Patient and physician explanatory models for acute bronchitis
- Patients often do not understand the difference between viral and bacterial infections.
- Patients think that acute bronchitis will not improve and will probably get worse if not treated with antibiotics.
- Physicians and patients tend to falsely equate productive coughs (green-yellow sputum) with having a bacterial infection that requires antibiotic treatment.
- Physicians report significant internal conflict regarding treatment of acute bronchitis, characterized by a recognition that antibiotics are of little value, a universal assumption that patients expect antibiotics, a desire for patient satisfaction, perceived pressure from employers to get the patient “back to work,” and fear of “missing” a more serious infection.
- OBJECTIVES: Our goals were to develop explanatory models to better understand how physicians diagnose and treat acute bronchitis; to describe patient expectations and needs when experiencing an episode of acute bronchitis; and to enhance communication between physician and patient.
- STUDY DESIGN: We used qualitative, semi-structured, in-depth interviews to generate patient and physician explanatory models.
- POPULATION: We had a purposeful, homogeneous sample of 30 family physicians and 30 adult patients.
- OUTCOMES MEASURED: Our multidisciplinary team of investigators used an editing style of analysis to develop patient and physician explanatory models based on the following topics: (1) what caused my illness/etiology, (2) what symptoms I had/onset of symptoms, (3) what my sickness did to me/pathophysiology, (4) how severe is my sickness/course of illness, and (5) what kind of treatment should I receive/treatment.
- RESULTS: We found that patient and physician models were congruous for symptoms of acute bronchitis and incongruous for etiology and course of illness. Models were congruous for treatment, although for different reasons.
- CONCLUSIONS: Patients may have a very vague understanding of the process of infection and the difference between bacteria and viruses. Compounding this confusion is frequent miscommunication from physicians regarding the clinical course of untreated illness. These factors and non-communicated expectations from patients and fear of missing something on the part of physicians contribute to the decision to treat with antibiotics.
Clinical trials and meta-analyses of these trials1-3 have found that antibiotics do not provide clinically relevant improvements in patient outcomes in the treatment of otherwise healthy adults with acute bronchitis. Despite these findings, antibiotics remain the traditional choice of therapy.4-6 To better understand the process of making a diagnosis and deciding to treat, further study is needed to explore the complex interaction between patients and physicians.
Explanatory models of illness, pioneered by Arthur Kleinman, provide insight into the dynamics of physician and patient processes in a clinical encounter.7-10 Physician and patient models are elicited through the use of semi-structured, in-depth interviews. The physician’s model has 5 basic topics: etiology, onset of symptoms, pathophysiology, course of illness, and treatment of illness. A patient will generally consider these same issues in a different framework: What caused my illness?, What symptoms have I had?, What does my sickness do to me?, How severe is my sickness?, and What kind of treatment should I receive? The patient model, which is often drawn from cultural traditions and norms and may not be fully articulated, tends to be less abstract, possibly inconsistent, and even self-contradictory. 8 Differences between patient and physician explanatory models may lead to conflict, poor communication, low compliance, decreased patient satisfaction, and worse patient outcomes.
The purpose of this study was to elicit and analyze explanatory models to better understand how physicians make the diagnosis of acute bronchitis and decide on treatment for a given patient and describe patient expectations and needs when experiencing an episode of acute bronchitis.
Methods
Participants
This qualitative study used a purposeful, homogeneous sample of 30 family physicians and 30 patients from several types of medical practices in the Dallas, Texas area. It was purposeful in that we deliberately tried to include patients and physicians from a variety of settings. The study was approved by the institutional review boards of University of Texas Southwestern Medical Center and Southern Methodist University.
A letter inviting participation was mailed to physicians. This letter also requested access to adult patients who were seen with an episode of acute bronchitis from 4 weeks to 6 months previously. This mailing was followed by a telephone call from a research assistant to set up an interview. A similar process was followed for patients.
In-depth interviews and data collection
Interview scripts had open-ended questions and standard probes to elicit information about the explanatory model. After obtaining informed consent, interviews were conducted by 1 trained interviewer and audio recorded, transcribed, and checked for accuracy.
Data analysis
An editing style of analysis was used in which the text of the interviews was read line by line and data were grouped into themes.11 Two data management software programs were used to develop codes and labeling, Ethnograph version 4.0 (Qualis Research Association, Salt Lake City, UT) and NVivo (Revision 1.2, Qualitative Solutions and Research Pty Ltd, Cambridge, MA). We explored the data for linkages and connections of the coded groups for hierarchical and non-hierarchical relationships.
