Are physicians with better clinical skills on licensing examinations less likely to prescribe antibiotics for viral respiratory infections in ambulatory care settings?

Med Care. 2011 Feb;49(2):156-65. doi: 10.1097/MLR.0b013e3182028c1a.


Background: Viral respiratory infections (VRIs) are a common reason for ambulatory visits, and 35% are treated with an antibiotic. Antibiotic use for VRIs is not recommended, and it promotes antibiotic resistance. Effective patient-physician communication is critical to address this problem. Recognizing the importance of physician communication skills, licensure examinations were reformed in the United States and Canada to evaluate these skills.

Objective: To assess whether physician clinical and communication skills, as measured by the Canadian clinical skills examination (CSE), predict antibiotic prescribing for VRI in ambulatory care.

Research design and subjects: A total of 442 Quebec general practitioners and pediatricians who wrote the CSE in 1993-1996 were followed from 1993 to 2007, and their 159,456 VRI visits were identified from physician claims.

Measures: The outcome was an antibiotic prescription from a study physician dispensed within 7 days of the VRI visit. Multivariate logistic regression analyses were used to estimate the association between antibiotic prescribing for VRI and CSE score, adjusting for physician, patient, and encounter characteristics.

Results: Better clinical and communication skills were associated with a reduction in the risk of antibiotic prescribing, but only for female physicians. Every 1-standard deviation increase in CSE score was associated with a 19% reduction in the risk of antibiotic prescribing (risk ratio, 0.81; 95% confidence interval, 0.68-0.97). Better clinical skills were associated with an even greater reduction in risk among female physicians with higher workloads (risk ratio, 0.48; 95% confidence interval, 0.29-0.79).

Conclusion: Physician clinical and communication skills are important determinants of antibiotic prescribing for VRI and should be targeted by future interventions.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Ambulatory Care / organization & administration*
  • Anti-Bacterial Agents / therapeutic use*
  • Child
  • Clinical Competence* / statistics & numerical data
  • Drug Prescriptions / statistics & numerical data
  • Educational Measurement
  • Female
  • General Practice / education
  • General Practice / organization & administration
  • Health Services Research
  • Humans
  • Insurance Claim Reporting / statistics & numerical data
  • Licensure, Medical* / statistics & numerical data
  • Logistic Models
  • Longitudinal Studies
  • Male
  • Middle Aged
  • Multivariate Analysis
  • Patient Selection
  • Pediatrics / education
  • Pediatrics / organization & administration
  • Practice Patterns, Physicians' / organization & administration*
  • Quebec
  • Respiratory Tract Infections* / drug therapy
  • Respiratory Tract Infections* / virology
  • Sex Factors
  • Workload / statistics & numerical data


  • Anti-Bacterial Agents