Article Figures & Data
Tables
Main Topic Area Specific Approach Introductions Explain rationale for the study URTI consultation Inquire how they manage the URTI consultation Interviewer to use open questions until satisfied participants’ comments highlight: Usual practice An understanding as to why, how, and when they elicit expectations, if at all The type of gambits used and why they use them How they structure their consultation Eliciting expectations Ask for their views on eliciting expectations for antibiotics Consultation map Show participants a visual aid of the consultation map and seek participants’ views on whether it is a valid representation: Gathering information 1: history Gathering information 2: examination ± commentary Diagnosis spin Management plan ± negotiating shared decision Wrap-up Ask if there are any questions Ask whether this has been an opportunity to reflect -
URTI = upper respiratory tract infection.
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- Table 2
Themes, Subthemes, and Codes Describing Family Physicians’ Views and Experiences of the URTI Consultation
Main Theme Subthemes Codes Family physicians’ views about managing the URTI consultation: the challenge of the consultation Prior physician expectation Clinician assumption Preset clinician intent not to prescribe Recognition of evolving practice and patient culture Loss of discrimination between treatment options because of swine influenza Conflict within the consultation Situations that raise potential for conflict Avoiding conflict Negative impact of seeking patients’ views Minimize potential for conflict Delayed provision of prescription under pressure/insistence Delayed provision of prescription to avoid confrontation Prescribing to avoid complaints/confrontation Patients’ high expectations for antibiotics Explore reasoning when patient seeks antibiotics Challenge or modify antibiotic-seeking behavior Patients’ beliefs about antibiotics Delayed provision of a prescription under pressure/insistence Inappropriate prescribing a source of dissatisfaction/poor practice/failure Challenges Patient/parent behavior with respect to social norms/culture/family Challenge with respect to parental anxiety Challenge with respect to age Challenge with respect to patients’ previous experiences Delayed provision of prescription perceived as quicker Delayed provision of prescription for social reasons Prescribe according to symptom duration Prescribe according to previous symptom progression Prescribe in cases of chronic illness Family physicians develop strategies to elicit and influence expectations of antibiotics: the solution to the challenging consultation Thorough examination Examination is good practice and part of physicians’ role Examine to justify visit Running commentary shares information Careful word choice Diagnosis spin: minimize mismatch Running commentary to reassure Diagnosis spin: reassures, uses careful tone Diagnosis spin: empathetic Diagnosis spin: uses affirmation Running commentary Shares information Used with strategic intent Reassures Used to educate Means to educate URTI consultation is a means to educate Diagnosis spin: associate viruses with nonantibiotic management and bacteria with antibiotic management Antibiotics: adverse effects Antimicrobial resistance Physician refers to evidence-based medicine and guidelines Physician encourages autonomy Challenge or modify antibiotic-seeking behavior Physician explains distinguishing feature across consultation Maintain/increase physician-patient relationship Delayed provision of prescription for social reason Delayed provision of prescription for physician-patient relationship Delayed provision of prescription for borderline cases Nonantibiotic prescription justifies patient visit Safety net Family physicians influenced by relational, technical, and professional factors: the goal to be a good professional Thorough examination (technical) As for “thorough examination” above Hedging (technical) Diagnosis spin accounts for potential for symptom progression Careful word choice (relational) As for “careful word choice” above Elicit expectations using open questions/ideas, concerns, expectations Means to educate (educational) As for “means to educate” above Organizational Personal/practice pride in prescribing data Inappropriate prescribing as a source of dissatisfaction/poor practice/failure Clinicians are to blame for antimicrobial resistance/pattern of patients’ behavior -
URTI = upper respiratory tract infection.
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- Table 3
Summary of Themes Describing Family Physicians’ Views and Experiences of the URTI Consultation
Main Theme Description, Subthemes Views about managing the URTI consultation The challenges: Family physicians’ preset intention not to prescribe antibiotics, when feasible Consultation is viewed as a source of conflict Assumption that patients/parents expect to be given antibiotics Family physicians’ understanding of multiple, complex determinants of patient/parent antibiotic expectation Strategies to elicit and influence expectations of antibiotics The solutions: Indirect elicitation of patient or parent expectation of antibiotics Elicit indirectly before physical examination Use physical examination and running commentary to shape patient or parent expectation of antibiotics Influence of relational, technical, and professional factors The goals: Preserve the physician-patient relationship Prescribe appropriately -
URTI = upper respiratory tract infection.
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Additional Files
The Article in Brief
Managing Expectations of Antibiotics for Upper Respiratory Tract Infections: A Qualitative Study
Mohammed Mustafa , and colleagues
Background A number of studies have looked at doctor visits in which antibiotics are expected by patients or parents but may not be indicated by the clinical findings. There have been few efforts, however, to ask family physicians about the ways in which they handle expectations for antibiotics. This study explores how and why family physicians elicit and address patient or parents' expectations for antibiotics in visits for upper respiratory tract infections.
What This Study Found Family physicians prefer not to explore patient expectations for antibiotics in a direct manner or early on in visits for upper respiratory tract infections, contrary to the advice of many communications experts. Clinicians prefer more indirect methods to explore treatment expectations in an effort to avoid conflict and potential threats to the ongoing physician-patient relationship and trust. They report using open questions and building a foundation for nonantibiotic management by using strategies to indicate their reasoning and influence expectations, including running commentary on physical examination findings.
Implications
- The authors suggest that interventions to promote appropriate antibiotic prescribing include a focus on training in communication skills that integrates indirect methods as a part of building collaborative physician-patient relationships and uses the running commentary of examination findings to facilitate participation in clinical decisions.
Annals Journal Club
Jan/Feb 2014: Managing Expectations for Antibiotics When Seeing Patients With Upper Respiratory Tract Infections
The Annals of Family Medicine encourages readers to develop a learning community of those seeking to improve health care and health through enhanced primary care. You can participate by conducting a RADICAL journal club and sharing the results of your discussions in the Annals online discussion for the featured articles. RADICAL is an acronym for Read, Ask, Discuss, Inquire, Collaborate, Act, and Learn. The word radical also indicates the need to engage diverse participants in thinking critically about important issues affecting primary care and then acting on those discussions.1
HOW IT WORKS
In each issue, the Annals selects an article or articles and provides discussion tips and questions. We encourage you to take a RADICAL approach to these materials and to post a summary of your conversation in our online discussion. (Open the article online and click on "TRACK Comments: Submit a response.") You can find discussion questions and more information online at: http://www.AnnFamMed.org/site/AJC/.
CURRENT SELECTION
Article for Discussion
- Mustafa M, Wood F, Butler CC, Elwyn G. Managing expectations of antibiotics for upper respiratory tract infections: a qualitative study. Ann Fam Med. 2014;12(1):29-36.
Discussion Tips
This study uses qualitative methods to try to tap into the wisdom of experienced family physicians for their strategies to reduce inappropriate antibiotic prescribing by managing expectations. The article presents an opportunity to develop subtlety in practice.
Discussion Questions
- What question is asked by this study and why does it matter?
- How does this study advance beyond previous research and clinical practice on this topic?
- How strong is the study design for answering the question?
- To what degree can the findings be accounted for by the following2
- How participants were selected? (Did the authors achieve saturation? That is, did they sample until the point at which no new information was obtained from further sampling?)
- How the data were collected?
- Preconceptions on the part of the investigators?
- How the findings were analyzed and interpreted?
- The theoretical framework used to guide the investigation?
- What are the main study findings?
- How relevant is the study sample to you and your practice? Does it matter that the physicians are not a representative sample? What is your judgment about the transferability of the findings to your setting?
- What contextual factors are important for interpreting the findings?
- How might this study change your practice? Policy? Education? Research?
- Who are the constituencies for the findings, and how they might be engaged in interpreting or using the findings?
- What are the next steps in interpreting or applying the findings?
- What researchable questions remain?
References
- Stange KC, Miller WL, McLellan LA, et al. Annals Journal Club: It's time to get RADICAL. Ann Fam Med. 2006;4(3):196-197.
- Malterud K. Qualitative research: standards, challenges, and guidelines. Lancet. 2001;358(9280):483-488.
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- Risks of use and non-use of antibiotics in primary care. Qualitative study of prescribers views
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- What matters when managing childhood fever in the emergency department? A discrete-choice experiment comparing the preferences of parents and healthcare professionals in the UK
- Education as a low-value improvement intervention: often necessary but rarely sufficient
- Antibiotic prescribing for acute respiratory tract infections in primary care: an updated and expanded meta-ethnography
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- Influences on the start, selection and duration of treatment with antibiotics in long-term care facilities
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- In This Issue: Team-Based Care and Information to Improve Practice