Qualitative analysis of family physician preceptors’ management of sleeping problems
| Theme; subtheme | Illustrative quote |
|---|---|
| General approach to sleep disorder | |
| Sleeping problems are a symptom, not a diagnosis | I would want to really flesh that out first. So, asking ... why is it that you’re not sleeping and what’s going through your mind when you’re lying down, and I would suspect that that would unearth quite a bit of ... emotional baggage and ... grief, maybe depression. — Participant 4 Explore ... those bigger picture things, and just try to really get a sense of this patient’s context. — Participant 6 Look at all the other factors that might be affecting this person. … Who knows what else is going on? — Participant 8 |
| Acknowledging patient distress | Sleep is an emotional discussion, right? ... People get very upset about the lack of sleep, or perceived poor sleep. [Patients] who are not getting sleep lose the ability to be perfectly rational. — Participant 3 You need to balance compassion for the patient’s experience, much like ... depression or anxiety. It ... affects different people in different ways. And so, you can never really assume how debilitating ... or bothersome someone’s insomnia is. — Participant 4 |
| Individualizing care: balancing risks and breaking rules | Insomnia treatment … is very challenging. … You need to balance compassion for the patient’s experience. … But that needs to be balanced with the fact that a … lot of the most common treatments that people have been on or exposed to or heard about are quite dangerous or risky when misused. — Participant 4 It’s very dissimilar to the approach to a lot of other meds. ... Like managing asthma … it’s individual medicine, it doesn’t follow guidelines. It’s like you’re breaking rules so that you can actually do what’s right. … There [are] as many ways to manage substance use and sleep and pain as there are people who have those problems. … You really have to do it differently every time. — Participant 2 I don’t have a sort of formula for it. — Participant 7 It’s a very situational kind of thing. — Participant 8 You have to be really comfortable with uncertainty. — Participant 2 |
| Sedative wariness | |
| Nondrug treatment as first-line | I try to avoid medication wherever possible or at least build it into a more comprehensive plan. — Participant 4 I try to focus first on nonpharmacological interventions whenever possible, whether [the problem is] ... organic or not organic. — Participant 2 |
| Medication hesitancy | I’m not a huge one in favour of medications. I don’t believe in medications. If we do use them, try not to use the benzos, use the tricyclic or something else, depending on the patient, whether it’s safe or not. — Participant 8 I’m not a huge fan of Zopiclone. But … I might use ... Zopiclone. And why? Just because it’s super short-term. ... I don’t love the benzos. I certainly don’t want [patients] to take Gravol. Because we just know it doesn’t benefit the sleep cycle ... it makes things worse. I think benzo is similar to treating your sleep with booze, which many people do. You ... get sleepy with booze, but then it wrecks the sleep cycle. So then over time [patients] get more tired and ... may get more depressed. — Participant 1 There’s a lot of fear that you’re going to harm the patient. There’s a lot of fear that if you prescribe [sedatives] as an attending, the [regulator] is going to come after you. — Participant 2 So Z-drugs, I use very, very sparingly. — Participant 9 I am slightly — I call it crazy — I hate [Z]-drugs, and usually when patients talk to me about insomnia, they want a Z-drug. … I’m very hesitant about it. … I think all of these drugs to treat insomnia sometimes mask the problem. — Participant 3 I also try and get [patients] to not jump to medication as ... a first line. And if they’re going to take ... a medication route, to just be aware of the breadth of different options. — Participant 4 Benzos seem to be pretty taboo right now. Or, like in the past few years, they’ve really gotten a really bad rap. — Participant 10 |
| Exceptions to general approach | |
| The exceptional indication | There are definitely significant exceptions regarding Z-drugs, I have easily ... 5 patients I can think of that I do prescribe without question for. … There are totally reasonable exceptions, but I won’t understand if a person meets my reasonable expectation or exception criteria if I don’t have this conversation with them. So ... with an acute stressor ... I think that we had come up with this a little bit in ... talking about some of my past examples, I automatically see a lane into my exception pathway. — Participant 3 I feel comfortable in choosing patients that I’m going to be able to get off of [sedatives] once we get them through whatever. — Participant 2 |
| Prescribing for another physician’s patient | You can’t step into another provider’s shoes and expect to change ... a multidecade treatment plan over the course of a week. — Participant 4 How do you manage a treatment plan that you maybe don’t personally agree with but that has been initiated by another prescriber? And so, the idea of ... immediate patient safety being a number one consideration and then not trying to ... go off and do your own thing, but involve ... their provider in whatever you want to do or whatever you think needs to be done as a long-term plan. — Participant 4 Not my patient, don’t have a relationship with them, hard to have a tough conversation [about deprescribing]. — Participant 3 There are some of our colleagues that if you were to try and suggest some alternative strategies would be [pause] a little sensitive. — Participant 5 This is one of those things, it’s not my patient, I have to sort of “Band-Aid” the situation. — Participant 8 |