ORIGINAL RESEARCH

Patient and physician explanatory models

for acute bronchitis
LAURA M. SNELL, MPH; RUTH P. WILSON, PHD; KEVIN C. OEFFINGER, MD; CAROLYN SARGENT, PHD;
OLIVE CHEN, PHD; AND KRISTEN M. COREY, MA
Dallas, Texas, and San Jose, California

KEY POINTS FOR CLINICIANS

Patients often do not understand the difference between viral and bacterial infections.
Patients think that acute bronchitis will not
improve and will probably get worse if not
treated with antibiotics.
Physicians and patients tend to falsely equate
productive coughs (green-yellow sputum)
with having a bacterial infection that requires
antibiotic treatment.
Physicians report significant internal conflict
regarding treatment of acute bronchitis, characterized by a recognition that antibiotics are
of little value, a universal assumption that
patients expect antibiotics, a desire for patient
satisfaction, perceived pressure from employers to get the patient back to work, and fear
of missing a more serious infection.

O B J E C T I V E S Our goals were to develop

explanatory models to better understand how physicians diagnose and treat acute bronchitis; to describe
patient expectations and needs when experiencing
an episode of acute bronchitis; and to enhance communication between physician and patient.
S T U D Y D E S I G N We used qualitative, semistructured, in-depth interviews to generate patient
and physician explanatory models.
P O P U L A T I O N We had a purposeful, homogeneous sample of 30 family physicians and 30 adult patients.
O U T C O M E S M E A S U R E D Our multidisciplinary team of investigators used an editing style of
analysis to develop patient and physician explanatory models based on the following topics: (1) what
caused my illness/etiology, (2) what symptoms I
had/onset of symptoms, (3) what my sickness did to
me/pathophysiology, (4) how severe is my sickness/course of illness, and (5) what kind of treatment
should I receive/treatment.
R E S U L T S We found that patient and physician
models were congruous for symptoms of acute bronchitis and incongruous for etiology and course of illness. Models were congruous for treatment, although
for different reasons.
C O N C L U S I O N S Patients may have a very

vague understanding of the process of infection and

the difference between bacteria and viruses.
Compounding this confusion is frequent miscommunication from physicians regarding the clinical course
of untreated illness. These factors and non-communicated expectations from patients and fear of missing
something on the part of physicians contribute to the
decision to treat with antibiotics.
KEY
W O R D S Acute bronchitis, qualitative,
explanatory models. (J Fam Pract 2002; 51:
10351040)

linical trials and meta-analyses of these trials13

have found that antibiotics do not provide clinically relevant improvements in patient outcomes in
the treatment of otherwise healthy adults with acute
bronchitis. Despite these findings, antibiotics remain
the traditional choice of therapy.46 To better understand the process of making a diagnosis and deciding to treat, further study is needed to explore the
complex interaction between patients and physicians.
Explanatory models of illness, pioneered by
Arthur Kleinman, provide insight into the dynamics of physician and patient processes in a clinical
encounter.710 Physician and patient models are
elicited through the use of semi-structured, indepth interviews. The physicians model has 5
basic topics: etiology, onset of symptoms, pathophysiology, course of illness, and treatment of illness. A patient will generally consider these same
issues in a different framework: What caused my
illness?, What symptoms have I had?, What does
my sickness do to me?, How severe is my sickness?, and What kind of treatment should I receive?
The patient model, which is often drawn from cultural traditions and norms and may not be fully
articulated, tends to be less abstract, possibly
From the Department of Family Practice and Community Medicine,
The University of Texas Southwestern Medical Center at Dallas
(L.M.S., K.C.O., O.C.) and the Department of Anthropology, Southern
Methodist University (C.S., K.M.C.), Dallas, TX; and the Department
of African-American Studies, College of Social Work, San Jose State
University, San Jose, CA (R.P.W). Support for this study was provided through the Joint American Academy of Family
Physicians/American Academy of Family Physicians Foundation.
Address reprint requests to Laura M. Snell, MPH, Department of
Family Practice and Community Medicine, The University of Texas
Southwestern Medical Center at Dallas, 6263 Harry Hines Boulevard,
Dallas, TX 75390-9067. E-mail: laura.snell@utsouthwestern.edu.

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inconsistent, and even self-contradictory.8

Differences between patient and physician
explanatory models may lead to conflict, poor
communication, low compliance, decreased
patient satisfaction, and worse patient outcomes.
The purpose of this study was to elicit and analyze explanatory models to better understand how
physicians make the diagnosis of acute bronchitis
and decide on treatment for a given patient and
describe patient expectations and needs when
experiencing an episode of acute bronchitis.

METHODS
Participants

This qualitative study used a purposeful, homogeneous sample of 30 family physicians and 30
patients from several types of medical practices in
the Dallas, Texas area. It was purposeful in that we
deliberately tried to include patients and physicians from a variety of settings. The study was
approved by the institutional review boards of
University of Texas Southwestern Medical Center
and Southern Methodist University.
A letter inviting participation was mailed to
physicians. This letter also requested access to
adult patients who were seen with an episode of
acute bronchitis from 4 weeks to 6 months previously. This mailing was followed by a telephone
call from a research assistant to set up an interview. A similar process was followed for patients.

Data analysis

An editing style of analysis was used in which the

text of the interviews was read line by line and
data were grouped into themes.11 Two data management software programs were used to develop
codes and labeling, Ethnograph version 4.0 (Qualis
Research Association, Salt Lake City, UT) and
NVivo (Revision 1.2, Qualitative Solutions and
Research Pty Ltd, Cambridge, MA). We explored
the data for linkages and connections of the coded
groups for hierarchical and non-hierarchical relationships.
The data were analyzed and interpreted by a
multidisciplinary team consisting of a family physician (K.C.O.), an epidemiologist (L.M.S.), 2 medical
anthropologists (R.P.W., C.S.), a medical anthropology graduate student (K.M.C.), and a qualitative
research assistant (O.C.). Through a series of meetings, we shared findings, discussed relationships,
explored areas of discrepancy and outlying data,
and developed the explanatory models.

RESULTS
Participant demographics are provided in the
Table. To contrast models, results are presented for
the 5 statements with the patient model followed
by the physician model.
What caused my illness/etiology

About one third of the patients felt that their bronchitis was triggered by external factors such as
allergies, pollution, smoking, or cold weather. As 1
In-depth interviews and data collection
patient stated, I think that living here, in being
Interview scripts had open-ended questions and stanexposed to a lot of pollutants over a period of
dard probes to elicit information about the explanatoyears, has weakened our bronchial areas and
ry model. After obtaining informed consent, interviews
therefore, I am more susceptible to the weather
were conducted by 1 trained interviewer and audio
changes, the dampness, wind blowing, cold.
recorded, transcribed, and checked for accuracy.
Approximately
one
third
referred
to
an
infectious
agent
or
TA B L E 1
an infection causing the bronchiPhysician and patient demographic data
tis, using words such as bug and
germ. Only 2 patients mentioned
the words viral or bacterial and
Physicians (n = 30)
Patients (n = 30)
the references were nonspecific.
Frequency
%
Frequency
%
One stated, I assumed a bug of
Age, y
some sort and I am utterly unclear
2535
9
30
9
30
about, you know, whats a virus,
3645
10
33
10
33
a bacteria, viral versus bacterial
4655
8
27
6
20
infection. Others talked about
how being stressed or tired low55
3
10
5
17
ered their resistance and caused
Sex
the bronchitis. There was another
Male
21
70
11
37
group of patients who felt that
Female
9
30
19
63
they did not know what caused
Race/ethnicity
their bronchitis.
European American
24
79
24
80
Most physicians reported that
African American
2
7
4
13
acute bronchitis is generally viral,
Hispanic
2
7
1
4
but added that it could also be
Asian
2
7
1
4
due to Mycoplasma pneumoniae,
Chlamydia pneumoniae, Haemo1036

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philus influenzae, or Streptococcal pneumoniae

and that it was difficult to say what caused an individuals illness. Environmental exposures, such as
smoking, air pollution, and allergies, were also felt
to play a role in etiology. This was typified by 1
physician who stated, I see it most frequently in
people who are smokers or passive smokers. A
few physicians expressed the view that the cause of
bronchitis was not really understood.
Symptoms I have had/onset of symptoms

Patients tended to report symptoms in order of

occurrence. An example was, My head stopped
up and I felt . . . head congestion, my chest was
congested. Sometimes it was hard for me to
breathe, and coughing and sneezing and I hurt.
Patients were asked to rank their symptoms in
order of seriousness. Approximately one third
reported coughing as their most serious complaint.
Another third listed difficulty breathing. Comments
about this symptom reflected a strong sense of
concern or fear such as, I had a hard time breathing at night. That was one of the things that was
kind of scary . . . it was something I couldnt relate
to at first and is probably the worst symptom.
When asked if there was 1 symptom that particularly worried them, coughing was the most common response followed by breathing difficulties
and then a wide array of symptoms such as fever
and chest pain.
When patients described their cough, there tended to be those who used adjectives such as dry,
mild, and tickle, and those who used terms such as
deep, substernal, barking, goes down below your
hips. The cough was commonly described as productive or nonproductive and ongoing or constant.
In general, patients fell into 2 camps: those who
reported being sick for a short time (13 days)
and those who waited longer (13 weeks) before
going to a doctor. Most patients had experienced
prior episodes of bronchitis. Those with more
experience tended to feel that they needed to see
a physician.
All physicians reported cough as the classic
symptom of bronchitis. Approximately half indicated that the cough was typically productive and
described the color of the phlegm. The others stated that cough was the classic symptom but did not
specify the characteristics. Other symptoms listed
were fever, shortness of breath, wheezing, congestion, malaise, aches, and chills.
When patients were asked what they felt would
be the most worrisome symptom of bronchitis,
over two thirds reported coughing, especially
when it affected sleep or work functioning and
was persistent and productive. When reporting
their own most worrisome symptoms, however,
physicians listed high fever, chest pain, or purulent
sputum and were concerned about serious underlying diseases such as pneumonia.

Physicians felt there was wide variation in the

time that patients with bronchitis symptoms waited
to be seen. Approximately half of the physicians
reported that patients were sick for 1 week or less
before their appointment. The other half reported
wide intervals ranging from 1 day to 3 weeks.
What my sickness did to me/
pathophysiology

Most patients responded that they had never

thought about what the illness did to them. When
probed, patients generally responded that they
had an infection in the bronchial pipes or a
cold in the chest.
Physicians were asked to describe the pathophysiology of acute bronchitis and discuss how
they arrive at a diagnosis. In general, they
described how a virus or bacteria invades the
respiratory tract, causing inflammation of the airways and bronchioles, resulting in increased
mucus production. Several physicians described
bacterial overgrowth occurring. Physicians separated acute bronchitis from an upper respiratory
infection based on the cough, especially if it was
productive, and from pneumonia by the absence
of more severe signs or symptoms, such as high
fever, shortness of breath, or presence of rales.
Several physicians tied their diagnosis to treatment, as illustrated by a physician who stated, I
think that many doctors use bronchitis as the
excuse to give an antibiotic. And I sometimes fall
into that trap. So if I want them to think they
deserve an antibiotic, then sometimes I will give
them the diagnosis of bronchitis.
How severe is my sickness/course
of illness

One third of patients reported feeling very bad

and one third felt moderately bad. The remainder
reported variability in the way they felt or not feeling ill at all. Similarly, one third reported a cough
duration of 3 weeks or longer and one third felt
that the illness had a major impact on their work
and daily routine. When asked what would have
happened if they had not seen the doctor, patients
consistently reported that they would have been
sick longer, would not have recovered, or would
have gotten pneumonia. Three patients felt they
could have died. None said that they would have
recovered on their own.
Physicians were asked how many days of work
were missed by patients with acute bronchitis.
More than two thirds estimated that patients
missed from 1 to 3 days. A number of physicians
mentioned that factors such as work motivation,
attitudes about illness, and availability of paid sick
leave influenced the number of days off. Most
physicians thought it would take patients 1 week
or longer before they felt well enough to return to
their normal routine.

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What kind of treatment should I

receive/treatment

All patients recalled that the primary treatment for

their acute bronchitis was a prescription medication such as an antibiotic, cough suppressant, or
decongestant. Twenty-seven reported receiving an
antibiotic prescription. An inhaler was prescribed
for about one third of patients. Several patients
commented on the inhalers effectiveness for
relieving symptoms. This is illustrated by a patient
who stated, the inhaler is the thing that helped me
instantaneously. About one third of patients
reported receiving medical advice such as drinking
lots of liquids and resting.
Most patients agreed that the treatment they
received was what they expected, but when asked
to articulate what they expected, they had problems doing so. After probing by the interviewer,
more than 50% stated that an antibiotic was what
they needed for treating their illness. This is typified by the response of one patient, I would like
[bronchitis] to be treated more aggressively. ...
[Physicians] want to wait until youve got a full
blown infection before they do anything and I
wish that would be different next time.
When patients were asked about treatment satisfaction, about two thirds reported that they were
satisfied because they felt better pretty fast. There
was wide variation in their definition of pretty fast,
ranging from 1 day to 3 weeks. Several patients
were somewhat dissatisfied with their treatment but
felt that nothing else could have been done. A few
patients expressed strong dissatisfaction because
of slow recovery time or because the prescribed
medications did not relieve the symptoms.
Two major treatment approaches emerged from
the physician interviews: use of antibiotics or a primary focus on symptom relief. Most physicians
who commonly used antibiotics were concerned
about which antibiotics were more effective. They
also were concerned about patients who were sick
longer than 1 week, had discolored sputum, were
members of high-risk populations (especially
smokers), and who did not improve with treatment. A few physicians who focused on symptom
relief prescribed cough suppressants, -agonist
inhalers, or decongestants. These physicians felt it
was important to educate patients about differences between viral and bacterial diseases, disadvantages of overusing antibiotics, and ways to
relieve symptoms at home instead of relying on
prescribed medications.
When asked about expectations of treatment, all
30 physicians thought that their patients wanted
them to prescribe antibiotics. About one third
reported that patients also expected to have a prescribed cough medicine. Three fourths of the
physicians perceived patients antibiotic expectations as a pressure, although with different rationales. Several physicians admitted that they pre1038

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scribed antibiotics to make the patient happy.

One said, I think people expect it. If you get
somebody that has come in and has done everything they can figure out to do to try to get better,
then you can certainly end up with patients that
are unhappy if you refuse to give them antibiotics.
Some physicians suggested that the pressure of
prescribing antibiotics was not from the individual,
but from the system, including the employer, the
legal system, and the health insurance system.
Physicians who did not feel pressure to prescribe antibiotics could be grouped into those who
usually used antibiotics to treat acute bronchitis
and those who took time to explain to their
patients why they did not want to prescribe antibiotics. Some quotations that illustrate the views of
this latter group were: Usually I try to involve the
patient in my thinking, until we feel some sort of
consensus and I basically lay out why Im not
[prescribing an antibiotic]. A synopsis of the models is presented in Figure 1.

DISCUSSION
It is well recognized in the literature that antibiotic
usage in the therapy of acute bronchitis in the otherwise healthy adult (1) does not confer a clinically
relevant shorter course of illness, (2) does not prevent the rare progression to pneumonia any better
than placebo, (3) has a significantly negative impact
on public health by contributing to antibiotic resistance, and thus (4) is not warranted.13,5,12,13
Nevertheless, antibiotic usage patterns have not
changed significantly in the past 10 years, and
antibiotics are still the traditional first-line therapy in
practice. Reasons for this dichotomy are complex.
The purpose of this qualitative study was to begin
to clarify some of the complexities by determining
incongruous areas of patient and physician beliefs
regarding the diagnosis and management of acute
bronchitis. Similarities and differences in 3 areas of
patient and physician models warrant further discussion: etiology of acute bronchitis, course if
untreated, and factors affecting the decision to treat.
Patients in this study had a vague understanding
of the concept of infection and differences
between bacteria and viruses. This finding has
been reported in other patient-centered studies1315
regarding respiratory infections and is likely due to
inadequate or contradictory information imparted
by the medical community through individual
physician-specific communications and from the
medical system as a whole. In contrast, physicians
in the study uniformly noted a viral cause of most
cases of bronchitis but often qualified the statements with concern of not knowing which individuals might have bacterial infections and the lack
of tools to distinguish between viral and bacterial
etiologies.
Further complicating this paradigm of conflict and
confusion regarding viral and bacterial causes,

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FIGURE 1
Patient Model

Physician Model

What caused my illness

Etiology

Triggered by external factors such as smoking,

Usually viral

pollution, or allergies

Sometimes bacterial

Often occurred when fatigued or stressed

Possible bacterial overgrowth

Vague concept of germs/bacteria/viruses

Unable to distinguish between viral and bacterial

Symptoms I had

Onset of symptoms

Cough and difficulty breathing

Cough and difficulty breathing

Deep productive cough vs shallow/dry cough

Cough, productive or otherwise

Variation in duration before going to the doctor

Variation in duration before coming to the doctor

What my sickness did to me

Pathophysiology

Never thought about it

Virus or bacteria invade respiratory tract

Infection in the bronchial pipes

Inflammation, mucus production

Course of illness

How severe is my sickness

Moderate to very bad

Self-limiting illness

Would not get better or worsen if I did not go to

Miss 13 days of work

A while to get back to normal

the doctor and get treated

What kind of treatment should I receive

Treatment

Something to help the symptoms

Patients expect an antibiotic

An antibiotic

Generally treat with an antibiotic

Dissatisfaction if slow recovery

Focus on symptom relief

Fear of missing something

The amount the circles overlap represents the degree of concordance of the patient and physician models.The question mark (?) reflects the uncertainty
regarding the patient model.

patients consistently thought that not treating acute

bronchitis with antibiotics would lead to prolonged,
worsening, and potentially life-threatening illness.
There is a lack of understanding among patients that
acute bronchitis often results in a cough lasting
longer than 2 weeks, and this may contribute to the
misconception that prolonged duration of illness is
evidence of more serious infection.
One cannot separate these 2 themesconfusion
regarding etiology and miscommunication about
the clinical course of untreated illnessfrom the
decision to treat and the role of antibiotics. From
the patients perspective, without antibiotics they
would not get better. Compounding this belief is
the patients urgent desire for symptom relief.
Physicians reported significant internal conflict
regarding treatment, characterized by a recognition
that antibiotics were of little value, a universal
assumption that patients expected antibiotics, a
desire for patient satisfaction, perceived pressures
from employers, and a fear of missing a more
serious disease or making a mistake (from the
desire to heal and the fear of medicolegal actions).
These complex and conflicting perceptions, emotions, and cognitions are illustrated in Figure 2.
Over the past several decades, medical and lay
traditions have evolved to imply that productive
coughs with green-yellow sputum or colds with
green-yellow nasal discharge represent bacterial

infections or something that requires an antibiotic.4,5,16,17 Randomized clinical trials have not shown
that treatment with antibiotics leads to significantly
improved clinical outcomes.13,5 In a study of 1398
children, Vinson and Lutz reported that parental
expectation of an antibiotic was second only to the
presence of rales in increasing the likelihood of the
diagnosis of bronchitis.18 With little in history or
examination to distinguish between viral and bacterial infections and the fear of missing something, the presence or absence of yellow-green
nasal secretions and sputum have become the
key questions in our medical history. This has
created a medical tradition that falsely implies to
patients a different illness or outcome from those
without secretion production or clear discharge. Is
it any surprise that patients expect antibiotics?
In evaluating the generalizability of this study,
potential biases and limitations of qualitative studies should be considered. First, the creation of this
explanatory model was designed to generate ideas
and hypotheses, not to test them. Second, the views
represented were from a single medical specialty in
one geographic area and based on physicians and
patients subjective perceptions. Nevertheless, the
goal of such a study was to provide a theoretical
model of communication between patient and
physician that generates questions for further
exploration and areas for potential intervention.

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FIGURE 2

Physician Model

Patient Model
Tired of cough/symptoms

Recognition of patient expectation

Desire for relief of symptoms

and return to normal routine

Desire for patient satisfaction

Perceived need "to do something"

Vague concept of infection

(bacteria vs virus vs germs)

Pressure from employer

S
Fear of severe consequences,
including dying, if not appropriately treated

Fear of "missing" a more serious diagnosis

or progression of disease, if not treated

I
O

Magical thinking regarding the

"power" of antibiotics

Feeling that antibiotic resistance is a population, not an individual, problem

In summary, if, as a medical community, we

hope to develop new strategies to decrease unwarranted antibiotic usage, we need to educate
patients and health care professionals regarding
the causation and natural history of respiratory
infections. Gonzales and associates reported
impressive results with office-based interventions
targeting physicians and patients, and this work
needs to be generalized.19,20 However, until there is
a major public health emphasis on education at the
community level regarding respiratory infections
concurrent with an educational effort targeted for
health care professionals to dispel the myth that
characteristics of sputum and nasal discharge are
good predictors of clinical outcomes, progress will
be slow. To enhance communication between
patient and physician, it is important that we elicit
and appropriately address patient fears and concerns regarding the natural course of illness with
an episode of bronchitis.
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