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

OBJECTIVE We identified those aspects of physician-patient communication th at influence physicians to prescribe antibiotics for respiratory infections . STUDY DESIGN A multimethod comparative case study was performed including d escriptive 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 29 8 outpatient Visits for acute respiratory tract (ART) infections were selec ted for analysis from more than 1600 encounters observed. OUTCOMES MEASURED Unnecessary antibiotic use and patterns of physician-pati ent 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 D isease Control and Prevention guidelines. Patients were observed to pressur e physicians for medication. The types of patterns identified were direct r equest, 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 circums tances, and previous use of antibiotics. Also, clinicians were observed to rationalize their antibiotic prescriptions by reporting medically acceptabl e reasons and diagnoses to patients. CONCLUSIONS Patients strongly influence the antibiotic prescribing of physi cians by using a number of different behaviors. To decrease antibiotic use for ART infections, patients should be educated about the dangers and limit ed benefits of such use, and clinicians should consider appropriate respons es to these different patient pressures to prescribe antibiotics.