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Understanding medical overuse: the case of problematic polypharmacy and the potential of ethnography

Understanding medical overuse: the case of problematic polypharmacy and the potential of ethnography The problem of medical overuse Medical overuse is increasingly highlighted as a significant problem in contemporary health care. Attention globally is focusing on the possible harms and avoidable waste of ‘too much medicine’ (1), such as the OECD’s recent report on the need to tackle wasteful health care spending such as diagnostic tests and interventions which offer patients little or no benefit (2). Terms such as overdiagnosis, overtreatment and overuse are not straightforward to define (3,4) and encompass a range of different kinds of medical overactivity. Concerns initially focused on cancer screening but now extend to a wide range of clinical activities (5). For example, making a diagnosis which may be ‘correct’ according to current standards, but for which existing treatment offers little or no benefit may cause undue anxiety and may result in harm (e.g. from treatment side effects or the perceived need for ongoing monitoring) (6). A recently published review of ongoing studies of overdiagnosis across medical disciplines showed that approximately half were in oncology, but the scope of this work also extends into areas such as mental disorders, infectious diseases and cardiovascular disease (7). The potential consequences of overuse may be significant and include such harms as the psychological and behavioural effects of disease labelling, physical harms and side effects of unnecessary tests or treatments, the ‘burden of treatment’ (8) negatively affecting quality of life, increased financial costs to individuals and wasted resources and opportunity costs to the health system (6,9,10). Balancing under and over use Alongside these potential harms from overuse lie those which may arise from ‘too little’ rather than ‘too much’ medicine: in the words of Iona Heath, past president of the UK’s Royal College of General Practitioners, ‘overdiagnosis of the well and undertreatment of the sick are the conjoint twins of modern medicine’ (9). The Lancet Right Care series has sought to show how underuse and overuse of medical and health services typically exist side-by-side, with each bringing poor outcomes for patients (11). Contributions examine the extent of overuse and underuse worldwide (12,13), consider the drivers of poor care (14), and seek to identify means through which they might be tackled (15). The desire to identify both drivers and possible solutions is a common theme in relation to overuse. In an effort to develop a comprehensive overview, recent work from Australia has mapped the possible drivers into broad categories and linked them to their respective potential solutions (16). The majority of articles included in the mapping exercise described above were analyses or commentaries rather than empirical studies (although the authors state that many of the analysis pieces were informed by empirical work) and articles were selected because of their explicit attention to ‘drivers’ and ‘responses’ (or ‘solutions’). Although there may be considerable merit in these findings, further empirical work is needed to understand whether, how and to what extent such ‘drivers’ play out in practice, in which contexts they may be more (or less) relevant, and how these (and possibly other) drivers may be interconnected and mutually reinforcing. Without this subtle and nuanced understanding of how the balance between under- and overuse can go awry, calls for health care professionals at the frontline to be better equipped to minimize under- and overuse and to manage the tension between them are likely to be frustrated (17). Problematic polypharmacy Polypharmacy is one manifestation of overuse. It is of particular relevance to primary care since General Practitioners and community pharmacists may be well placed to work with patients, carers and other professionals to raise awareness of the potential pitfalls of polypharmacy and take action when it is thought to represent overuse. Polypharmacy refers to the concurrent use of four or more medicines by one person. Although this is often necessary, it becomes ‘problematic’ when multiple medicines are prescribed inappropriately or the intended benefits are not realized (18). Those coining the term ‘problematic’ polypharmacy cite a range of possible reasons for it including treatments not being evidence-based; risk of harm exceeding potential benefits; and cascade prescribing (when one medication is prescribed to treat the side effect of another). One substantial challenge faced by clinicians is that evidence produced from randomized controlled trials, which is typically organized around a ‘single disease’ model, can rarely be usefully interpreted in the context of a patient with multimorbidity and polypharmacy. Polypharmacy in the context of multimorbidity is rarely, if ever, ‘evidence-based’, even when a clear argument can be made for the prescription of individual items. This is particularly challenging in older patients as inter-individual variability in health, disease and disability increases with age (the principle of aged heterogeneity) (19). In this context, it becomes even harder to draw generalized conclusions about prescribing (of single items, let alone drug combinations) for particular individuals (20). Clinicians face considerable uncertainty as they balance competing prescribing priorities and integrate these into overall goals of care which may be more far-reaching (21,22). The rise in evidence-based medicine coupled with an emphasis on eliminating risk of disease has together contributed to the current predicament of ‘too much medicine’, in which privileging one set of priorities for risk reduction has contributed, paradoxically (and at great cost), to new drug-related risks. Polypharmacy, as with many instantiations of overuse, is a ‘wicked problem’ arising at the interface of patients, clinicians and diseases and encompassing cultural, technological, economic and sociopolitical dimensions (23) unlikely to be amenable to ‘quick fix’ solutions. Medication reviews provide an opportunity for shared decision-making and raise awareness that deprescribing may be possible, but are underused (24). However, even the most sophisticated shared decision-making in the clinical consultation—though important—may only be part of the answer, given that decision-making around medicines is often conducted in the home and family context. The potential of ethnography Ethnography, which is relatively little used in primary care, may offer valuable insights into polypharmacy through observing ‘real world’ practices of professionals, patients and their social networks in everyday settings, paying attention to wider contextual factors that sustain (or challenge) polypharmacy (25). A key focus of ethnography is on making explicit aspects of culture, practice, assumptions and beliefs which may not be readily articulated by informants in an interview study (26) and which may be regarded as mundane or ‘taken-for-granted’. It is driven by a curiosity to find out ‘What is happening here?’ or ‘What is being accomplished?’ with a focus on learning from the details of the particular or ‘telling case’ rather than on generalizations (27). It opens up the possibility of new understandings about how polypharmacy may emerge insidiously from a complex array of interconnected practices and social contexts, and how it may be sustained through routines and ‘ways of working’, even in the face of widely held understandings that it may indeed be problematic. It also offers opportunities to observe how patients and professionals negotiate difficult terrain. For the professional, this may include conversations fraught with uncertainty and ‘unknowables’ or judgments about stopping medicines prescribed by trusted colleagues. For patients, it may include observations of how and to what extent they have the capacity to accommodate medicines-taking into their daily lives, how they prioritize their medicines or whether and how they enter into conversations about medicines that are no longer wanted or no longer taken. With a focus on meaning-making, the aim is to go beyond simple description and offer interpretation—informed by theory—making polypharmacy visible in new ways and offering new concepts to ‘think with’ that may go some way towards addressing this complex phenomenon. Declaration Funding: Natalie Armstrong is supported by a Health Foundation Improvement Science Fellowship. Deborah Swinglehurst has funding from the National Institute for Health Research (NIHR) through a Clinician Scientist Award. Ethical approval: Not applicable for an editorial. Conflict of interest: Natalie Armstrong is an Associate Editor of this journal. Deborah Swinglehurst is Principal Investigator for the APOLLO-MM project: Addressing the Polypharmacy Challenge in Older People with Multimorbidity (www.polypharmacy.org.uk). References 1. BMJ . Too Much Medicine 2018 . http://www.bmj.com/too-much-medicine (accessed on 28 February 2018 ). 2. OECD . Tackling Wasteful Spending on Health . Organisation for Economic Co-operation and Development , 2017 . Paris: OECD Publishing. 3. Carter SM , Rogers W , Heath I , et al. The challenge of overdiagnosis begins with its definition . BMJ 2015 ; 350 : h869 . Google Scholar Crossref Search ADS PubMed 4. Brodersen J , Schwartz LM , Heneghan C , et al. Overdiagnosis: what it is and what it isn’t . BMJ Evid Based Med 2018 ; 23 ( 1 ): 1 – 3 . Google Scholar Crossref Search ADS PubMed 5. Hofmann B , Welch HG . New diagnostic tests: more harm than good . BMJ 2017 ; 358 : j3314 . Google Scholar Crossref Search ADS PubMed 6. Moynihan R , Doust J , Henry D . Preventing overdiagnosis: how to stop harming the healthy . BMJ 2012 ; 344 : e3502 . Google Scholar Crossref Search ADS PubMed 7. Jenniskens K , de Groot JAH , Reitsma JB , et al. Overdiagnosis across medical disciplines: a scoping review . BMJ Open 2017 ; 7 : e018448 . Google Scholar Crossref Search ADS PubMed 8. Mair FS , May CR . Thinking about the burden of treatment . BMJ 2014 ; 349 : g6680 . Google Scholar Crossref Search ADS PubMed 9. Heath I . Role of fear in overdiagnosis and overtreatment—an essay by Iona Heath . BMJ 2014 ; 349 : g6123 . Google Scholar Crossref Search ADS PubMed 10. Hicks LK . Reframing overuse in health care: time to focus on the harms . J Oncol Pract 2015 ; 11 ( 3 ): 168 – 70 . Google Scholar Crossref Search ADS PubMed 11. Lancet . Right Care Series 2017 . http://www.thelancet.com/series/right-care (accessed on 28 February 2018 ). 12. Brownlee S , Chalkidou K , Doust J , et al. Evidence for overuse of medical services around the world . Lancet 2017 ; 390 ( 10090 ): 156 – 68 . Google Scholar Crossref Search ADS PubMed 13. Glasziou P , Straus S , Brownlee S , et al. Evidence for underuse of effective medical services around the world . Lancet 2017 ; 390 ( 10090 ): 169 – 77 . Google Scholar Crossref Search ADS PubMed 14. Saini V , Garcia-Armesto S , Klemperer D , et al. Drivers of poor medical care . Lancet 2017 ; 390 ( 10090 ): 178 – 90 . Google Scholar Crossref Search ADS PubMed 15. Elshaug AG , Rosenthal MB , Lavis JN , et al. Levers for addressing medical underuse and overuse: achieving high-value health care . Lancet 2017 ; 390 ( 10090 ): 191 – 202 . Google Scholar Crossref Search ADS PubMed 16. Pathirana T , Clark J , Moynihan R . Mapping the drivers of overdiagnosis to potential solutions . BMJ 2017 ; 358 : j3879 . Google Scholar Crossref Search ADS PubMed 17. Kearney M , Treadwell J , Marshall M . Overtreatment and undertreatment: time to challenge our thinking . Br J Gen Pract 2017 ; 67 : 442 – 3 . Google Scholar Crossref Search ADS PubMed 18. Duerden M , Avery T , Payne R. Polypharmacy and Medicines Optimisation: Making It Safe and Sound . London, UK : The King’s Fund , 2013 . https://www.kingsfund.org.uk/publications/polypharmacy-and- medicines-optimisation (accessed on 28 February 2018). 19. Nelson EA , Dannefer D . Aged heterogeneity: fact or fiction? The fate of diversity in gerontological research . Gerontologist 1992 ; 32 ( 1 ): 17 – 23 . Google Scholar Crossref Search ADS PubMed 20. Spinewine A , Schmader KE , Barber N , et al. Appropriate prescribing in elderly people: how well can it be measured and optimised ? Lancet 2007 ; 370 ( 9582 ): 173 – 84 . Google Scholar Crossref Search ADS PubMed 21. Fried TR , Tinetti ME , Iannone L . Primary care clinicians’ experiences with treatment decision making for older persons with multiple conditions . Arch Intern Med 2011 ; 171 : 75 – 80 . Google Scholar PubMed 22. Steinman MA , Hanlon JT . Managing medications in clinically complex elders: “There’s got to be a happy medium” . JAMA 2010 ; 304 ( 14 ): 1592 – 601 . Google Scholar Crossref Search ADS PubMed 23. Swinglehurst D , Fudge N . The polypharmacy challenge: time for a new script ? Br J Gen Pract 2017 ; 67 : 388 – 9 . Google Scholar Crossref Search ADS PubMed 24. Jansen J , Naganathan V , Carter SM , et al. Too much medicine in older people? Deprescribing through shared decision making . BMJ 2016 ; 353 : i2893 . Google Scholar Crossref Search ADS PubMed 25. Atkinson P , Hammersley M. Ethnography . 1st ed . London, UK : Routledge , 2007 , p. 288 . 26. Erickson F. Qualitative Methods in Research on Teaching . Vol Occasional Paper No. 81. Michigan : The Institute for Research on Teaching , 1985 . 27. Mitchell J. “Producing Data: Case Studies,” in Ethnographic Research: A Guide to General Conduct . London : Academic Press , 1984 . © The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Family Practice Oxford University Press

Understanding medical overuse: the case of problematic polypharmacy and the potential of ethnography

Natalie, Armstrong,; Deborah, Swinglehurst,
Family Practice , Volume 35 (5) – Sep 18, 2018
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Oxford University Press
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© The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
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0263-2136
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Abstract

The problem of medical overuse Medical overuse is increasingly highlighted as a significant problem in contemporary health care. Attention globally is focusing on the possible harms and avoidable waste of ‘too much medicine’ (1), such as the OECD’s recent report on the need to tackle wasteful health care spending such as diagnostic tests and interventions which offer patients little or no benefit (2). Terms such as overdiagnosis, overtreatment and overuse are not straightforward to define (3,4) and encompass a range of different kinds of medical overactivity. Concerns initially focused on cancer screening but now extend to a wide range of clinical activities (5). For example, making a diagnosis which may be ‘correct’ according to current standards, but for which existing treatment offers little or no benefit may cause undue anxiety and may result in harm (e.g. from treatment side effects or the perceived need for ongoing monitoring) (6). A recently published review of ongoing studies of overdiagnosis across medical disciplines showed that approximately half were in oncology, but the scope of this work also extends into areas such as mental disorders, infectious diseases and cardiovascular disease (7). The potential consequences of overuse may be significant and include such harms as the psychological and behavioural effects of disease labelling, physical harms and side effects of unnecessary tests or treatments, the ‘burden of treatment’ (8) negatively affecting quality of life, increased financial costs to individuals and wasted resources and opportunity costs to the health system (6,9,10). Balancing under and over use Alongside these potential harms from overuse lie those which may arise from ‘too little’ rather than ‘too much’ medicine: in the words of Iona Heath, past president of the UK’s Royal College of General Practitioners, ‘overdiagnosis of the well and undertreatment of the sick are the conjoint twins of modern medicine’ (9). The Lancet Right Care series has sought to show how underuse and overuse of medical and health services typically exist side-by-side, with each bringing poor outcomes for patients (11). Contributions examine the extent of overuse and underuse worldwide (12,13), consider the drivers of poor care (14), and seek to identify means through which they might be tackled (15). The desire to identify both drivers and possible solutions is a common theme in relation to overuse. In an effort to develop a comprehensive overview, recent work from Australia has mapped the possible drivers into broad categories and linked them to their respective potential solutions (16). The majority of articles included in the mapping exercise described above were analyses or commentaries rather than empirical studies (although the authors state that many of the analysis pieces were informed by empirical work) and articles were selected because of their explicit attention to ‘drivers’ and ‘responses’ (or ‘solutions’). Although there may be considerable merit in these findings, further empirical work is needed to understand whether, how and to what extent such ‘drivers’ play out in practice, in which contexts they may be more (or less) relevant, and how these (and possibly other) drivers may be interconnected and mutually reinforcing. Without this subtle and nuanced understanding of how the balance between under- and overuse can go awry, calls for health care professionals at the frontline to be better equipped to minimize under- and overuse and to manage the tension between them are likely to be frustrated (17). Problematic polypharmacy Polypharmacy is one manifestation of overuse. It is of particular relevance to primary care since General Practitioners and community pharmacists may be well placed to work with patients, carers and other professionals to raise awareness of the potential pitfalls of polypharmacy and take action when it is thought to represent overuse. Polypharmacy refers to the concurrent use of four or more medicines by one person. Although this is often necessary, it becomes ‘problematic’ when multiple medicines are prescribed inappropriately or the intended benefits are not realized (18). Those coining the term ‘problematic’ polypharmacy cite a range of possible reasons for it including treatments not being evidence-based; risk of harm exceeding potential benefits; and cascade prescribing (when one medication is prescribed to treat the side effect of another). One substantial challenge faced by clinicians is that evidence produced from randomized controlled trials, which is typically organized around a ‘single disease’ model, can rarely be usefully interpreted in the context of a patient with multimorbidity and polypharmacy. Polypharmacy in the context of multimorbidity is rarely, if ever, ‘evidence-based’, even when a clear argument can be made for the prescription of individual items. This is particularly challenging in older patients as inter-individual variability in health, disease and disability increases with age (the principle of aged heterogeneity) (19). In this context, it becomes even harder to draw generalized conclusions about prescribing (of single items, let alone drug combinations) for particular individuals (20). Clinicians face considerable uncertainty as they balance competing prescribing priorities and integrate these into overall goals of care which may be more far-reaching (21,22). The rise in evidence-based medicine coupled with an emphasis on eliminating risk of disease has together contributed to the current predicament of ‘too much medicine’, in which privileging one set of priorities for risk reduction has contributed, paradoxically (and at great cost), to new drug-related risks. Polypharmacy, as with many instantiations of overuse, is a ‘wicked problem’ arising at the interface of patients, clinicians and diseases and encompassing cultural, technological, economic and sociopolitical dimensions (23) unlikely to be amenable to ‘quick fix’ solutions. Medication reviews provide an opportunity for shared decision-making and raise awareness that deprescribing may be possible, but are underused (24). However, even the most sophisticated shared decision-making in the clinical consultation—though important—may only be part of the answer, given that decision-making around medicines is often conducted in the home and family context. The potential of ethnography Ethnography, which is relatively little used in primary care, may offer valuable insights into polypharmacy through observing ‘real world’ practices of professionals, patients and their social networks in everyday settings, paying attention to wider contextual factors that sustain (or challenge) polypharmacy (25). A key focus of ethnography is on making explicit aspects of culture, practice, assumptions and beliefs which may not be readily articulated by informants in an interview study (26) and which may be regarded as mundane or ‘taken-for-granted’. It is driven by a curiosity to find out ‘What is happening here?’ or ‘What is being accomplished?’ with a focus on learning from the details of the particular or ‘telling case’ rather than on generalizations (27). It opens up the possibility of new understandings about how polypharmacy may emerge insidiously from a complex array of interconnected practices and social contexts, and how it may be sustained through routines and ‘ways of working’, even in the face of widely held understandings that it may indeed be problematic. It also offers opportunities to observe how patients and professionals negotiate difficult terrain. For the professional, this may include conversations fraught with uncertainty and ‘unknowables’ or judgments about stopping medicines prescribed by trusted colleagues. For patients, it may include observations of how and to what extent they have the capacity to accommodate medicines-taking into their daily lives, how they prioritize their medicines or whether and how they enter into conversations about medicines that are no longer wanted or no longer taken. With a focus on meaning-making, the aim is to go beyond simple description and offer interpretation—informed by theory—making polypharmacy visible in new ways and offering new concepts to ‘think with’ that may go some way towards addressing this complex phenomenon. Declaration Funding: Natalie Armstrong is supported by a Health Foundation Improvement Science Fellowship. Deborah Swinglehurst has funding from the National Institute for Health Research (NIHR) through a Clinician Scientist Award. Ethical approval: Not applicable for an editorial. Conflict of interest: Natalie Armstrong is an Associate Editor of this journal. Deborah Swinglehurst is Principal Investigator for the APOLLO-MM project: Addressing the Polypharmacy Challenge in Older People with Multimorbidity (www.polypharmacy.org.uk). References 1. BMJ . Too Much Medicine 2018 . http://www.bmj.com/too-much-medicine (accessed on 28 February 2018 ). 2. OECD . Tackling Wasteful Spending on Health . Organisation for Economic Co-operation and Development , 2017 . Paris: OECD Publishing. 3. Carter SM , Rogers W , Heath I , et al. The challenge of overdiagnosis begins with its definition . BMJ 2015 ; 350 : h869 . Google Scholar Crossref Search ADS PubMed 4. Brodersen J , Schwartz LM , Heneghan C , et al. Overdiagnosis: what it is and what it isn’t . BMJ Evid Based Med 2018 ; 23 ( 1 ): 1 – 3 . Google Scholar Crossref Search ADS PubMed 5. Hofmann B , Welch HG . New diagnostic tests: more harm than good . BMJ 2017 ; 358 : j3314 . Google Scholar Crossref Search ADS PubMed 6. Moynihan R , Doust J , Henry D . Preventing overdiagnosis: how to stop harming the healthy . BMJ 2012 ; 344 : e3502 . Google Scholar Crossref Search ADS PubMed 7. Jenniskens K , de Groot JAH , Reitsma JB , et al. Overdiagnosis across medical disciplines: a scoping review . BMJ Open 2017 ; 7 : e018448 . Google Scholar Crossref Search ADS PubMed 8. Mair FS , May CR . Thinking about the burden of treatment . BMJ 2014 ; 349 : g6680 . Google Scholar Crossref Search ADS PubMed 9. Heath I . Role of fear in overdiagnosis and overtreatment—an essay by Iona Heath . BMJ 2014 ; 349 : g6123 . Google Scholar Crossref Search ADS PubMed 10. Hicks LK . Reframing overuse in health care: time to focus on the harms . J Oncol Pract 2015 ; 11 ( 3 ): 168 – 70 . Google Scholar Crossref Search ADS PubMed 11. Lancet . Right Care Series 2017 . http://www.thelancet.com/series/right-care (accessed on 28 February 2018 ). 12. Brownlee S , Chalkidou K , Doust J , et al. Evidence for overuse of medical services around the world . Lancet 2017 ; 390 ( 10090 ): 156 – 68 . Google Scholar Crossref Search ADS PubMed 13. Glasziou P , Straus S , Brownlee S , et al. Evidence for underuse of effective medical services around the world . Lancet 2017 ; 390 ( 10090 ): 169 – 77 . Google Scholar Crossref Search ADS PubMed 14. Saini V , Garcia-Armesto S , Klemperer D , et al. Drivers of poor medical care . Lancet 2017 ; 390 ( 10090 ): 178 – 90 . Google Scholar Crossref Search ADS PubMed 15. Elshaug AG , Rosenthal MB , Lavis JN , et al. Levers for addressing medical underuse and overuse: achieving high-value health care . Lancet 2017 ; 390 ( 10090 ): 191 – 202 . Google Scholar Crossref Search ADS PubMed 16. Pathirana T , Clark J , Moynihan R . Mapping the drivers of overdiagnosis to potential solutions . BMJ 2017 ; 358 : j3879 . Google Scholar Crossref Search ADS PubMed 17. Kearney M , Treadwell J , Marshall M . Overtreatment and undertreatment: time to challenge our thinking . Br J Gen Pract 2017 ; 67 : 442 – 3 . Google Scholar Crossref Search ADS PubMed 18. Duerden M , Avery T , Payne R. Polypharmacy and Medicines Optimisation: Making It Safe and Sound . London, UK : The King’s Fund , 2013 . https://www.kingsfund.org.uk/publications/polypharmacy-and- medicines-optimisation (accessed on 28 February 2018). 19. Nelson EA , Dannefer D . Aged heterogeneity: fact or fiction? The fate of diversity in gerontological research . Gerontologist 1992 ; 32 ( 1 ): 17 – 23 . Google Scholar Crossref Search ADS PubMed 20. Spinewine A , Schmader KE , Barber N , et al. Appropriate prescribing in elderly people: how well can it be measured and optimised ? Lancet 2007 ; 370 ( 9582 ): 173 – 84 . Google Scholar Crossref Search ADS PubMed 21. Fried TR , Tinetti ME , Iannone L . Primary care clinicians’ experiences with treatment decision making for older persons with multiple conditions . Arch Intern Med 2011 ; 171 : 75 – 80 . Google Scholar PubMed 22. Steinman MA , Hanlon JT . Managing medications in clinically complex elders: “There’s got to be a happy medium” . JAMA 2010 ; 304 ( 14 ): 1592 – 601 . Google Scholar Crossref Search ADS PubMed 23. Swinglehurst D , Fudge N . The polypharmacy challenge: time for a new script ? Br J Gen Pract 2017 ; 67 : 388 – 9 . Google Scholar Crossref Search ADS PubMed 24. Jansen J , Naganathan V , Carter SM , et al. Too much medicine in older people? Deprescribing through shared decision making . BMJ 2016 ; 353 : i2893 . Google Scholar Crossref Search ADS PubMed 25. Atkinson P , Hammersley M. Ethnography . 1st ed . London, UK : Routledge , 2007 , p. 288 . 26. Erickson F. Qualitative Methods in Research on Teaching . Vol Occasional Paper No. 81. Michigan : The Institute for Research on Teaching , 1985 . 27. Mitchell J. “Producing Data: Case Studies,” in Ethnographic Research: A Guide to General Conduct . London : Academic Press , 1984 . © The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

Journal

Family Practice – Oxford University Press

Published: Sep 18, 2018

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