Cultures of resistance? A Bourdieusian analysis of doctors' antibiotic prescribing

Abstract

Abstract:The prospect of an 'antimicrobial perfect storm' in the coming decades through the emergence and proliferation of multi-resistant organisms has become an urgent public health concern. With limited drug discovery solutions foreseeable in the immediate future, and with evidence that resistance can be ameliorated by optimisation of prescribing, focus currently centres on antibiotic use. In hospitals, this is manifest in the development of stewardship programs that aim to alter doctors' prescribing behaviour. Yet, in many clinical contexts, doctors' antibiotic prescribing continues to elude best practice. In this paper, drawing on qualitative interviews with 30 Australian hospital-based doctors in mid-2013, we draw on Bourdieu's theory of practice to illustrate that 'sub-optimal' antibiotic prescribing is a logical choice within the habitus of the social world of the hospital. That is, the rules of the game within the field are heavily weighted in favour of the management of immediate clinical risks, reputation and concordance with peer practice vis-à-vis longer-term population consequences. Antimicrobial resistance is thus a principal of limited significance in the hospital. We conclude that understanding the habitus of the hospital and the logics underpinning practice is a critical step toward developing governance practices that can respond to clinically 'sub-optimal' antibiotic use.

Interventions to improve antimicrobial prescribing of doctors in training (IMPACT): a realist review

“…This is not only a result of particular prescribing habits being passed down the hierarchy, but derives from the complex ways in which doctors in training build and sustain their social capital through exhibiting competence, as judged by the context-specific norms and routines of each different clinical environment. Bourdieu's practice theory as applied by Broom et al 53 resonates with the findings of this review and particularly with CMOCs 1-3 on the role of hierarchies, CMOCs 6-8 on the role of guidelines and CMOCs 11-13 on the social network of prescribing. By thinking about social capital against the data emerging from the review, we have been able to identify mechanisms such as the need to preserve one's professional reputation as key in driving prescribing behaviour and willingness to ask questions (see, for example, Chapter 3, Part B: asking for advice and challenging decisions).…”

“…Broom et al, 53 who used Bourdieu's practice theory). Other theoretical frameworks were sought specifically to cover particular aspects of the phenomena we were attempting to explain.…”

Pharmacist-led feedback workshops increase appropriate prescribing of antimicrobials

“…Broom et al 22 and Mattick et al 23 have recently proposed that suboptimal prescribing can be logical and realistic when we consider the social context of clinical workplaces. Their findings support our finding that junior doctors often perceive suboptimal prescribing as being acceptable or necessary within the context of workplaces.…”

Special Issue: Complexity, Routines, and Reflexivity in Professional Work

“…These studies consider how risk gets translated into different contexts (see Arribas-Ayllon & Sarangi, 2014;Burton-Jeangros, Cavalli, Gouilhers, & Hammer, 2013), how practitioners intervene to minimise risks in practice (see Cabral, Lucas, Ingram, Hay, & Horwood, 2015;Cricco-Lizza, 2010), and/or how caring is carried out amid (or in spite of) contexts characterised in terms of risk (see Broom, Broom, & Kirby, 2014;Iversen, Broström, & Ulander, 2017). These three features of risk work-interpreting risk knowledge, intervening to minimize risk, and handling social relations and interactions-are illuminated in these studies alongside some connections between them (Gale et al, 2016).…”

“…As Timmermans and Buchbinder (2012, p. 210) found in their research on screening for genetic birth "disorders," even when doubts are cast about the value (cost-benefit) of screening, "it is difficult to turn back the screening momentum precisely because the [hands-on] work in the clinic buffers ontological incompatibilities." There is, therefore, also much to gain from looking beyond lifeworld dynamics towards questions of everyday embodied and reflexive practices among professionals, where the reproductive tendencies of the (professional) habitus (Bourdieu, 1977, Broom et al 2014) may be an alternative or complementary means of explaining the "momentum" behind the unquestioned continuation of interventions and practices-regardless of tensions of truth, legitimacy and authenticity-and the relative lack of tensions amid seemingly contrary practices (see Chivers, 2018).…”