe drugs.
This observation rests on statements about cardiovascular
prevention and comparisons with other drugs and nonphar-
4.2.1. Attitudes towards Prevention. There was consensus
concerning the priority of symptom-relieving drugs before
preventive drugs and of secondary prevention before pri-
mary prevention. Yet attitudes towards preventive medicine
diverged. One argument for reluctance to engage in preven-
tive medicine was the risk of harming healthy people when
labelling them with diagnoses. Another was lack of resources
in primary care, yet another that taking drugs instead of
changing an inappropriate habit was an easy way out and
no cure. These arguments all implied low inclination to
“They (occupational health services and private
practices) measure cholesterol values in healthy
ladies and young guys and refer them to us
...doesn’t make you very happy, does it? It’s
Reasons for engagement in preventive medicine were not
only to do good, that is, to prevent disease, but also to do
what is right according to guidelines. Emphasis on these
seemingly similar arguments differed.
“I put it like this: people that know more than I
have assessed this and it’s something we give to
everyone in this situation to diminish risks....”
“I have something else. I try to involve the patient
in the choice ...I think it increases the will to take
it and if I think it is good I also want the patient to
4.2.2. Attitudes towards Drugs. Pharmacological treatments
were regarded as powerful. A strict indication and avoidance
of unnecessary prescriptions were judged important. Side
effects were spontaneously and thoroughly discussed in the
“It’s really dangerous when people come to hos-
pitals or nursing homes and all of a sudden the
nurses start giving them everything they’ve been
The participants’ own experience of drug use influenced
the inclination to prescribe
“...after I had my disease ...my attitude towards
drugs is less negative.”
Lifestyle change (change in diet, physical exercise, smok-
ing, and alcohol intake) was regarded either as an alternative
or a supplement to medication. As an alternative, it was seen
as preferable, sparing the patient from drug treatment, or
at least postponing it. Some described lifestyle change as
harmless, and a possible cure of risk conditions; opinions
that indicate low inclination to prescribe but not necessarily
reluctance to engage in preventive medicine.
“You don’t start medication till you’ve made
several measurements, and if you think you can
lower cholesterol with lifestyle change you do that
4.3. The Patient in front of Me
4.3.1. A Personal Relation. A personal relation and personal
encounters with patients were described as a must for the
prescribing of new drugs. The participants often referred
to the patient as “the person in front of me” when
describing clinical situations. Sending prescriptions by mail
was dismissed as exceptions made only when there was an
established relation or when a followup appointment was
scheduled. Mutual exchange of information was viewed as
fundamental for prescribing decisions.
4International Journal of Family Medicine
“It depends on the patient in front of me, their
personality, my experience of them, and whether
I have met them before.”
4.3.2. Deciding Who Decides. The GPs’ descriptions of their
behaviour when prescribing suggested different views on the
responsibility for decision making. Adjustments of decision
allocation between patient and doctor depended on the
individual patient and situations arising in the clinical
The view of the decision as the doctor’s responsibility
was motivated by the doctor’s better knowledge and duty
to achieve the best possible adherence to, and result of,
“He’s feeling quite well actually, but he still takes
some of the drugs ...in my opinion he absolutely
has to continue with them because he still has his
damaged vessels ....”
Some participants stated that they saw the patient as the
ultimate decision maker, and that the doctor’s responsibility
was limited to conveying correct and necessary information
for the patient’s decision.
“I am not in charge in this case, but an advisor.
I’m someone the patient wishes to get advice from
...and I must not force anything on the patient.”
Consultations with decision making on treatment were
depicted as negotiations. Some described reaching agree-
patient satisfaction and adherence to prescribed treatments.
In choices between equal options according to the doctor,
or when treatment was considered advantageous but not
essential, the patient might be given more influence on the
When the patient’s risk was estimated by the doctor to
be high or when patient adherence to treatment was felt to
be low, the GPs described adjustments towards a directive
“I might think that it’s important also for that
person to value his life, but there I might take
it’s important to keep the coronary arteries in
shape as long as possible and avoid an infarction.”
Fear of making patients worried was one reason for
not involving them. Uncertain or lacking facts on risk
combined with an experienced need to reassure the patient
sometimes led to increased decisiveness, and the adoption
of a directive style. Assessments of patients’ capacity to
comprehend necessary information and of their wish to
participate also affected the doctor’s decision on who should
decide about treatment.
“How do you introduce that way of seeing it with
the patient in a complicated reality, when the
patient has several diseases and many drugs, half
of which at least are treatments for some hazy
5.1. Comments on Findings. We present the ingredients of
cardiovascular preventive drug prescribing as seen from the
GP perspective. The aim, methods, and size of the study
did not allow a description of individual GPs styles nor
interpretations on gender or age specific attitudes. Consul-
tation behaviour was described to fall along a continuum
from an authoritative physician’s decision to an informed
patient’s decision. With “shared decision making” as an
intermediate, this conforms to the model of consultation
styles described by Charles et al. . Similarly, Silwer et al.
found GPs to have different views on the allocation of
on primary cardiovascular prevention were to be made
. However, the GPs in our study described situational
adjustments to their prescribing behaviour. Agreement, a
shared decision, and flexibility when prescribing may be
regarded as goals in themselves and may also lead to better
outcomein terms of perceived healthand patient satisfaction
high cardiovascular risk or low drug adherence were in our
study reported as leading to a directive consultation style.
With regard to the benefits of shared decision making, such
adjustments may be counterproductive.
In the shared decision making model, the doctor is
to identify equipoise between treatment alternatives before
sharing the decision with the patient. This places the
interpretive prerogative about equipoise with the doctor
and thus also the power to decide [21, 22]. Our results
confirm this reasoning among the GPs in the process of
risk, as judged by the GP, he or she tended to decide not
to decide, or not to take full responsibility for decision
making. As a consequence, patients were more likely to
be invited to partake in decision making when less was
at stake but the choice was more delicate and laden
with uncertainty. Exceptions were when the GP perceived
the patient to be unwilling, incapable, or too anxious to
decide. These situational adjustments of decision making
are understandable, but from the patient’s point of view,
neither fully rational nor desirable. As with the possibly
counterproductive adjustments when cardiovascular risk is
high, they cannot be solved by modifications of guidelines or
the implementation of them, which has been suggested .
Our aim was to explore GPs’ drug prescribing. Nonphar-
macological treatments were brought up and discussed in
relation to drug treatments. GPs’ choice between lifestyle
interventions and drug prescribing has been reported as a
dilemma and a possible obstacle to drug treatment when
requires that lifestyle change and drugs are regarded as
conflicting and mutually exclusive choices. Our results
confirm this as one, but not the only, way of seeing it. Parallel
initiation of lifestyle change and drug therapy was also
International Journal of Family Medicine5
reported. This is in accordance with Silwer et al. who found
that GPs regarded pharmaceutical and nonpharmaceutical
prevention as independent options .
Clinical inertia, defined as “clinicians’ failure to initiate
or intensify drug treatment when indicated”, has been put
forward as an obstacle to adequate prescribing, and to
treatment targets being reached in practice [23, 24]. The
inherent uncertainty of probabilistic reasoning has been
suggested as one rationale for clinical inertia [10, 11, 13].
“Soft” reasons have also been referred to . Our GPs
expressed concern about the lack of non-measurable facts
in risk algorithms, evoking patients’ anxiety with talk of
risk, harming frail elderly people with drugs, causing side
effects in asymptomatic people, and labelling them with risk
diagnoses. Such “soft” arguments against drug treatment
emanating from GPs’ interaction with “the patient in front
of them” may be well as solid as the alleged “hard” facts of
“the patient as calculated” [25, 26].
Thedecision toprescribehasbeendescribed asaproduct
of clinical interaction . Our results were in accordance
with this. Ultimately the relation with “the patient in
front of me” appeared to be the frame of the decision
on prescribing and the weight of numeric values of “the
patient as calculated” were subjected to negotiation. In
fact, discourse-analytical studies of audio recordings from
clinical consultations have shown treatment decisions to be
based on negotiated blood-pressure values rather than actual
measured values .
5.2. Comments on Methods. We interviewed groups of col-
leagues working together. In group interviews controversies
may be suppressed and a consensual understanding rein-
forced . On the other hand, in-house hierarchy and con-
sensual understanding are the basis for clinical action . It
is purposeful to collect data in peer groups that reflects and
articulates the norms that guide their practice. There were
disagreements and descriptions of shortcomings, indicating
an open discussion climate and that the participants did
not experience the interviews as a knowledge test. The
latter has been proposed as a risk when interviewing peers
The material proved to be sufficiently rich and varied
to suffice for the purpose. Further data collection would
that the major features of our findings would have changed.
For practical reasons, the interval between the interviews
was three years. The specific contents of the categories, such
it as a strength that all categories were derived from both
group interviews and thus proved to be stable over the
This interview study renders information about GPs’
thoughts and views on prescribing, but only their described
behaviour. Further studies of real life consultations are
needed to explore how GPs and patients handle decision
making on cardiovascular preventive drugs. How do the
ethical dilemmas of public health epidemiology come to
expression in clinical practice where individuals interact?
GPs’ prescribing of cardiovascular preventive drugs, from
their own descriptions, involved “the patient as calculated”
and “the inclination to prescribe,” which were negotiated in
the interaction with “the patient in front of me.”
In situations with high cardiovascular risk, the GPs
described a tendency to adopt a directive consultation style
to make the patient adhere to treatment. In situations with
low cardiovascular risk, the GPs reported inclination to
retreat from the shared decision making model to take on
a mainly informative role. Adjustments towards directive
consultation styles, regardless of the motive, may decrease
results. By adjustments towards informed patient choice
in low risk situations, the patients became relatively more
responsible when there was great uncertainty on the benefits
of preventive drugs. We conclude that these situational
adjustments in decision making are understandable, but
from the patient’s point of view, neither fully rational nor
our findings, they may yet serve as a memento for clinicians,
and we suggest them to be considered in the training of
communication skills. Our findings imply patterns of how
the responsibility for decision making is shared between
doctors and patients. Further studies of this with regard
to drug prescribing should be undertaken in actual clinical
This work was supported by the Research Board of Local
Care Eastern¨Osterg¨ otland and the Research and Develop-
ment Unit of the County Council of ¨Osterg¨ otland. The
authors are grateful to the GPs who generously participated
and shared their thoughts.
 J. L. G. Nilsson and A. Melander, “Increased introduction,
advertising, and sales of preventive drugs during 1986–2002
in Sweden,” Journal of Ambulatory Care Management, vol. 29,
no. 3, pp. 238–249, 2006.
of guidelines on cardiovascular risk assessment: which rec-
ommendations should clinicians follow for a cardiovascular
health check?” Archives of Internal Medicine, vol. 170, no. 1,
pp. 27–40, 2010.
 N. J. Wald and M. R. Law, “A strategy to reduce cardiovascular
disease by more than 80%,” British Medical Journal, vol. 326,
no. 7404, pp. 1419–1423, 2003.
 L. Getz, A. L. Kirkengen, I. Hetlevik, S. Romundstad, and J. A.
Sigurdsson, “Ethical dilemmas arising from implementation
of the European guidelines on cardiovascular disease preven-
tion in clinical practice: a descriptive epidemiological study,”
Scandinavian Journal of Primary Health Care, vol. 22, no. 4,
pp. 202–208, 2004.
6 International Journal of Family Medicine
 B. Hagstrom, B. Mattsson, A. Wimo, and R. K. Gunnarsson,
ic disease and medication,” Scandinavian Journal of Public
Health, vol. 34, no. 6, pp. 584–588, 2006.
 H¨ also-och sjukv˚ ardslagen (Health and Medical Service Act),
 D. L. Sackett, W. M. C. Rosenberg, J. A. M. Gray, R. B. Haynes,
and W. S. Richardson, “Evidence based medicine: what it
is and what it isn’t. It’s about integrating individual clinical
expertise and the best external evidence,” British Medical
Journal, vol. 312, no. 7023, pp. 71–72, 1996.
 “The rational use of drugs: report of the Conference of
Experts,” in Conference of Experts on the Rational Use of Drugs,
World Health Organization, November 1985.
 F. Taylor, K. Ward, T. H. Moore et al., “Statins for the primary
prevention of cardiovascular disease,” Cochrane Database of
Systematic Reviews, vol. 1, p. CD004816, 2011.
 I. Skoglund, K. Segesten, and C. Bj¨ orkelund, “GPs’ thoughts
benefit aspect is a strong motivator,” Scandinavian Journal of
Primary Health Care, vol. 25, no. 2, pp. 98–104, 2007.
 P. B. Rahmner, L. I. Gustafsson, J. Larsson, U. Rosenqvist, G.
Tomson, and I. Holmstr¨ om, “Variations in understanding the
drug-prescribing process: a qualitative study among Swedish
GPs,” Family Practice, vol. 26, no. 2, pp. 121–127, 2009.
 W. S. M. Summerskill and C. Pope, “‘I saw the panic rise in
her eyes, and evidence-based medicine went out of the door’.
An exploratory qualitative study of the barriers to secondary
prevention in the management of coronary heart disease,”
Family Practice, vol. 19, no. 6, pp. 605–610, 2002.
 E. Fh¨ arm, O. Rolandsson, and E. E. Johansson, “‘Aiming for
the stars—GPs’ dilemmas in the prevention of cardiovascular
disease in type 2 diabetes patients: focus group interviews,”
Family Practice, vol. 26, no. 2, pp. 109–114, 2009.
 U. H. Graneheim and B. Lundman, “Qualitative content anal-
ysis in nursing research: concepts, procedures and measures to
achieve trustworthiness,” Nurse Education Today, vol. 24, no.
2, pp. 105–112, 2004.
 B. G. Glaser and A. L. Strauss, The Discovery of Grounded
Theory, Strategies for Qualitative Research, Aldine, Chicago, Ill,
 C. Charles, T. Whelan, and A. Gafni, “What do we mean
by partnership in making decisions about treatment?” British
Medical Journal, vol. 319, no. 7212, pp. 780–782, 1999.
 L. Silwer, R. Wahlstr¨ om, and C. S. Lundborg, “Views on
primary prevention of cardiovascular disease-an interview
study with Swedish GPs,” BMC Family Practice, vol. 11, article
 M. A. Stewart, “What is a successful doctor-patient interview?
A study of interactions and outcomes,” Social Science and
Medicine, vol. 19, no. 2, pp. 167–175, 1984.
 M. Klein Buller and D. B. Buller, “Physicians’ communication
style and patient satisfaction,” Journal of Health and Social
Behavior, vol. 28, no. 4, pp. 375–388, 1987.
 M. Marinker, From Compliance to Concordance: Achieving
Shared Goals in Medicine Taking, Royal Pharmaceutical Soci-
ety, in partnership with Merck Sharp & Dohme, London, UK,
 V. Wirtz, A. Cribb, and N. Barber, “Patient-doctor decision-
making about treatment within the consultation - A critical
analysis of models,” Social Science and Medicine, vol. 62, no. 1,
pp. 116–124, 2006.
 L. M. Ong et al., “Doctor-patient communication: a review of
the literature,” Social Science & Medicine, vol. 40, no. 7, pp.
 L. S. Phillips, W. T. Branch, C. B. Cook et al., “Clinical inertia,”
Annals of Internal Medicine, vol. 135, no. 9, pp. 825–834, 2001.
 P. Midl¨ ov, R. Ekesbo, L. Johansson et al., “Barriers to
adherence to hypertension guidelines among GPs in southern
Sweden: a survey,” Scandinavian Journal of Primary Health
Care, vol. 26, no. 3, pp. 154–159, 2008.
 M. M. Safford, R. Shewchuk, H. Qu et al., “Reasons for
not intensifying medications: differentiating “clinical inertia”
from appropriate care,” Journal of General Internal Medicine,
vol. 22, no. 12, pp. 1648–1655, 2007.
 P. Brindle, A. Beswick, T. Fahey, and S. Ebrahim, “Accuracy
and impact of risk assessment in the primary prevention of
cardiovascular disease: a systematic review,” Heart, vol. 92, no.
12, pp. 1752–1759, 2006.
 M. S. Blois, Information and Medicine : the Nature of Medical
Descriptions, University of California Press, Berkeley, Calif,
 S. Svensson, P. Linell, and K. I. Kjellgren, “Making sense of
blood pressure values in follow-up appointments for hyper-
tension,” International Journal of Cardiology, vol. 123, no. 2,
pp. 108–116, 2008.
 J. Gabbay and A. Le May, “Evidence based guidelines or
collectively constructed “mindlines?” Ethnographic study of
knowledge management in primary care,” British Medical
Journal, vol. 329, no. 7473, pp. 1013–1016, 2004.
 L. Coar and J. Sim, “Interviewing one’s peers: methodological
issues in a study of health professionals,” Scandinavian Journal
of Primary Health Care, vol. 24, no. 4, pp. 251–256, 2006.