A new paper in Health Psychology highlights the role that patient pressure can play in antibiotic prescribing, raising questions about how non-clinical factors contribute to overprescribing and inappropriate antibiotic use, and how those factors can be addressed.
While the finding aren't necessarily surprising, they shed light on the pressure that physicians can feel when presented with patients who feel antibiotics are necessary, even if their condition suggests differently.
High expectations, low expectations
The paper describes a series of experiments in which family physicians in the United Kingdom were presented with hypothetical patient scenarios, or vignettes, and then asked to complete an online questionnaire.
The first vignette involved a 15-year-old competitive swimmer in the third day of typical earache symptoms—including fever, ear pain, and reduced hearing—but with no signs of a more significant infection (no perforation or discharge from the ear). Under UK treatment guidelines for acute otitis media, the recommended approach for such a case would be to withhold antibiotics until the condition worsened.
The investigators then added another layer to the vignette. In the high-expectation scenario, the girl's mother requests that she be given antibiotics so she can compete in an upcoming swim meet that could determine whether she'll get a scholarship. In the low-expectation scenario, the girl has already competed in her final swim meet of the season.
As part of the questionnaire, the physicians were asked to assess, on a scale of zero to 10, the probability of prescribing an antibiotic. They were also asked the percentage probability (zero to 100%) that the girl had a bacterial infection. The order of the questions was manipulated randomly for each survey participant.
The results showed that, no matter the order of the questions, the physicians presented with the high-expectation scenario were more likely to prescribe antibiotics for the girl, a difference that was statistically significant. This relationship held true even though they were no more likely than those presented with the low-expectations scenario to assess the infection as bacterial: Both groups rated the probability of bacterial infection around 40%.
"Thus, we found decisive experimental evidence that patients' expectations for antibiotics amplify physicians' willingness to prescribe antibiotics regardless of the response order of the probability and prescribing question," the authors write.
The second experiment presented a different group of doctors with two similar stories. The first vignette was similar to the first experiment, except the swimmer was 18 years old and attending college and was not accompanied by a parent. In the second vignette, the patient was a 38-year-old man presenting with symptoms of cough and cold who wanted to get back to work. Each vignette included high-expectation and low-expectation scenarios. In both cases, the participants were asked whether they would prescribe antibiotics (yes or no) and to assess the probability that the hypothetical patient had a bacterial infection.
Overall, 52% of the physicians said they would prescribe antibiotics to the patient in the first vignette, although, as in the first experiment, the respondents were more likely to do so when there was a high expectation of antibiotics. In the second vignette, only 12.2% of the respondents said they would prescribe an antibiotic and were actually less likely to prescribe in the high-expectation scenario. And in both cases, high expectation of antibiotics had no effect on the respondents' assessment of the probability of bacterial infection.
The authors of the paper say that while their findings provide evidence that patient expectations can increase a physician's willingness to prescribe antibiotics, the effect was "localized." In other words, the patient's desire for antibiotics did not distort the physicians' perceived probability of bacterial infection.
"Imagine, for example, that a physician rationalized her decision to prescribe the antibiotics by increasing the perceived probability of a bacterial infection," lead author Miroslav Sirota, PhD, of the University of Essex said in a press release from the American Psychological Association (publisher of Health Psychology). "We did not find any evidence of that happening, which is good news, and has taught us something new about the 'localized' effect of expectations."
Patients want to feel better
Jon Hallberg, MD, a family medicine physician and director of the University of Minnesota Physicians Mill City Clinic, says he's familiar with these types of high-expectation scenarios. In his case, they tend to involve patients who are going on a trip in a few days and want to feel better so they can enjoy their vacation. "That happens all the time," he told CIDRAP News.
Hallberg said that although many physicians today are highly cognizant of their role as antibiotic stewards, addressing how psychological pressure can impact stewardship is worthwhile. "We've all kind of known about patient expectation, but to have it be made so clear…I think that's an important contribution to the literature, and to our understanding of this issue," he said.
At the Mill City Clinic, Hallberg said, patients to come to him with the expectation for antibiotics for two reasons. "They're in pain, and they're scared," he said. "They think that the antibiotic is going to take care of their discomfort, and we all know that analgesics and other things can be used for that," he said.
In those situations, if there isn't travel involved, Hallberg said he'll tell patients that the illness is likely viral and to contact him in 48 to 72 hours if they haven't gotten better. And in most cases, those patients' symptoms end up resolving without antibiotics. If the patient is traveling, Hallberg will give him or her what he calls a "wait-and-see" prescription, while also making it clear that the condition doesn't yet warrant antibiotics. The key, he said, is taking the time to communicate and explain to patients his reasoning.
"People are just reassured, because the conversation took care of the fear," Hallberg said.
Hallberg added that overall, though, he actually doesn't get a lot of direct pressure in his practice to prescribe antibiotics. "The pressure I get is people want to feel better," he explained. "And we sometimes erroneously interpret that as 'they're asking me for antibiotics,' and that's not always the case."
Hallberg said he's actually sensed a bit of a "sea change" regarding antibiotics in recent years, with more patients saying they 'd prefer not to take antibiotics unless absolutely necessary. "It's very heartening that the message is being heard loud and clear."
Feb 16 Health Psychol study
Feb 16 American Psychological Association press release