BMJ 1998;317:637-642 ( 5 September )

General Practice

Understanding the culture of prescribing: qualitative study of general practitioners' and patients' perceptions of antibiotics for sore throats

Christopher C Butler, lecturer, a Stephen Rollnick, senior lecturer in general practice, a Roisin Pill, professor of general practice research, a Frances Maggs-Rapport, research officer, b Nigel Stott, professor of general practice. a

a Department of General Practice, University of Wales College of Medicine, Llanedeyrn Health Centre, Maelfa, Cardiff CF3 7PN, b Department of Dental Public Health, University of Wales College of Medicine, Lansdowne Hospital, Cardiff

Correspondence to: Dr Rollnick genpract{at}cf.ac.uk

Objectives: To better understand reasons for antibiotics being prescribed for sore throats despite well known evidence that they are generally of little help.
Design: Qualitative study with semi-structured interviews.
Setting: General practices in South Wales.
Subjects: 21 general practitioners and 17 of their patients who had recently consulted for a sore throat or upper respiratory tract infection.
Main outcome measures: Subjects' experience of management of the illness, patients' expectations, beliefs about antibiotic treatment for sore throats, and ideas for reducing prescribing.
Results: Doctors knew of the evidence for marginal effectiveness yet often prescribed for good relationships with patients. Possible patient benefit outweighed theoretical community risk from resistant bacteria. Most doctors found prescribing "against the evidence" uncomfortable and realised this probably increased workload. Explanations of the distinction between virus and bacterium often led to perceived confusion. Clinicians were divided on the value of leaflets and national campaigns, but several favoured patient empowerment for self care by other members of the primary care team. Patient expectations were seldom made explicit, and many were not met. A third of patients had a clear expectation for antibiotics, and mothers were more likely to accept non-antibiotic treatment for their children than for themselves. Satisfaction was not necessarily related to receiving antibiotics, with many seeking reassurance, further information, and pain relief.
Conclusions: This prescribing decision is greatly influenced by considerations of the doctor-patient relationship. Consulting strategies that make patient expectations explicit without damaging relationships might reduce unwanted antibiotics. Repeating evidence for lack of effectiveness is unlikely to change doctors' prescribing, but information about risk to individual patients might. Emphasising positive aspects of non-antibiotic treatment and lack of efficacy in general might be helpful.

Key messages

  • Doctors know that antibiotics do not help most sore throat sufferers but try not to jeopardise relationships with patients over this issue

  • Patients' expectations are seldom explicit, and satisfaction is not necessarily related to receiving an antibiotic: information and reassurance are sometimes more important

  • Consulting techniques that make expectations explicit, preserve relationships, and facilitate acceptable management are important

  • Opportunities for empowering patients who are not acutely ill could be better used, and emphasising positive aspects of non-antibiotic treatment, especially in children, could be fruitful

  • Risks to individuals from unnecessary antibiotics (rather than trial evidence for marginal benefit) should be emphasised



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Rapid Responses:

Read all Rapid Responses

What can be done to reduce antibiotic prescribing in patients with sore throat?
Morten Lindbæk
bmj.com, 7 Sep 1998 [Full text]
Antibiotics are seen as having magical powers
Len Ratoff
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Lack of knowledge in diseases of the head and neck
Andreas F P Temmel, et al.
bmj.com, 10 Sep 1998 [Full text]
Prescribing of antibiotics for sore throats
Andrew Sanderson
bmj.com, 11 Sep 1998 [Full text]
Understanding the culture of prescribing: the decision is more complex than you think
Kamila Hawthorne
bmj.com, 11 Sep 1998 [Full text]
Doctors do not always know why they make decisions
Roy M Poses
bmj.com, 7 Oct 1998 [Full text]
Irrational prescribing because of shifting therapeutic thresholds for sore throats and for coughing
Samuel Coenen, et al.
bmj.com, 29 Oct 1998 [Full text]
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