Pharmacy World & Science

, Volume 32, Issue 6, pp 805–814 | Cite as

Diagnosing infections: a qualitative view on prescription decisions in general practice over time

  • Ingunn BjörnsdóttirEmail author
  • Karl G. Kristinsson
  • Ebba Holme Hansen
Research Article


Objective Antibiotics may frequently be prescribed on the basis of vague diagnoses, possibly resulting in unnecessary antimicrobial resistance. Our aim is to map general practitioners’ (GPs’) decision-making for common infections, exploring their diagnostic basis for antibiotic prescriptions. Setting General practice in Iceland. Method Ten in-depth qualitative interviews with, and three observations of, GPs in 1995. Diagnostic issues extracted and analysed. In 2006, eight GPs commented on analysis and updated (email/telephone). Main outcome measure Diagnostic variability and reasons for prescribing antibiotics, consistency or changes over time. Results Wide variations were uncovered in diagnostic procedures, although each GP remained consistent through time. Some GPs had developed “rules-of-thumb”. They often balanced risks against issues like money, time, need for the workforce (perceived importance of the patient’s job), client’s need for job/earnings (perceived ability to afford a sick day) and doctor-patient relationship (risk of refusal adversely affecting the relationship). Perceptions of risk varied from focusing on resistance development to focusing on possible harm from untreated infections, also ranging between considering both to worrying about neither. Changes over time were not prominent but included increased point-of-care testing and the perception by GPs that patients were increasingly willing to “wait and see”. Conclusions Large variability and individuality characterized the GPs’ diagnostic procedures, contrasted by consistency through time. If modification of diagnostic routines is needed, provision of “scientific facts” and technological aids is insufficient. A prerequisite for changing practice is GPs’ acceptance of accuracy of information and of reliability, applicability, and relevance of technology, for physician and/or patient.


Anti-bacterial agents Diagnosis Evidence-based medicine Iceland Infection Physician’s practice patterns 



We thank our informants for the participation and Maxine Ingalls, RN, for proofreading.


Research is a part of our duties within our ordinary paid jobs. This research was done within that scope.

Conflicts of interest

We have no conflicts of interests to declare.


  1. 1.
    Friedman CR, Srinivasan A. Public health responses to antimicrobial resistance in outpatient and inpatient setting, Chapter 16. In: Wax RG, Lewis K, Salyers AA, Taber H, editors. Bacterial resistance to antimicrobials, 2nd ed. Boca Raton: CRC Press; 2008. ISBN 978-0-8493-9190-3.Google Scholar
  2. 2.
    O’Brien MA, Rogers S, Jamtvedt G, Oxman AD, et al.. Educational outreach visits: effects on professional practice and health care outcomes (Review). Reprint of a Cochrane review, published in The Cochrane Library 2008(3). Accessed on 7 May 2010.
  3. 3.
    Björnsdóttir I, Hansen EH. Telephone prescribing of antibiotics: general practitioners’ views and reflections. Eur J Pub Health. 2001;11(3):260–3.CrossRefGoogle Scholar
  4. 4.
    McGavock H, Webb CH, Johnston GD, Milligan E. Drug marketing: the most powerful external influence on prescribing. In: McGavock H, et al., editors. The prescribing jigsaw. Belfast: Drug Utilisation Research Unit, Queen’s University; 1998.Google Scholar
  5. 5.
    Wick A. The importance of diagnosis in general practice. Schweiz Rundsch Med Prax. 1993;82:68–76.PubMedGoogle Scholar
  6. 6.
    Kaplan RM. Uncertainty, variability, and resource allocation in the health care decision process, Chapter 14. In: Friedman HS, Silver RC, editors. Foundations of health psychology. New York: Oxford University Press; 2007. ISBN: 978-0-513959-4.Google Scholar
  7. 7.
    Gyssens IC, Kullberg BJ. Improving the quality of antimicrobial drug use can result in cost containment. Pharm World Sci. 1995;17(5):163–7.CrossRefPubMedGoogle Scholar
  8. 8.
    Henriksen K, Hansen EH. The threatened self: general practitioners’ self-perception in relation to prescribing medicine. Soc Sci Med. 2004;59(1):47–55.CrossRefPubMedGoogle Scholar
  9. 9.
    Bradley C. Insights from qualitative research are needed to improve GP prescribing. Eur J Gen Pract. 2002;8:3–4.CrossRefGoogle Scholar
  10. 10.
    Strauss A, Corbin J. Basics of qualitative research: grounded theory procedures and techniques. Newbury Park: Sage Publications; 1990.Google Scholar
  11. 11.
    Janesick V. The choreography of qualitative research design: minutes, improvisations and crystallization. In: Denzin NK, Lincoln YS, editors. Handbook of qualitative research. 2nd ed. Thousand Oaks, CA: Sage Publications, Inc.; 2000. p. 379–99.Google Scholar
  12. 12.
    Hansen EH. Rationality and common sense in Danish drug therapy. J Soc Adm Pharm. 1988;5(3/4):105–13.Google Scholar
  13. 13.
    Björnsdóttir I. Studies in prescribing of antibiotics in Iceland: a qualitative and quantitative approach. Copenhagen: The Royal Danish School of Pharmacy, Department of Social Pharmacy, 1999.Google Scholar
  14. 14.
    Wigton RS, Darr CA, Corbett KK, Nickol DR, Gonzales R. How do community practitioners decide whether to prescribe antibiotics for acute respiratory tract infections? J Gen Intern Med. 2008;23(10):1615–20. doi: 10.1007/s11606-008-0707-9.CrossRefPubMedGoogle Scholar
  15. 15.
    Howie JGR. Some non-bacteriological determinants and implications of antibiotic use in upper respiratory tract illness. Scand J Infect Dis Suppl. 1983;39:68–73.PubMedGoogle Scholar
  16. 16.
    Fahey T. Bronchitis and sinusitis, Chapter 4.1. In: Gibson PG, editor. Evidence-based respiratory medicine. Oxford: Blackwell Publishing; 2005. ISBN: 978-0-7279-1605-1.Google Scholar
  17. 17.
    Sundberg M. Optical methods for tympanic membrane characterisation. Linköping studies in science and technology dissertation no. 1173. Linköping: Linköping University; 2008. ISBN 978-91-7393-933-1.Google Scholar
  18. 18.
    Appelman CLM, Claessen JQPJ, Touw-Otten FWMM, Hordijk GJ, de Melker RA. Severity of inflammation of tympanic membrane as predictor of clinical course of recurrent acute otitis media. BMJ. 1993;306:895.CrossRefPubMedGoogle Scholar
  19. 19.
    Reid MC, Lane DA, Feinstein AR. Academic calculations versus clinical judgments: practicing physicians’ use of quantitative measures of test accuracy. Am J Med. 1998;104:374–80.CrossRefPubMedGoogle Scholar
  20. 20.
    McIsaac WJ, Goel V. Sore throat management practices of Canadian family physicians. Fam Pract. 1997;14:34–9.CrossRefPubMedGoogle Scholar
  21. 21.
    Paluck E, Katzenstein D, Frankish CJ, Herbert CP, Milner R, Speert D, Chambers K. Prescribing practices and attitudes toward giving children antibiotics. Can Fam Physician. 2001;47:521–7.PubMedGoogle Scholar
  22. 22.
    Howie JG. Diagnosis: the Achilles heel? J R Coll Gen Pract. 1972;22(118):310–5.PubMedGoogle Scholar
  23. 23.
    Coenen S, van Royen P, Vermeire E, Hermann I, Denekens J. Antibiotics for coughing in general practice: a qualitative decision analysis. Fam Pract. 2000;17(5):380–5.CrossRefPubMedGoogle Scholar
  24. 24.
    Finch R. Bacterial resistance: the clinical challenge. Clin Microbiol Infect. 2002;8(Suppl 3):21–32.CrossRefPubMedGoogle Scholar
  25. 25.
    Andre M, Borgquist L, Molstad S. Use of rules of thumb in the consultation in general practice: an act of balance between the individual and the general perspective. Fam Pract. 2003;20(5):514–9.CrossRefPubMedGoogle Scholar
  26. 26.
    Gabbay J, le May A. Evidence based guidelines or collectively constructed “mindlines?” Ethnographic study of knowledge management in primary care. BMJ. 2004;329(7473):1013.CrossRefPubMedGoogle Scholar
  27. 27.
    Cockburn J, Pit S. Prescribing behaviour in clinical practice: patients’ expectations and doctors’ perceptions of patients’ expectations: a questionnaire study. BMJ. 1997;315(7107):520–3.PubMedGoogle Scholar
  28. 28.
    Arason VA, Sigurdsson JA, Kristinsson KG, Getz L, Gudmundsson S. Otitis media, tympanostomy tube placement, and use of antibiotics. Cross-sectional community study repeated after five years. Scand J Prim Health Care. 2005;23(3):184–91.CrossRefPubMedGoogle Scholar
  29. 29.
    Kristinsson KG. Modification of prescribers’ behavior: the Icelandic approach. Clin Microbiol Infect. 1999;5(Suppl 4):S43–7.CrossRefPubMedGoogle Scholar
  30. 30.
    Lambert MF, Masters GA, Brent SL. Can mass media campaigns change antimicrobial prescribing? A regional evaluation study. J Antimicrob Chemother. 2007;59(3):537–43. doi: 10.1093/jac/dk1511.CrossRefPubMedGoogle Scholar
  31. 31.
    Anonymous. Use of drugs in Iceland 1996-2005. Icelandic Ministry of Health. Accessed 7 May 2010.
  32. 32.
    Armstrong D. Clinical autonomy, individual and collective: the problem of changing doctors’ behaviour. Soc Sci Med. 2002;55(10):1771–7.CrossRefPubMedGoogle Scholar
  33. 33.
    Publications and reports (In Icelandic = Rit og skýrslur). The Directorate of Health (Landlæknisembættið). Accessed 7 May 2010.
  34. 34.
    Clinical guidelines (In Icelandic = Klínískar leiðbeiningar). The Directorate of Health (Landlæknisembættið). Accessed 7 May 2010.
  35. 35.
    Rosenberg W, Donald A. Evidence based medicine: an approach to clinical problem-solving. BMJ. 1995;310:1122–6.PubMedGoogle Scholar
  36. 36.
    Forde R. Competing conceptions of diagnostic reasoning: is there a way out? Theor Med Bioeth. 1998;19(1):59–72.CrossRefPubMedGoogle Scholar
  37. 37.
    Fargason CA Jr, Evans H, Ashworth CS, Capper SA. The importance of preparing medical students to manage different types of uncertainty. Acad Med. 1997;72:688–92.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media B.V. 2010

Authors and Affiliations

  • Ingunn Björnsdóttir
    • 1
    • 2
    Email author
  • Karl G. Kristinsson
    • 2
    • 4
  • Ebba Holme Hansen
    • 1
    • 3
  1. 1.Department of Pharmacology and Pharmacotherapy, Section for Social PharmacyUniversity of CopenhagenCopenhagenDenmark
  2. 2.Research Institute for Pharmaceutical Outcomes and PolicyUniversity of IcelandReykjavíkIceland
  3. 3.FKL—Research Centre for Quality in Medicine UseCopenhagenDenmark
  4. 4.Clinical MicrobiologyLandspitali University HospitalReykjavíkIceland

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