Antibiotic Use in Acute Respiratory Infections and the Ways Patients Pressure Physicians for a Prescription
Physicians’ Response to Prescribing an Unnecessary Antibiotic
When physicians prescribed an antibiotic unnecessarily, they often rationalized this practice by finding symptoms or assigning diagnoses that, to them, justified prescribing antibiotics. Physicians used various rationales, such as red throat or enlarged tonsils; severe, prolonged, or productive cough; yellow or green mucus; sinus tenderness on palpation; associated chronic disease; history of previous infection; and the desire to “cover” the patient “just in case.” None of these rationales are supported by evidence as correlating with bacterial infection. An example of this kind of rationalization follows:
This is a 20-year-old woman coming in with a complaint of a worsening cough. She said that her chest had a prickly, burning sensation, and it hurt to breathe. Dr Hart asked if she was able to bring anything up. She said that she really couldn’t. It was just a really terrible barky cough. Following the physician examination, the physician told the patient that her lungs basically sounded clear, but she could certainly hear some rough bronchial sounds. With this, she said. “What I think is happening here with your cold is that it is probably ending up in a bronchitis-type situation, and probably what we should do is put you on an antibiotic and order a decongestant.”
Discussion
This investigation, in agreement with the pediatric studies of Stivers,9,10 suggests that the connection between patient diagnosis and physician prescribing is highly complex, involving patient presentation and physician-patient communication as much as, if not more than, physician diagnostic skills. Also, these data suggest that physicians are better able to resist patient pressures that are framed in medical terms such as candidate diagnoses or implied candidate diagnoses but are much less able to resist pressures that are not medicalized, such as portraying severity of illness and use of life-world circumstances. Thus, it is not surprising that past interventions designed to increase physician knowledge regarding when to prescribe antibiotics have had limited success.14,15 Physicians appear to be trying to maximize patient satisfaction by giving antibiotic-seeking patients what they want. Our findings show the need to modify current thinking about the diagnostic and treatment process to reduce the use of antibiotics. Rather than thinking of these processes as physician controlled, the powerful role patients play in this interaction must be considered.
Our study has important implications for future research. From a methodologic standpoint, our findings illustrate the importance of qualitative evaluation of directly observed medical encounters. The patterns of patient behavior observed could not have been discerned using survey, interview, or focus group data.
Limitations
Because these data were collected by field researchers who were unaware that ART infection would be a focus of our study, it is possible that there were other patient symptoms and behavior related to ART infection, as well as physician behaviors related to antibiotic prescribing, that were not recorded. The data were sufficiently rich, however, to easily and reliably apply the CDC guidelines for appropriate use of antibiotics. Any unrecorded behaviors might add to, but not substantially change, our conclusions that patients indirectly pressure their physicians for treatment, and physicians respond by giving antibiotics. Studies using videotaped encounters might uncover such additional important patient and physician behaviors. Since the patient population studied was limited to a single midwestern state, it is possible that other populations with a different ethnic or racial mix might behave differently. Future research in this area should attempt to include such populations. Finally, too few encounters per physician were observed in this study to evaluate whether particular physicians were high or low prescribers (such a pattern has been reported by De Sutter and colleagues16).
Conclusions
Physicians should be educated about the subtle approaches patients use to pressure them for antibiotic treatment and should be shown techniques for responding to these pressures without prescribing antibiotics unnecessarily. Our findings also suggest the need to increase patients’ awareness both of the dangers and lack of effectiveness of using antibiotics for ART infections and of the amount of influence that patients have on antibiotic prescribing. Macfarlane and coworkers17 have shown that use of patient education materials reduces visits for ART infection. Additional approaches to decreasing patient pressure for antibiotic prescriptions are needed to diminish antibiotic overuse and its public health consequences.
Acknowledgments
Our study was funded by the Agency for Healthcare Research and Quality Grant R01 HS08776. Dr Scott is a postdoctoral fellow supported by the Health Resources and Services Administration (HRSA) PE1011 and the Agency for Healthcare Research and Quality (AHRQ) HS09788. Analysis of these data was supported by a Research Center grant from the American Academy of Family Physicians (Center for Research in Family Practice and Primary Care). Drs Jaen and Crabtree are associated with the Center for Research in Family Practicer and Primary Care, Cleveland, New Brunswick, Allentown. and San Antonio. The authors wish to thank the family physicians of Nebraska who were willing to open their practices to us. We also thank Kurt C. Stange, MD, PhD, for his thoughtful comments on drafts of this manuscript.
