a McMaster University, Faculty of Health Sciences, 1200 Main Street West, HSC 2V14, Hamilton, Ontario, Canada L8N 3Z5; b Department of General Practice, University of Wales College of Medicine, Llanedeyrn Health Center, Cardiff CF23 9PN, UK
![]() |
Abstract |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
Introduction |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
The paternalistic model |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Assumption one: a single best treatment exists
As far back as the 1950s, trial evidence showed antibiotics had similar effects to placebo on sore throats.14 However, a recent trial15 found a greater benefit from penicillin for sore throat than many might have expected.2,16 In some presumed respiratory tract infections, anti-inflammatory treatment may be more appropriate than antibiotics.17 In one study, clinicians were unsure of their clinical diagnoses of sinusitis in one-third of cases and correct in only 40% when compared with ultrasound diagnoses.18 Diagnosing pneumonia,19 streptococcal throat infection2022 and otitis media23 is also notoriously difficult with a high degree of false positives and inter-observer variation. When faced with doubt about active bacterial infection, clinicians tend to prescribe antibiotics.24,25 Clinical error in estimating the likelihood of group A streptococci infection contributes to unnecessary antibiotic use in patients with sore throat.26 Recent work has questioned traditional diagnostic categories and suggested that sinusitis, upper respiratory tract infection and acute bronchitis are all variations on the same clinical condition.27 Therefore, there is often uncertainty not only about best treatment but also at the level of diagnosis.
Assumption two: physicians know the best treatments available and consistently apply them
Applying epidemiological evidence to individual treat-ment decisions can be difficult.28 Antibiotic prescribing for winter colds in children was found to range from 20 to 60%.29 Clinicians' reported prescribing decisions varied when social components of clinical scenarios were changed.30 An association has been found between the prescription of antibiotics for children with the prescription of psychotropic drugs for their mothers.31 There is wide variation in antibiotic prescribing within and between countries.2,8,3236 Consistency is therefore not the norm.
Assumption three: physicians are in the best position to evaluate trade-offs between different treatments and to make treatment decisions
With evidence for marginal benefit of antibiotics in many situations and high rates of side effects from antibiotic treatment,3741 clinicians should no longer be confident they are in the best position to make costbenefit analyses for patients. Patients make their own evaluations, and problems arise when these are not elicited and addressed in the consultation.12 An association has been found between misunderstandings about medication and patients' lack of participation in the consultation.12 Only a small minority of those preferring not to take antibiotics express this.10,12 Such unvoiced agenda items have been associated with unwanted prescriptions, non-use of prescriptions and non-adherence to treatment.11 The item most commonly desired by patients but not received was found to be discussion of the patient's ideas about treatment.42 Given this uncertainty and lack of overt exploration of patients' evaluations, doctors try to second-guess what patients want. When doctors think patients want medicines, they are 10 times more likely to prescribe,43 and over 20% of patients not expecting medication leave the consultation with a prescription.43,44 Physicians' perceptions of parental expectations for antibiotics have been identified as the only significant predictor of prescribing antibiotics for presumed viral aetiology.45 Non-clinical factors influenced nearly half the prescribing decisions for patients with acute lower respiratory tract symptoms, with perceived patient pressure most frequently cited.24 Paediatricians acknowledged prescribing antibiotics when they are not indicated because of pressure from parents.46
Perceived patient expectations for antibiotics appeared to influence the diagnostic process itself: physicians who perceived high parent expectations for antibiotics were twice as likely to record a diagnosis for which antibiotics could be justified, and three times more likely to prescribe an antibiotic.47 However, patient expectations may be based on false assumptions with many overestimating the effectiveness of antibiotic treatment. For example, cross sectional surveys in the USA found that 79% of respondents believed antibiotics are effective for a discoloured nasal discharge,48 and 3161% believed antibiotics to be effective against colds.4850 In a European survey, over 50% of respondents believed that antibiotics should be prescribed for all respiratory tract infections with the exception of a simple cold.51 Thus, clinicians on their own do not know whether or not antibiotics are, on balance, best for individual patients: their antennae for sensing what patients want may be active but are frequently inaccurate. Moreover, patients' hopes for antibiotics may be based on unsound assumptions or experiences in previous consultations.
Assumption four: because of their professional concern for the welfare of their patients, physicians have a legitimate investment in each treatment decision
Appeals to reduce antibiotic prescribing often arise more out of concern for the health of the general public rather than for the well-being of individual patients. As one clinician commented in a qualitative study of doctors' and patients' accounts of consultations for sore throats, it would be better for the community [if] people would not take antibiotics, but I have a feeling for the individual it is better for him or for her to take antibiotics.10 Moreover, the interests of the organization employing clinicians intrude increasingly into decisions about treatment for individuals, especially in managed care contexts.52,53
Many clinicians continue to consult in a paternalistic mode because they perceive it to be quick and antibiotics are used to bring closure to the consultation providing a tangible indication the patient has been taken seriously.10,54,55 Some clinicians do not feel that it is worth jeopardizing their relationship with a patient over the relatively minor matter of hoped-for antibiotics.10 Given the increasingly shaky justifications for paternalistic consulting, it is not surprising that the prescription of antibiotics has been described as one of the most uncomfortable prescribing decisions general practitioners make.56
![]() |
The informed choice model |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
Shared decision-making |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
The procedures for sharing the process and yet sometimes agreeing to disagree about the treatment decision represent a particular challenge, given differential power relationships in the consultation.6769 A set of skills and steps for shared decision-making has been proposed (see Table).70 Actual strategies for successfully negotiating all of these steps in the consultation have not yet been fully described or evaluated. However, illustrative examples of simple questions that could provide a platform for involving patients in health care decision about antibiotic treatment include:
|
There are dangers to promoting this approach: some clinicians might misinterpret shared decision-making as a license to transfer decisional responsibility to the patient and lapse into informed or consumerist consulting after the portrayal of options. However, shared decision-making involves several steps beyond this stage (Table).
Consulting in this spirit will be more time consuming, and pressure of time is a frequently cited reason for prescribing antibiotics for viral infections.10,54,55 While a prescription saves time in the short term, antibiotic treatment is associated with more frequent consultations for future similar problems,75 and so clinicians create a rod to beat their own backs (and the backs of their colleagues).10 If the problems of over-prescribing antibiotics are as serious as some suggest,7678 then investing the time necessary for effective shared decision-making may be worthwhile, particularly if self-care options and the potential downsides of antibiotic treatment are incorporated in the information exchange. Importantly, this approach may also come to provide a structure for enhancing physicianpatient understanding and building relationships at a fundamental rather than symbolic level. By exploring individual's ideas, fears and expectations about treatment, clinicians may engage patients about what matters to them as unique individuals rather than using a prescription as a symbol of concern.45,79
![]() |
Conclusion |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
Acknowledgements |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
Notes |
---|
![]() |
References |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
2 . Del Mar, C. B. & Galsziou, P. P. (2001). Antibiotics for the symptoms and complications of sore throat. In The Cochrane Library, Issue 1, 2001. Update Software, Oxford.
3 . Glasziou, P. P., Hayem, M. & Del Mar, C. B. (2001). Treatment for acute otitis media in children: antibiotic versus placebo. In The Cochrane Library, Issue 1, 2001. Update Software, Oxford.
4 . Williams, J. W., Aguilar, C., Makela, M., Cornell, J., Hollman, D. R., Chiquette, E. et al. (2001). Antibiotics for acute maxillary sinusitis. In The Cochrane Library, Issue 1, 2001. Update Software, Oxford.
5 . Becker, L., Glazier, R., McIsaac, W. & Smucny, J. (2001). Antibiotics for acute bronchitis. In The Cochrane Library, Issue 1, 2001. Update Software, Oxford.
6 . Little, P. & Willaimson, I. (1995). Sore throat management in general practice. Family Practice 13, 31721.[Abstract]
7 . Butler, C. C., Rollnick, S., Kinnersley, P., Jones, A. & Stott, N. C. H. (1998). Reducing antibiotics for respiratory tract symptoms in primary care; consolidating why and considering how. British Journal of General Practice 48, 186570.[ISI][Medline]
8
.
Watson, R. L., Dowell, S. F., Jayaraman, M., Keyserling, H., Kolczak, M. & Schwartz, B. (1999). Antimicrobial use for pediatric upper respiratory infections: reported practice, actual practice and patient beliefs. Pediatrics 104, 12517.
9
.
Belongia, E. A. S. B. (1998). Strategies for promoting judicious use of antibiotics by doctors and patients. British Medical Journal 317, 66871.
10
.
Butler, C. C., Rollnick, S., Maggs-Rapport, F., Pill, R. M. & Stott, N. C. H. (1998). Understanding the culture of prescribing: A qualitative study of general practitioners' and patients' perceptions of antibiotics for sore throats. British Medical Journal 317, 63742.
11
.
Barry, C. A., Bradley, C. P., Britten, N., Stevenson, F. A. & Barber, N. (2000). Patients' unvoiced agendas in general practice consultations: qualitative study. British Medical Journal 320, 124650.
12
.
Britten, N., Stevenson, F. A., Barry, C. A., Barber, N. & Bradley, C. P. (2000). Misunderstandings in prescribing decisions in general practice: qualitative study. British Medical Journal 320, 4848.
13 . Charles, C., Gafni, A. & Whelan, T. (1999). Decision-making in the physicianpatient encounter: revisiting the shared treatment decision-making model. Social Science and Medicine 49, 65161.[ISI][Medline]
14 . Hardy, L. M. & Traisman, H. S. (1956). Antibiotics and chemotherapeutic agents in the treatment of uncomplicated respiratory infections in children: a controlled study. Journal of Pediatrics 48, 14656.[ISI]
15
.
Zwart, S., Sachs, A. P. E., Ruijs, G. J. H. M., Gubbels, J. W., Hoes, A. W. & De Melker, R. A. (2000). Penicillin for acute sore throat: randomised double blind trial of seven days versus three days treatment or placebo in adults. British Medical Journal 320, 1504.
16 . Fahey, T., Stocks, N. & Thomas, T. (1998). Systematic review of treatment of upper respiratory tract infection. Archives of the Diseases of Childhood 79, 22530.
17 . Hueston, W. J. (1991). A comparison of albuterol and erythromycin for the treatment of acute bronchitis. Journal of Family Practice 33, 47680.[ISI][Medline]
18 . van Duijn, N. P., Brouwer, H. J. & Lamberts, H. (1992). Use of symptoms and signs to diagnose maxillary sinusitis in general practice: comparison with ultrasonography. British Medical Journal 305, 6847.[ISI][Medline]
19
.
Metlay, J. P., Kapoor, W. N. & Fine, M. J. (1997). Does this patient have community acquired pneumonia? Diagnosing pneumonia by history and physical examination. Journal of the American Medical Association 278, 14405.
20 . Bisno, A. L., Gerber, M. A., Gwaltney, J. M., Kaplan, E. L. & Schwartz, R. H. (1997). Diagnosis and management of Group A Streptococcal pharyngitis: A practice guideline. Clinical Infectious Diseases 25, 57483.[ISI][Medline]
21 . Commission on Acute Respiratory Diseases. (1994). Endemic exudative pharyngitis and tonsillitis. Etiology and clinical characteristics. Journal of the American Medical Association 125, 11619.
22
.
Ebell, M. H., Smith, M. A., Barry, H. C., Ives, K. & Carey, M. (2000). Does this patient have strep throat? Journal of the American Medical Association 284, 29128.
23 . van Buchem, F. L., Peeters, M. F. & van't Hof, M. A. (1985). Acute otitis media: a new treatment strategy. British Medical Journal 290, 10337.[ISI][Medline]
24 . MacFarlane, J., Lewis, S. A., MacFarlane, L. R. & Homes, W. (1997). Contemporary use of antibiotics in 1089 adults with acute lower respiratory tract illness in general practice in the UK: implications for developing management guidelines. Respiratory Medicine 91, 42734.[ISI][Medline]
25 . Miller, E., MacKeigan, L. D., Rosser, W. & Marshman, J. (1999). Effects of perceived patient demand on prescribing anti-infective drugs. Canadian Medical Association Journal 191, 13942.
26 . McIsaac, W. J. & Butler, C. C. (2000). Does clinical error contribute to unnecessary antibiotic use? Medical Decision Making 20, 338.[ISI][Medline]
27 . Hueston, W. J., Mainous, A. G., Dacus, E. N. & Hopper, J. E. (2000). Does acute bronchitis really exist? Journal of Family Practice 49, 4016.[ISI][Medline]
28 . Jacobsen, L. D., Edwards, A. K., Granier, S. K. & Butler, C. C. (1997). Evidence based medicine and general practice. British Journal of General Practice 77, 44952.
29 . Stott, N. C. H. (1979). Management and outcome of winter upper respiratory tract infections in children aged 09 years. British Medical Journal 6155, 2931.
30 . Howie, J. G. R. (1976). Clinical judgement and antibiotic use in general practice. British Medical Journal 2, 10614.[ISI][Medline]
31 . Howie, J. G. R. & Bigg, A. R. (1980). Family trends in psychotropic and antibiotic prescribing in general practice. British Medical Journal 280, 8368.[ISI][Medline]
32
.
Mainous, A. G., Hueston, W. J. & Love, M. M. (1998). Antibiotics for colds in children: who are the high prescribers? Archives of Pediatric and Adolescent Medicine 152, 34952.
33 . De Melker, R. A. & Kuyvenhoven, M. M. (1991). Management of upper respiratory tract infection in Dutch general practice. British Journal of General Practice 41, 5047.[ISI][Medline]
34 . Guillemot, D., Carbon, C., Vauzelle-Kervroedan, F., Balkau, B., Maison, P., Bouvenot, G. et al. (1998). Inappropriateness and variability of antibiotic prescription among French office-based physicians. Journal of Clinical Epidemiology 51, 618.[ISI][Medline]
35 . Touw-Otten, F. W. M. M. & Johansen, S. (1992). Diagnosis, antibiotic treatment and outcome of acute tonsillitis: report of a WHO Regional Office for Europe Study in 17 European countries. Family Practice 9, 25562.[Abstract]
36
.
Huchon, G. J., Gialdroni-Grassi, G., Leophonte, P., Manresa, F., Schaberg, T. & Woodhead, M. (1996). Initial antibiotic therapy for lower respiratory tract infection in the community: a European survey. European Respiratory Journal 9, 15905.
37 . van Balen, F. A. M., De Melker, R. A. & Touw-Otten, F. W. M. M. (1996). Double-blind randomised trial of co-amoxiclav versus placebo for persistent otitis media with effusion in general practice. Lancet 348, 7136.[ISI][Medline]
38 . Kaiser, L., Lew, D., Hirschel, B., Auckenthaler, R., Morabia, A., Heald, A. et al. (1996). Effects of antibiotic treatment in the subset of common-cold patients who have bacteria in nasopharyngeal secretions. Lancet 347, 150710.[ISI][Medline]
39
.
Fahey, T., Stocks, N. & Thomas, T. (1998). Quantitative systematic review of randomised controlled trials comparing antibiotic with placebo for acute cough in adults. British Medical Journal 316, 90610.
40 . Verheij, T. J. M., Hermans, J. & Mulder, D. (1994). Effects of doxycycline in patients with acute cough and purulent sputum: a double blind placebo controlled trial. British Journal of General Practice 44, 4004.[ISI][Medline]
41 . King, D. E., Williams, W. C., Bishop, L. & Schechter, A. (1998). Effectiveness of erythromycin in the treatment of acute bronchitis. Journal of Family Practice 42, 6015.
42 . Kravitz, R. L., Cope, D. W., Bhrany, V. & Leake, B. (1994). Internal medicine patients' expectations for care during office visits. Journal of General Internal Medicine 9, 7581.[ISI][Medline]
43
.
Cockburn, J. & Pit, S. (1997). Prescribing behaviour in clinical practice: Patients' expectations and doctors' perceptions of patients' expectations a questionnaire study. British Medical Journal 315, 5203.
44
.
Britten, N. & Ukoumunne, O. (1997). The influence of patients' hopes of receiving a prescription on doctors' perceptions and the decision to prescribe: a questionnaire survey. British Medical Journal 315, 150610.
45
.
Mangione-Smith, R., McGlynn, E. A., Elliot, M. N., Krogstad, P. & Brook, R. H. (1999). The relationship between perceived parental expectations and pediatrician antimicrobial prescribing behaviour. Pediatrics 103, 7118.
46
.
Bauchner, H., Pelton, S. I. & Klein, J. O. (1999). Parents, physicians, and antibiotic use. Pediatrics 103, 395401.
47 . Vinson, D. C. & Lutz, L. J. (1997). The effect of parental expectation on treatment of children with a cough: A report from ASPN. Journal of Family Practice 37, 237.
48 . Mainous, A. G., Zoorob, R. J., Oler, M. J. & Haynes, D. M. (1997). Patient knowledge of upper respiratory infections: Implications for antibiotic expectations and unnecessary utilization. Journal of Family Practice 45, 7583.[ISI][Medline]
49 . Braun, B. L., Fowles, J. B., Solberg, L., Kind, E., Healey, M. & Anderson, R. (2000). Patient beliefs about the characteristics, causes and care of the common cold. Journal of Family Practice 49, 1536.[ISI][Medline]
50 . Brett, A. S. & Mathieu, A. E. (1982). Perceptions and behaviors of patients with upper respiratory tract infection. Journal of Family Practice 15, 27792.[ISI][Medline]
51 . Braithwaite, A. & Pechere, J.-C. (1996). Pan-European survey of patients' attitudes to antimicrobials and antibiotic use. Journal of Internal Medicine Research 24, 22938.
52 . Loewy, E. H. (1996). Guidelines, managed care and ethics. Archives of Internal Medicine 156, 203840.[ISI][Medline]
53 . Sorum, P. C. (1996). Ethical decision making in managed care. Archives of Internal Medicine 156, 20415.[ISI][Medline]
54 . Comaroff, J. (1976). A bitter pill to swallow: placebo therapy in general practice. Sociology Review 24, 7996.
55 . Schwartz, R. K., Soumerai, S. B. & Avorn, J. (1989). Physician motivation for nonscientific prescribing. Social Science and Medicine 28, 57782.[ISI][Medline]
56 . Bradley, C. P. (1992). Uncomfortable prescribing decisions: a critical incident study. British Medical Journal 304, 2946.[ISI][Medline]
57 . Miller, Y. W., Eady, E. A., Lacey, R. W., Cove, J. H., Joanes, D. N. & Cunliffe, W. J. (1996). Sequential antibiotic therapy for acne promotes the carriage of resistant staphylococci on the skin of contacts. Journal of Antimicrobial Chemotherapy 38, 82937.[Abstract]
58 . Mainous, A. G., Evan, M. E., Hueston, W. J., Titlow, W. B. & McCown, L. J. (1998). Patterns of antibiotic-resistant Streptococcus pneumoniae in children in a day-care setting. Journal of Family Practice 46, 1426.[ISI][Medline]
59
.
Magee, J. T., Pritchard, E. L., Fitzgerald, K. A., Dunstan, F. D. J. & Howard, A. J. (1999). Antibiotic prescribing and antibiotic resistance in community practice: retrospective study, 19968. British Medical Journal 319, 123940.
60
.
Arason, V. A., Kristinsson, K. G., Sigurdsson, J. A., Stefansdottir, G., Molstad, S. & Gudmundsson, S. (1996). Do microbials increase the carriage rate of penicillin resistant pneumococci in children? Cross sectional prevalence study. British Medical Journal 313, 38791.
61
.
Seppala, H., Klaukka, T., Vuopio-Varkila, J., Muotiala, A., Heleniuc, H., Lager, K. et al. (1997). The effect of changes in the consumption of macrolide antibiotics on erythromycin resistance in group A streptococci in Finland. Finnish Study Group for Antimicrobial Resistance. New England Journal of Medicine 337, 4416.
62 . Audit Commission. (1994). A Prescription for Improvement. Towards More Rational Prescribing in General Practice. HMSO, London.
63 . Mainous, A. G., Hueston, W. J. & Clark, J. (1996). Antibiotics and upper respiratory infection. Do some folks think there is a cure for the common cold? Journal of Family Practice 42, 35761.[ISI][Medline]
64 . Benbassat, J., Pilpel, D. & Tiggemann, M. (1998). Patients' preferences for participation in clinical decision-making: a review of published surveys. Behavioral Medicine 24, 818.[ISI][Medline]
65
.
McKinstry, B. (2000). Do patients wish to be involved in decision making in the consultation? A cross sectional survey with video vignettes. British Medical Journal 321, 86771.
66 . Tuckett, D., Boulton, M., Olson, C. & Williams, A. (1985). Meetings Between Experts. An Approach to Sharing Ideas in Medical Consultations. Tavistock, London.
67 . Elwyn, G., Gwyn, R., Edwards, A. & Grol, R. (1999). Is shared decision-making feasible in consultations for upper respiratory tract infections? Assessing the influences of antibiotic expectations using discourse analysis. Health Expectations 2, 10517.[Medline]
68 . Gwyn, R. & Elwyn, G. (1999). When is a shared decision not (quite) a shared decision? Negotiating preferences in a general practice encounter. Social Science and Medicine 49, 43747.[ISI][Medline]
69 . Maynard, D. W. (1991). Interaction and asymmetry in clinical discourse. American Journal of Sociology 97, 44895.[ISI]
70 . Elwyn, G., Edwards, A., Kinnersley, P. & Grol, R. (2000). Shared decision making and the concept of equipoise: the competences of involving patients in health care choices. British Journal of General Practice 50, 8927.[ISI][Medline]
71 . Stewart, M., Belle Brown, J., Wayne Weston, W., McWhinney, I. R., McWilliam, C. L. & Freeman, T. R. (1995). Patient-Centered Medicine: Transforming the Clinical Method. Sage Publications, Thousand Oaks, CA.
72 . Elwyn, G., Edwards, A. & Kinnersley, P. (1999). Shared decision-making in primary care: the neglected second half of the consultation. British Journal of General Practice 49, 47782.[ISI][Medline]
73 . Rollnick, S., Mason, P. & Butler, C. C. (1999). Health Behaviour Change: A Guide for Practitioners. Churchill Livingstone, Edinburgh.
74 . Stott, N. C. H. (1983). Primary Health Care: Bridging the Gap between Theory and Practice. Springer-Verlag, Berlin.
75
.
Little, P., Gould, B., Williamson, I., Warner, G., Gantley, M. & Kinmonth, A.-L. (1997). Reattendance and complications in a randomised trial of prescribing strategies for sore throat: the medicalising effect of prescribing antibiotics. British Medical Journal 315, 3502.
76
.
Swartz, M. N. (1997). Use of antimicrobial agents and drug resistance. New England Journal of Medicine 337, 4912.
77 . Hawkey, P. M. (1998). Action against antibiotic resistance: no time to lose. Lancet 351, 12989.[ISI][Medline]
78 . Schwartz, B., Bell, D. M. & Hughes, J. M. (1997). Preventing the emergence of antimicrobial resistance. Journal of the American Medical Association 278, 9445.[ISI][Medline]
79 . van der Geest, S. & Whyte, S. (1989). The charm of medicines: metaphors and metonyms. Medical Anthropology Quarterly 3, 34567.
80
.
Howie, J. G. R., Heaney, D. J. & Maxwell, M. (1994). Evaluating care of patients reporting pain in fundholding practices. British Medical Journal 309, 70510.
81
.
Howie, J. G. R., Heaney, D. J., Maxwell, M. & Walker, J. J. (1998). A comparison of a Patient Enablement Instrument (PEI) against two established satisfaction scales as an outcome measure of primary care consultations. Family Practice 15, 16571.
Received 15 February 2001; returned 29 May 2001; revised 21 June 2001; accepted 28 June 2001