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

Discussion

Though individual best practice has not been referred to as such, it is by no means a novel idea and is at the core of the evidence-based practice debate, wherein evidence obtained from research is often viewed as being at odds with clinician experience.^14-16 However, our study also revealed that some clinicians were unfamiliar with the research-based evidence they claimed to use. For example, 2 clinicians who claimed familiarity with research-based evidence indicated they would strongly consider prescribing antibiotics for a productive cough regardless of other historical or exam findings.

Perceived patient satisfaction has received much attention in and out of the “antibiotic” literature for its powerful influence on clinical decision-making.^1,17-19 Our findings further this concept by identifying several of the factors that influence it, including patient-driven (eg, unique patient situations) and clinician-driven (eg, business concerns).

Though balancing acts is a new term, 3 of the 4 types of balancing acts have been alluded to in the antibiotic literature. Several studies have demonstrated that patient education can decrease antibiotic prescribing and use.^10,20,21 Similarly patient negotiation, through the use of delayed antibiotic prescribing or a contingency plan for delayed prescribing, has also decreased antibiotic prescribing^22,23 and increased patient satisfaction.²⁴ Furthermore, it is well documented that the act of giving in to perceived patient desires for antibiotics occurs frequently.^1,10,25

Holding firm was the only balancing act not paralleled in the literature. This likely stems from the fact that most research efforts have focused on situations where antibiotics were inappropriately prescribed, as opposed to situations where they were appropriately withheld. However, now that there is evidence of a decrease in antibiotic use for ARIs,^26,27 it is likely that holding firm is occurring more often.

Study strengths and limitations

Interviewing both physicians and nurse practitioners increases our study’s overall applicability. Moreover, the fact that our participants practiced in the same close-knit community increased the likelihood that they were dealing with a consistent patient population.

One facet that serves as both a strength and limitation is that the main investigator (Hart) worked as a nurse practitioner in the community of study. Her experience treating patients with ARIs and her role as a community clinician undoubtedly helped her gain access to the participants, but being an “inside” investigator might have caused participants to be less candid than they would have been with an unknown investigator.

Our study relied solely on information gleaned from participant interviews; thus it is possible that some of the participants described their antibiotic prescribing processes differently than how the processes actually work during clinical encounters.

Finally, our findings represent actual descriptions of clinicians’ practices. Balancing acts and related concepts should not be confused with our beliefs about “ideal” clinical decision-making.

Implications

The balancing acts process and related concepts have several implications for clinician education and practice. Regarding individual best practice, we need to recognize that clinicians make decisions based on many different forms of evidence, including but not limited to research-based evidence, outdated or incorrect sources of literature, and personal and professional experiences. They also may be most comfortable practicing in the manner and style they were exposed to in their initial training experiences. Thus, in addition to exposing clinicians to research-based evidence, we need to teach them how to integrate research-based evidence into their practices, as well as how to deal with research findings that seem to conflict with their own observations or primary training experiences. Recognizing and using local peer influences is one way to support this concept and has been shown to be an effective strategy.²⁸

Furthermore, we should not underestimate the impact of perceived patient satisfaction on clinician decision-making. Clinicians need to understand patient satisfaction and how it influences their practices. They need to appreciate that their own perceptions of patient desires may be inaccurate.^29,30 They also need to be aware that studies have shown no relationship between antibiotic prescribing and patient satisfaction,^30-32 and that patients are most satisfied when clinicians spend time with them, respect their symptoms, and honestly address their concerns.^33-35