Emotional Reaction Drives Some Clinicians to Prescribe Inappropriate Antibiotics

Julia E. Szymczak, PhD, from the Perelman School of Medicine at the University of Pennsylvania, shares the results of her study which revealed that fear drives some clinicians to prescribe inappropriately.

Interview transcript (slightly modified for readability):

The primary focus of our study was looking at the sense-making that inpatient clinicians use to make sense of why antibiotics are overused in their setting. We utilized a qualitative approach, which means that we interviewed clinicians and asked them, in an open-ended way, “Can you explain to us what are some of the ways that patients receive inappropriate antibiotics?”

When we analyzed the data, one of the most common and repeated themes that occurred across data—and, we gathered interviews from 3 different health systems, from 60 individuals—was fear.

The clinicians that we spoke with said that one of the large reasons why, in the inpatient setting, patients sometimes get inappropriate antibiotics they don’t need, is because the prescribers themselves have a very strong emotional reaction that drives the use of antibiotics. Sometimes you might hear this [reason] in other settings in which clinicians will say, “We use antibiotics to comfort ourselves.” This study was trying to unpack that [statement] and understand what the prescriber is talking about when they talk about these emotions.

What we found is that this emotional response is embedded in a more complex array of factors.

First of all, you have a stage that is set for prescribers to experience this emotional reaction, which is the fact that medical practice is very uncertain, and so clinicians are constantly managing and navigating the uncertainty of a very sick patient who is in front of them and they don’t know what’s wrong. They might not have all the diagnostic information that they need to identify what the patient is sick with, but they are very sick. That [situation] is coupled with the fact that [the prescriber] has a very large burden of being responsible for ensuring that this sick person in front of them is going to be okay.

We have uncertainty and this burden of responsibility that sets the stage. [Furthermore,] clinicians are working in very complicated and complex environments that are characterized by a number of factors that also set the stage for this emotional reaction. Things like: time pressures, a fear of medical-legal ramifications, constant assessments of their competence by their colleagues, as well as by their patients and the families [of the patients]. And, finally, it is a very busy setting in which there are multiple teams of clinicians who are working together, and the "handing off" of patients between clinical teams adds another layer of uncertainty.

[Again,] we have this uncertainty and this level of responsibility that is coupled together and when a clinician is faced with a patient that may be infected [with something,] but they don’t really know what is going on, what we found is that our respondents described this very strong emotional reaction that they get that then triggers an urge to do something. It triggers an action-orientation in which they quickly put a patient on a broad-spectrum antibiotic in an almost automatic and unquestioned way.

The clinician will start a patient on a broad-spectrum antibiotic, and one of the major principles of stewardship is when you get the lab reports back [and learn what the actual bug is,] either you pull the patients off the antibiotic or you put them on an antibiotic that is more narrow-spectrum. What we found, however, was that when clinicians talked about this emotional driver of prescribing, that it applied just as much to the act of stopping or de-escalating antibiotics.

Throughout the continuum of the prescribing pathway is this constant emotional experience of fear. Fear of something happening to the patient, fear of being wrong, fear of being sued, etc. This emotional reaction is constantly there, and when we think about stewardship, we don’t often think about that aspect. When you talk to antimicrobial stewards, they will say that they understand this, but we have not incorporated [this aspect] fully into our stewardship interventions.