Description of participants
A total of 27 interviews with primary care physicians were conducted with an interview duration of 28:14 minutes on average. All physicians were members of a primary care network participating in the ARena study. Quotes extracted from the data and cited here with specific transcript position were translated into English with due diligence. Table 1 presents sample characteristics.
Table 1. Socio-demographic characteristics of primary care practices and physicians
participating in this qualitative study (n=27)
Characteristics
|
Physicians (n=27)
|
Sex (f/m)
|
9/18
|
Age years (range) (mean)
|
43-66 (55.2)
|
Experience in current position in years (range) (mean)
|
10-38 (26.07)
|
Working in general practice (n) (%)
|
18 (66)
|
Type of practice: (n) (%)
single practice
group practice
shared rooms*
medical center
|
12 (44.4)
12 (44.4)
2 (7.4)
1 (3.7)
|
Patients/quarter: (n) (%)
500-1000
1,001-1,500
> 1,500
|
6 (22.2)
11 (40.7)
10 (37.0)
|
*separate financial entities and indemnity insurances, but shared rooms, equipment and staff
|
Overview
The results of the study indicate that most physicians were rarely asked directly by their patients for antibiotics. A few physicians were frequently asked for an antibiotic prescription. A predominantly perceived reason for this demand was that patients would want to recover quickly and think that antibiotics could help them best. On closer examination, the data shows that physicians realized that their patients do not all demand antibiotics from them and that they may wrongly suspect this.
“‘Oh, thank God, I don't really want to.’ This is what the majority say, whereas before, you had the feeling that a certain attitude of expectation was [...] there.” (PH26)
When asked whether there are specific groups of patients with an increased demand for antibiotics, most of the participants felt that this occurred mainly among young people who were professionally committed, experienced stress and wanted to return to work as soon as possible. In addition, demands were reported to be more common in patients from countries where antibiotics are sold over the counter. The analysis identified initially three different strategies of dealing with patient expectations regarding the prescription of antibiotics: meet expectations uncontested, expectations have no perceived influence on a physician’s prescribing decision and, the most frequently mentioned option, expectations are relevant and taken into consideration. When an influence of expectations was acknowledged, different strategies were reported. The most relevant strategy cited was physician-patient communication. Such communication strategies were identified by using BCT taxonomy and will be detailed below: re-attribution, pros and cons, comparative imagining of future outcomes, information about health consequences, information about social and environmental consequences, credible source and incompatible beliefs.
Some participants mentioned certain cases where they met patients requests for an antibiotics prescription even if they considered it non-indicated. This was explained with the assumption that patients otherwise would consult another physician who would prescribe antibiotics anyway. To prevent this, they rather prescribed it themselves. They also reported about patients who explicitly do not want antibiotics and want to be treated with alternative medications. Some physicians also met this type of patient expectation.
The described physicians differed from the group of physicians, who explained in the interviews that patient expectations had no influence on the prescription of antibiotics. If they considered an antibiotic to be unwarranted, then they would not prescribe it and accepted the risk of losing the patient to another physician over this.
Most physicians explained that they took patient expectations seriously and into consideration. There were different ways in which to proceed with those expectations. One of these approaches was based on the principle of delayed prescribing (DP), which almost all respondents applied in their practice. Delayed prescribing means that the physician issues an antibiotics prescription to the patient to take home with the instruction to use it only in case of a worsening state of health [15]. The most commonly reported reason for applying this strategy was an exceptional situation; for example, shortly before the weekend or when the patient wants to go on vacation. Further reasons given were diagnostic uncertainty and that the prescription provided the patient with a sense of security. An argument against the use of DP was the shift of the treatment decision to the patient, when it is actually the physician’s job.
Communication
The results demonstrate that communication with the patient was the most important approach for addressing patient expectations in the decision-making process concerning prescription of antibiotics, as almost all strategies used were related to physician-patient communication. This is illustrated by the following statement.
“The crucial point is always the communication between physician and patient. If a corresponding relationship of trust is established at this point, and the patient [...] receives the corresponding information, he is then in a position to develop a strategy together with the physician that is individually tailored to the situation.” (PH04)
Physicians used communication to teach patients that an antibiotics prescription was not required in their case. Through the provision of information, patients could understand why it was not needed, and an unnecessary antibiotic prescription thus was prevented.
The physicians revealed various behaviors and strategies to deal with patient expectations, all of which can be assigned to the inductive main category "communication". The following six strategies were inductively derived from the main category "communication" (i) taking time; (ii) taking the patient seriously; (iii) trusting conversation; (iv) address the topic of antibiotics openly; (v) alternative treatment and (vi) patient education. These strategies could be linked to a total of seven strategies of the BCT taxonomy. The connections between the inductively formed categories and the linking with BCT strategies can be seen in figure 1. An overview of key quotes for the different categories of this analysis can be obtained in Additional file 3 (Table S1).
Taking time and taking patients seriously
To be able to discuss with patients their expectations and the adequacy of an antibiotic prescription, there were communication components the attending physicians had to meet. The majority of the physicians agreed that they had to take sufficient time to talk and listen to patients and to take them seriously.
“It is very important that the patient is also heard; i.e., not immediately blocking [...] but you also have to understand the patient, perceive his worries, perceive his complaints.” (PH01)
Taking time for communication and taking patients seriously also meant to gain a deeper understanding of the individual patient and to question behaviour. This approach reflected the BCT strategy "re-attribution". Some physicians used this strategy when they felt uncertain about reasons for a patient’s desire for an antibiotic treatment other than the feeling of being ill. Potential reasons stated were that patients wanted to limit being absent from work to a short time or avoid that at all, because they absolutely had to go to work and therefore wanted to recover quickly.
"[…] maybe I have to take a look – is there a bit more behind it or is it a repression of the patient? You have to see that a little bit." (PH10)
Trusting conversation
If the patients felt accepted and met with understanding, they were more willing to listen to and be informed by physicians. If both aspects had been fulfilled, then a participative discussion, which the participants described as essential, could develop.
Further in-depth strategies of this approach are described by the BCT strategies "pros and cons", in which advantages and disadvantages of patient behavior are discussed, and "comparative imagining of future outcomes", in which it is discussed how the current behavior (here: expectation of an antibiotic) can affect the future of the patient.
Such a discussion could arise if, for example, the physician conveyed information to the patient necessary to weigh up the pros and cons of an antibiotic prescription.
“He may have a certain lack of information; I must provide him with the information to enable him to make a decision here, and this is usually the case when the patient understands that an antibiotic has more disadvantages than advantages.” (PH04)
The BCT strategy ‘Comparative imagining of future outcomes’ aims to clarify how patients’ current behavior will affect the future if not changed. A physician illustrated this strategy by talking about efforts of trying to show patients that it was not important to be fit again the next day, but to be healthy in the future, when they would be older and, therefore, an antibiotic should not always be used, but rather, for example, rest should be preferred to medication.
Address the topic antibiotics openly
An open discussion could also result from the strategy of asking the patient about his expectations and thus openly addressing the subject of antibiotics. The physicians reported that through this strategy, they confronted patients with the topic, and it did not remain unspoken. In addition, they sometimes observed whether the patient actually wanted an antibiotic or whether they had the wrong impression of the patient.
A suitable BCT strategy follows the approach of not only openly addressing the topic of antibiotics, but also making patients feel a little insecure, so that they realize that the expectation of an antibiotic has no discernible reason.
The BCT ‘Incompatible beliefs’ is a technique for dealing with a patient's demand for antibiotics. It demonstrates that a demand is unwarranted and in doing so, a slight discomfort is created. One of the physicians used this technique by asking patients which exact antibiotic they thought they needed if they were certain about the prescription. Patients then felt a little discomfort as they realized they could not answer the question and that their current behavior made little sense and probably did not reflect their actual self-image.
“[The] best line is always ‘I need an antibiotic’, and I ask back, ‘Which one?’ (laughs). Then the answer is, ‘You must know that’, and then I say, ‘I know that you don't need one, I can't think of one that would help with your illness; you'll have to tell me, so I can write one down for you, because there isn't actually any.’ [...] and then, 'yeah uhh' and then the thing is usually over.” (PH17)
Alternative treatment
A further strategy to dissuade patients from their demand for antibiotics was to propose alternative treatments. If these did not cure the patient, then they could come back for a re-assessment and a new consideration regarding a potentially necessary antibiotic treatment.
Patient education
The most frequently cited strategy was patient education. All interviewed physicians made it clear that it was of fundamental importance to educate patients and explain why an antibiotic prescription was not indicated. If this information was provided in detail, then the probability of patients agreeing not to take an antibiotic was high.
“There's actually a lot of lack of knowledge, ok, you have to say that, but if you explain it a bit and also clearly say why I recommend it now, most people go along.” (PH12)
The strategies used by the physicians to educate their patients reflect the BCT strategies ‘Credible source’, Information about health consequences’ and ‘Information about social and environmental consequences’.
Using guidelines and theories as credible sources, physicians explained to patients that their diagnosis and treatment were correct so that patients did not feel they had been treated insufficiently in cases where no antibiotics were prescribed. In addition, physicians explained they demonstrated to patients that an antibiotic would cause more harm than good in their case. Pointing out the effects of non-indicated antibiotic prescriptions on the environment was identified as a further strategy used by the physicians.
“And when I have the feeling [...] that I don't want to prescribe an antibiotic at this point [...] I prepare a bit of the theory, so that he doesn't have the feeling that he is being treated wrongly, but that this is correct according to probability.” (PH16)
“I also explain to the patient that an antibiotic given in the wrong place changes the microbiome in the intestine in any case and that this can then also have a negative influence on the immune system, on the intestinal flora. So, to describe it amateurishly, an antibiotic given in the wrong place can also cause damage to the body; I have always said so.” (PH14).
“[…] that if it really proves to be an uncomplicated infection, it does more harm than good, and at some point, we won't have any antibiotics left to work.” (PH20)