Antibiotic prescribing: risk if you do, risk if you don’t

There has been lots of coverage in the press recently around over-prescription of antibiotics and the major global risk that resistant bacteria presents. It is now commonly cited as one of the greatest crises facing mankind, with a recent study highlighting a 40 per cent increase in antibiotic prescribing in the last 10 years.

It is interesting how the press interprets such studies, with one headline claiming ’Pushy patients making GPs prescribe antibiotics’. My initial reaction to this was that perhaps the publication was dramatising things a little. But when you get into the detail of the study it seems not too far from the truth – with 90 per cent of GPs regularly feeling pressured into prescribing antibiotics.

Some proposals to combat over-prescribing include the introduction of actively delayed prescriptions, where the patient has to wait a number of days before filling the prescription (ostensibly to see if the infection resolves on its own) and the production of cheap, rapid and accurate diagnostic tools to ascertain the bacterial or viral nature of an illness on site. Better patient education is also an overall target.

Nearly half of doctors (45 per cent) also admitted prescribing an antibiotic when they were sure the illness was viral. So, although they knew that it would not help, they felt enough pressure to prescribe anyway. The study also found that 70 per cent of GPs prescribe antibiotics when unsure whether an infection is bacterial or viral – and this is a difficulty faced by most GPs, most days.

It strikes me that there are a number of pressures at play here. Cases received at MDDUS which involve a failure to treat serious bacterial infection often have devastating outcomes. Cases involving sepsis commonly result in death or severe injury which could have been avoided had antibiotic treatment been administered at first and sometimes second or third presentations. So being unsure is not necessarily being bullied or giving into pressure, it may just be a matter of considering the information at hand and progressing with the safest course of action.

These, I think, are real-life pressures which are often discounted when these studies are interpreted and presented in the press. Doctors and GPs in particular find themselves caught between immediate pressure from the patient to prescribe (and perhaps with diagnostic uncertainty) and the pressure from the “establishment” to resist prescribing – a difficult daily dilemma.

Consider the 45 per cent of GPs who might prescribe antibiotics because of pressure from the patient rather than a consideration of the symptoms. You can easily empathise with a doctor faced with a concerned parent with a sick child or an aggressive patient. But there are other factors at play.

What it is that you find difficult to manage when saying “no” in these instances. Is it the patient’s reaction – upset, anger, concern? Is it the potential for this to damage your relationship with the patient? Or is it time constraints and the full waiting room on the other side of the door pressuring you to speedily conclude the consultation?

These are all valid concerns. But the greater risks surrounding overprescribing and the operational mismanagement of a patient’s expectations for future consultations with you and your colleagues are also factors to be considered.

So what techniques might you employ to help redirect the patient and enhance the interaction when you are certain there is no clinical need for antibiotics? How can you say “no” without causing upset or anger? There is no easy fix-all for refusing a patient request, but there are some communication techniques which can be helpful in these situations. I think it’s important to point out here that, foremost, consistency across clinicians in dealing with these scenarios is key in managing patient expectations.

It might also be a matter of educating the patient on the differences between viral and bacterial infections using language which is clear, jargon-free and pitched at the patient’s level of understanding. Allowing time for questions and clarification is also important.

Use positive language. For example, an explanation such as “I can’t prescribe an antibiotic as it’s a viral infection” could be better presented as “Viral infections respond well to fluids, regular paracetamol and rest”. Tell the patient what can be done rather than what can’t be done.

No doubt, such consultations can be challenging – but consistency, providing relevant information and utilising positive assertive language might just help reduce over-prescribing without jeopardising the doctor-patient relationship.

You can explore these techniques further in an MDDUS video module available to members on our website. It runs through some common scenarios and provides various approaches to consider. Go to: Human factor risks: assertiveness <link>.

As ever, we would be pleased to hear your own thoughts and strategies for managing these issues in your practice. Please submit any comments below.