What is a Medical Prescription?

Introduction

A prescription, often abbreviated ℞ or Rx, is a formal communication from a physician or other registered health-care professional to a pharmacist, authorising them to dispense a specific prescription drug for a specific patient.

Historically, it was a physician’s instruction to an apothecary listing the materials to be compounded into a treatment – the symbol ℞ (a capital letter R, crossed to indicate abbreviation) comes from the first word of a medieval prescription, Latin: Recipere (“Take thou”), that gave the list of the materials to be compounded.

Brief History

The idea of prescriptions dates back to the beginning of history. So long as there were medications and a writing system to capture directions for preparation and usage, there were prescriptions.

Modern prescriptions are actually extemporaneous prescriptions (from the Latin ex tempore, “at/from the time”), meaning that the prescription is written on the spot for a specific patient with a specific ailment. This is distinguished from a non-extemporaneous prescription that is a generic recipe for a general ailment. Modern prescriptions evolved with the separation of the role of the pharmacists from that of the physician. Today the term extemporaneous prescriptions is reserved for compound prescriptions that requires the pharmacist to mix or compound the medication in the pharmacy for the specific needs of the patient.

Predating modern legal definitions of a prescription, a prescription traditionally is composed of four parts: a superscription, inscription, subscription, and signature.

The superscription section contains the date of the prescription and patient information (name, address, age, etc.). The symbol “℞” separates the superscription from the inscriptions sections. In this arrangement of the prescription, the “℞” is a symbol for recipe or literally the imperative “take!” This is an exhortation to the pharmacist by the medical practitioner, “I want the patient to have the following medication” – in other words, “take the following components and compound this medication for the patient.”

The inscription section defines what is the medication. The inscription section is further composed of one or more of:

  • A basis or chief ingredient intended to cure (curare).
  • An adjuvant to assist its action and make it cure quickly (cito).
  • A corrective to prevent or lessen any undesirable effect (tuto).
  • A vehicle or excipient to make it suitable for administration and pleasant to the patient (jucunde).

The subscription section contains dispensing directions to the pharmacist. This may be compounding instructions or quantities.

The signature section contains directions to the patient and is often abbreviated “Sig.” or “Signa.” It also obviously contains the signature of the prescribing medical practitioner though the word signature has two distinct meanings here and the abbreviations are sometimes used to avoid confusion.

Thus sample prescriptions in modern textbooks are often presented as:

  • Rx: medication.
  • Disp.: dispensing instructions.
  • Sig.: patient instructions.

Format and Definition

For a communication to be accepted as a legal medical prescription, it needs to be filed by a qualified dentist, advanced practice nurse, physician or veterinarian, for whom the medication prescribed is within their scope of practice to prescribe. This is regardless of whether the prescription includes prescription drugs, controlled substances or over-the-counter treatments.

Prescriptions may be entered into an electronic medical record system and transmitted electronically to a pharmacy. Alternatively, a prescription may be handwritten on pre-printed prescription forms that have been assembled into pads, or printed onto similar forms using a computer printer or even on plain paper according to the circumstance. In some cases, a prescription may be transmitted from the physician to the pharmacist orally by telephone. The content of a prescription includes the name and address of the prescribing provider and any other legal requirement such as a registration number (e.g. DEA Number in the United States). Unique for each prescription is the name of the patient. In the United Kingdom and Ireland the patient’s name and address must also be recorded. Each prescription is dated and some jurisdictions may place a time limit on the prescription. In the past, prescriptions contained instructions for the pharmacist to use for compounding the pharmaceutical product but most prescriptions now specify pharmaceutical products that were manufactured and require little or no preparation by the pharmacist. Prescriptions also contain directions for the patient to follow when taking the drug. These directions are printed on the label of the pharmaceutical product.

The word “prescription”, from “pre-” (“before”) and “script” (“writing, written”), refers to the fact that the prescription is an order that must be written down before a drug can be dispensed. Those within the industry will often call prescriptions simply “scripts”.

Contents

Every prescription contains who prescribed the prescription, who the prescription is valid for, and what is prescribed. Some jurisdictions, drug types or patient groups require additional information as explained below.

Drug Equivalence and Non-Substitution

Many brand name drugs have cheaper generic drug substitutes that are therapeutically and biochemically equivalent. Prescriptions will also contain instructions on whether the prescriber will allow the pharmacist to substitute a generic version of the drug. This instruction is communicated in a number of ways. In some jurisdictions, the pre-printed prescription contains two signature lines: one line has “dispense as written” printed underneath; the other line has “substitution permitted” underneath. Some have a pre-printed box “dispense as written” for the prescriber to check off (but this is easily checked off by anyone with access to the prescription). In other jurisdictions, the protocol is for the prescriber to handwrite one of the following phrases: “dispense as written”, “DAW”, “brand necessary”, “do not substitute”, “no substitution”, “medically necessary”, “do not interchange”. In Britain’s National Health Service, doctors are reminded that money spent on branded rather than generic drugs is consequently not available for more deserving cases.

Prescriptions for Children

In some jurisdictions, it may be a legal requirement to include the age of child on the prescription. For paediatric prescriptions some advise the inclusion of the age of the child if the patient is less than twelve and the age and months if less than five. In general, including the age on the prescription is helpful, and adding the weight of the child is also helpful.

Label and Instructions

Prescriptions in the USA often have a “label” box. When checked, the pharmacist is instructed to label the medication and provide information about the prescription itself is given in addition to instructions on taking the medication. Otherwise, the patient is simply given the instructions. Some prescribers further inform the patient and pharmacist by providing the indication for the medication; i.e. what is being treated. This assists the pharmacist in checking for errors as many common medications can be used for multiple medical conditions. Some prescriptions will specify whether and how many “repeats” or “refills” are allowed; that is whether the patient may obtain more of the same medication without getting a new prescription from the medical practitioner. Regulations may restrict some types of drugs from being refilled.

Writing Prescriptions

Legal Capacity to Write Prescriptions

National or local (i.e. US state or Canadian provincial) legislation governs who can write a prescription. In the United States, physicians (either M.D., D.O. or D.P.M.) have the broadest prescriptive authority. All 50 US states and the District of Columbia allow licensed certified Physician Assistants (PAs) prescription authority (with some states, limitations exist to controlled substances). All 50 US states and the District of Columbia, Puerto Rico and Guam allow registered certified nurse practitioners and other advanced practice registered nurses (such as certified nurse-midwives) prescription power (with some states including limitations to controlled substances). Many other healthcare professions also have prescriptive authority related to their area of practice. Veterinarians and dentists have prescribing power in all 50 US states and the District of Columbia. Clinical pharmacists are allowed to prescribe in some US states through the use of a drug formulary or collaboration agreements. Florida pharmacists can write prescriptions for a limited set of drugs. In all US states, optometrists prescribe medications to treat certain eye diseases, and also issue spectacle and contact lens prescriptions for corrective eyewear. Several US states have passed RxP legislation, allowing clinical psychologists who are registered as medical psychologists and have also undergone specialised training in script-writing, to prescribe drugs to treat emotional and mental disorders.

In August 2013, legislative changes in the UK allowed physiotherapists and podiatrists to have independent prescribing rights for licensed medicines that are used to treat conditions within their own area of expertise and competence. In 2018 this was extended to paramedics.

Standing Orders

Some jurisdictions allow certain physicians (sometimes a government official like the state Secretary of Health, sometimes physicians in local clinics or pharmacies) to write “standing orders” that act like a prescription for everyone in the general public. These orders also provide a standard procedure for determining if administration is necessary and details of how it is to be performed safely. These are typically used to authorise certain people to perform preventive, low-risk, or emergency care that would be otherwise logistically cumbersome to authorise for individual patients, including vaccinations, prevention of cavities, birth control, treatment of infectious diseases, and reversal of drug overdoses.

Legibility of Handwritten Prescriptions

Doctors’ handwriting is a reference to the stereotypically illegible handwriting of some medical practitioners, which sometimes causes errors in dispensing. In the US, illegible handwriting has been indirectly responsible for at least 7,000 deaths annually.

There are several theories about the causes of this phenomenon. Some sources say the extreme amount of writing doctors employ during training and at work leads to bad handwriting, whereas others claim that doctors neglect proper handwriting due to medical documents being intended to be read solely by medical professionals, not patients. Others simply classify the handwriting of doctors as a handwriting style. The issue may also have a historical origin, as physicians from Europe-influenced schools have historically used Latin words and abbreviations to convey prescriptions; many of the abbreviations are still widely used in the modern day and could be a source of confusion.

Some jurisdictions have legislatively required prescriptions to be legible – Florida, US specifies “legibly printed or typed” – and the Institute for Safe Medication Practices advocated the elimination of handwritten prescriptions altogether. There have been numerous devices designed to electronically read the handwriting of doctors, including electronic character recognition, keyword spotters, and “postprocessing approaches,” though the gradual shift to electronic health records and electronic prescriptions may alleviate the need for handwritten prescriptions altogether. In Britain’s NHS, remaining paper prescriptions are almost invariably computer printed and electronic (rather than paper) communication between surgery and pharmacy is increasingly the norm.

Conventions for Avoiding Ambiguity

Over the years, prescribers have developed many conventions for prescription-writing, with the goal of avoiding ambiguities or misinterpretation. These include:

  • Careful use of decimal points to avoid ambiguity:
    • Avoiding unnecessary decimal points and trailing zeros, e.g. 5 mL rather than 5.0 mL, 0.5 rather than .50 or 0.50, to avoid possible misinterpretation as 50.
    • Always using leading zeros on decimal numbers less than 1: e.g. 0.5 rather than .5 to avoid misinterpretation as 5.
  • Directions written out in full in English (although some common Latin abbreviations are listed below).
  • Quantities given directly or implied by the frequency and duration of the directions.
  • Where the directions are “as needed”, the quantity should always be specified.
  • Where possible, usage directions should specify times (7 am, 3 pm, 11 pm) rather than simply frequency (three times a day) and especially relationship to meals for orally consumed medication.
  • The use of permanent ink.
  • Avoiding units such as “teaspoons” or “tablespoons”.
  • Writing out numbers as words and numerals (“dispense #30 (thirty)”) as in a bank draft or cheque.
  • The use of the apothecaries’ system or avoirdupois units and symbols of measure – pints (O), ounces (℥), drams (ℨ), scruples (℈), grains (gr), and minims (♏︎) – is discouraged given the potential for confusion. For example, the abbreviation for a grain (“gr”) can be confused with the gram, abbreviated g, and the symbol for minims (♏︎), which looks almost identical to an ‘m’, can be confused with micrograms or metres. Also, the symbols for ounce (℥) and dram (ℨ) can easily be confused with the numeral ‘3’, and the symbol for pint (O) can be easily read as a ‘0’. Given the potential for errors, metric equivalents should always be used.
  • The degree symbol (°), which is commonly used as an abbreviation for hours (e.g., “q 2-4°” for every 2-4 hours), should not be used, since it can be confused with a ‘0’ (zero). Further, the use of the degree symbol for primary, secondary, and tertiary (1°, 2°, and 3°) is discouraged, since the former could be confused with quantities (i.e. 10, 20 and 30, respectively).
  • Micrograms are abbreviated mcg rather than µg (which, if handwritten, could easily be mistaken for mg (milligrams). Even so, pharmacists must be on the alert for inadvertent over- or under-prescribing through a momentary lapse of concentration.

Abbreviations

Many abbreviations are derived from Latin phrases. Hospital pharmacies have more abbreviations, some specific to the hospital. Different jurisdictions follow different conventions on what is abbreviated or not. Prescriptions that do not follow area conventions may be flagged as possible forgeries.

Some abbreviations that are ambiguous, or that in their written form might be confused with something else, are not recommended and should be avoided. These are flagged in the table in the main article. However, all abbreviations carry an increased risk for confusion and misinterpretation and should be used cautiously.

Non-Prescription Drug Prescriptions

Over-the-counter medications and non-controlled medical supplies such as dressings, which do not require a prescription, may also be prescribed. Depending upon a jurisdiction’s medical system, non-prescription drugs may be prescribed because drug benefit plans may reimburse the patient only if the over-the-counter medication is taken at the direction of a qualified medical practitioner. In the countries of the UK, National Health Service (NHS) prescriptions are either free or have a fixed price per item; a prescription may be issued so the patient does not have to purchase the item at commercial price.

Some medical software requires a prescription.

Legislation may define certain equipment as “prescription devices”. Such prescription devices can only be used under the supervision of authorised personnel and such authorisation is typically documented using a prescription. Examples of prescription devices include dental cement (for affixing braces to tooth surfaces), various prostheses, gut sutures, sickle cell tests, cervical cap and ultrasound monitor.

In some jurisdictions, hypodermic syringes are in a special class of their own, regulated as illicit drug use accessories separate from regular medical legislation. Such legislation often allows syringes to be dispensed only with a prescription.

Use of Technology

As a prescription is nothing more than information among a prescriber, pharmacist and patient, information technology can be applied to it. Existing information technology is adequate to print out prescriptions. Hospital information systems in some hospitals do away with prescriptions within the hospital. There are proposals to securely transmit the prescription from the prescriber to the pharmacist using smartcard or the internet. In the UK a project called the Electronic Transfer of Prescriptions (ETP) within the National Programme for IT (NPfIT) is currently piloting such a scheme between prescribers and pharmacies.

Within computerised pharmacies, the information on paper prescriptions is recorded into a database. Afterwards, the paper prescription is archived for storage and legal reasons.

A pharmacy chain is often linked together through corporate headquarters with computer networking. A person who has a prescription filled at one branch can get a refill of that prescription at any other store in the chain, as well as have their information available for new prescriptions at any branch.

Some online pharmacies also offer services to customers over the internet, allowing users to specify the store that they will pick up the medicine from.

Many pharmacies now offer services to ship prescription refills right to the patient’s home. They also offer mail service where you can mail in a new, original prescription and a signed document, and they will ship the filled prescription back to you.

Pharmacy information systems are a potential source of valuable information for pharmaceutical companies as it contains information about the prescriber’s prescribing habits. Prescription data mining of such data is a developing, specialised field.

Many prescribers lack the digitised information systems that reduce prescribing errors. To reduce these errors, some investigators have developed modified prescription forms that prompt the prescriber to provide all the desired elements of a good prescription. The modified forms also contain predefined choices such as common quantities, units and frequencies that the prescriber may circle rather than write out. Such forms are thought to reduce errors, especially omission and handwriting errors and are actively under evaluation.

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On This Day … 03 November

People (Deaths)

  • 1957 – Wilhelm Reich, Ukrainian-Austrian psychotherapist and author (b. 1897).

Wilhelm Reich

Wilhelm Reich (24 March 1897 to 03 November 1957) was an Austrian doctor of medicine and psychoanalyst, a member of the second generation of analysts after Sigmund Freud. The author of several influential books, most notably Character Analysis (1933), The Mass Psychology of Fascism (1933), and The Sexual Revolution (1936), Reich became known as one of the most radical figures in the history of psychiatry.

Reich’s work on character contributed to the development of Anna Freud’s The Ego and the Mechanisms of Defence (1936), and his idea of muscular armour – the expression of the personality in the way the body moves – shaped innovations such as body psychotherapy, Gestalt therapy, bioenergetic analysis and primal therapy. His writing influenced generations of intellectuals; he coined the phrase “the sexual revolution” and according to one historian acted as its midwife. During the 1968 student uprisings in Paris and Berlin, students scrawled his name on walls and threw copies of The Mass Psychology of Fascism at police.

After graduating in medicine from the University of Vienna in 1922, Reich became deputy director of Freud’s outpatient clinic, the Vienna Ambulatorium. Described by Elizabeth Danto as a large man with a cantankerous style who managed to look scruffy and elegant at the same time, he tried to reconcile psychoanalysis with Marxism, arguing that neurosis is rooted in sexual and socio-economic conditions, and in particular in a lack of what he called “orgastic potency”. He visited patients in their homes to see how they lived, and took to the streets in a mobile clinic, promoting adolescent sexuality and the availability of contraceptives, abortion and divorce, a provocative message in Catholic Austria. He said he wanted to “attack the neurosis by its prevention rather than treatment”.

From the 1930s he became an increasingly controversial figure, and from 1932 until his death in 1957 all his work was self-published. His message of sexual liberation disturbed the psychoanalytic community and his political associates, and his vegetotherapy, in which he massaged his disrobed patients to dissolve their “muscular armour”, violated the key taboos of psychoanalysis. He moved to New York in 1939, in part to escape the Nazis, and shortly after arriving coined the term “orgone” – from “orgasm” and “organism” – for a biological energy he said he had discovered, which he said others called God. In 1940, he started building orgone accumulators, devices that his patients sat inside to harness the reputed health benefits, leading to newspaper stories about sex boxes that cured cancer.

Following two critical articles about him in The New Republic and Harper’s in 1947, the US Food and Drug Administration obtained an injunction against the interstate shipment of orgone accumulators and associated literature, believing they were dealing with a “fraud of the first magnitude”. Charged with contempt in 1956 for having violated the injunction, Reich was sentenced to two years imprisonment, and that summer over six tons of his publications were burned by order of the court. He died in prison of heart failure just over a year later, days before he was due to apply for parole.

Reviewing Work & Mental Health in Doctors

Research Paper Title

Work and Mental Health in Doctors: A Short Review of Norwegian Studies.

Background

Previous studies have found relatively good physical health in doctors, whereas several studies now report relatively high levels of mental distress among them. This applies in particular to stress, burnout, and depressive symptoms – and especially among medical students and young doctors early in their careers. However, we lack representative prevalence studies of mental disorders among doctors. There is little empirical support for the notion that there is more mental distress in medical students compared to that in other university students, nor do they differ from other students with respect to personality traits.

Despite this, several studies have found more suicide among physicians than in other occupational groups. This may be partly due to their attempts in committing suicide being more frequently successful; yet, this may also represent the tip of an iceberg of frustration and inadequate mental health care among medical doctors.

Presumed Risk Factors from Longitudinal Studies

What do we know about individual and work-related predictors and risk factors of mental distress from the prospective and longitudinal studies so far? Some landmark early follow-up studies in the United States and United Kingdom put doctors’ work and mental health on the agenda in the 1970’s and 1980’s. In the following, we will pay most attention to the Longitudinal Study of Norwegian Medical Students and Doctors (NORDOC). This study has since 1993/1994 followed repeatedly 2 cohorts of medical students (N = 1052) with 6 years apart for 20 years (2014), and there is now an ongoing 25-year follow up.

There are 2 main hypotheses with regard to possible risks factors. First, it may be due to individual factors such as personality traits, past mental health problems, etc. Second, contextual stress may influence mental health among doctors, whether this is unhealthy working conditions or negative life events (i.e., stress outside of work). Both individual and work-related factors seem to be of importance. Individual factors may be more important with respect to more severe clinical mental disorders, whereas work-related factors are more important for stress, burnout, and minor emotional disturbance.

In terms of individual factors, NORDOC has included personality traits, as one of very few studies in doctors. Neuroticism personality trait is related to vulnerability, self-criticism, low self-esteem, and proneness to stress compatible with the modern common term “hypersensitivity.” This trait predicts stress, anxiety, and depression in the general population, and, as expected, in NORDOC it predicts work stress, burnout, and even severe depressive symptoms among doctors. Studies among medical students and young doctors have found the combination of conscientiousness (or obsessiveness) and neuroticism seems to be especially important for school and work stress. In addition, NORDOC has identified a particular trait (reality weakness) that is associated with severe personality pathology. This trait predicts independently a need for mental health treatment, lack of help-seeking, severe depressive symptoms, and even aggravation of suicidal ideation among medical students and doctors. Another important individual factor is the increased rate of female medical students and young doctors. In Norway, there has been an increase from 55% to 70% of women in medical schools during the past 2 decades. We have previously found little gender differences in NORDOC, but a recent study among Norwegian medical students find considerable reduction in subjective well-being in 2015 compared to that 20 years ago, and this reduction was most prominent among the female students. This reflects recent trends in Norway and other Western societies which observe increased anxiety and depressive symptoms among young female adults.

With regard to contextual stress, it seems that both work-related stress and stress outside of work are of importance. NORDOC studies have found that demanding patient work is associated with mental health problems early in the medical career, and that difficulty with balancing life – such as work–home interface stress – is a sustaining problem over the course of the career. The detrimental role of such stress is also in keeping with studies among US doctors. Work–home stress predicts burnout (emotional exhaustion) in a NORDOC 5-year follow-up study. A promising finding is that such stress was less prominent in the youngest cohort of Norwegian doctors 10 years after leaving medical school. This may be due to increased coverage of kindergarten as well as changed and more liberal gender roles in our Scandinavian society over recent years.

There are also studies that associate time pressures and burnout with suicidal ideation among medical students and doctors. Sleep-deprivation due to call work and long hours may be one important reason for more depressive symptoms measured in young doctors. A recent NORDOC study of life satisfaction during 15 years of the career controlled for all possible individual factors, and found the following work-related predictors and possible risk factors: work–home stress, lack of colleague support, and emotional demands at work. Doctors often feel a 24/7 responsibility and obligation for individual patients and their treatment and this puts extraordinary emotional demands on this occupational group.

Does Stress among Doctors have Consequences for their Patient Care?

Many studies can indicate lowered quality of patient care among stressed doctors with burnout, but a large majority of these studies build on self-report by the doctors themselves of more errors and poorer care. We lack an empirical foundation for the notion that stress and burnout really impair doctors’ functioning with respect to observed poorer quality of care. There are 2 classical observation studies demonstrating that long hours and time pressures interfere with doctors functioning, but we lack studies that find burnout to lead to observed errors or poorer care. The burnout concept and scales are not very valid with respect to impaired functioning, for example, with respect to valid cut-off for defining a case.38 On the other hand, depression and other mental disorders lead to poor functioning. We need more studies on working conditions and the levels of stress and poor health among young doctors that lead to lowered patient care.

What are the Most Common Mental Disorders among Doctors?

In general, doctors may have the same disorders that strike anyone else; doctors are not invincible. Although depressive symptoms seem to be prevalent in the early years of the medical career, some of this may be due to exhausting work stress by frequent on-call work. We lack representative studies on the occurrence of valid depression among doctors compared to that in other occupational groups. Suicide is more common among doctors than among other groups of academics, but since it is also very common in veterinarians, this may also be due to available knowledge and means (drugs) for committing suicide during mental health deterioration. Alcoholism and drug abuse is an additional known risk factor for suicide and the SAD triad (suicidal behaviour–alcoholism–depression) may be particularly important for medical doctors. From clinical experience with doctor–patients, we know the slippery slope from self-medication with tranquilisers to cope with the stresses to dependency of alcohol and drugs, in addition to other boundary violations. There are very few clinical studies including diagnostic interviews among doctors. One previous Spanish study emphasises the importance of dual diagnoses, especially in alcohol dependence and mood disorders. From own experience, we know that bipolar disorder (type II) is quite common among physicians, but we lack sound empirical studies that compare occurrence of mental disorders in doctors with that in other groups. American impaired physician programs have for many years shown high and promising recovery rates (70–80%). The programmes used to focus on addiction and substance abuse, but they now put increasing emphasis on psychiatric diagnoses. A family history, opioid use, and psychiatric comorbidity predicted relapse of substance abuse among doctors and other healthcare workers.

In Norway, we have implemented a successful low-threshold intervention, the Villa Sana programme. This intervention seems to reduce burnout in doctors. It includes 2 separate schemes, a 1-day individual counselling scheme, and a 1-week group-based scheme in a psychiatric hospital. The Norwegian Medical Association pays for the programme that is free for all doctors.

With respect to medical students and young doctors, we have also a large longitudinal study on mindfulness-based stress reduction. This is a randomised-controlled trial of second year medical and psychology students, and they have now been followed-up for 6 years, for the medical students into the first 2 postgraduate years. The reduction of emotional distress by mindfulness training is most prominent in female students.46 The training has a stronger impact among those with vulnerable personality (high neuroticism and conscientiousness). During the follow-up, there is an increase in active coping and reduction in passive or avoidance coping – the effects on ways of coping may be important psychological mechanisms of mindfulness training.

Future Research Challenges

We need more long-term follow-up studies that use validated instruments to capture changes in working conditions and their impact on physician health. For instance, there are few studies in doctors of Karasek’s Demand-Control model. There are more studies by this model in other healthcare workers. More studies are required that measure the effect of physicians’ health problems on their performance and patient care. Gender issues are important, since there are now more women entering the medical career. As mentioned, we also need more studies with diagnostic interviews that compare frequency of valid disorders in samples of physicians with that in other groups. Doctors are nowadays moving, and we should study the effect of globalisation on doctor’s health. Cross-national disparities may be due to differences in the health systems, working conditions, etc. Finally, we need more studies on positive psychology and factors that may promote and enhance well-being among physicians.

Reference

Tyssen, R. (2019) Work and Mental Health in Doctors: A Short Review of Norwegian Studies. Porto Biomedical Journal. 4(5), pp.e50. Published online 2019 Sep 9. doi: 10.1097/j.pbj.0000000000000050.