Sociology and AMS

I have a love hate relationship with sociology. The hate part relates to Sociologists tending to be very academic, which I find mentally exhausting. They use big, jargonistic words. There is always some theory that you've never heard of before to consider. It's pretty much impossible to have a straightforward conversation about a topic, it's always deep and I'm often left feeling a bit simple because I don't always pick up on the concepts or understand what they're talking about. But I find that it's worth enduring this because whatever the topic under discussion, I always leave the conversation with something to think about. This is the very reason that I sought out having a Sociologist as my PhD supervisor - to make sure I don't accept the superficial but explore the broader context and interplay between varying constructs.

So seeing that the latest Purple Pen Podcast episode was Sociology and Antimicrobial Resistance with Prof Alex Broom made me very curious. And listening to it left me with a few points to ponder and consider more deeply that I thought I would write down to help me think them through. For me the learnings aren't necessarily to do with antimicrobials, but that's the thing about discussions with Sociologists, they take your mind down different rabbit holes that are fun to explore. I'm going to share my thoughts as they were presented in the podcast and provoked my thinking, so it's a bit disjointed.

What we often miss in health environments is how who we are really shapes our illness and what we experience

This has been one of my biggest learnings from my PhD and interviews with people managing cancer and coexisting chronic conditions. I went into it thinking about medication management mechanistically. That people are bound to experience issues with their medicines when they're going through cancer treatment because they get presented with a greater workload relating to managing their health, but have reduced capacity because of the effects of cancer and it's treatment. What I learned was how much someone's sense of identity and life experiences shapes their perception of this health experience. If someone has lived a life where they have lost a child and a husband and experienced a prolonged period of deep grief, then getting diagnosed with bowel cancer isn't necessarily seen as all that bad. If someone has suffered through the onset of MS that completely disrupted their career and life plans and set them on a path of self-management, then their approach to taking an active role in their breast cancer treatment is quite different from someone who only ever goes to the GP when they get sick. Health experiences are way more complex than health literacy.

Optimisation and judiciousness not just being about accuracy but actually being about responsibility. Then what we do becomes a moral question.

This was discussed in the context of how antimicrobial stewardship programs aren't just about getting the right antimicrobial to the right patient, but about society more broadly. There are two different approaches to AMS, or what I would consider marketing strategies. The typical one that is seen is AMS correcting misuse of antimicrobials, which is a fairly negative construct where prescribers feel constrained or disciplined and pharmacists (or others) get a bit stuck in the middle. Compare this to presenting AMS as an opportunity for care providers to act in the collective best interests of both the patient in front of them, and future generations. This allows people to demonstrate their professional commitment by taking action to contribute to the mission and do something positive. I think this quite obviously applies to all QUM; policing drug use compared to optimising medication outcomes for individuals and society as a whole.

if we approach AMS as a problem of behaviour management we risk missing the broader super structures that shape how people behave

This was discussed in the context of challenging the ideology of changing individual behaviour. Again, so relevant to broader medication management, in particular medication taking behaviour. Just the terms compliance and adherence demonstrate the emphasis that we place on individual behaviour. Yet, we're clearly failing to make much progress as rates of non-adherence have sat pretty consistently at around 50% for the past fifty years or so. We are not skilled at shaping medication taking behaviour, and  sometimes I wonder if as a profession we even really care. I mean, a hell of a lot more research has been conducted relating to quantifying the problem rather than understanding why it occurs. I believe that comes down to scientific disciplines like Pharmacy over-valuing quantitative and under-valuing qualitative research. The flow on from this is that most of the strategies we've implemented to address these issues focus on unintentional non-adherence, which is only about one third of the problem. But it's a bit hard to address intentional non-adherence when you don't understand it I guess. Much easier to ignore it and hope no one who funds services notices it's still a big problem.

misalignment of the values of the institution with the necessary values that would drive AMS

That might not be a direct quote, but it's what is generally spoken about at the 8'55 mark. It's discussed within the context of AMS being seen as a requirement from a governance perspective, so programs are put in place, stewards employed etc. But unless such programs are supported by the institution getting behind the approach and demonstrating that it is something they truly value and see as a way of achieving better outcomes it's pretty much a given that success will be limited. AMS is then seen as a tick box exercise for achieving accreditation. People don't take personal responsibility to contribute to the mission which prevents the desired goal from being achieved in a meaningful way. Again, this relates to so many aspects of pharmacy practice, and I can think of multiple examples of where I have been placed in this type of position where I've been tasked with implementing something but when it came down to it the support just wasn't there. And being in that position suuuuuucks.

culture articulates all the structures we need to work with in order to implement in real world settings

How many times have you read a journal article about an implementation project where the biggest barriers were noted to be cultural? I bet you most of them offer more education and training as a solution to overcoming this. Do you think that will work? No, me neither.

not about correction but motivating people that what they are doing is making a difference

This was in response to a question about how do you actually create an environment where doing the right thing becomes accepted, normalised behaviour. He talked about it coming down to feedback and reward systems that enable tracking without creating a sense of winners and losers. That cross-comparisons can be useful, but they are not always used in a positive, constructive way. When you think about this from a social justice perspective, reasons people don't feel motivated are that they're not understood, or they feel like their environment isn't conducive to achieving what's required. This is something that I've been thinking about a lot lately. Not information sources about antimicrobial use, but about how we can shift the culture toward that of an infinite rather than zero sum game. How do we build in constructs that make people feel valued, and motivate through progress and growth in contribution rather than inspiration and shame? What types of information would help to foster a culture where being the vanguards of QUM isn't about professional identity and tribalism, but social responsibility?

the risk is we're going to get more and more resources thrown in to identify what's wrong with what people are doing rather than what is right. And that's a big problem.

This! This pretty much sums up where I think we are at the moment with the Pharmacy profession. We're so focussed on using information about what's wrong and demonstrating all the problems relating to medication safety, and how much inappropriate prescribing there is in aged care, and everything else that justifies our role, and it becomes all consuming. Lets put energy into implementing innovative solutions, building a better culture, making real change.