Balancing acts: Deciding for or against antibiotics in acute respiratory infections

Types of evidence used/valued to inform practice was the most influential of the 5 categories. Twelve clinicians indicated that their main source of clinical evidence was current research-based findings and related practice guidelines. The other 9 based their clinical practice on other forms of evidence, including personal and professional observations or experiences; discussions with pharmaceutical representatives; discussions with colleagues; and experiences reported by patients. Regarding personal experiences, one clinician said, “We’ll talk about my personal experiences…. Just like you have yours, I have mine and they don’t just include patients that I see. They include family members and people that I live with who’ve had an infection for 5 days—I give them an antibiotic. Two days later, they are up and about…so my empiric evidence over and over again reinforces that antibiotics are great. They work.”

Perceived patient/parent satisfaction, the second concept, describes how clinicians attempted to satisfy patients or parents according to their own perceptions of the patients’ potential to be satisfied. The 4 categories influencing the concept of perceived patient satisfaction are shown at the bottom of the TABLE.

Business concerns was the most interesting category. All 21 clinicians described the impact of patient satisfaction on the financial aspects of their practices. The 16 clinicians who collected on a fee-for-service basis described patient satisfaction as an important aspect of their livelihood as illustrated in the following comment: “You shouldn’t be treating all respiratory infections with antibiotics? Certainly. Is it practical? Probably not. I probably wouldn’t have as good of a collection rate. I truly think that part of what you’re doing is consumer-based medicine.”

Conversely, the 5 clinicians who were salaried and who did not charge on a fee-for-service basis indicated that, from a business standpoint, they were not as concerned about patient satisfaction. One clinician stated, “We can practice the better standards because of the cost elements…. You know I would feel very put upon if I had to charge every time I saw someone.”

Balancing acts. Further analysis revealed that the basic social process common to all participants was balancing acts—a process whereby clinicians weigh individual best practice against perceived patient satisfaction. Each clinician had ideas about what constituted best practice; however, each was also concerned about maintaining good patient relationships and often saw these 2 concepts at odds. Every decision that included individual best practice information was adjusted for perceived patient satisfaction. As one clinician aptly commented, “I always debate. I do a lot of mental hand wringing.”

Four types of balancing acts were identified: (a) education, (b) negotiation, (c) giving in, and (d) holding firm.

• By educating patients about the data informing their decision to not prescribe antibiotics, clinicians offered that they could often increase perceived patient satisfaction and successfully refrain from prescribing antibiotics: “Eighty percent of the time, if I explain to them about the study where they actually punctured the maxillary sinuses and cultured what they brought out and you know 90% of them did not grow out—they’re shocked, and lots of time, they’ll say, “Why didn’t my doctor ever tell me this?”
• Negotiation was another strategy identified for increasing perceived patient satisfaction. Every clinician described discussions and prescriptions regarding symptom management as a negotiation strategy for increasing patient satisfaction. Eleven clinicians described how they would negotiate with the patient about what to do if symptoms did not improve: “So I give them a specific date…and I say, “Well, let’s give it a week—if it’s not any better then call and if there are no new symptoms, then I’ll call something (an antibiotic) in for it.”
• All of the clinicians reported situations where education and negotiation failed to work, or where the patient seemed so unconvincible that attempt seemed futile. In these situations, clinicians found themselves giving in—ie, abandoning individual best practice to salvage perceived patient satisfaction. One example: “Well in some cases, when someone seems so persistent, I will say, ‘Look, I’ve been able to tell you how I feel and what I think about what’s going on with you. If you are still adamant that you need an antibiotic, then fine, if you’re going to go somewhere else to get an antibiotic, I will prescribe an antibiotic for you.’”
• The last balancing act described by all but 1 of the clinicians was holding firm to their ideas regarding individual best practice, regardless of perceived patient satisfaction: “Once in awhile, I just kind of have to say, ‘You know, I don’t think antibiotics are necessary. I just don’t want to do that.’”

TABLE
The balancing act: Individual best practice vs patient satisfaction