Subtle pressure from patients could influence doctors to overprescribe antibiotics

May 22, 2021

Overprescribing antibiotics due to patient pressure is a major cause of antibiotic resistance. (AP Photo/Rich Pedroncelli)

The dangerous overprescription of antibiotic drugs could be partly due to doctors feeling pressure from patients who mention specific bacterial infections during their visits, a new video analysis of doctor's office interactions suggests.

The study, published May 11 in Social Science & Medicine, provides new insight into why antibiotics are still so heavily prescribed despite the medical community's awareness that overprescription can give rise to drug-resistant superbugs, Tanya Stivers, a professor of sociology at the University of California, Los Angeles, and the lead author of the study, told The Academic Times. "Most of the time, patients are following what doctors suggest," she said. "But we are seeing that these pressuring behaviors are happening a fair bit of the time." 

A 2016 study conducted by the U.S. Centers for Disease Control and Prevention concluded that 1 in 3 antibiotics prescribed in the U.S. are unnecessary. What is more, for the past several decades, antibiotics have been losing their punch against certain kinds of harmful bacterial infections because of overuse, which can create drug resistance. This long-term trend is a major public health concern, deemed to be "one of the biggest threats to global health, food security and development today" by the World Health Organization, which tracks the strains of bacteria that represent the greatest threats with its Global Antimicrobial Resistance Surveillance System

For the UCLA study, the researchers analyzed 68 video recordings of interactions between patients and physicians during primary care visits, finding that patients often applied subtle pressure rather than explicitly requesting antibiotics, usually by naming bacterial illnesses such as sinus infections, strep throat and pneumonia, Stivers said. 

"They do stuff that, on the face of it, sounds like it's not that much pressure," she explained. "They say things like, 'I think I have strep throat' or 'I think my daughter has strep throat.' If you are thinking like a doctor, you're thinking about what this patient has from the minute you glance at their file. Just like sitting in a movie theater and seeing images of popcorn and candy come up and then thinking, 'I want to go outside and get a chocolate,' you know, nobody forced that down your throat. But these ideas influence our decision-making, and that's kind of what we think is going on in these medical visits as well." 

Patients who said they thought they had a bacterial infection — priming the idea of an antibiotic drug regimen — rather than strictly describing symptoms such as a sore throat or runny nose influenced the outcome of their visits. Priming was found in 47% of the visits analyzed by the researchers, and patients resisting treatments that didn't involve antibiotics were observed in just under a quarter of cases. 

And the pressure worked: In 60% of cases in which patients mentioned a bacterial infection but exhibited no clinical signs of having such an infection, physicians prescribed them antibiotics. "But without that pressure, physicians prescribe [antibiotics] a third of the time, so the pressure is doubling the amount of inappropriate prescriptions," Stivers said. 

Stivers has been recording medical visits with patients' permission since the mid-1990s and, along with her colleagues at UCLA, has access to more than 1,000 such videos from various studies. "Patients are very willing, and I think they recognize that we're trying to learn about how actual communication works, rather than imagine how communication might work," she said. 

The researchers did not administer surveys asking patients whether they intended to pressure physicians to prescribe antibiotics, and did not ask doctors to report their perceptions and intentions. Rather, they analyzed how physicians responded to patient behavior in real-world scenarios. 

"The idea is that patients might not always be intending to pressure physicians," Stivers said. "Whether you're exhibiting these behaviors because you really want antibiotics and think you should have them or you're just worried about your symptoms, it is pretty common to have patients saying and doing things that physicians perceive as a form of pressure."

To determine whether a physician's prescription of antibiotics was appropriate or unwarranted, the researchers used CDC-recommended criteria, such as severity of symptoms and duration of illness. "When the physician is articulating what the clinical findings are and none of those are consistent with prescription, and then they prescribe, we called that an inappropriate prescription," Stivers said. "Anytime it was unclear or was somehow on the cusp, we assumed the doctor was prescribing appropriately. We erred on the side of the doctor." 

"If we had asked the doctor, 'Why did you prescribe in this case?' they may well have had a rationale," she continued. "But that rationale went beyond CDC guidelines, and that's kind of our point: Whatever factors they're using to determine whether they want to prescribe goes outside these guidelines, and we think part of that is because of the pressure they're feeling." 

The study's authors suggest that doctors could use a "foreshadowing" strategy to prime patients to expect treatment options that don't involve antibiotics. "They can say things like, 'A lot of what we're seeing now are viral infections that cause sore throats.' They haven't said anything specific, but foreshadowed that the [illness] may well be viral," Stivers said. "Or they could say, 'From what I'm seeing, this looks viral, but we're going to keep looking.' … It helps to manage patients' expectations." 

She believes one of the reasons the overprescription of antibiotics continues is that the drugs aren't perceived as a threat to individual safety in the same way as opioid-based painkillers. "You can be pressured for both, but it's easier for doctors and patients to recognize that opioid prescribing puts individual people at risk," Stivers said. "If I give you an antibiotic and you don't need it, the side effects are so small; it's low-risk.

"We're going to just keep barrelling toward this crisis because people don't worry about things that are down the road and don't affect them as individuals," she added. 

The study, "Arriving at no: Patients pressure to prescribe antibiotics and physicians' responses," published May 11 in Social Science & Medicine, was authored by Tanya Stivers and Stefan Timmermans, University of California, Los Angeles. 

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