Among children with acute respiratory tract infections, broad-spectrum antibiotics were not associated with better clinical or patient-centered outcomes compared with narrow-spectrum antibiotics, and were associated with higher rates of adverse events. These data support the use of narrow-spectrum antibiotics for most children with acute respiratory tract infections.

IMPORTANCE When clinicians work with symptoms of infection, they can put patients and colleagues at risk. Little is known about the reasons why attending physicians and advanced practice clinicians (APCs) work while sick.OBJECTIVE To identify a comprehensive understanding of the reasons why attending physicians and APCs work while sick. DESIGN, SETTING, AND PARTICIPANTS We performed a mixed-methods analysis of a cross-sectional, anonymous survey administered from January 15 through March 20, 2014, in a large children's hospital in Philadelphia, Pennsylvania. Data were analyzed from April 1 through June 1, 2014. The survey was administered to 459 attending physicians and 470 APCs, including certified registered nurse practitioners, physician assistants, clinical nurse specialists, certified registered nurse anesthetists, and certified nurse midwives. MAIN OUTCOMES AND MEASURES Self-reported frequency of working while experiencing symptoms of infection, perceived importance of various factors that encourage working while sick, and free-text comments written in response to open-ended questions. RESULTS Of those surveyed, we received responses from 280 attending physicians (61.0%) and 256 APCs (54.5%). Most of the respondents (504 [95.3%]) believed that working while sick put patients at risk. Despite this belief, 446 respondents (83.1%) reported working sick at least 1 time in the past year, and 50 (9.3%) reported working while sick at least 5 times. Respondents would work with significant symptoms, including diarrhea (161 [30.0%]), fever (86 [16.0%]), and acute onset of significant respiratory symptoms (299 [55.6%]). Physicians were more likely to report working with each of these symptoms than APCs (109 [38.9%] vs 51 [19.9%], 61 [21.8%] vs 25 [9.8%], and 168 [60.0%] vs 130 [50.8%], respectively [P < .05]). Reasons deemed important in deciding to work while sick included not wanting to let colleagues down (521 [98.7%]), staffing concerns (505 [94.9%]), not wanting to let patients down (494 [92.5%]), fear of ostracism by colleagues (342 [64.0%]), and concern about continuity of care (337 [63.8%]). Systematic qualitative analysis of free-text comments from 316 respondents revealed additional reasons why attending physicians and APCs work while sick, including extreme difficulty finding coverage (205 [64.9%]), a strong cultural norm to come to work unless remarkably ill (193 [61.1%]), and ambiguity about what constitutes "too sick to work" (180 [57.0%]). CONCLUSIONS AND RELEVANCE Attending physicians and APCs frequently work while sick despite recognizing that this choice puts patients at risk. The decision to work sick is shaped by systems-level and sociocultural factors. Multimodal interventions are needed to reduce the frequency of this behavior.

Objective.Inappropriate antibiotic prescribing commonly occurs in pediatric outpatients with acute respiratory tract infections. Antimicrobial stewardship programs are recommended for use in the hospital, but less is known about whether and how they will work in the ambulatory setting. Following a successful cluster-randomized trial to improve prescribing for common acute respiratory tract infections using education plus audit and feedback in a large, pediatric primary care network, we sought to explore the perceptions of the intervention and antibiotic overuse among participating clinicians.Methods.We conducted a qualitative study using semistructured interviews with 24 pediatricians from 6 primary care practices who participated in an outpatient antimicrobial stewardship intervention. All interviews were transcribed and analyzed using a modified grounded theory approach.Results.Deep skepticism of the audit and feedback reports emerged. Respondents ignored reports or expressed distrust about them. One respondent admitted to gaming behavior. When asked about antibiotic overuse, respondents recognized it as a problem, but they believed it was driven by the behaviors of nonpediatric physicians. Parent pressure for antibiotics was identified by all respondents as a major barrier to the more judicious use of antibiotics. Respondents reported that they sometimes “caved” to parent pressure for social reasons.Conclusions.To improve the effectiveness and sustainability of outpatient antimicrobial stewardship, it is critical to boost the credibility of audit data, engage primary care pediatricians in recognizing that their behavior contributes to antibiotic overuse, and address parent pressure to prescribe antibiotics.

Context Among medical educators, there are concerns that the 2003 Accreditation Council for Graduate Medical Education (ACGME) duty hour rules (DHR) has encouraged the development of a “shift work” mentality among residents while eroding professionalism by forcing residents to either abandon patients when they hit 80 hours or lie about hours worked. In this qualitative study, we explore how medical and surgical residents perceive and respond to DHR by examining the ‘local’ organizational culture in which their work is embedded. Methods In 2008, we conducted three months of ethnographic observation of internal medicine and general surgery residents as they went about their everyday work in two hospitals affiliated with the same training program. We also conducted in-depth interviews with seventeen residents. Field notes and interview transcripts were analyzed for perceptions and behaviors surrounding coming and leaving work, reporting of duty hours, and resident opinion about DHR. Findings Our respondents did not exhibit a “shift work” mentality in relation to their work. We found that residents: 1) occasionally stay in the hospital in order to complete patient care tasks even when, according to the clock, they were required to leave because the organizational culture stressed performing work thoroughly, 2) do not blindly embrace noncompliance with DHR but are thoughtful about the tradeoffs inherent in the regulations, and 3) express nuanced and complex reasons for erroneously reporting duty hours that suggest that reporting hours worked is not a simple issue of lying or truth telling. Conclusions Concerns about DHR and the erosion of resident professionalism via the development of a “shift work” mentality are likely to have been over-stated. At the institution we examined, residents did not behave as automatons punching in and out at prescribed times. Rather, they are mindful of the consequences and meaning surrounding the decisions they make to stay or leave work. When work hour rules are broken, residents do not perceive this behavior to be deviant but rather as a reflection of the higher priority that they place on providing patient care than on complying strictly with DHR. The influence of DHR on professionalism is more complex than conventional wisdom suggests and requires additional assessment.