Patient and physician explanatory models for acute bronchitis

What my sickness did to me/pathophysiology

Most patients responded that they had never thought about what the illness did to them. When probed, patients generally responded that they had an infection “in the bronchial pipes” or a “cold in the chest.”

Physicians were asked to describe the pathophysiology of acute bronchitis and discuss how they arrive at a diagnosis. In general, they described how a virus or bacteria “invades” the respiratory tract, causing inflammation of the airways and bronchioles, resulting in increased mucus production. Several physicians described bacterial overgrowth occurring. Physicians separated acute bronchitis from an upper respiratory infection based on the cough, especially if it was productive, and from pneumonia by the absence of more severe signs or symptoms, such as high fever, shortness of breath, or presence of rales. Several physicians tied their diagnosis to treatment, as illustrated by a physician who stated, “I think that many doctors use bronchitis as the excuse to give an antibiotic. And I sometimes fall into that trap. So if I want them to think they deserve an antibiotic, then sometimes I will give them the diagnosis of bronchitis.”

How severe is my sickness/course of illness

One third of patients reported feeling very bad and one third felt moderately bad. The remainder reported variability in the way they felt or not feeling ill at all. Similarly, one third reported a cough duration of 3 weeks or longer and one third felt that the illness had a major impact on their work and daily routine. When asked what would have happened if they had not seen the doctor, patients consistently reported that they would have been sick longer, would not have recovered, or would have gotten pneumonia. Three patients felt they could have died. None said that they would have recovered on their own.

Physicians were asked how many days of work were missed by patients with acute bronchitis. More than two thirds estimated that patients missed from 1 to 3 days. A number of physicians mentioned that factors such as work motivation, attitudes about illness, and availability of paid sick leave influenced the number of days off. Most physicians thought it would take patients 1 week or longer before they felt well enough to return to their normal routine.

What kind of treatment should I receive/treatment

All patients recalled that the primary treatment for their acute bronchitis was a prescription medication such as an antibiotic, cough suppressant, or decongestant. Twenty-seven reported receiving an antibiotic prescription. An inhaler was prescribed for about one third of patients. Several patients commented on the inhaler’s effectiveness for relieving symptoms. This is illustrated by a patient who stated, “the inhaler is the thing that helped me instantaneously.” About one third of patients reported receiving medical advice such as drinking lots of liquids and resting.

Most patients agreed that the treatment they received was what they expected, but when asked to articulate what they “expected,” they had problems doing so. After probing by the interviewer, more than 50% stated that an antibiotic was what they needed for treating their illness. This is typified by the response of one patient, “I would like [bronchitis] to be treated more aggressively. … [Physicians] want to wait until you’ve got a full blown infection before they do anything and I wish that would be different next time.”

When patients were asked about treatment satisfaction, about two thirds reported that they were satisfied because they felt better “pretty fast.” There was wide variation in their definition of “pretty fast,” ranging from 1 day to 3 weeks. Several patients were somewhat dissatisfied with their treatment but felt that nothing else could have been done. A few patients expressed strong dissatisfaction because of slow recovery time or because the prescribed medications did not relieve the symptoms.

Two major treatment approaches emerged from the physician interviews: use of antibiotics or a primary focus on symptom relief. Most physicians who commonly used antibiotics were concerned about which antibiotics were more effective. They also were concerned about patients who were sick longer than 1 week, had discolored sputum, were members of high-risk populations (especially smokers), and who did not improve with treatment. A few physicians who focused on symptom relief prescribed cough suppressants, ß-agonist inhalers, or decongestants. These physicians felt it was important to educate patients about differences between viral and bacterial diseases, disadvantages of overusing antibiotics, and ways to relieve symptoms at home instead of relying on prescribed medications.

When asked about expectations of treatment, all 30 physicians thought that their patients wanted them to prescribe antibiotics. About one third reported that patients also expected to have a “prescribed cough medicine.” Three fourths of the physicians perceived patients’ “antibiotic expectations” as a pressure, although with different rationales. Several physicians admitted that they prescribed antibiotics “to make the patient happy.” One said, “I think people expect it. If you get somebody that has come in and has done everything they can figure out to do to try to get better, then you can certainly end up with patients that are unhappy if you refuse to give them antibiotics.” Some physicians suggested that the pressure of prescribing antibiotics was not from the individual, but from the system, including the employer, the legal system, and the health insurance system.