Antibiotic Use in Acute Respiratory Infections and the Ways Patients Pressure Physicians for a Prescription

Results

Women made up 59% of the study sample; 64% were 16 years or older (and classified as adults). Antibiotics were prescribed in 204 of the 298 ART infection encounters (68%). Antibiotic use was unnecessary according to the CDC guidelines in 164 of these (80%). Adults were more likely than children to receive unnecessary antibiotics Table 1.

Our analysis identified 6 different types of patient behaviors that advocated for medication, particularly antibioticsTable 2. These behaviors fell into 3 broad categories: explicit requests, presentation of chief complaint, and appeals to lifeworld circumstances. Multiple pressures were noted in many encounters.

While patients occasionally made direct requests for antibiotics, they much more frequently positioned themselves indirectly for receiving antibiotic treatment by the way they presented the chief complaint. Four distinct approaches were identified: symptoms only,⁹ candidate diagnosis,⁹ implied candidate diagnosis,⁹ and portraying the severity and inability to shake the illness.

A second category of indirect approach used life-world circumstances¹⁰ (eg, an upcoming family vacation) or a past history with successful antibiotic treatment to formulate appeals for antibiotics in the current encounter. In those cases in which antibiotics were clearly unnecessary, physicians often rationalized their prescribing practices by finding symptoms or assigning diagnoses to justify antibiotic use. Each of these patient pressures, as well as the physician-rationalizing behavior, is illustrated with sample visits. The samples are taken directly from transcribed field notes, but the names have been altered to protect the identity of patients and clinicians.

Explicit Request

Explicit requests for antibiotics were observed in only 6% of cases (n=15). For example:

Claire asked the patient, “How are you doing?” and she said, “Well, I’m coughing up phlegm, I ache and I have chills and a sore throat.” Claire said, “You have bronchoconstriction, and 3 times a day, if you need to, you should use proventil.” The patient asked if she could have an antibiotic for her cold; cephalexin has worked in the past. Claire said that she would get her cephalexin and also some samples of an inhaler.

Presentation of the Chief Complaint

Patients frequently put pressure on the physician for treatment during the presentation of the chief complaint, the exception being the symptoms-only presentation. This is different from the other indirect pressures, which usually occurred during different parts of the medical encounter.

Symptoms-only presentation (eg, “I have a cough and a sore throat.”) In the symptoms-only approach (n=15), the patient reports his or her symptoms with little embellishment. This approach does not pressure physicians for antibiotic treatment.

Candidate diagnosis (eg, “I think I’ve got strep throat.”) In contrast, patients also presented their chief complaint to the physician by offering a candidate diagnosis (n=18). As shown in the following example, the patient responds by offering a diagnosis. This is a way of indirectly advocating for antibiotic treatment.

A 21-year-old white woman went to see Dr. Maxwell with an acute problem of congestion. Dr Maxwell said, “Well, how are you doing?” The patient said, “It sounds like bronchitis. It started about 4 days ago.”

Implied candidate diagnosis (eg, “My throat hurts; it’s red; and it has white spots.”) The implied candidate diagnosis is a hybrid of the symptoms-only and the candidate diagnosis approaches (n=48). When presenting their chief complaint, patients reported very specific symptoms that indexed a particular diagnosis. For example:

A 29-year-old woman went to see Dr Redmond with swollen glands, congestion, and white spots on her throat. When Dr Redmond and I went into the examination room, the patient had a pink paper top on, and Dr Redmond told her that her throat culture was negative.

The patient reports that she has swollen glands, congestion, and white spots on her throat. The symptoms specifically index a particular condition (strep throat). The patient’s presentation of symptoms clearly implies a diagnosis of strep throat, and the physician ordered a strep culture before seeing the patient.

Candidate diagnoses and implied candidate diagnoses delicately assert that the nature of the patient’s problem is already known. The reason for the medical visit is to seek treatment for the patient’s already known condition. When candidate and implied candidate diagnoses point to a condition the patient believes to be treatable (eg, bronchitis, strep throat, ear infection), this way of presenting the chief complaint looks directly ahead to a treatment involving a prescription for an antibiotic and thus indirectly pressures the physician to prescribe one.

Portraying the severity of one’s illness (eg, “I can’t shake this, Doc.”) The most common strategy was for patients to subtly pressure physicians for medication by portraying the severity of their condition and their inability to shake the illness on their own (n=99). For example: