Doctor Patient Communication and Its Influence on Antimicrobial Prescribing

When physicians perceive that a patient or parent expects an antimicrobial they are significantly more likely to inappropriately prescribe [12, 16, 52-57]. However, physician perceptions are poorly correlated with actual patient or parent expectations for antimicrobials [16, 53-55, 58, 59]. Although 50-70% of patients and parents expect to receive antimicrobials when they attend visits for ARI, only 1-6% make direct verbal requests for them [58, 60]. Even when no direct requests for antimicrobials are made, physicians still perceive an expectation 34% of the time [58]. If miscommunication about expectations could be avoided, much inappropriate antimicrobial prescribing could potentially be prevented.

In pediatrics, physician perceptions are largely predicted by various indirect parent communication behaviors that occur during visits for ARI [57]. Through a series of qualitative studies, Stivers [61-63] identified 3 parent communication practices that appeared to be related to physician perceptions that parents expected antimicrobials. These were the parent suggesting a candidate diagnosis early in the visit, resisting the physician's diagnosis in viral cases, and resisting the physician's non-antimicrobial treatment plans [61-63]. Presenting a candidate diagnosis involves the parent suggesting their child has a diagnosis where antimicrobials are commonly prescribed, for example 'I think he's got sinusitis again,' rather then just listing their child's symptoms, 'She has a cough and a runny nose'. Diagnosis resistance occurs when the parent questions the physician's diagnosis. Treatment resistance is when the parent questions the physician's treatment plan. Confirming what Stivers hypothesized based on qualitative analyses, a recent quantitative study showed that parents who use candidate diagnoses are significantly more likely to expect antimicrobials (27% increase) and be perceived as expecting them (9% increase) [64]. Surprisingly, parents who expect antimicrobials are no more likely to question their child's physician about non-antimicrobial treatment plans than parents without expectations. Whether parents expect antimicrobials or not, they are significantly more likely to be perceived as expecting antimicrobials (20% increase) when they question the physician's treatment plan [64]. These findings may explain some of the gap between actual and perceived expectations.

Parent questioning of non-antimicrobial treatment plans is largely determined by how physicians present these plans to them. Stivers identified 2 main ways that physicians present non-antimicrobial treatment plans during visits for ARI: positively formatted treatment plans (e.g. 'You can try running a humidifier in her room at night to settle the cough down') and negatively formatted or 'rule-out' treatment plans (e.g. 'An antibiotic isn't going to touch this thing') [63]. When physicians use negatively formatted treatment plans and rule-out the need for antimicrobials, parents are significantly more likely to question the plan (24% increase) [64]. Thus, focusing treatment plans on what parents can do to make their child feel better rather then on why antimicrobials are unnecessary decreases parent questioning of treatment plans and may decrease inappropriate antimicrobial prescribing that results from physicians perceiving pressure to prescribe.

Although much of the work examining the relationship between communication practices and inappropriate antimicrobial prescribing has been conducted in the pediatric setting, many of the findings apply to the adult medical setting as well [60]. Adult patients similarly employ candidate diagnoses to indirectly communicate their expectations for antimicrobials, but also use additional communication practices in this regard. Scott et al. [60] found adults most frequently portray their illness as being severe and thus in need of treatment beyond what they have tried at home, for example 'I just can't shake it, Doc'. They also appeal to non-medical circumstances such as going out of town on a vacation, or noting that the last time they had this illness another physician in the same office treated with an antimicrobial and it seemed to work.

Communication, Satisfaction and Antimicrobial Prescribing

Contrary to commonly held beliefs among medical professionals, providing an antimicrobial prescription is unlikely to result in a satisfied patient or parent in the absence of high-quality communication [11, 65]. In visits for ARI, parent satisfaction is most strongly related to the quality of communication during the visit, rather than unfulfilled expectations for antimicrobials [11, 56]. Among parents who don't receive expected antimicrobials, those offered a contingency plan from the physician (i.e. the possibility of receiving antimicrobials in the future if their child does not get better) have a higher mean satisfaction score than parents not receiving a contingency plan (76 vs. 59% on a 0-100% scale; p < 0.05) [58]. Parents who receive a contingency plan also trend toward having higher mean satisfaction than parents who receive antimicrobials (76 vs. 65%; p = 0.07). This suggests that physicians should consider providing a contingency plan to parents who question non-antimicrobial treatment plans as it may preserve or enhance their satisfaction with the visit and prevent inappropriate antimicrobial prescribing.

Among adult patients, satisfaction similarly is not related to receiving expected antimicrobials [16, 55]. Rather, it is strongly associated with how well physicians explain things during the visit and how much time they spend with the patient.

Communication-Based Interventions to Decrease Inappropriate Antimicrobial Prescribing

Data on the effectiveness of communication-based interventions aimed at decreasing inappropriate antimicrobial prescribing are sparse. One multi-faceted intervention trial included a communication skills training session for physicians [66]. The

Fig. 1. The relationships between physician-parent communication, physician perceptions, inappropriate antimicrobial prescribing and satisfaction.

communication skills included exploring patient worries and expectations, and informing patients about the natural course of symptoms, self-medication and alarm symptoms that indicated the need for a return visit. Although physicians in the treatment arm significantly reduced their rates of inappropriate antimicrobial prescribing, it is difficult to know how much of this improvement was attributable to the communication training they received as opposed to other interventions employed, such as small group meetings and performance feedback.

The relationships between doctor-patient (or doctor-parent) communication, inappropriate prescribing and satisfaction are complex. Figure 1 represents a summary of research findings to date and suggests some key leverage points for future interventions aimed at improving communication during medical encounters for ARI. As shown in the figure, a communication practice called 'online commentary' shows promise for potentially decreasing rates of inappropriate antimicrobial prescribing [67]. This physician communication practice consists of describing what is being seen, felt or heard during the physical examination of the patient. The 2 primary types of online commentary are: (1) online commentary suggesting a problem on physical examination ('problem' online commentary), for example 'That cough sounds very chesty', and (2) online commentary that indicates the physical examination findings are not problematic ('no problem' online commentary), for example 'Her throat is only slightly red'.

In one study, antimicrobials were prescribed 91% of the time in cases where the presumed diagnosis was viral and the physician used at least some 'problem' online commentary. In contrast, when physicians exclusively used 'no problem' online commentary in such cases, antimicrobials were prescribed only 27% of the time. Use of 'no problem' online commentary did not add significantly to visit length [68]. Thus 'no problem' online commentary is a communication technique that may provide an effective and efficient method for resisting perceived pressure to prescribe antimicrobials.

Physician-patient/parent communication is clearly associated with inappropriate antimicrobial prescribing. Future interventions must continue to address these communication issues if we are to make further progress in addressing this serious public health problem.

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