Antibiotic use in acute respiratory infections and the ways patients pressure physicians for a prescription

OBJECTIVE: We identified those aspects of physician-patient communication that influence physicians to prescribe antibiotics for respiratory infections. STUDY DESIGN: A multimethod comparative case study was performed including descriptive field notes of outpatient visits. POPULATION: We included patients (children and adults) and clinicians in 18 purposefully selected family practices in a midwestern state. A total of 298 outpatient visits for acute respiratory tract (ART) infections were selected for analysis from more than 1600 encounters observed. OUTCOMES MEASURED: Unnecessary antibiotic use and patterns of physician-patient communication were measured. RESULTS: Antibiotics were prescribed in 68% of the ART infection visits, and of those, 80% were determined to be unnecessary according to Centers for Disease Control and Prevention guidelines. Patients were observed to pressure physicians for medication. The types of patterns identified were direct request, candidate diagnosis (a diagnosis suggested by the patient), implied candidate diagnosis (a set of symptoms specifically indexing a particular diagnosis), portraying severity of illness, appealing to life-world circumstances, and previous use of antibiotics. Also, clinicians were observed to rationalize their antibiotic prescriptions by reporting medically acceptable reasons and diagnoses to patients. CONCLUSIONS: Patients strongly influence the antibiotic prescribing of physicians by using a number of different behaviors. To decrease antibiotic use for ART infections, patients should be educated about the dangers and limited benefits of such use, and clinicians should consider appropriate responses to these different patient pressures to prescribe antibiotics.