Table 1
A glossary of terms used in this paper.
| TERM | DEFINITION |
|---|---|
| MEDICAL GENERALISM | An illness approach that considers the patient’s whole health and well-being, not just their symptoms; it is holistic and adaptable [19]. It is a particular skill of physicians and can be practiced by all specialties, not only general practitioners [19, 20]. |
| INTERPRETIVE PRACTICE | The critical, thoughtful, professional use of an appropriate range of knowledges in the dynamic, shared exploration and interpretation of individual illness experience, in order to support the creative capacity of individuals in maintaining their daily lives [21]. |
| PROBLEMATIC POLYPHARMACY (PP) | Polypharmacy denotes the use of ≥5 medications simultaneously; this can be appropriate. Problematic polypharmacy describes the situation where the intended benefits from the use of multiple medications are not realised [4]. |
| MEDICINES OPTIMISATION (MO) | ‘A person centred approach to safe and effective medicines use, to ensure people obtain the best possible outcomes from their medicines’ [9]. N.B. In North America this term may be conflated with medicines intensification. This is not how the term is used in this paper. |
| DEPRESCRIBING | ‘The supervised withdrawal of potentially inappropriate medication; it is a planned, supervised process of dose reduction or the stopping of medicines that may be causing harm or conferring no additional benefit with the goal of managing polypharmacy and improving outcomes’ [2]. |
| MECHANISM | In realist evaluation, underlying processes that are real but usually hidden, which operate in particular contexts to generate outcomes of interest [22]. |
| CONTEXT, (INTERVENTION), MECHANISM, OUTCOME CONFIGURATION (C(I)MOC) | A heuristic, in the form of a statement or diagram that spells out the relationship between particular features of context, particular mechanisms and particular outcomes [22]. Intervention may be added to the configuration to form a CIMOC to avoid conflation between context and intervention. |
| PROGRAMME THEORY (PT) | A hypothesis, developed through realist research via primary or secondary data to explain how a programme works to produce outcomes [23]. |
Table 2
Details of interviewees. Please note that most interviewees had split job roles and taught healthcare professionals alongside research, administrative or policy roles.
| CATEGORY | DETAILS |
|---|---|
| NUMBER OF PARTICIPANTS | 16 |
| MEDIAN INTERVIEW DURATION | 55 minutes |
| GENDER DISTRIBUTION | Male: 9, Female: 7 |
| GEOGRAPHIC REPRESENTATION | All devolved nations of the UK (England, Scotland, Wales, Northern Ireland) |
| PROFESSIONAL BACKGROUND | Pharmacists: 6, Physicians: 10 |
| UNIVERSITY AFFILIATIONS | 12 UK universities represented; 10 interviewees held professorial chairs |
| ORGANISATIONAL AFFILIATIONS | The majority of interviewees held senior committee membership: NHS England, National Institute of Health and Care Research, Royal Pharmaceutical Society, British Pharmacological Society, Prescribing Safety Assessment, Medical Schools Council, and others. |
| EXPERTISE AREAS | Prescribing safety, polypharmacy, medicines optimisation (including deprescribing and systematic medication reviews, within clinical practice or education), clinical reasoning, behaviour change, interpretive generalist medical practice, clinical pharmacology and therapeutics education, assessment in medical education. |
| PROFESSIONAL LEARNER GROUPS TAUGHT | Physicians/medical students: 12 Pharmacists/pharmacy students: 4 Allied health professionals: 6 Interviewees frequently taught >1 professional group. |
Figure 1
Partial programme theory #1: Prioritisation, perceptions of value (that is importance) and engagement. Black arrows suggest how one element might influence another. The national context will influence the institutional context which will influence the individual learner context.
Figure 2
Partial programme theory #2: Prerequisites, a place to trial and reflect and a community of practice. Each oval represents a programme intervention element; the areas of overlap represent resource or response mechanisms.
Figure 3
Partial programme theory #3: An interprofessional generalist community of practice prioritising routine medicines optimisation. The circles represent broader outcomes with more specific outcomes at the areas of overlap.
Figure 4
Diagram of the overall programme theory explaining the generation of outcomes from MO educational programmes at the undergraduate level. The diagram uses all 35 CMOC en masse and is designed to demonstrate the links between the three partial programme theories (Figures 1, 2, and 3). Mechanisms within the yellow area are those provided by the intervention’s resources. The mechanisms in lilac are learners’ responses to those resources. MO: medicines optimisation.
Table 3
Transferable insight resulting from an understanding of the workings of MO educational interventions at the undergraduate level.
| INSIGHT |
|---|
1. Education seeking to integrate interpretive principles into decision-making embedded in the biomedical approach must be valued by learners to garner the engagement necessary for learning
|
2. Education seeking to enable students to integrate interpretive medical practice principles with the biomedical agenda should be sufficiently aligned with the culture experienced within educational institutions and the workplace so as not to be rejected by learners
|
3. Learners need to feel they have permission to practice according to interpretive principles when healthcare structures may be organised to the contrary
|