Managing Expectations of Antibiotics for Upper Respiratory Tract Infections: A Qualitative Study

This paper by Mustafa and coauthors gives a good picture of how GPs handle URTIs in real life. Already early in the consultation the GP will usually become quite certain that antibiotics are not needed, and prepare herself or himself for a discussion with the patient, who they expect usually wants antibiotics. However, the GP is usually not 100% certain whether a course of antibiotics is needed or not, and it will be important to get information from both history and physical examination to increase the level of certainty. This implies a somewhat awaiting and humble attitude in the consultation, that patients appreciate. I see no benefit of discussing with the patient whether antibiotics should be prescribed or not before the physical examination has been finished, unless the patient brings it up. In any case the discussion should not lead to a conclusion at this stage. Regardless, GPs in this paper wanted to elicit the patient's expectation regarding antibiotics before the physical examination. Doing this they will be able to manipulate the significance of physical findings in the running communication with the patient, when antibiotics are expected but not found necessary. This is a somewhat sad consequence of the pressure the GPs expect from their patients.

Isn't it a question of diagnostic uncertainty? If the GPs could be more certain that a course of antibiotics is not needed, would it not be possible to be more straightforward and relaxed? Scandinavian GPs base their decision on antibiotic prescribing on the C-reactive protein test, when in doubt.(1) Maybe that's why they are less concerned about the patients' expectations? Whereas Welsh GPs in the GRACE study perceived that 55% of the patients with acute cough expected antibiotics, the corresponding figures for GPs from Norway and Sweden were 16%-18%.(1)

References

1. Jakobsen KA, Melbye H, Kelly MJ et al. Influence of CRP testing and clinical findings on antibiotic prescribing in adults presenting with acute cough in primary care. Scand J Prim Health Care 2010;28(4):229-236.

Competing interests: None declared