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General Practice

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

BMJ 1998; 317 doi: (Published 05 September 1998) Cite this as: BMJ 1998;317:637
  1. Christopher C Butler, lecturera,
  2. Stephen Rollnick, senior lecturer in general practicea,
  3. Roisin Pill, professor of general practice researcha,
  4. Frances Maggs-Rapport, research officerb,
  5. Nigel Stott, professor of general practicea
  1. aDepartment of General Practice, University of Wales College of Medicine, Llanedeyrn Health Centre, Maelfa, Cardiff CF3 7PN
  2. bDepartment of Dental Public Health, University of Wales College of Medicine, Lansdowne Hospital, Cardiff
  1. Correspondence to: Dr Rollnick


    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.

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