Finding “What's Wrong With Us”: Antibiotic Prescribing Practice Among Physicians in the United States

Abstract

Antibiotic stewardship-or the responsible use of antibiotics-has been touted as a solution to the problem of antibiotic resistance. Antibiotic stewardship in medical institutions attempts to change the antibiotic prescribing "behaviors" and "habits" of physicians. Interventions abound targeting "problem prescribers," or those physicians whose practice is out of line with physician peers. Thus, the locus of decision-making in antibiotic prescribing is thought to be the found with the individual physician. Based on 18 months of participant observation and in-depth interviewing of antibiotic-prescribing physicians at two medical institutions in the United States, this paper will question notions of antibiotic stewardship that center on individual "behaviors" and "habits." Many physicians have taken to heart a reductionist approach in studies of antibiotic prescribing, including several physicians I encountered during research who enthusiastically located the benefit of my research in the ability to identify "what's wrong with us." In this paper, I use two representative ethnographic case studies to argue that antibiotic stewardship interventions aimed at identifying and correcting "bad" physician practice limit the possibilities of understanding the social dynamics of the institution. Through an analysis of everyday encounters in the hospital setting, I show how decision-making in antibiotic prescribing can more productively be located between and among institutions, physicians, patient charts, and other hospital-based staff members (e.g., pharmacists, nurses). By demonstrating that antibiotic prescribing is a collective practice occurring through engagement with social and material surroundings, I argue that we can better account for the weighted ways in which social action and relations unfold over time.

Drivers of Broad-Spectrum Antibiotic Overuse across Diverse Hospital Contexts—A Qualitative Study of Prescribers in the UK, Sri Lanka and South Africa

“…Antibiotic decision making is a collective, multi-disciplinary activity [ 31 , 32 ], and approaches to reducing BSA overuse need to involve all stakeholders in the hospital in changing the systems, processes and behaviors that result in reliance on BSAs. This will not be achieved through a focus on doctors alone, but requires doctors to be involved as part of wider a team across the organization, working together towards shared objectives, with strong leadership.…”

Quality, availability and suitability of antimicrobial stewardship guidance: a multinational qualitative study

“…Significant time pressure under which physicians make antibiotic decisions is documented in other studies. 31 , 32 If support instruments, such as guidelines, are not in a format that is easy and quick to use, then it is not realistic to expect that physicians will spend time that is already in deficit to engage with guidelines that are not user-friendly. When designing guidelines it is crucial to offer them in diverse formats, such as smartphone/tablet apps, desktop-based programmes, posters, printable flowcharts or visual prompts to improve guideline usability.…”

Vignette Research Methodology: An Essential Tool for Quality Improvement Collaboratives

“…Acknowledgement of these external influences should lead us to look beyond the individual toward an alternative approach to behavior change. Targeting change in the attitudes of the collective rather than the individual may be a more effective approach [54,55]. Individuals do not practice in a vacuum conveniently hidden from external influence.…”