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

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.