Fear Drives Inappropriate Prescribing of Antibiotics in Hospitals

Julia E. Szymczak, PhD

Antibiotic stewardship programs in acute care settings largely focus on educating clinicians about appropriate prescribing practices; in terms of which antibiotics to prescribe for which infections and duration of therapy. However, researchers from the University of Pennsylvania wanted to take it a step further and learn why clinicians in inpatient settings may be inappropriately prescribing antibiotics in the first place. Is it because of a knowledge gap on appropriate prescribing practices, or could there be something else influencing these clinicians?

As it turns out there may be something else influencing acute care clinicians’ prescribing practices: fear.

“Fear of what?” the reader may be asking. Contagion® sat down with Julia E. Szymczak, PhD, assistant professor in the department of biostatistics, epidemiology and informatics at the Perelman School of Medicine at the University of Pennsylvania to find out the answer to that very question.

Dr. Szymczak and her colleagues conducted a series of semi-structured interviews with 60 clinicians across 3 health systems. Participants were asked questions aimed at eliciting the clinicians’ perceptions “about the barriers and facilitators to optimal antibiotic prescribing,” according to the study abstract. Two coders then transcribed the recorded interviews and systematically analyzed the results, “to identify how prescribers discussed the drivers of antibiotic overuse in acute care settings.” Their results revealed that there was a strong emotional reaction driving clinicians to prescribe broad-spectrum antibiotics.

“When we analyzed the data,” said Dr. Szymczak, “One of the most common and repeated themes that occurred across the data 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 is because the prescribers themselves have a very strong emotional reaction that drives this 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 say ‘emotions’.”

This emotional response is the result of a complex array of factors, according to Dr. Szymczak, such as the fact that despite how much we’d like to think otherwise, the practice of medicine is uncertain. Clinicians are faced with treating the very sick patient in front of them, many times without a lot (or any) diagnostic information and bearing the large burden of responsibility for ensuring that patient’s well-being.

Additionally, clinicians work in busy and complex environments characterized by time pressures, the fear of legal ramifications, and constant assessments of their competence by their colleagues, as well as their patients and the families [of the patients]. One also needs to factor in that there are multiple teams involved in patient care, shared Dr. Szymczak, and the handing off of patients between clinical teams adds another layer of uncertainty.

This combination of factors creates a perfect storm for an emotional response.

“What we found,” said Dr. Szymczak, “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.”

Furthermore, this emotional drive carried throughout the continuum of the prescribing pathway. “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 patient off the antibiotic, or you put them on an antibiotic that is more narrow-spectrum,” she shared. “What we found, however, was that when we talk about this emotional driver of prescribing, it applied just as much to the act of stopping or de-escalating antibiotics.”

This emotional reaction is constantly there and although antimicrobial stewards will state that they understand this aspect of prescribing, many of them have not incorporated it into their stewardship interventions, and this is to a serious detriment to health outcomes. “In the inpatient acute setting, particularly in intensive care units, or oncology units, or units where you have patients who are pretty sick and might be getting sicker quickly, and there is a pressure to see a lot of patients, discharge patients, move through a lot of patients quickly, we overlook [this emotional reaction] at our peril,” stated Dr. Szymczak.

Although one of the core elements of antimicrobial stewardship programs is education—ensuring that clinicians understand antimicrobial resistance and optimal prescribing—stewards may be focusing too much on this aspect and ignoring others. “[We need to understand that] antibiotic overprescribing is about more than [the idea that] the clinician does not know what to do or that they don’t care enough,” said Dr. Szymczak. “These are well-intentioned individuals who are navigating really complex systems, and we need to think about that when we think about our interventions.”

Work to best categorize the emotional determinants of prescribing is still in its infancy; however, the work of Dr. Szymczak and her colleagues is an important first step. Still, she feels that more data is needed on the psychological factors that underpin a clinician’s likelihood to experience this emotional reaction, as well as whether or not it is possible for them to have a moment before they act on that emotion. Her team is working on developing a model of an intervention that incorporates cognitive behavior therapy to teach clinicians how to self-manage their emotions while dealing with patients who are dying. Although the model is currently being worked through with clinicians who are attempting to incorporate palliative care consults into their everyday practice while working with patients who are seriously ill, aspects of the model could be extrapolated out to apply to stewardship.

“I think we need more work like that [in which we] start paying attention to the clinician as a human,” shared Dr. Szymczak. “Prescribers are people, too. They have the same kinds of fears, and hopes, and social pressures as any other person. Just because they are in the medical setting and making decisions based on evidence-based practices, they are still humans. We have to really think about what it’s like to be a human caring for sick people, and what is that experience like and how can we give them support to make them feel more comfortable making the most judicious choice. They are all reacting to very real pressures and we can do a better job of providing our prescribers with support to help them make these choices that feel very weighty.”

Hear more from Dr. Szymczak in the video below:

Source of headshot of Dr. Szymczak: University of Pennsylvania, Perelman School of Medicine.