Understanding the culture of prescribing: qualitative study of general practitioners' and patients' perceptions of antibiotics for sore throats
BMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7159.637 (Published 05 September 1998) Cite this as: BMJ 1998;317:637
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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.
Competing interests: No competing interests
Dear Sir
Butler et.al. did not report a procedure that I use when I am faced
with either a sore throat about which I am unsure or where the patient has
asked for antibiotics. I tell the patient that I think that it is viral,
but take a throat swab, with the promise that if the throat is still
sore and the swab is positive, then I will prescribe the antibiotic
suggested by the swab result. Most seem happy - at least I don't see many
again.
Yours Sincerely
Andrew Sanderson
Ref :- Butler, C.C.,Rollnick, S., Maggs-Rapport, F.,Stott, N.
Understanding the culture of prescribing: qualitative study of general
practitioners' and patients' perceptions of antibiotics for sore throats.
BMJ 1998;317:637-642
No conflict of interest
Competing interests: No competing interests
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
Competing interests: No competing interests
Sore throat is a very unspecific term, it includes pain and
dysesthesia of the oral and pharyngeal area. The diseases involved could
be due to mucosal changes of the lip or the oral cavity, the
lymphoepithelial organs, the pharynx (epi-, oro- and hypopharynx) or the
salivary glands. The “classic sore throat” is localised in the throat. In
a textbook you will find reasons such as angina (tonsillar, lingual,
retronasal or lateral), pharyngitis, mononucleosis, angina Plaut Vincent,
stomatitis, scarlet fever, peritonsillar abscess, retropharyngeal abscess,
abscess of the flour of the mouth, epiglottitis, Eagle-syndrom, trauma
(burning, foreign body,..) and neoplasms (1). Most of the diseases, but
symptoms of a viral upper respiratory infection, require an antibiotic
treatment.
It is quite difficult for a general practitioner (GP) to differentiate all
the above quoted disease without results of laboratory examinations,
because, at least in Austria, the GP training in otolaryngology is very
short (two months). In our opinion most of the prescriptions of
antimicrobial agents are made to be on the safe side. In case of a viral
infection sure it will not help, but it will not harm a lot either.
Patients are usually told to take care if diarrhoea occurs or sometimes
are provided with a suitable medication against diarrhoea right from the
start. Occasionally we see patients suffering from a carcinoma of the head
and neck, who have run through various courses of antibiotics.
In our opinion GPs, who are not sure about the diagnosis of a sore throat,
need to refer patients to an ENT-specialist, who is trained in the therapy
of “sore throat ”.
Reference:
(1) Naumann-HH. Differentialdiagnostik in der Hals-Nasen-Ohrenheilkunde
Georg Thieme 1990
Competing interests: No competing interests
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.
Competing interests: No competing interests
I found the article of Butler et al very interesting (1). In Norway the problems with resistant bacteriae is limited, and have been stable for ten years. The most important reason for this is probably the low total prescription of antibiotics and the high proportion of penicillin V. The total prescription of antibiotics has decreased by 10% since 1993. One of the reasons for this decrease is possibly the use of rapid tests in general practice.
A rapid test for detection of GAS has a sensitivity and specificity over 90%. The answer of this test is ready within 5 minutes, and has a direct impact on prescribing antibiotics. As GAS is the only pathogen in sore throat that benefits from treatment with penicillin V (2) and has a frequency of 30 %, this can potentially reduce the prescription for sore throat to a large extent. Since the answer comes so rapidly, you can take the patient into your office after the test, explain the result and why you would/would not prescribe penicillin V. This is a good pedagogic tool to explain the difference of viral sore throat and GAS-infection.
In a recent study we have demonstrated that a rapid test of C-reactive protein done in the GP's office, and giving the answer within 10 minutes, can be helpful in finding patients with respiratory tract infections who are in need of antibiotic treatment (3). The test contributed to reduce the antibiotic consumption by one fourth in our investigation. We feel that this test is one of the best tools to exclude bacterial causes of acute bronchitis, and is also a good pedagogic tool.
After 15 years of general practice I have a definite impression that the attitudes about use of antibiotics has changed. Not so seldom I meet parents with the following comment after I have investigated their child and stated that the child probably has a viral infection by use of one or two rapid tests: "That's fine. I am glad that my child does not need to have an antibiotic this time".
I look forward to hearing more about your research on this important topic. Would it be possible for you to look at the effect of use of a rapid test as explained and evaluate how this would affect the rate of prescribing and the patients attitudes?
References:
1. Butler CC, Rollnick S, Pill R, Maggs-Rapport F, Stott N. Understanding the culture of prescribing: qualitative study of general practitioners' and patients' preceptions of antibiotics for sore throat. BMJ 1998; 317: 637-42.
2. Dagnelie CF et al. Do patients with sore throat benefit from penicillin? A randomized double-blind placebo-controlled clinical trial with penicillin V in general practice. Br J Gen Pract 1996; 46: 589-93.
3. Lindbæk M, Hjortdahl P. C-reactive protein in primary care - a useful diagnostic tool in infections. Tidsskr Nor Lægeforen 1998; 118: 1176-9.
Competing interests: No competing interests
Irrational prescribing because of shifting therapeutic thresholds for sore throats and for coughing
Editor, Butler and co-workers1 conclude that antibiotics are
prescribed for a variety of complex reasons.
In our medical decision analysis study addressing the management of
‘coughing’, we also used a qualitative study: focus groups2 to answer our
first research question: "In patients with coughing as the reason for
encounter, what arguments do general practitioners use to make decisions,
suspecting a respiratory tract infection?"
From our focus groups the key decision in such patients is to prescribe
antibiotics or not. So we asked ourselves: "Are Butler and co-workers’
conclusions congruent with our results?" and " Are their results
transferable to an other clinical setting?"
Concerning the Interviews with general practitioners, our results are
similar, except for the Explanations for irrational prescribing. Bulter
and co-workers state: "The vast majority said they had increased their
prescribing as their knowledge of their patients increased". Quite
opposite we found that more knowledge about patients is less likely
associated with prescribing an antibiotic.
We believe diagnostic uncertainty (mathematically expressed as
probability3) has an important impact on prescribing decisions.
The explanation for irrational prescribing under this condition, is the
use of doctor and patient factors besides the ‘clinical pointers1’.
Because differentiating between bacterial and viral infections is not
possible with any certainty on clinical grounds alone1, general
practitioners quite often get stuck on probabilities of disease within the
test area, defined by Pauker and Kassirer4, leaving them with reasonable
diagnostic doubt. We believe this load of diagnostic uncertainty
determines that factors such as fear of medicolegal problems1 are also
used in decision making. They do not change probabilities of disease.
But we assume general practitioners take them into account to manipulate
their therapeutic thresholds.
Why then do such doctor and patient factors tend to shift the
therapeutic thresholds in favour of prescribing antibiotics? This we
believe is because of chagrin5, e.g. if chagrin on not having prescribed
antibiotics when necessary is higher than on an unnecessary prescription.
This hypothesis frames ‘the variety of complex reasons’.
Looking again at the results of Butler and co-workers, they seem
congruent with our results, with the exception that our general
practitioners seem to have higher tolerance for chagrin with increasing
knowledge of their patients.
Therefor we can transfer the ‘key messages1’ to our clinical setting.
To change prescription habits general practitioners need to develop a
higher tolerance for chagrin in cases of diagnostic uncertainty. By
sharing this doubt and chagrin with their patients?
Drs. Samuel Coenen
Dr. Hugo Van Puymbroeck
Dr. Luc Debaene
Prof. Dr. Paul Van Royen
Prof. Dr. Joke Denekens.
Correspondence
Drs. Samuel Coenen
Research Assistant for the Fund of Scientific Research - Flanders
University of Antwerp - UIA - Centre for General Practice Antwerp
Universiteitsplein 1, B-2610 Antwerp, Belgium
Tel: 00 32 3 820.25.29 Fax: 00 32 3 820.25.26
Email: samuel@uia.ua.ac.be
References
1. Butler CC, Rollnick S, Pill R, Maggs-Rapport F, Stott N.
Understanding the culture of prescribing: qualitative study of general
practitioners' and patients' perceptions of antibiotics for sore throats.
BMJ 1998;317(7159):637-42.
2. Kitzinger J. Introducing focus groups. BMJ 1995;311(29 July):299-302.
3. Sox jr H. Medical Decision Making: Butterworths, 1988.
4. Pauker S, Kassirer J. The threshold approach to clinical decision
making. NEJM 1980;302(20):1109-17.
5. Feinstein A. The 'Chagrin Factor' and Qualitative Decision Analysis.
Arch Intern Med 1985;145:1257-9.
Competing interests: No competing interests