Drug related problems after discharge from an Australian teaching hospital

Objective To reconcile patients’ medicines and to classify drug related problems identified during medication review conducted after discharge from hospital. Setting Patients were discharged from the cardiology unit of Westmead Hospital after recruitment into the Westmead Medicines Project which ran from 2004 to 2007. Method This retrospective study involved an analysis of drugs, diseases and drug related problems in medication review reports available for 76 out of 85 patients who received a Home Medicines Review (HMR). Data sources for medication reconciliation and analyses also included hospital discharge summaries (n = 70) and GP referrals for HMR (n = 44). Comprehensive clinical profiles were constructed for the 76 subjects whose drug related problems were identified, coded, and then classified from their HMR reports. Main outcome measures Number, type, distribution and international classification of drugs, diseases and drug-related problems. Results Patients were prescribed drugs for a broad range of cardiovascular, circulatory, endocrine, respiratory and digestive system diseases. Mean number of drugs per patient in discharge summaries: 8.7 ± SD 3.3 (range 3–19); in GP referrals: 8.9 ± SD 4.3 (range 2–23); and in HMR reports: 10.8 ± SD 4.0 (range 3–24). Mean number of diseases per patient in discharge summaries: 4.1 ± SD 2.9 (range 1–11); and in HMR reports: 4.7 ± SD 2.6 (range 1–12). A total of 398 drug related problems were identified for 71 (93.3%) patients with mean 5.6 ± SD 4.3 problems (range 1–21). The most frequently recorded problems were the patients’ uncertainty about drug aim: n = 128 (32.0%); potential interactions n = 89 (22.4%); and adverse reactions n = 60 (15.1%). Conclusion This study showed that patients recently discharged from a tertiary care hospital had a significant number of drug related problems. Classification of drugs and diseases revealed a broad range of non-cardiovascular medicines and conditions in the patients from an acute care cardiology unit. We found that home medicines review provided continuity of care and an opportunity for medication reconciliation which revealed marked differences in number of drugs, between hospital discharge and medicines review. The patients’ uncertainly about their drugs and their diverse range of co-morbidities indicated the need for timely counselling by pharmacists in the community.     

Post-discharge medication reviews for patients with heart failure: a pilot study

Background Medication misadventure is greatest at times of change such as the transition from hospital to community. Patients with heart failure are prone to medication misadventure due to polypharmacy, inappropriate medication use and frequent readmissions. Objective To identify the barriers encountered when implementing a Liaison Pharmacist facilitated post-discharge medication management service for patients with heart failure. Method A Liaison Pharmacist contacted the patient’s General Practitioner (GP), sent them a medication discharge summary and organised an appointment for the patient with the GP approximately 2 days post-discharge to make a Home Medicines Review (HMR) referral. The patient’s community pharmacist was also contacted, sent a medication discharge summary and requested to engage an accredited pharmacist to undertake the HMR. The Liaison Pharmacist arranged for the HMR report to be sent to the outpatient department clinic to enable assessment of outcomes at the outpatient department follow-up 12 weeks post-discharge. Main outcome measure: GP HMR referral rates. Results 90 patients were offered the service. Fifty-nine patients (66%) agreed to have their GP contacted with 56 GPs agreeing to order a HMR and 41 patients having an HMR post-discharge. Barriers to the implementation of a HMR post-discharge included: patient withdrawal, low GP awareness of the HMR process and conducting the HMR in a timely manner. Conclusion This study provides evidence for the feasibility of a post-discharge pharmacy service for patients with heart failure although barriers to implementation have been identified.     

The effect on medication errors of pharmacists charting medication in an emergency department

Objective To determine the frequency and clinical significance of medication errors when (a) pharmacists elicit medication histories in the Emergency Department after medications have been prescribed by doctors and (b) pharmacists obtain and chart medication histories prior to doctors’ approval. Setting The Queen Elizabeth Hospital, a 350 bed South Australian teaching hospital, serving the local adult community. Method Emergency Department patients at risk of medication misadventure were recruited in two phases with a ‘usual practice’ arm (6 weeks) and a ‘pharmacist medication charting’ arm (5 weeks) reflecting an alternative intervention. In the ‘usual care’ arm, medication histories were compiled by a pharmacy researcher after a doctor had completed the medication chart. The researcher-elicited medication histories were compared with the doctors’ medication charts and unintentional discrepancies were recorded. In the ‘pharmacist medication charting’ arm, the same process was followed except the researcher compiled the patients’ medication histories at triage, prior to patients seeing a doctor. The medication history was then transcribed onto a medication chart for authorisation by a doctor. In addition, whether resolution of unintentional discrepancies for patients in the ‘usual care’ arm had occurred by discharge was determined by examining patients’ medical records. Main outcome measure Frequency of unintentional discrepancies and medication errors. Results The study included 45 and 29 patients in the ‘usual care’ and intervention arms, respectively. In the ‘usual care’ arm, 75.6% of patients had one or more unintentional discrepancies compared with 3.3% in the ‘pharmacist medication charting’ arm. This resulted in an average of 2.35 missed doses per patient in the ‘usual care’ arm and 0.24 in the intervention arm. In addition, an average of 1.04 incorrect doses per patient were administered in the ‘usual care’ arm and none in the ‘pharmacist medication charting’ arm. The differences observed between the arms were statistically significant (P < 0.05) and deemed clinically significant by a multidisciplinary panel. Conclusion This study provides evidence for pharmacists eliciting medication histories to prepare medication charts at the earliest possible opportunity following a patient’s presentation to the Emergency Department     

Effects of a three party healthcare network on the incidence levels of drug related problems

Background Drug related problems (DRPs) are impairing patients’ health and cause high costs. Neither delegation of home medication review nor regular pharmaceutical care are common in Germany. Objective We aimed to reduce several DRP by the implementation of a three party healthcare team [AGnES-practice assistant, pharmacist, general practitioner (GP)] and adherence supporting strategies (using a medication reminder chart, medication compliance aid). Setting The setting was ambulatory primary healthcare in German rural areas with a cohort of home-dwelling, elderly, mostly multimorbid patients with limited mobility (study period: 06/2006–12/2008). Methods We conducted a prospective non-randomized implementation cohort study with home medication review (home medication review module; mean participation time: 9 months). Data collection was delegated to additionally qualified AGnES-practice assistants (AGnES: GP-supporting, community-based, e-health-assisted systemic intervention). The intervention comprised pharmaceutical care by the local pharmacy in addition to medical interventions by the GP. 408 patients (mean age: women: 80.7 years; men: 75.3 years) received both pharmaceutical care and at least one follow-up visit. Main outcome measurement Outcome measurements comprised self-reported DRPs, objectively evaluated DRP, and prevalence of adherence supporting strategies. Results The three party healthcare team approach reduced self-reported forgetfulness (7.7–3.2 %; p = 0.001), the proportion of patients with intermittent drug intake (5.3–1.3 %; p < 0.001), and the proportion of patients with potentially clinical relevant drug–drug interaction (61.6–51.2 %; p < 0.001). Self-reported adverse drug reactions decreased non-significantly (5.4–4.6 %; p = 0.564; all tests χ²-McNemar). The median number of active substances taken was reduced from 8 to 7 (p < 0.001; Wilcoxon signed rank test). The proportions of patients using medication charts and compliance aids increased significantly (75.2–90.3 %; p < 0.001) and (70.0–80.1 %; p > 0.001), respectively. Conclusion This is the first study evaluating effects of a three party team on DRPs in a primary healthcare setting in Germany. This approach led to reduction in the occurrence of several DRPs and improved adherence supporting strategies. However, the study is a pre-post analysis, and had no control group.     

GPs’ views on patient drug use and the pharmacist’s role in DRP management

Objective The aim of this study was to examine general practitioners’ (GPs’) views on (1) patients’ drug-related problems (DRPs) and noncompliance and (2) the role of pharmacy practitioners in DRP management. Method A brief questionnaire was designed and distributed to 224 GPs in Sweden. Results Totally 152 GPs responded (68%). Most felt that pharmacy practitioners could improve patients’ drug use by identifying DRPs. A majority of the GPs also found presentations and analyses of their local pharmacies’ DRP documentation valuable. According to the GPs’ experiences, adverse drug effects and therapy failure were the most salient problems in patients’ drug use. Half of the doctors believed that 50–75% of their patients were compliant with their prescribed drug treatments. A majority of the GPs found a 75–95% degree of compliance acceptable. Conclusion The surveyed GPs demonstrated very positive attitudes towards the role of pharmacy practitioners in improving patients’ drug use and managing DRPs. The GPs realised that many patients were not compliant with their prescribed drug treatments and accepted an imperfect compliance.     

Pharmaceutical care for patients with ischemic stroke: improving the patients quality of life

Objectives To improve patients health-related quality of life (HQL) after transient ischemic attack (TIA) or ischemic stroke; to guarantee an effective secondary prevention; to increase the patient’s satisfaction with recommendations regarding their medication by pharmacists. Setting Stroke Unit, neurological ward at the Klinikum Fulda, rehabilitation hospitals and community-based pharmacies in the region of Fulda, Germany. Method Patients with TIA or ischemic stroke were included. The patients were assigned to an intervention group (IG) or a control group (CG). The individual assignment of patients to IG or CG was based on the type of the local pharmacy to which patients belong. Community-based pharmacies either delivered standard care (CG) or provided additional intensified pharmaceutical care (PC; IG). Pharmacies delivering PC belong to a pre-existing “Quality Assurance Working Group” (QAWG). To evaluate the patient’s HQL, the Short Form-36 (SF-36) was used at study entry in hospital and at 12 months. The secondary prevention was documented at study entry in hospital and at 12 months. The patients’ satisfaction was measured by a questionnaire at the end of the study. Main outcome measures Patients’ HQL; secondary prevention; patients’ satisfaction with recommendations of the pharmacists with regards to their medication. Results Out of 1316 patients screened for participation in this study, 255 were recruited with 90/255 patients assigned to the IG and 165/255 patients assigned to the CG. During the study, the HQL of the patients in the IG did not change significantly. A significant decrease in the HQL was observed for the CG in 7/8 subscales and in both summary measures of the SF-36. After 12 months, 85.3% of the patients in the IG and 86.3% of the patients in the CG were treated with antiplatelet drugs or oral anticoagulants in accordance to treatment guidelines. Patients in the IG were significantly more satisfied with the individualized recommendations of the pharmacists than patients in the CG. Conclusion Our findings indicate that an intensified PC of patients after ischemic stroke by dedicated pharmacists may have a positive impact on HQL and patients’ satisfaction. PC in this study had no impact on adherence to secondary prevention medication.     

Investigation of the Drug–Drug Interaction Between α-Lipoic Acid and Valproate via Mitochondrial β-oxidation

Purpose  To investigate the potential drug–drug interaction (DDI) between lipoic acid (LA) and valproate (VA) via the mitochondrial β-oxidation pathway in rats. Methods   In vitro mitochondrial assays were performed to compare the biotransformation of VA to valproyl-CoA (VA-CoA), in the absence and presence of LA. In vitro microsomal and protein binding assays were performed to elucidate their potential DDI at the microsomal metabolism and distribution levels. A pharmacokinetic study was conducted in Lister Hooded rats to ascertain the in vivo DDI between LA and VA. Results  LA was shown to decrease significantly (p < 0.05) the in vitro formation of VA-CoA in a concentration-dependent manner. Our in vitro assay results confirmed that there was minimal interaction between LA and VA in microsomal metabolism and protein binding. Based on the pharmacokinetic data, the absolute bioavailability of VA was determined to be 1.3 in the presence of LA. Conclusions  Our study demonstrated for the first time that there is a potential DDI between LA and VA at the mitochondrial β-oxidation level. While further clinical study is essential, our preliminary finding suggested that medical practitioners need to be prudent when managing epileptic patients who are co-administered with both VA and LA.     

Evaluating categorisation and clinical relevance of drug-related problems in medication reviews

Objectives We aimed to evaluate the categorisation and clinical relevance of DRPs identified by community pharmacists, and further, to assess the quality of interventions with the patients and the physicians as documented by the pharmacists. Setting 23 Norwegian community pharmacies. Method Patients with type 2 diabetes were recruited by 24 community pharmacists who performed structured medication reviews based on the patients’ drug profiles and patient interviews. The DRPs identified were subsequently categorised. An evaluation group (EG) retrospectively evaluated the reviews. Clinical/practical relevance of each DRP and quality of community pharmacists’ intervention with patients and physician were scored. Average agreement between the EG and the community pharmacists was calculated. Internal agreement in the EG was calculated using a modified version of Fleiss’ Kappa coefficient. Results A total of 73 patients were included (mean age 62 years, 52% female, on average prescribed 8.7 drugs). The pharmacists identified 88 DRPs in 43 of the patients. The most common DRPs were adverse drug reactions (22%) and wrong drug or dose used by patient (14%). Anti-diabetic drugs and lipid modifying drugs were associated with the most DRPs. The EG agreed with detection and categorisation of DRPs in more than 80% of the cases. The clinical/practical relevance of the detected DRPs was scored by the EG to be high or medium in 87% of the cases. The quality of the follow-up with patients and physicians was scored to be good or satisfactory in 93 and 98% of the cases, respectively. Conclusions Pre-defined categories of DRPs supported by structured forms were reliable and valid tools for identifying DRPs. The evaluation demonstrated that community pharmacists were able to identify DRPs of high to medium clinical/practical relevance, and to perform follow-ups of the DRPs with the patients and the physicians with a good or satisfactory quality.     

Understanding the meaning of medications for patients: The medication experience

Objective: To understand and describe the meaning of medications for patients. Methods: A metasynthesis of three different, yet complementary qualitative research studies, was conducted by two researchers. The first study was a phenomenological study of patients’ medication experiences that used unstructured interviews. The second study was an ethnographic study of pharmaceutical care practice, which included participant observation, in-depth interviews and focus groups with patients of pharmaceutical care. The third was a phenomenological study of the chronic illness experience of medically uninsured individuals in the United States and included an explicit aim to understand the medication experience within that context. The two researchers who conducted these three qualitative studies that examined the medication experience performed the meta-synthesis. The process began with the researchers reviewing the themes of the medication experience for each study. The researchers then aggregated the themes to identify the overlapping and similar themes of the medication experience and which themes are sub-themes within another theme versus a unique theme of the medication experience. The researchers then used the analytic technique, “free imaginative variation” to determine the essential, structural themes of the medication experience. Results: The meaning of medications for patients was captured as four themes of the medication experience: a meaningful encounter; bodily effects; unremitting nature; and exerting control. The medication experience is an individual’s subjective experience of taking a medication in his daily life. It begins as an encounter with a medication. It is an encounter that is given meaning before it occurs. The experience may include positive or negative bodily effects. The unremitting nature of a chronic medication often causes an individual to question the need for the medication. Subsequently, the individual may exert control by altering the way he takes the medication and often in part because of the gained expertise with the medication in his own body. Conclusion: The medication experience is a practice concept that serves to understand patients’ experiences and to understand an individual patient’s medication experience and medication-taking behaviors in order to meet his or her medication-related needs.     

Development of an evidence-based checklist for the detection of drug related problems in type 2 diabetes

Objective To develop an evidence-based checklist to identify potential drug related problems (PDRP) in patients with type 2 diabetes. Setting The evidence based checklist was applied to records of ambulatory type 2 diabetes patients in New South Wales, Australia. Method After comprehensive review of the literature, relevant medication groups and potential drug related problems in type 2 diabetes were identified. All the relevant information was then structured in the form of a checklist. To test the utility of the evidence-based checklist a cross-sectional retrospective study was conducted. The PDRP checklist was applied to the data of 148 patients with established type 2 diabetes and poor glycaemic control. The range and extent of DRPs in this population were identified, which were categorized using the PCNE classification. In addition, the relationship between the total as well as each category of DRPs and several of the patients’ clinical parameters was investigated. Main outcome measure: Number and category of DRPs per patient. Results The PDRP checklist was successfully developed and consisted of six main sections. 682 potential DRPs were identified using the checklist, an average of 4.6 (SD = 1.7) per patient. Metabolic and blood pressure control in the study subjects was generally poor: with a mean HbA1c of 8.7% (SD = 1.5) and mean blood pressure of 139.8 mmHg (SD = 18.1)/81.7 mmHg (SD = 11.1). The majority of DRPs was recorded in the categories ‘therapy failure’ (n = 264) and ‘drug choice problem’ (n = 206). Potentially non-adherent patients had a significantly higher HbA1c than patients who adhered to therapy (HbA1c of 9.4% vs. 8.5%; P = 0.01). Conclusion This is the first tool developed specifically to detect potential DRPs in patients with type 2 diabetes. It was used to identify DRPs in a sample of type 2 diabetes patients and demonstrated the high prevalence of DRPs per patient. The checklist may assist pharmacists and other health care professionals to systematically identify issues in therapy and management of their type 2 diabetes patients and enable earlier intervention to improve metabolic control.     

Relationship between drug-related problems and health outcomes: a cross-sectional study among cardiovascular patients

Objective To describe drug-related problems (DRPs) and expense problems (EPs) identified by a standardised community pharmacist-based medication review (MR) program among Swiss cardiovascular outpatients (56–75 years old) and to evaluate the need for collaborative pharmacy practice to achieve economic, clinical and humanistic outcomes. Setting A pilot population of 85 cardiovascular outpatients who were customers of 14 community pharmacies (members of the pharmacieplus virtual chain) and insured with Groupe Mutuel health insurance. Method Cross-sectional study of a structured medication review program, conducted by 11 pharmacists in collaboration with 61 general practitioners (GPs), with patient interviews and access to medical data. Main outcome measure Numbers and types of DRPs and EPs within the study population and odds ratios between them, as well as economic, clinical and humanistic outcomes. Results Of the included patients, 91% had at least one DRP or EP. The odds ratios indicated that not being exposed to DRPs was associated with a higher chance of reaching the clinical target (OR: 3.4; IC95%:1.1–10.5; P = 0.01), of having a better physical quality of life than the median (OR: 2.5; IC95%:0.9–7.3; P = 0.05) and having lower total health care costs (OR: 3.2; IC95%:1.1–9.8; P = 0.02). Conclusions This cross-sectional study shows that the control of cardiovascular risk factors, quality of life and healthcare costs are statistically related to the presence of DRPs detected by a community pharmacist-based MR program.     

Pharmacist-initiated general practitioner referral of patients with suboptimal asthma management

Objective To assess the impact of an intervention initiated by community pharmacists, involving the provision of educational material and general practitioner (GP) referral, on asthma knowledge and self-reported asthma control and asthma-related quality of life (QOL) in patients who may have suboptimal management of their asthma, as evidenced by pharmacy dispensing records. Setting Community pharmacies throughout Tasmania, Australia. Methods Forty-two pharmacies installed a software application that data mined dispensing records and generated a list of patients with suboptimal asthma management, as indicated by having three or more canisters of inhaled short-acting beta-2-agonists dispensed in the preceding 6 months. Identified patients were randomised to an intervention or control group. At baseline, intervention patients were mailed intervention packs consisting of a letter encouraging them to see their GP for a review, educational material, asthma knowledge, asthma control and asthma-related QOL questionnaires, and a letter with a dispensing history to give to their GP. Pharmacists were blinded to the control patients’ identities for 6 months, after which time intervention patients were sent repeat questionnaires, and control patients were sent intervention packs. Main outcome measures Asthma knowledge, asthma control and asthma-related QOL scores. Results Thirty-five pharmacies completed the study, providing 706 intervention and 427 control patients who were eligible to receive intervention packs. Intervention patients’ asthma control and asthma-related QOL scores at 6 months were significantly higher compared to the control patients (P < 0.01 and P < 0.05, respectively) and to the intervention patients’ baseline scores (P < 0.001 and P < 0.05, respectively). Symptom-related QOL was significantly higher compared to the control patients (P < 0.01) and activities-related QOL significantly improved compared to baseline (P < 0.05). No significant change was observed in asthma knowledge. Conclusion The results suggest that community pharmacists are ideally placed to identify patients with suboptimal asthma management and refer such patients for a review by their GP. This type of collaborative intervention can significantly improve self-reported asthma control and asthma-related QOL in patients identified as having suboptimal management of their asthma. A larger trial is needed to confirm the effects are real and sustained.     

Antiretroviral adherence program in HIV patients: a feasibility study in the Swiss HIV Cohort Study

Objective To evaluate the feasibility of a comprehensive, interdisciplinary adherence program aimed at HIV patients. Setting Two centers of the Swiss HIV Cohort Study: Lausanne and Basel. Method 6-month, pilot, quasi-experimental, 2-arm design (control and intervention). Patients starting a first or second combined antiretroviral therapy line were invited to participate in the study. Patients entering the intervention arm were proposed a multifactorial intervention along with an electronic drug monitor. It consisted of a maximum of six 30-min sessions with the interventionist coinciding with routine HIV check-up. The sessions relied on individualized semi-structured motivational interviews. Patients in the control arm used directly blinded EDM and did not participate in motivational interviews. Main outcome measures Rate of patients’ acceptance to take part in the HIV-adherence program and rate of patients’ retention in this program assessed in both intervention and control groups. Persistence, execution and adherence. Results The study was feasible in one center but not in the other one. Hence, the control group previously planned in Basel was recruited in Lausanne. Inclusion rate was 84% (n = 21) in the intervention versus 52% (n = 11) in the control group (P = 0.027). Retention rate was 91% in the intervention versus 82% in the control group (P = ns). Regarding adherence, execution was high in both groups (97 vs. 95%). Interestingly, the statistical model showed that adherence decreased more quickly in the control versus the intervention group (interaction group × time P < 0.0001). Conclusion The encountered difficulties rely on the implementation, i.e., on the program and the health care system levels rather than on the patient level. Implementation needs to be evaluated further; to be feasible a new adherence program needs to fit into the daily routine of the centre and has to be supported by all trained healthcare providers. However, this study shows that patients’ adherence behavior evolved differently in both groups; it decreased more quickly over time in the control than in the intervention group. RCTs are eventually needed to assess the clinical impact of such an adherence program and to verify whether skilled pharmacists can ensure continuity of care for HIV outpatients.     

A new probabilistic rule for drug–dug interaction prediction

An innovative probabilistic rule is proposed to predict the clinical significance or clinical insignificance of DDI. This rule is coupled with a hierarchical Bayesian model approach to summarize substrate/inhibitor’s PK models from multiple published resources. This approach incorporates between-subject and between-study variances into DDI prediction. Hence, it can predict both population-average and subject-specific AUCR. The clinically significant DDI, weak DDI, and clinically insignificant inhibitions are decided by the probabilities of predicted AUCR falling into three intervals, (−∞, 1.25), (1.25, 2), and (2, ∞). The main advantage of this probabilistic rule to predict clinical significance of DDI over the deterministic rule is that the probabilistic rule considers the sample variability, and the decision is independent of sampling variation; while deterministic rule based decision will vary from sample to sample. The probabilistic rule proposed in this paper is best suited for the situation when in vivo PK studies and models are available for both the inhibitor and substrate. An early decision on clinically significant or clinically insignificant inhibition can avoid additional DDI studies. Ketoconazole and midazolam are used as an interaction pair to illustrate our idea. AUCR predictions incorporating between-subject variability always have greater variances than population-average AUCR predictions. A clinically insignificant AUCR at population-average level is not necessarily true when considering between-subject variability. Additional simulation studies suggest that predicted AUCRs highly depend on the interaction constant K _i and dose combinations.     

Exploring patients’ perspectives of pharmacist supplementary prescribing in Scotland

Aim The aim of this study was to explore patients’ perspectives and experiences of pharmacist supplementary prescribing (SP) in Scotland. Method A survey in primary and secondary care in Scotland. Pharmacist supplementary prescribers (n = 10) were purposively selected across Scotland. All pharmacists distributed questionnaires to 20 consecutive patients as they attended appointments during October to December 2006. Reminders were mailed to all 20 patients by each pharmacist 2 weeks after initial distribution. Main outcome measures The questionnaire contained items on: attitudes towards pharmacist SP derived from earlier qualitative research; consultation satisfaction derived from a validated scale developed initially for general practitioners, with the term ‘doctor’ being replaced by ‘pharmacist prescriber’; and demographics. Closed and Likert scales were used as response options. Results One pharmacist withdrew. The patient response rate was 57.2% (103/180). The median age was 67 years (interquartile range 56.5–73 years), with 53.4% being female. Most (76, 73.8%) consulted with the pharmacist in a general practice setting. Patients reported positive consultation experiences with 89.3% agreeing/strongly agreeing that they were satisfied with the consultation, 78.7% thought the pharmacist told them everything about their treatment and 72.9% felt the pharmacist was interested in them as a person. Most patients were positive in their attitudes, agreeing that they would recommend a pharmacist prescriber to others and that they had trust in the pharmacist. However, 65% would prefer to consult a doctor. Conclusion Most patient respondents were satisfied with, and had a positive attitude towards, pharmacist prescribing consultations. However, most patients would still elect to see a doctor given the choice.