Challenge the (doctors’) party line on antibiotics

Jill U. Adams is a health journalist and an associate editor at HealthNewsReview.org. She tweets as @juadams.

A couple of years ago, I was working in a coffee shop when a friend — an emergency room physician — stopped by to chat. I told him I was working on a story for a doctors’ newsletter comparing different guidelines for treating sinus infections. My friend went on a rant. “It doesn’t matter!” he blurted. “People come in and demand antibiotics! If you don’t give them what they want, they’ll go somewhere else and get it.”

Essentially, he told me, it didn’t matter whether or not he or any other primary care doctor bothered learning about the small discrepancies between evidence-based guidelines put out by different medical societies, in this case the Infectious Diseases Society of America and the American Academy of Otolaryngology-Head & Neck Surgery. 

I have sympathy for overworked ER doctors and I like my friend. His rant prompted me to ask a few extra questions of my sources as I reported my article, sources who acknowledged feeling stuck in the middle of patient demands and clinical guidelines. The guidelines cited evidence that antibiotics offer little-to-no benefit for adults with acute sinusitis, even when symptoms last ten days. One family doctor told me: “No one waits ten days — not the patients, not the doctors.” 

Overuse of antibiotics is demonstrably real

A number of studies demonstrate the mismatch between actual prescription rates and clinical guidelines. Take acute bronchitis — a 2014 study in the Journal of the American Medical Association found that that rates of prescribing antibiotics for acute bronchitis in the US have held steady for nearly two decades. In the doctors’ offices and emergency rooms, coughing patients walk out with a prescription for antibiotics, on average, 71% percent of the time. The rate, if clinical guidelines were followed, should be 0%.  That’s because bronchitis, like sinus infections, are most likely to be caused by a virus and antibiotics target bacterial pathogens.

For acute respiratory tract infections in children, another 2014 study, estimated that every year some 11.4 million antibiotic prescriptions are written that probably shouldn’t be. 

The problem of antibiotic overuse is having real and serious consequences now. A news story last week described the death of a patient from a superbug that 23 different antibiotics failed to quell. The number of pathogens that have developed resistance to antibiotics grows larger each year and they account for an estimated 2 million human infections and 23,000 deaths in the US each year, according to the Centers for Disease Control and Prevention

Do patients really demand antibiotics?

Health journalists who report on antibiotic overuse or who write consumer pieces about sinus infections typically interview practicing doctors, primary care doctors or emergency room doctors, such as my coffee shop friend. The doctors are asked about their experience treating patients. They are asked about applying clinical practice guidelines and they are asked about prescribing antibiotics. 

Often, those doctors tell journalists that patients demand antibiotics. And often, health journalists believe them. After all, the doctors are the expert sources and the scenario sounds plausible. 

But it is not the whole story. And as journalists, we should challenge the party line. How? We can interview patients for their side of the story, or advocates who lobby for antibacterial restraint, or researchers who study doctor-patient interactions. 

Pediatrician and researcher Rita Mangione-Smith remembers reading an American Academy of Pediatrics newsletter article years ago that put the blame for antibiotic overprescribing squarely on insistent parents. She was bothered by that. “In my personal experience, in emergency rooms and outpatient settings, there wasn’t direct demand,” she says.  

Doctor-patient communication – fraught or not?

She decided to study the phenomenon directly. Mangione-Smith and her colleagues recorded 300 exam room conversations between doctors and parents of sick kids at two Los Angeles pediatrics practices. Parents verbally asked for antibiotics in fewer than 5% of visits. And yet, doctors reported (on a post-visit questionnaire) that parents wanted antibiotics 38% of the time. Further, Mangione-Smith and her colleagues found that when doctors perceived an expectation for antibiotics, they were much more likely to prescribe them. “It happens in indirect communication,” she says. “It leaves a lot of room for misinterpretation.” 

A second study evaluated specific phrasing in the exam room that was linked to lower antibiotic prescribing. Sometimes physicians offered steps parents could take to reduce their child’s symptoms (a positive treatment recommendation) and sometimes they informed parents that antibiotics wouldn’t help (a negative treatment recommendation). When doctors did both, prescribing rates were the lowest.

Mangione-Smith now works to improve communications between doctor and patient. Rather than be burdened by trying to satisfy patients, doctors can benefit from customer care training, she says.  For starters, when doctors say, ‘It’s just a virus, there’s nothing we can do,” patients may hear, ‘You shouldn’t have come in, you’re wasting my time.”  However, if the doctor validates the patient’s illness and offers positive recommendations, such as comfort care and follow-up options, the patient is more likely to be satisfied — even without a prescription.  

This is golden information. For a physician audience, it provides real-life scenarios and tools for improving one’s practice. For a consumer audience, it helps readers see how doctors think and gives patients some ideas on how to better communicate with their own doctors. 

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Comments (3)

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Graham Walker

January 25, 2017 at 1:30 pm

As an emergency physician, the demand is real, as you note. At 2am, when the patient is there for a dry cough, they want antibiotics. Do I prescribe them? Typically not.

What are the consequences to many emergency physicians? The threat of lower “patient satisfaction scores,” which are now tied to hospital reimbursement, so they’re of course also tied to many emergency physicians’ salaries (thankfully though, not mine). So currently, “doing the right thing” (not giving antibiotics) is weighed against a number of other factors: getting paid less (if you prescribe a medicine, that also counts toward being able to bill a higher level of care in addition to the patient satisfaction reimbursement), extending the length of the ED visit (when the physician has other patients to tend to), and the stress of often getting yelled at by the patient, threatened or cursed at (even without that — we’re human, it doesn’t feel good to make a patient walk away unhappy).

How are we surprised that the prescription rate hasn’t budged in decades?

Charles Carter

January 25, 2017 at 10:07 pm

Dr Walker’s comments are absolutely germane. But my experience as a PCP and now a hospitalist conforms to the article. I’ve dealt with plenty of patients who were fine with no Rx, just relieved they didn’t have pneumonia. And enough that blithely say their old doc gave them antibiotics at the first sign of a URI and they got better within hours.

Stephen Smith

January 27, 2017 at 12:04 pm

Even when the patients ask for antibiotics, they aren’t always actually asking for antibiotics. Instead, they may be simply asking to get better and they believe that antibiotics are the standard of care–a misperception shaped by physician overuse of antibiotics. I prepared a video that portrays a real-life scenario that I encountered that illustrates this point (https://www.youtube.com/watch?v=kh7EKP9wSgE).