For all the clinical measures and medical interventions used in infection control, much of the task of protecting the patient comes down to the arcane art of changing human behavior. Thus, infection preventionists are turning to social scientists to better understand why it is so difficult to get people to consistently wash their hands or, in a more recent example, stop them from overprescribing drugs or inappropriately using broad-spectrum antibiotics that will select out resistant organisms.
In that regard, a question-and-answer discussion was held at a recent antibiotic stewardship workshop convened by the Society for Healthcare Epidemiology of America. Preeti N. Malani, MD, MSJ, chief health officer and a professor of medicine in infectious diseases at the University of Michigan, posed questions to Julia E. Szymczak, PhD, a social science researcher and assistant professor of epidemiology and medicine at the University of Pennsylvania. The exchange was edited for length and clarity.
Malani: There are a lot of studies that look at behavioral change. These include topics like feedback, restricting workers, prior authorization. Some of these are really good studies, as rigorous a study as you can do, but the results are variable. It surprises my colleagues that behavioral change doesn’t work and if it works sometimes it doesn’t last. What is your view as a social scientist on some of these studies?
Szymczak: When you look at the literature about stewardship, at its core this is about changing prescribing behavior of clinicians, who are highly educated and powerful people in the hierarchy of the hospitals. Those dynamics are not always incorporated into our stewardship interventions. We have things like education, which might improve the problem a little but doesn’t move the dial as far as we would like to. We can put restrictive policies in place — requiring that people get approval or stopping them from using particular drugs. These highly autonomous, highly educated people work around those kinds of interventions.
I think the missing link is that if you think about antimicrobial prescribing as a knowledge deficit or as a sort of a resource deficit — people don’t have access to the laboratory testing or the information at their fingertips that they need. [We need to] think of it that way and not as a social or emotional issue by a physician, or a PA, or a nurse practitioner, making the choice to give a drug to a patient. That is a highly social interaction and it’s influenced by human behavior. I think a lot of our interventions previously have not really taken that into account. I think we have some great examples now of people starting to incorporate elements of the behavioral sciences into the design of an intervention.
Malani: The term “stewardship” is relatively new. We used to use the term “antibiotic restriction,” probably to our detriment. People today, when I think about the antimicrobial stewardship team, [might have] some hostility at times to [and a perception of] the “antibiotic police.” What are some of your thoughts on how we might handle this better?
Szymczak: An anecdote that has arisen in one of my research studies [regards] this idea of [what] was called antibiotic restrictions. There has been sort of a transition in the language that we use to describe this work from restriction, to antibiotic controls in the era of managed care, and people are moving to this idea of stewardship. I had someone tell me they started antibiotic stewardship in an ICU and the intensivist said, “Look, we agree with the idea of doing this, but we don’t want to call it stewardship.” When you think of the word “stewardship,” it is about protecting resources. We recognize that is a resource that we need to protect and care for and steward for future patients. But that intent is not being communicated. So, this idea of antibiotic police or getting resistance from frontline physicians is an opportunity for us to go to them and ask them what they believe and what are their concerns about what we are asking them to do. We don’t ignore the people who are calling us the antibiotic police. We go to them and try to uncover what is it that they believe about what we are asking them to do.
Malani: One of the things I have heard is that the next iteration of this might be “antimicrobial safety,” which may be a better term. Stewardship is not just preserving resources, it is actually about protecting patients.
Szymczak: Absolutely, and one of the things I try to make part of my work is [the importance] of the way we frame the goal. Everyone wants patients to do well. That’s not an issue. When clinicians start to think of stewardship as cost containment or [being based on] other motivations, [there may be less buy-in]. The clinician cares about the patient, so the way we frame and explain what we are doing is of crucial importance.
Malani: Sometimes these drugs are used inappropriately because patients and parents of children demand them. What can we do to better educate families about why antibiotics are not always good?
Szymczak: I think this phenomenon is really an interesting and complex one to unpack. When you talk to clinicians about why they are giving antibiotics, [they often say], “My patients demand it,” particularly in ambulatory settings or the emergency room. I think you might feel, “Well, we just need to educate patients and families.”
But I actually think there is a more complex issue at work here, and that is what is happening in that doctor-patient interaction, that communication space. There has been some really excellent work done on what parents of children with respiratory tract infections symptoms expect going to the doctor visit. What we see is a real mismatch. In many cases, the pediatricians perceived that the parents were asking for antibiotics when they actually didn’t. What is happening is that the pediatrician is assuming they know what the patient wants, when actually they may not.
We have a communication mismatch, and I think we need to teach clinicians and families strategies about how to communicate their expectations and concerns in a more efficient and clear way. We are starting to see in recent research that the public is becoming a bit more savvy than we may perceive them to be and they may be a more willing partner. It is a partnership, though.
Malani: As a clinician I am particularly interested in relationships among my providers. What can be done to leverage these relationships to further stewardship efforts?
Szymczak: When I talk about relationships between clinicians being a social determinant in antibiotic prescribing, what I mean is that group interactions, expectations, and norms around what is OK to say to your colleagues very powerfully influence the kind of decisions that people make. For example, we know that antibiotic prescribing is sensitive to a hierarchy. So, if you are a resident and you are caring for your patients and your attending [physician]wants to use an antibiotic longer or a different kind of antibiotic that you know really isn’t the best choice, you are reluctant to say something. They are your superior and they are judging you. This comes up a lot, not only in training settings, but in other areas. If this person made a decision, I am not going to question it.
Try to create a culture in which it is OK to talk about each other’s prescribing decisions so that you are comfortable asking questions and being questioned. Half of it is just bringing the decision-making out into the open. You may still do the same thing, but if people don’t talk about it you don’t have an opportunity to make change.