More than a quarter of Americans have misrepresented symptoms to get antibiotics, surveys show
Chris Dall, MAToday at 2:16 p.m.
Antimicrobial Stewardship
Efforts to promote antibiotic stewardship in doctor’s offices and other outpatient settings often butt up against the pressure that clinicians sometimes feel to prescribe antibiotics to patients who believe they need them for an illness, regardless of whether their symptoms are caused by a bacterial infection.
In these scenarios, patients might emphasize how sick they feel, how they need to get better quickly so they can return to work, or how antibiotics have helped them with a similar illness in the past. Parents of sick children might say they just want something to help a miserable child with an earache feel better.
But two new surveys by the same group of researchers indicate that nearly one-third of patients might use an additional tactic: Misrepresenting their or their child’s symptoms.
The surveys, published last week in JAMA Network Open, found that 28% of adult respondents reported misrepresenting their symptoms in order to obtain antibiotics for an illness at some point, while 27% of caregivers did the same to get antibiotics for their child. The misrepresentation of symptoms included exaggerating symptoms, making up symptoms, or both.
Respondents who misrepresented symptoms were more likely to be younger, and to report they often feel like clinicians don’t take their symptoms seriously. Some viewed lying as more acceptable. Others said they think antimicrobial resistance is a hoax. In both surveys, fewer than a third respondents who lied to get antibiotics said they regretted the misrepresentation or using the antibiotics they obtained.
And that’s a real challenge for clinicians who want to practice and promote appropriate antibiotic use, says the lead author of the two studies.
“When patients don’t feel like they can be fully honest about their symptoms…this can represent a really important barrier to effective patient-clinician communication and shared decision-making,” Alistair Thorpe, PhD, a researcher at the University of Utah Spencer Fox Eccles School of Medicine, told CIDRAP News.
Exaggeration and fabrication
Both online surveys involved adults recruited by a commercial marketing research company. Respondents were asked two questions about whether they had misrepresented symptoms to get antibiotics for themselves or, if they were a caregiver, for their child.The first question asked participants whether they had exaggerated symptoms by telling a healthcare provider the symptoms were worse, or were lasting longer, than they actually were. “Like saying you’ve had a cough for two weeks instead of one,” Thorpe explained.
The second question asked whether they had ever fabricated symptoms. Respondents were also asked about health behaviors and beliefs, health experiences, and individual psychological characteristics.
Thorpe, whose research focuses on improving healthcare delivery and patient experience, said there’s been a fair amount of research on patients knowingly misrepresenting information in clinical encounters. But it usually takes the form of withholding information, like how much alcohol a patient consumes. Less is known about misrepresentation of symptoms within the context of outpatient antibiotic prescribing, which relies on clinical observations and patient-reported information.
But Thorpe said some literature and anecdotal data suggest clinicians often suspect their patients may be exaggerating their symptoms.
“We wanted to provide some quantitative data on what the prevalence of this [behavior] is, and why it’s happening,” Thorpe said.
Of the 959 adults (mean age, 50.7 years; 49.8% female) who responded to the first survey, 268 (27.9%) reported ever misrepresenting their symptoms to get antibiotics, with 108 (40.3%) saying they exaggerated symptoms, 19 (7.1%) saying they fabricated symptoms, and 141 (52.6%) doing both. Cold-like symptoms were the most frequently misrepresented (176 respondents, 65.7%); patients also exaggerated urinary symptoms, skin-related symptoms, and stomach issues to obtain antibiotics.
Participants cited several reasons for misrepresenting their symptoms, including that they felt very sick (62.2%), thought antibiotics were the only thing that would help them (61.8%), were worried they might develop a serious infection (53.6%), and thought antibiotics would help them get back to their responsibilities faster (61%).
Many who misrepresented symptoms (43.1%) said they figured out what to say to get antibiotics from their own personal experience, while 34.5% cited advice from friends or family. Only 28.7% said they regretted misrepresenting their symptoms.
The findings from the caregiver survey were similar. Of the 236 caregivers (mean age, 41.7 years; 51.7% female) who responded, 63 (26.7%) reported ever misrepresenting a child’s symptoms to obtain antibiotics, with 24.2% exaggerating actual symptoms, 23.6% fabricating symptoms, and 19.1% doing both. The most commonly endorsed reasons were that their child felt very sick, the belief that antibiotics were the only thing that would help, and that respondents believed they knew their child’s medical history better than a clinician did.
Thorpe says the finding, from both surveys, that patients were more likely to misrepresent symptoms when they feel that clinicians don’t take symptoms seriously is an important one for clinicians and everyone involved in health communication. Sick patients, he said, need to feel supported whether or not that results in them getting an antibiotic prescription.
“I think it all points to us making sure that we’re making patients feel heard, that we’re getting them the right information at the right time, and in a way that’s meaningful and resonates with them,” he said.
Clinicians must act in patients’ best interest
Knowingly misrepresenting symptoms to obtain antibiotics not only poses a challenge for clinicians who are trying to prescribe antibiotics appropriately, but it can have additional consequences, Thorpe and his collaborators say.“These medications are not totally benign for the patient,” Andrea Levy, PhD, professor of social sciences at Connecticut State Community College Middlesex and one of the first authors on the study, said in a University of Utah press release. “And antibiotic use contributes to increasing antimicrobial resistance, which is a broader public health concern.”
And as Jeffrey Linder, MD, MPH, writes in an accompanying commentary, of the eight categories listed in the surveys for which patients could misrepresent symptoms, only one (urinary symptoms) was a clear justification for antibiotics.
“For these non–antibiotic-appropriate diagnoses, prescribing antibiotics is medically incorrect and could itself be considered a form of dishonesty or lying mainly to assuage the patient,” he writes.
Linder, a primary care physician and professor at Northwestern University’s Feinberg School of Medicine, says that, ultimately, the decision to prescribe an antibiotic should be based on a clinician’s diagnosis. And the question that clinicians should be asking themselves is whether prescribing an antibiotic is more likely to help or hurt the patient.
“Clinicians’ obligation is to act in patients’ best interest, even if patients are hoping we do something different, even if patients do not like it, or even if patients lie about their symptoms,” he writes.