Prescription memory: Is it time to change the script?

We are all familiar with the term ‘muscle memory’. Obviously, this does not refer to a ‘memory’ in the usual sense, within the muscular system of the body; it simply refers to the fact that as an action is rehearsed and becomes familiar, it becomes automatic and no longer requires conscious effort, and as a consequence is easier to achieve because it has been learned. Technically, it usually involves consolidating a motor task – and is thus a form of procedural memory that is also sometimes referred to as motor memory. It has a complex basis that involves the imprinting of emotion on memory and decision-making (Tyng et al., 2017). Day to day it serves an essential function and is thought to make tasks such as driving, typing and playing certain sports and musical instruments easier and more efficient.

In a similar vein, we propose the novel term ‘prescription memory’, to refer to the prescription of medications because of habit and familiarity rather than case-by-case deliberation. This is not to say that no thought is put into deciding which medication to prescribe, because the decision is undoubtedly informed by knowledge and clinical experience when first formulated. However, in this context, prescription memory (PM) refers to pursuing rehearsed prescribing patterns rather than thinking anew and truly engaging with alternatives and different possibilities for optimally tailored care. In practice, busy clinicians are tempted to make prescription decisions because of a patient’s diagnosis – which automatically brings to mind certain possibilities and their prior experience with specific medications, and this understandably results in some medications being ‘favoured’. Clinically, this is an important problem because it can limit consideration of salient factors that may inform an evidence-based decision.

Thought processes that are necessary to make a reasoned decision require free will and choice and are thought to be linked to the concept of moral responsibility (Tyng et al., 2017). This does not suggest that by prescribing a set choice one is not exercising moral responsibility or being ethical, but by not re-evaluating various options and exercising choice on every occasion, perhaps best practice is not always being followed, and this may be perceived as unethical. Importantly, careful consideration and thought may not ultimately change what is actually prescribed or how things are managed, but by not exercising choice and considering various options and alternatives, something may be lost in the therapeutic process. This is the risk inherent in PM which may also limit versatility in dosing and the employment of different strategies. Furthermore, PM may also thwart the efforts of clinicians both to keep abreast of therapeutic advances in their field and to tailor therapy to subtypes of illness.

In most cases, PM is learned because the doctor has become familiar with prescribing certain medications and these appear to be effective in their particular ‘hands’ and this is appealing. It may also reflect limited access to various medications in certain settings or jurisdictions of care. Naturally, the more experience a doctor gains in prescribing a particular medication, the more PM is reinforced. One could argue that PM is beneficial in this regard, as doctors gain extensive experience of certain molecules, in regard to both efficacy and tolerability (i.e. side effects), which in practice is often equally problematic as medications not having the desired effect (Papakostas et al., 2007).

Alas, as with many matters in medicine, not everything is clear cut. And so, while PM is limiting in some regards, it also constitutes experience. Nevertheless, some degree of consideration of alternatives should be part of the prescription process, especially at the outset of treatment where there is an abundance of choice and treatment can be nuanced and tailored. An over reliance on PM is likely to hinder individualised interactions with each and every patient, in which an examination of their preferences and concerns leads to Shared Decision Making, better adherence to treatment and therapeutic advice in general.

One consequence of PM, and the repeated prescription of similar agents, is that the adoption of new and improved agents is likely to be much slower. This may mean that the implementation of advances is slowed, and in reality, the actual range and breadth of treatments on offer remains limited. This limitation has its own pros and cons, in that newer is not always better, but at the same time, adherence to treatments that have clearly been surpassed is equally unhelpful (Bauer et al., 2008).

Ultimately, the objective evaluation of prescribing options is difficult when the emotional impact of prior experience, expanding pharmacological complexity, peer-group practices, lack of experience with very old or very new medications, pressures from pharmaceutical companies and cost are present (Grant et al., 2013). The drive to exert critical examination of the prescribing options, including the willingness to examine new and/or unfamiliar options, is easily submerged but vital to optimal treatment. The final decision requires a willingness to reflect objectively upon the available options and challenge the ‘automatic’ selections driven by habit and confounding processes such as the pressures of limited time. Surely, it’s time to change the script.