Antibiotic Use in Acute Respiratory Infections and the Ways Patients Pressure Physicians for a Prescription
The patient was sitting up on the table, and right away he told Dr Lamont, “I just can’t shake it. I feel like the back of my throat has raw hamburger hanging in it.” Dr Lamont checked the patient’s throat well, and the patient said, “This has lasted 4 days and it has been getting worse today.” Dr Lamont checked the patient’s ears, glands, and lungs. “I’m going to give you a shot of penicillin, slow release. It’s some kind of an infection. It may be a virus.”
Portraying the severity of one’s illness may not in and of itself advocate for medication; however, portrayals of the severity of one’s condition were usually accompanied by other actions implicating the need for medication. By opening the encounter with the announcement “I just can’t shake it,” the patient implies that he needs help in getting well. This subtly suggests the need for a prescription medication to alleviate his sore throat. At the end of this visit, the patient receives an antibiotic shot.
Appeals to Nonmedical Circumstances
Patients also used nonmedical circumstances to advocate for medication. These behaviors tended to occur after the problem presentation in the encounter and either centered on some important event, such as a big examination or a trip out of town (n=16), or focused on a previous positive experience with antibiotics for themselves or a family member (n=39).
Appealing to life-world circumstance (eg, “But I’m going to Disney World.”) This patient uses an upcoming trip to make an appeal to the clinician to prescribe medication:
The patient is a 33-year-old man coming in with an acute problem of a sore throat. The patient stated that he had been trying to manage this on his own, but he was taking his wife and 2 children to Disney World at the end of the week and was becoming worried that he was still going be sick and not able to enjoy a trip that they had saved so long for. He also told Dr Liam: “I know we’ll just get to Florida, and the kids will get sick, and then we’ll all be sick again. Dr. Liam said, “Well, we can have you bring them in, but then we’d be treating them for something that they haven’t gotten. Let me think about this a bit.” He does the rapid strep test, and it’s negative. Dr Liam reported the news of a negative strep test and said, “Many times we get a 50% false-negative, so I’m gonna go ahead and put you on an antibiotic and see if we can’t get you feeling better.” With this the patient said, “Well, what do you think I should do about my kids?” Dr. Liam asked if the kids were seen in this clinic, and the patient responded that they had never been seen there before. Dr Liam said, “Well, I’ll go ahead and give you a script for erythromycin in case these kids get sick down in Florida. If they do, go ahead and give them the medicine; if they don’t, throw away the prescription.”
This case is interesting because once he is treated with an antibiotic, the patient uses the same argument to make an appeal for antibiotics for his children (both of whom have never been seen by this physician).
Previous positive experience with antibiotics (eg, “I got an antibiotic for this before.”). Patients also appealed to other nonmedical contingencies to advocate for antibiotic treatment. For example:
Our next patient was a 51-year-old woman complaining of a cold and laryngitis. The doctor asked the patient about her symptoms. The patient responded, saying that she had been taking medication during the end of December for the same symptoms; they had cleared after taking antibiotics, and now they were back again.
The patient indirectly makes an appeal for antibiotic treatment by stating that she received antibiotics in the past for the same symptoms that she has now.
Patients used several variations of this approach. These included stating that another physician prescribed an antibiotic for this illness in the past; that others in the family are sick with an illness for which they received antibiotics; that they have a history of illness for which antibiotics are regularly prescribed; and that they were recently taking an antibiotic for an illness that has not improved (with the idea that an antibiotic is needed again).
Effectiveness of Patient Pressures
Physicians prescribed an antibiotic unnecessarily in 80% of the encounters in which some patient pressure was observed. They seemed able to resist certain types of pressures better than others. Unnecessary antibiotics were prescribed for a smaller percentage of implied candidate diagnoses and candidate diagnoses and for a larger percentage of direct patient requests and previous positive experiences with antibiotics Table 3.
