RT Journal Article SR Electronic T1 Negotiating the polypharmacy paradox: a video-reflexive ethnography study of polypharmacy and its practices in primary care JF BMJ Quality & Safety JO BMJ Qual Saf FD BMJ Publishing Group Ltd SP bmjqs-2022-014963 DO 10.1136/bmjqs-2022-014963 A1 Deborah Swinglehurst A1 Lucie Hogger A1 Nina Fudge YR 2022 UL http://qualitysafety.bmj.com/content/early/2022/09/02/bmjqs-2022-014963.abstract AB Background Polypharmacy is an important safety concern. Medication reviews are recommended for patients affected by polypharmacy, but little is known about how they are conducted, nor how clinicians make sense of them. We used video-reflexive ethnography (VRE) to: illuminate how reviews are conducted; elicit professional dialogue and concerns about polypharmacy; invite new transferable understandings of polypharmacy and its management.Methods We conducted 422 hours of fieldwork (participant observation), filmed 18 consultations between clinicians and patients receiving 10 or more regular items of medication (so-called ‘higher risk’ polypharmacy) and played short clips of film footage to 34 participants (general practitioners, nurses, clinical pharmacists, practice managers) in seven audio-recorded reflexive workshops. Our analysis focused on ‘moments of potentiation’ and traced clinicians’ shifting understandings of their practices.Results Participants rarely referenced biomedical aspects of prescribing (eg, drug-drug interactions, ‘Numbers Needed to Treat/Harm’) focussing instead on polypharmacy as an emotional and relational challenge. Clinicians initially denigrated their medication review work as mundane. Through VRE they reframed their work as complex, identifying polypharmacy as a delicate matter to negotiate. In patients with multimorbidity and polypharmacy it was difficult to disentangle medication review from other aspects of patients’ medical care. Such conditions of complexity presented clinicians with competing professional obligations which were difficult to reconcile. Medication review was identified as an ongoing process, rather than a discrete ‘one-off’ activity. Meaningful progress towards tackling polypharmacy was only possible through small, incremental, carefully supported changes in which both patient and clinician negotiated a sharing of responsibility, best supported by continuity of care.Conclusions Supporting acceptable, feasible and meaningful progress towards addressing problematic polypharmacy may require shifts in how medication reviews are conceptualised. Responsible decision-making under conditions of such complexity and uncertainty depends crucially on the affective or emotional quality of the clinician-patient relationship.No data are available. Our ethics approval and consent procedures were based on the anonymity of the individuals who participated, hence further access to the full data set cannot be granted.