Patient and physician explanatory models for acute bronchitis

The data were analyzed and interpreted by a multidisciplinary team consisting of a family physician (K.C.O.), an epidemiologist (L.M.S.), 2 medical anthropologists (R.P.W., C.S.), a medical anthropology graduate student (K.M.C.), and a qualitative research assistant (O.C.). Through a series of meetings, we shared findings, discussed relationships, explored areas of discrepancy and outlying data, and developed the explanatory models.

Results

Participant demographics are provided in the Table. To contrast models, results are presented for the 5 statements with the patient model followed by the physician model.

TABLE 1
Physician and patient demographic data

What caused my illness/etiology

About one third of the patients felt that their bronchitis was triggered by external factors such as allergies, pollution, smoking, or cold weather. As 1 patient stated, “I think that living here, in being exposed to a lot of pollutants over a period of years, has weakened our bronchial areas and therefore, I am more susceptible to the weather changes, the dampness, wind blowing, cold.”

Approximately one third referred to an infectious agent or an infection causing the bronchitis, using words such as bug and germ. Only 2 patients mentioned the words viral or bacterial and the references were nonspecific. One stated, “I assumed a bug of some sort and I am utterly unclear about, you know, what’s a virus, a bacteria, viral versus bacterial infection.” Others talked about how being stressed or tired lowered their resistance and caused the bronchitis. There was another group of patients who felt that they did not know what caused their bronchitis.

Most physicians reported that acute bronchitis is generally viral, but added that it could also be due to Mycoplasma pneumoniae, Chlamydia pneumoniae, Haemophilus influenzae, or Streptococcal pneumoniae and that it was difficult to say what caused an individual’s illness. Environmental exposures, such as smoking, air pollution, and allergies, were also felt to play a role in etiology. This was typified by 1 physician who stated, “I see it most frequently in people who are smokers or passive smokers.” A few physicians expressed the view that the cause of bronchitis was not really understood.

Symptoms I have had/onset of symptoms

Patients tended to report symptoms in order of occurrence. An example was, “My head stopped up and I felt … head congestion, my chest was congested. Sometimes it was hard for me to breathe, and coughing and sneezing and I hurt.”

Patients were asked to rank their symptoms in order of seriousness. Approximately one third reported coughing as their most serious complaint. Another third listed difficulty breathing. Comments about this symptom reflected a strong sense of concern or fear such as, “I had a hard time breathing at night. That was one of the things that was kind of scary … it was something I couldn’t relate to at first and is probably the worst symptom.” When asked if there was 1 symptom that particularly worried them, coughing was the most common response followed by breathing difficulties and then a wide array of symptoms such as fever and chest pain.

When patients described their cough, there tended to be those who used adjectives such as dry, mild, and tickle, and those who used terms such as deep, substernal, barking, goes down below your hips. The cough was commonly described as productive or nonproductive and ongoing or constant. In general, patients fell into 2 camps: those who reported being sick for a short time (1–3 days) and those who waited longer (1–3 weeks) before going to a doctor. Most patients had experienced prior episodes of bronchitis. Those with more experience tended to feel that they needed to see a physician.

All physicians reported cough as the classic symptom of bronchitis. Approximately half indicated that the cough was typically productive and described the color of the phlegm. The others stated that cough was the classic symptom but did not specify the characteristics. Other symptoms listed were fever, shortness of breath, wheezing, congestion, malaise, aches, and chills.

When patients were asked what they felt would be the most worrisome symptom of bronchitis, over two thirds reported coughing, especially when it affected sleep or work functioning and was persistent and productive. When reporting their own most worrisome symptoms, however, physicians listed high fever, chest pain, or purulent sputum and were concerned about serious underlying diseases such as pneumonia.

Physicians felt there was wide variation in the time that patients with bronchitis symptoms waited to be seen. Approximately half of the physicians reported that patients were sick for 1 week or less before their appointment. The other half reported wide intervals ranging from 1 day to 3 weeks.