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.
Antimicrobial stewardship programs have been associated with numerous impacts on medical practice including reductions in costs, antimicrobial resistance, and adverse events. While antimicrobial stewardship is now considered an essential element of medical practice, the understandings of the value of antimicrobial stewardship among medical practitioners vary. Additionally, non-physician practitioners are regularly left out of antimicrobial stewardship interventions targeting antimicrobial decision-making. Here, we contribute the perspective from resident physicians and specialists in pharmacy regarding their involvement in antimicrobial prescribing. Notably, our semi-structured interviews with 10 residents and pharmacy specialists described their limited autonomy in the clinical setting. However, the participants regularly worked alongside primary antimicrobial decision-makers and described feeling pressure to overtreat to be safe. The clear rationales and motivations associated with antimicrobial prescribing have a noticeable impact on physicians in training and non-physician practitioners, and as such, we argue that antimicrobial stewardship interventions targeting primary antimicrobial decision-makers are missing an opportunity to address the breadth of antimicrobial prescribing culture. By looking at the perspectives and rationales of physicians in training and non-physician practitioners, we can see evidence that the act of antimicrobial prescribing is impacted by individuals on all levels of the hierarchies present in medical practice.
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