Julia Szymczak of Penn’s Perelman School of Medicine likes to head off the obvious question from the outset. When she gives talks—and she’s given more than 50 during the last three years—she frequently opens the presentation with a slide that reads, “What’s a sociologist doing researching antibiotics?”
“My response is that antibiotic use is a great case study to ‘think with’ about more general research questions in medical sociology” says Szymczak, who spent three years studying infection-prevention practices as a postdoctoral fellow at Children’s Hospital of Philadelphia (CHOP). “It can help us understand how social relationships, group norms, and identity can shape medical decision making, and, ultimately, the quality of care.”
Now a faculty member in Penn Medicine’s Department of Biostatistics, Epidemiology, and Informatics, Szymczak has deepened her interest in infectious diseases, using her unique perspective to shed light on the complex factors that shape clinicians’ antibiotic prescribing practices. While commonplace, each antibiotic prescription issued has the potential to trigger meaningful ripple effects, as microbes rapidly gain resistance to our arsenal of drugs.
Most recently, through partnerships at the Hospital of the University of Pennsylvania (HUP), CHOP, and the School of Veterinary Medicine, as well as in more than a dozen hospitals around the country, Szymczak is trying to understand how a broad swath of clinicians view the need for judicious use of antibiotics, with an eye toward improving health outcomes in adult, pediatric, and even veterinary medicine.
“These kinds of cases are just great for my overarching research questions,” Szymczak notes. “Why is it so hard to make change in health care? How can we get people to take accountability for adverse outcomes? How do we get people to, as a society, make a particular goal rise to the top of our attention space? In what ways do our efforts to reform health care succeed and fail, and how do we get them to succeed and be meaningful?”
Szymczak has been turning these questions over in her mind and her research since her doctoral studies at Penn, completed under Charles Bosk in the School of Arts and Sciences’ Department of Sociology. Bosk, who she describes as “probably the preeminent medical ethnographer,” influenced her appreciation for qualitative research methods.
During her dissertation work, which focused on efforts to reduce hospital-acquired infections, she employed these methods—both interviews with subjects and ethnography, or the observation of her subjects as they worked—and sees them as a rich complement to quantitative methodology.
“There are a lot of areas of human experience that we just don’t have a tool to measure,” she says. “Qualitative research methods, particularly in-depth interviews, allow me to sit down with somebody and really try to get at how they make meaning of certain events or experiences. You just can’t do that in a survey.”
In some of her current projects, she is homing in on clinicians’ impressions of antibiotic stewardship programs. These programs, which vary in form but generally entail a set of interventions or practices to improve the use of antibiotics, have been around for a couple of decades at certain hospitals. But in 2017, The Joint Commission, an organization that accredits U.S. health care organizations, made it mandatory for hospitals and certain other health care facilities to have stewardship programs in place.
“Critically, it doesn’t mean use less antibiotics,” Szymczak notes. “It’s about the right medication, the right dose, the right duration, and the right route of administration for the patient.”
When a doctor gives a medication that isn’t matched to a diagnosis or prescribes a drug that is stronger or given for longer than is necessary, bacteria have the opportunity to mutate, potentially developing a strategy to evade the medication’s attack.
Yet the decision of whether to prescribe an antibiotic is complex and depends on more than just clinical factors. Social factors play a role as well, Szymczak notes, such as pressure from a patient or a patient’s family. Or a clinician may err on the side of prescribing a drug, even if it’s unlikely to help, for fear of missing an undetected infection.
In dozens of Szymczak’s interviews, clinicians of all stripes have described these competing motivations, sometimes in stark terms. One pediatric surgeon she spoke with conveyed the terror of caring for a newborn baby and wanting to do everything possible to protect it, even if that meant prescribing a potentially unnecessary antibiotic.
At their best, stewardship programs should offer a structure and feedback that allows clinicians to avoid these “what if” traps and inappropriate choices, while still feeling supported and empowered in their work.
In a set of parallel projects, Szymczak is collaborating with Jeffery Gerber at CHOP, Laurel Redding at Penn Vet, and Sondra Calhoun, a student in the V.M.D./Epidemiology Ph.D. program whom Szymczak is mentoring, to identify features of stewardship programs that would be most effective and welcomed by clinicians.
In the project at Penn Vet, clinicians are shown a metric that illustrates some component of their antibiotic use and asked about its utility. Veterinary medicine in particular hasn’t taken as much action on the issue of antibiotic stewardship, but Redding and others have been eager to put a stewardship plan in place for the vet school’s Ryan and New Bolton Center hospitals.
“I’ve been working on a project to quantify antibiotic use and prescribing practices using a number of different means and metrics,” Redding says. “The collaboration with Julia is intended to gauge clinicians’ responses to these metrics.”
The metrics that Szymczak, Redding, and Calhoun have been using attempt to quantify the clinicians’ use of antibiotics in a variety of ways, for example reporting the proportion of client visits in which the veterinarian prescribes an antibiotic, or the average length of antibiotic therapy being prescribed.
“One of the things that I believe to be really important if you want to change clinicians’ behavior is that you need to make sure that the numbers that you are creating are ones they care about, that the numbers make sense to them, that they're meaningful,” says Szymczak.
The team is still recruiting clinicians from Ryan to participate, but at this point in their study, Redding notes that “people seem enthusiastic about the issue of stewardship.
“At Penn we have a lot of clinicians who are concerned about the topic of judicious use of antibiotics. Probably we’re one of the places that is going to have best practices in place already. But there’s always room for improvement,” Redding says.
Szymczak is leading a host of other collaborative projects, including one funded by the U.S. Centers for Disease Control and Prevention focused on the communication strategies used by antibiotic stewards in order to gain clinician trust at 15 hospitals around the country. And that’s in addition to several initiatives she has in the works at HUP, CHOP, and elsewhere.
It turns out medical researchers can benefit from folding a sociologist into their pursuits.
“I bring something different to the table,” Szymczak says. “What I’m trying to do in my career is to take my sociological imagination and apply it to these problems, and hopefully add a new dimension to ongoing research. I’m not saying it’s the only way we’re going to make change. But it may be one way that we haven’t considered which may ultimately help make health care safer.”