Family Practice Vol. 21, No. 5 © Oxford University Press 2004, all rights reserved.
Acute cough: a qualitative analysis of how GPs manage the consultation when patients explicitly or implicitly expect antibiotic prescriptions
Department of General Practice, University Hospital, Heinrich Heine University Düsseldorf, PO Box 101007, D-40001 Düsseldorf, Germany
E-mail: altiner{at}med.uni_duesseldorf.de
Received 26 September 2003; Revised 24 March 2004; Accepted 17 May 2004.
Altiner A, Knauf A, Moebes J, Sielk M and Wilm S. Acute cough: a qualitative analysis of how GPs manage the consultation when patients explicitly or implicitly expect antibiotic prescriptions. Family Practice 2004; 21: 500–506.
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsResultsDiscussionDeclarationReferences |
|---|
Objective. The aim of this study was to analyse how GPs manage the consultation for acute cough when patients explicitly or implicitly expect antibiotic prescriptions.
Methods. A qualitative analysis of audio-taped consultations was carried out. The participants were eight GPs from eight general practices in Northrhine, Germany and their 42 patients with acute cough over a 2 week period. Three researchers analysed the consultations independently, finally agreed by discussion.
Results. Implicit expectations for antibiotics were found frequently, but in none of the 42 consultations was the patient asked directly what she or he expected in terms of therapy. The topic of expectations and demands itself normally was not discussed at all, not even in a non-direct manner. In some consultations, the possibility of an antibiotic prescription was ruled out by the GP from the beginning. In some consultations, even a ‘pseudo-consent’ was found, avoiding any explicit clarification.
Conclusion. GPs seem to overestimate the actual pressure to prescribe antibiotics for acute cough. The (over) prescription of antibiotics might not be a question of knowledge but a lack of patient centredness.
Keywords. Antibiotics, attitudes, consultation, prescriptions, upper respiratory tract infections.
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionDeclarationReferences |
|---|
Consultations for acute cough are one of the most common in general practice. Despite the fact that antibiotics have at best a marginal effect on acute cough,1,2 they are prescribed frequently.2–4 Many doctors are aware of this issue but feel that their patients urge them to prescribe antibiotics.5,6 In contrast, recent studies described that only a minority of patients ask for antibiotics, and patients do not want antibiotics as much as their doctors think they do.6–8 There seem to be misconceptions as well as misunderstandings about effective treatment of acute respiratory tract infections (ARTIs) on the part of both patients and doctors.9–11 While many questionnaire and interview studies focused on this phenomenon of a likely misunderstanding, the actual patient–doctor interaction in encounters for ARTIs only recently has become a topic of interest.12,13
The focus of this qualitative study is to provide an inside view of the consultation for acute cough in German general practice. We wanted to specify how patients' explicit and, even more cruciallly, implicit expectations for antibiotic prescriptions are handled within doctor–patient communication in Germany and how they contribute to the process of decision making.
|
Methods |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionDeclarationReferences |
|---|
Sample
A sample of 10 GPs (four female and six male) working in the Province of Northrhine, Germany, were asked to take part in the study. In order to obtain a contrasting range of consultation styles, we asked the top five highest antibiotic prescribers as well as the five lowest antibiotic prescribers who were identified in a prior study with 16 GPs4 to participate. The GPs were not informed about this recruitment procedure. Our pre-assumption from that prior study was that the way GPs and their patients communicate about antibiotics and the actual prescription rates are closely interconnected. We aimed at including 50 consultations in the study in order to gain a broad spectrum of patient–doctor interactions.
Before beginning with the recording of the consultations, the GPs and their reception staff were visited by two researchers (AA and AK), intensively instructed how the study was supposed to be performed and asked to give consent.
The GPs were asked to record, for a period of 2 weeks in November 2002, all consultations for acute cough. The standardized procedure involved the reception staff who identified patients with acute cough at reception. After meeting the inclusion criteria (age >16 years, no underlying chronic lung diseases, no immune deficiencies, no recent encounter due to acute cough), patients were asked to give their written consent for their participation in the study.14 They were informed that the study aimed to get a better understanding of what happened inside a routine consultation for acute cough.
An audio-recorder (mini disk) was started by a member of the reception staff before both the GP and the patient entered the consulting room.
Coding
After the recorded consultations were transcribed, three researchers (SW, JM and AA) coded the consultations independently using pre-defined categories shown in Figure 1, assisted by winMAX text analysing software. The individual results were then cross-validated and agreed through discussion, identifying all interactions that explicitly or implicitly touched on antibiotics. Finally, these patient–doctor interactions were interpreted in the whole context of the consultation by consensus.
|
The quotations from the consultations cited here were translated by AA from German into English. Since the paper's conclusions rest on the interpretation of these data, the English citations were then retranslated by MS into German and checked for conformity.
|
Results |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionDeclarationReferences |
|---|
Two GPs dropped out of the study (one low and one high prescriber). Reasons that were given were a malfunctioning audio-recorder and lack of patients with acute cough attending the practice. The remaining eight GPs recorded 42 consultations. Patients were aged from 16 to 72 years (23 women and 19 men). Table 1 shows the number of recorded consultations by each GP and the number of consultations with an antibiotic prescription.
|
Only one patient refused to participate in the study without giving a specific reason. The main reason for the low number of recordings per week was that only one or two members of the reception staff of each practice were collaborating in the study and therefore not all eligible patients could be included. As audio-recorders were started well in advance of the consultation and erasing of a recording would have been detected, the selection of consultations was not biased by patient–doctor interaction during the consultation.
The rate of prescribed antibiotics (24%) was lower than expected from the prior study [4], this being 
50%.
Patient explicitly expects and GP consents to a prescription (A2)
Patient: "Well my problem is, I thought all the way about it if, I should take an antibiotic. Because I have problems with it for quite a while."GP: "Well let's see. What's the worst symptom. Do you cough?"
Patient: "Of course."
GP: "Fine." (laughs)
Patient: "I've just coughed haven't I. The infection goes all the way down."
GP: "That fits in." (mumbles)
Patient: "I think so."
GP: "You're looking somehow miserable."
[...]
Patient: "Can you see the infection?"
[...]
GP: "Alright I'll prescribe a broad-spectrum antibiotic." (GPII/2)
Explicit expectations for antibiotics were found only rarely. In this consultation, the patient explicitly requests an antibiotic and adds support to the request for it by mentioning the term infection. The GP examines the patient, presumably to provide some ‘medical justification’ for the decision that has already been made and suggests the patient may be ‘miserable’. The patient is quite persistent and the doctor prescribes on the basis that the patient is ‘miserable’.
The main reasons for coding an implicit expectation were the patients' arguments aimed at an aggressive therapy and the idea that the cough was caused by a bacterial (or even viral) infection. This was based on the concept that antibiotics are regarded by both patients and doctors as the most ‘vigorous’ drug for the treatment of ARTIs.8,9,15
Patient implicitly expects antibiotic expressed by the desire to get immediate relief and GP consents to a prescription (B2)
Patient: "I have a very important meeting tomorrow; ought to be an injection or so to become immediately healthy."GP: "What's so important tomorrow?"
Patient: "I have an important meeting with a customer."
[...]
GP (during examination): ... "because it's going on for 3 days now, I'd like to offer you an antibiotic, because there is a good chance that some bacteria are on top of it."
[...]
GP: "One has to consider that it won't leave immediately, even not when treated with an antibiotic. How long will it take tomorrow?"
Patient: "Tomorrow? Probably half an hour."
GP: "But you are going to make it, aren't you?"
Patient: "I have to."
GP: "Well, can I do anything else for you?"
Patient: "It's an antibiotic isn't it?"
GP: "Yes, exactly." (GP I/3)
In this consultation, the idea of an immediate medical cure by the patient is an implicit expression of the wish for an antibiotic. The GP starts the physical examination and offers an antibiotic without discussing the topic with the patient. He finds a medical reason ‘bacteria on top’ for the prescription, although knowing and also expressing that this might not have any effect on the course of the disease. The interpretation of an implicit wish for an antibiotic in the beginning of the consultation is reconfirmed at the end of the consultation by the patient seeking reassurance that the prescribed drug is really an antibiotic.
Patient implicitly expects antibiotic expressed by complaints about disgusting phlegm and bad cough. GP firstly rejects (B1), and later consents to a prescription (B2)
GP: "Do you bring something up?"Patient: "Not really, only if I blow my nose."
GP: "All right."
Patient: "The coughing started to be really bad yesterday, I nearly had to vomit, it really obstructs my throat, it's disgusting."
GP: "Let's have a look then..."
[...]
GP: "Do you sometimes have trouble with your sinuses?"
Patient: "Well yes, but it has been a long time since."
[...]
GP: "Well that's [pause] influenza which is spreading around now, with an acute onset. I think you won't need an antibiotic."
Patient: "I find it very uncomfortable, I can't breathe well and especially when I cough it's so bad that I think I have to vomit."
GP: "I can't find a bronchial spasm..."
Patient: "Mmmh."
[...]
GP: "Well you take Zithromax [Azithromycin] as an antibiotic, that's good for your sinuses too." (GP VII/1)
The central complaint in this encounter is the disgusting viscous phlegm what seems to be an important issue to many patients. The GP explains that the patient might have common flu and would not benefit from an antibiotic. The patient seems not to be satisfied and continues to complain, instead of expressing relief about the diagnosis of a harmless disorder. It seems to be obvious to the GP that the patient expects an antibiotic but he does not want to prescribe it.
In focusing on the sinuses, which apparently do not play an important role for the patient, a ‘pseudo-consent’ is found. It allows the GP to prescribe an antibiotic without losing face but contradicting himself and his first judgement ("You won't need an antibiotic").
Patient implicitly expects antibiotic expressed by the complaint about a worsening disease. GP consents to a prescription (B2)
Patient: "I also took a herbal bath and made myself a sage tea, but somehow, I can't stand it any longer."GP: "It has got worse then within the last 6 days, or do you think...?"
Patient: "No, worse."
[...]
GP: "At that time [2 years ago] I also prescribed doxycycline to you, and that's alright, well and I would like to suggest that we do so again."
Patient: "Well..."
GP: "Well,"
Patient: "Well you mean that's an antibiotic."
GP: "Yes, because you feel worse and so I think that's for me a hint that just drinking enough and sage that's not enough."
Patient: "Yes, I also recognized that." (GP VIII/1)
Obviously the over-the-counter medication had no effect and the disease is worsening. The patient might have tried to avoid an antibiotic prescription by taking herbal preparations but now an antibiotic seems to be necessary ("I can't stand it any longer"). Patient and GP do agree at this point that an antibiotic prescription seems to be justified due to the course of the disease. As seen before, the patient is reassuring herself that the prescribed drug is an antibiotic.
Patient implicitly expects antibiotic expressed by complaints about disgusting phlegm and bad cough. GP does not consent to a prescription (B1)
Patient: "I couldn't sleep well and now I have this disgusting purulent taste."GP: "Say ah..." (starts with examination)
[...]
Patient: "I have been working with all that bronchitis, no."
GP: "Yes that's correct, it's bronchitis."
Patient: "Yes."
GP: "Let's try Gelomyrtol it's a herbal preparation. It tastes good."
Patient: "I think we already tried that."
GP: "No, we did not."
[...]
GP: "I hope you get better soon."
Patient: "Thanks."
GP: "Rest, drink a lot. Three times a day Gelomyrtol and then wait and see."
Patien: "OK".
GP: "Thank you for your co-operation."
Patient: "Thank you very much." (GP IV/4)
Phlegm is, as in consultation (GP VII/1), felt to be something very uncomfortable as well as disgusting. The patient even says that the phlegm brought up by coughing has a purulent taste. The GP reacts mildly sarcastically to the complaint of the disgusting taste. Instead of discussing the topic—we interpreted the mention of the purulent taste as an implicit wish for an antibiotic—a herbal preparation (with a quite biting peppery taste) is prescribed. Furthermore, the GP expresses his thanks for the patients ‘co-operation’, whereas the patient tries at several points to oppose him before he eventually gives in.
Patient implicitly expects antibiotic expressed by the desire to obtain immediate relief and complaints about phlegm. GP does not consent to a prescription (B1)
Patient: "I took aspirin; that helped a bit but unfortunately I can't wait any longer than Tuesday. That's why I just dropped in, so that you can prescribe something for me."[...]
GP: "How about the cough?"
Patient: "Yeah, slimy, really thick."
[...]
GP: "Well, drink a lot please."
Patient: "OK."
GP: "And I'll prescribe an expectorant as a supplement, but I'm not sure if it will be gone completely by Wednesday."
[...] [Patient goes on complaining about heavy work load whilst feeling sick and a job that has to be done on Wednesday]
GP: "I'll give you a certificate of unfitness for work until Tuesday."
Patient: "All right then." (GP V/4)
In this consultation, the patient has a clear idea of by when the disease has to be gone: by Tuesday at least. In the context of the consultation, we interpreted to "prescribe something" as an implicit expectation of an antibiotic. Instead of prescribing an antibiotic, the GP reacts by prescribing an expectorant and lowers the patient's expectation of an immediate cure. GP and patient seem to haggle over an antibiotic for quite a while. In issuing a certificate of unfitness for work, the GP finally honours the complaints without prescribing an antibiotic. This solution seems to satisfy the patient.
In some of the consultations, the GPs simply (and in one case obstinately) ignored patients' implicit expectation of an antibiotic without discussing reasons (B3). We felt that the GPs had noticed the expectation but ignored it as a way to handle it.
Ruled out prescriptions (C3)
In some encounters, the possibility of an antibiotic prescription was ruled out right from the beginning of the consultation. In some cases, the GPs shared wih the patient the knowledge that, for a viral infection, an antibiotic has no therapeutic value. This helped to make clear that the prescription of an antibiotic was unlikely, a strategy described before.13 The option of a delayed prescription of an antibiotic15 was also found within the observed encounters.
GP: "It's the usual flu that we find now. No bacterial infection. You probably don't need an antibiotic." C3 (GP I/7)GP: "It's the flu that you have now. You don't need an antibiotic." (GP VI/2)
GP: "You won't need an antibiotic. Only if it won't get better in a few days. If it gets worse you should contact me again." (GP III/5)
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionDeclarationReferences |
|---|
Due to the design of multiple analysers and cross-validation at several points of the analysis, a high internal validity was obtained. Nevertheless, it can be questioned whether the interpretations are always correct and consistent. Especially in what we describe as implicit expectations for antibiotics, room is left for other interpretations different from ours. The real expectations of the patients remain unknown as this was not focus of this study; these are analysed in other studies.
The actual question is why such a large degree of uncertainty is left for controversies in the interpretation of the recorded consultations.
As our inclusion criteria included only first time consultations for acute cough and ruled out underlying lung diseases and immune deficiencies, we assume that the majority of the antibiotics were given unnecessarily.1 Nevertheless, there could be some cases in which the prescription was justified by factors that were not found within the transcribed consultation.
In none of the 42 consultations was the patient asked directly what she or he expected as therapy. The topic of expectations and demands was normally not discussed at all, not even in a non-direct manner (e.g. "I have the feeling you are expecting an antibiotic..."). In some consultations, the (perceived) possibility of an antibiotic prescription was ruled out from the beginning. In some consultations, even a pseudo-consent was found, avoiding any explicit clarification.
This phenomenon of ‘avoidance of clarification’ can be interpreted as a lack of noticing and identifying patients' real preferences and expectations within the consultation.
Nevertheless, is has to be stated that a patient-centred approach was only the exception to the rule within the observed consultations. This might be a cultural phenomenon in Germany, probably different from other countries such as the UK. However, there are also reports about missed eliciting of patient expectations and reactions in similar standard consultations in the UK.13
The prescription rate for antibiotics was relatively low in this study. This might be due to a bias. Participating in the observational study might have caused a desired prescription behaviour. The participating GPs are possibly more likely to be innovators of changes in medical behaviour than a representative sample of GPs.
In the majority of consultations, no patient pressure to prescribe antibiotics was found. This is consistent with the idea that GPs seem to overestimate the pressure for prescribing antibiotics in consultations for acute cough, as found in other studies (e.g. Rollnick et al.13), but it is clearly different from Scott et al.12 who found much more pressure from patients. This difference may be due to cultural reasons or to the method used by Scott et al. (interpretation of direct observation by the field researcher).
When urged to prescribe an antibiotic, GPs frequently follow patients expectations probably in order to avoid conflicts.16,17 Studies on this question have diverse results: some show that patient satisfaction with treatment is related to the quality of the doctor– patient interaction rather than to prescription of an antibiotic,2,7,18 while some show that patients not receiving an antibiotic which they want are more likely to express dissatisfaction.19
In many consultations, antibiotics were not discussed at all, neither by the patient nor by the GP, and we could not find any expectation by the patient to receive an antibiotic. We cannot tell whether in these consultations patient and doctor instinctively knew about their agreement, whether they had discussed this topic in an earlier consultation or whether the topic ‘antibiotic or not’ was unimportant for both.
This leads to the impression that the (over) prescription of antibiotics might first of all not be a question of knowledge of the GP but a lack of patient centredness.
We think that a substantial amount of antibiotic prescriptions could be avoided if GPs could find out what the real expectations of their patients are. In taking the complaints seriously by a careful physical examination and communication, many patients could be convinced that an antibiotic would probably harm rather than cure. This surplus workload by a more in-depth communication could be repaid in future consultations as patients would learn that antibiotics are usually not necessary to treat acute cough. Moreover, GPs could replace a nebulous perceived pressure to prescribe by a satisfying understanding of patients' real preferences and expectations.
Future interventions targeting GPs' prescription behaviour should therefore aim at improving the communication about antibiotics by openly discussing the topic within a patient-centred approach.
|
Declaration |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionDeclarationReferences |
|---|
Funding: N/A
Ethical Approval: N/A
Conflicts of interest: None.
|
Acknowledgments |
|---|
We would like to thank the participating GPs and their reception staff for their contributions to this project and their commitment in our study.
|
References |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionDeclarationReferences |
|---|
1 Smucny J, Fahey T, Becker L, Glazier R. Antibiotics for acute bronchitis (Cochrane Review). In The Cochrane Library, Issue 3. Oxford: Update Software; 2003.
2 Gonzales R, Bartlett JG, Besser RE et al. Principles of appropriate antibiotic use for treatment of uncomplicated acute bronchitis: background. Ann Intern Med 2001; 134: 521–529.
3 Steinman MA, Landefeld CS, Gonzales R. Predictors of broad-spectrum antibiotic prescribing for acute respiratory tract infections in adult primary care. J Am Med Assoc 2003; 289: 719–725.
4 Altiner A, Wilm S, Haag H, Schraven C, Sensen A, Abholz HH. Verordnungen bei akutem Husten: 501 Medikamente für 356 Patienten [Prescribing for acute cough: 501 drugs for 356 patients]. Z Allg Med 2002; 78: 287–290.
5 Coenen S, Michiels B, van Royen P, van der Auwera JC, Denekens J. Antibiotics for coughing in general practice: a questionnaire study to quantify and condense the reasons for prescribing. BMC Fam Pract 2002; 3: 16.
6 Cockburn J, Pit S. Prescribing behaviour in clinical practice: patients' expectations and doctors' perceptions of patients' expectations–a questionnaire study. Br Med J 1997; 315: 520–523.
7 Hamm RM, Hicks RJ, Bemben DA. Antibiotics and respiratory infections: are patients more satisfied when expectations are met? J Fam Pract 1996; 43: 56–62.[ISI][Medline]
8 Britten N, Ukoumunne O. The influence of patients' hopes of receiving a prescription on doctors' perceptions and the decision to prescribe: a questionnaire study. Br Med J 1997; 315: 1506–1510.
9 Belongia EA, Naimi TS, Gale CM, Besser RE. Antibiotic use and upper respiratory infections: a survey of knowledge, attitudes, and experience in Wisconsin and Minnesota. Prev Med 2002; 34: 346–352.[CrossRef][ISI][Medline]
10 Mainous AG III, Zoorob RJ, Oler MJ, Haynes DM. Patient knowledge of upper respiratory infections: implications for antibiotic expectations and unnecessary utilization. J Fam Pract 1997; 45: 75–83.[ISI][Medline]
11 Chan CSY. What do patients expect from consultations for upper respiratory tract infections? Fam Pract 1996; 13: 229–235.
12 Scott JG, Cohen D, DiCicco-Bloom B, Orzano J, Jaén CR, Crabtree BF. Antibiotic use in acute respiratory infections and the ways patients pressure physicians for a prescription. J Fam Pract 2001; 50: 853–858.[ISI][Medline]
13 Rollnick S, Seale C, Rees M, Butler C, Kinnersley P, Anderson L. Inside the routine general practice consultation: an observational study of consultations for sore throat. Fam Pract 2001; 18: 506–510.
14 Block MR, Schaffner KF, Coulehan JL. Ethical problems of recording physician–patient interactions in family practice settings. J Fam Pract 1985; 21: 467–472.[ISI][Medline]
15 Dowell J, Pitkethly M, Bain J, Martin S. A randomised controlled trial of delayed antibiotic prescribing as a strategy for managing uncomplicated respiratory tract infection in primary care. Br J Gen Pract 2001; 51: 200–205.[ISI][Medline]
16 Coenen S, van Royen P, Vermeire E, Hermann I, Denekens J. Antibiotics for coughing in general practice: a qualitative decision analysis. Fam Pract 2000; 17: 380–385.
17 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 throat. Br Med J 1998; 317: 637–642.
18 Lundkvist J, Akerlind I, Borgquist L, Mölstad S. The more time spent on listening, the less time spent on prescribing antibiotics in general practice. Fam Pract 2002; 19: 638–640.
19 Macfarlane J, Holmes W, Macfarlane R, Britten N. Influence of patients' expectations on antibiotic management of acute lower respiratory tract illness in general practice: questionnaire study. Br Med J 1997; 315: 1211–1214.
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  L. Brooks, A. Shaw, D. Sharp, and A. D Hay Towards a better understanding of patients' perspectives of antibiotic resistance and MRSA: a qualitative study Fam. Pract., July 22, 2008; (2008) cmn037v1. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
F. Wood, S. Simpson, and C. C Butler Socially responsible antibiotic choices in primary care: a qualitative study of GPs' decisions to prescribe broad-spectrum and fluroquinolone antibiotics Fam. Pract., October 1, 2007; 24(5): 427 - 434. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. Altiner, S. Brockmann, M. Sielk, S. Wilm, K. Wegscheider, and H.-H. Abholz Reducing antibiotic prescriptions for acute cough by motivating GPs to change their attitudes to communication and empowering patients: a cluster-randomized intervention study J. Antimicrob. Chemother., September 1, 2007; 60(3): 638 - 644. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. A. M. McNulty, P. Boyle, T. Nichols, P. Clappison, and P. Davey The public's attitudes to and compliance with antibiotics J. Antimicrob. Chemother., August 1, 2007; 60(suppl_1): i63 - i68. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 Avoiding antibacterial overuse in primary care DTB, April 1, 2007; 45(4): 25 - 29. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 D. Merenstein, M. Diener-West, A. Krist, M. Pinneger, and L. A. Cooper An Assessment of the Shared-Decision Model in Parents of Children With Acute Otitis Media Pediatrics, December 1, 2005; 116(6): 1267 - 1275. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||