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

Butler and colleagues sought to raise several new hypotheses
about why physicians frequently prescribe antibiotics for
patients with sore throats(1). Several of these hypotheses,
however, are not new. In previous studies we have already raised and
tested the specific hypotheses that antibiotic prescribing is related to
the physician's judgment of the likelihood of bacterial infection, and
that these judgments may be based on patient characteristics, e.g., "green
phlegm, pus on the tonsils, and toxicity." We have shown prospectively
that physicians' decisions to prescribe empiric antibiotics were highly
correlated with their judgments of the probability of streptococcal
pharyngitis for individual patients. These judgments, in turn, were
related to a variety of clinical variables including not
only cough, pharyngeal exudates, and a toxic appearance, but also a
history of fever, previous exposure to streptococci,
rhinorrhea, and an elevated temperature, and findings of
pharyngeal inflammation, swollen tonsils, palatine petechiae, and anterior
cervical adenopathy.(2)

Because our study physicians overestimated the probability
of streptococcal pharyngitis, we developed an intervention to improve
these judgments, and tested it in a controlled trial, hoping it would also
decrease physicians' antibiotic prescribing. Unfortunately, although the
intervention improved physicians' judgments, it did not affect their
prescribing(3). We suspect that the relationship of the judgments to
prescribing decisions was not causal, but was due to confounding. Perhaps
the doctors actually had based their decisions on judgments of disease
severity and/or the likelihood that antibiotics would improve symptoms
compared to conservative treatment. These judgments, in turn, may have
been based on patient characteristics like those on which the judgments of
the probability of streptococcal
disease were based. This suggests that it is not easy to
determine how physicians actually make decisions, but only
interventions that address important elements of the decision process are
likely to work.

Butler and colleagues' study is valuable because some of the
hypotheses it raises about physicians antibiotic prescribing
decision making may really be new. However, not all may prove to be true.
Butlet and colleagues' qualitative data collection was based on the
assumption that physicians can adequately explain how they think or make
decisions when they are directly queried. There is already could evidence
that they cannot(4). That none of the physicians admitted to being an
above average prescriber suggests not only how difficult it was for them
to introspect about their decision processes, and the effects of ego
bias(5).

Yours truly

Roy M. Poses MD
Associate Professor of Medicine and Community Health
Brown University School of Medicine
Memorial Hospital of Rhode Island
111 Brewster St.
Pawtucket RI 02860
USA

Randall D. Cebul, M.D.
Professor of Medicine
Case -Western University School of Medicine
Chief, Division of General Medicine
MetroHealth Medical Center
3395 Scranton Rd.
Cleveland
OH 44109
USA

Robert S. Wigton, M.D.
Professor and Associate Dean for Graduate Medical Education
Professor of Internal Medicine
University of Nebraska Medical School
600 S. 42nd St.
Omaha
NE 68198
USA

REFERENCES

1. Butler CC, Rollnick S, Pill R, Maggs-Rapport F, Stott N.
Understanding the culture of prescribing: qualitative study of general
practioners' and patients' perceptions of antibiotics for sore throats.
Brit Med J 1998; 317: 637-642.

2. Poses RM, Cebul RD, Collins M, Fager SS. The accuracy of
experienced physicians' probability estimates for patients with sore
throats: implications for decision making. JAMA 1985; 254:925-929.
3. Poses RM, Cebul RD, Wigton RS. You can lead a horse to water -
improving physicians' knowledge of probabilities may not affect their
decisions. Med Decis Making 1995; 15: 65-75.
4. Evans JSBT, Harries C, Dennis I, Dean J. General practioners' tacit
and stated policies in the prescription of lipid lowering agents. Br J Gen
Pract 1995; 45: 15-18.
5. Poses RM, McClish DK, Bekes C, Scott WE, Morley JN. Ego bias, reverse
ego bias, and physicians' prognostic estimates. Crit Care Med 1991; 19:
1533-1539.

Editor – The article by Butler et al shows that the decision whether
to prescribe an antibiotic is a complex one. My experience of such
consultations started 10 years ago as a GP registrar, when a patient
dropped in to surgery while out shopping to pick up an antibiotic for her
sore throat. She was displeased that she was not seeing her ‘regular'
doctor, and even more so when I told her, after examining her, that the
sore throat would get better by itself. ‘Dr X always gives me an
antibiotic' she said, ‘and of course, I do have a heart condition'.
Looking through her notes I found an earlier registrar had put her on
Atenolol for a presumed but not confirmed irregular heartrate, but
resisted the temptation to tell her there and then that she probably
didn't need this either. Instead I ploughed into a discussion of her
smoking habits and how they may have resulted in her sore throat being
worse than it otherwise would have been. Really angry now, she got up to
leave and her parting shot was ‘I do hope you get on alright doctor, I do
realise you are only a student'.

Since then I have learnt better ways of giving the same information,
and as an established family doctor, find it much easier talking to
patients I already know well. I do find though that many people do not
really know what a virus is and why it does not respond to an antibiotic,
so discussions must start from basic principles. However, my last practice
in Central Manchester, had a large proportion of shifting patients, often
from very deprived circumstances, who were used to fighting with social
services, housing associations and health services to get what they felt
they needed. Achieving the same outcome in consultations there was much
more difficult, and patients were much less likely to agree with a
decision not to prescribe. They wanted to leave the surgery with a
prescription not only for antibiotics, but also sudacrem, cotton wool, E45
cream and paracetamol.

How do we fit all this into a 7.5 minute consultation, with numerous
patients per surgery? GPs work in an archaic system where we need to be
multi-faceted professionals with the wisdom of Solomon and the speed of
Batman. Many of my patients come with several problems at a time, at least
one of which may be social or psychological. I defy anyone to fit it all
in appropriately in the time we give ourselves.

Kamila Hawthorne General Practitioner
Four Elms Medical Centres, 103 Newport Road, Cardiff CF2 1AF

No conflict of interest

Editor, Butler and colleagues are to be congratulated on illuminating one of the most important reasons for GPs' apparently irrational behaviour in their inappropriate prescribing of antibiotics. i.e. their need not to endanger
the doctor-patient relationship. My thirty years in general practice endorses this view.

As one of the members of the seminar who, with Michael Balint in the 1960's examined the problems of repeat prescribing in general practice (Ref.) I would like to suggest for debate and research another possible determinant
of this irrational behaviour.

I believe, that embedded in the collective unconscious of society and shared by doctors, is a fantasy about the magical powers of antibiotics. Other therapeutic agents are usually seen as replacing missing items or stimulating physiological processes . Antibiotics, on the other hand
eliminate invisible threats to our existence. They kill the unseen invader. Even the term "antibiotic" itself reinforces this fantasy. They are "against (bad) life"

No wonder GPs want to give their patients the benefit of this magic.

Len Ratoff. Liverpool
Retired G.P. Liverpool
Currently, Audit Facilitator St. Helens and Knowsley MAAG.

Ref. Michael Balint, John Hunt, Dick Joyce, Marshall Marinker, & Jasper Woodcock. Treatment or Diagnosis. 1970 Mind and Medicine Monographs. Tavistock Publications 1970.