It’s been one full week since I decided to start recording my treatment decisions for nonspecific upper respiratory infections in an attempt to keep myself honest about (and motivate me to improve) my antibiotic prescribing. I know it’s not as exciting as trash cake, but I’ve decided I’m going to try to stick with it for a bit here, since I think it ACTUALLY MIGHT BE WORKING. (With my N of 1. N=me.)
Now, I’m fully aware it’s only been a week. And that week included, um, a four day weekend. Maybe not the most auspicious time to start? But whatevers, after 4 days of tracking my daily #AbxScore, here’s how I fared:
Day 1: The day I decide to start tracking. Because I’m all fired up, my AbxScore=3/3. YES.
Day 2: I’m embarrassed to say I only saw two patients the ENTIRE DAY, and neither of them had a URI. College campus + Thanksgiving eve = ghost town.
Day 3: AbxScore=3/4. Patient #1 had asthma and seriously funky sounding lungs, all the way to the bases. I just couldn’t convince myself that he didn’t have early CAP, despite normal vitals. Z-Pak given. But I rallied, and the following 3 URIs were given heaps of reassurance and symptom management advice.
Day 4, yesterday: AbxScore=6/6. KILLING IT. This was the day where I realized that even if my N remains 1 (ME) this is still worth doing. Because I saw a total of 6 URIs in patients with varying lengths of illness and varying pre-visit levels of commitment to the idea of leaving with antibiotics, and I did it. I DID IT. Even the patient who tearfully told me about the time when she came in with a cold and we “DID NOTHING” and she was sick for months and months until finally she was given antibiotics at home and just like that she was CURED – even SHE left without an antibiotic prescription for 3 days of nasal congestion and sinus pressure.
In a perfect world, obviously, the appropriate number of antibiotic prescriptions of dubious necessity given would be zero. But the reality is that the majority of visits for “bronchitis” (=nearly always viral) continue to end with an antibiotic prescription, so IMHO any reduction in this number whatsoever is an improvement.
Now, I will fully admit that I was already a bit of a striver; all those guilt-inducing missives to prescribers and patients alike over the years about conscientious prescribing were already getting to me, so it’s not like every single one of these URI patients would have left with antibiotics in my halcyon pre-AbxScore days. But if I’m being honest with myself: the girl with the tears, another girl with an asthma history, and a guy with an annoyingly persistent cough probably would have been given a script yesterday.
And now, since I knew I’d have to add them to my total for the day, I found myself that much more willing to a) commit to my diagnosis (is there evidence here of a bacterial infection, really and truly, or isn’t there?) and b) take the extra time to talk to patients about why exactly they don’t need antibiotics, so that we all leave the visit on the same page. Because if they believe me when I tell them that I’m confident antibiotics won’t make them any better, any faster, why would they want to take one?
Most of the time, I think we tend to assume that all patients want are antibiotics, so we “cave” with a prescription. Now, we all know that sometimes, they do. I’m sure I’ll be seeing one later this afternoon, or tomorrow. But often, more often than we think, our patients just want someone to listen to them, explain why they feel the way they do, and let them know what they can do to get better. Because whether or not they “need antibiotics”, viral infections suck big time. Really. And we can acknowledge that reality without writing a prescription that won’t actually make our patients’ mucousy misery go away any faster.
It even worked with the girl with the tears. Believe me, as soon as the crying began, I began to mentally subtract this visit from AbxScore numerator for the day. But after we spent some time talking about the whens and the whys of viral infections and sinusitis and antibiotics and all that, she’d agreed to go with sinus rinses, some guaifenesin, rest, and time.
So there it is. Week 1 down. Progress observed. And if you’d like to add to my N of 1, spread the word.