The care we want vs. the care we need

prescription

Alternative title #1: Why healthcare and retail are fundamentally different industries

Alternative title #2: The customer isn’t always right

Alternative title #3: PLEASE FOR THE LOVE OF GOD STOP DEMANDING ANTIBIOTICS YOU DON’T NEED

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When it comes to talking to patients about whether they need an antibiotic for their upper respiratory infection, I think I have a pretty decent spiel, wherein I spend boatloads of time talking about viral vs bacterial infections, and changes in clinical practice and evidence, and looming antibiotic resistance, and blah blah blah. Remember, last week, with that rockstar 6/6 AbxScore? I KNOW I can do this.

But as soon as I start talking, I can tell whether the patient is buying it. And yesterday, with my first URI of the day, she wasn’t buying it. Nope nope NOPE. Flat eyes, flat gaze. It looked like the effort required to avoid literally rolling her eyes at me may have been causing physical discomfort.

No big deal. I’ve been here before. And it’s okay, because I’ve been feeling like overall, this quest to reduce unnecessary antibiotic prescribing has been getting a little easier, slowly, over time, despite the occasional eye roll. Because WE’RE ALL IN THIS TOGETHER, RIGHT? And by WE, I mean all of us human beings, working together to maintain a world where antibiotics continue to functionally exist, one day at a time.

But also, and really, that WE is directed at every prescribing health care provider reading this blog right now. YES YOU.

Because sometimes I find myself reading articles like this one about the continued onward march of telemedicine, and wonder if maybe I’m on my own here.

With telemedicine, you simply log on from the comfort of your home, hand over your credit card number, and after a brief chat with a clinician, have a prescription sent conveniently to the pharmacy for you. No muss, no fuss, amirite?

Don’t worry. It’s not like they’re doing anything risky or irresponsible. “They can prescribe antibiotics and other common drugs for strep throat, headaches, bronchitis, and urinary tract infections, but not controlled-substances, such as addictive painkillers”, says Dr. Roy Schoenberg, CEO of some telemedicine company called American Well.

So, to clarify, this service exists pretty much ONLY to prescribe antibiotics, right? I mean, that’s essentially it, yes? What other drugs could they possibly be prescribing for sore throats and bronchitis, despite the fact that the vast majority of these antibiotic prescriptions are inappropriate?

I watched their YouTube video/ad and, surprise surprise, the example they used was of a sad, snotty guy with a red nose. After logging in from his iPad and describing what sounds like every viral upper respiratory infection ever, his kindly, white haired, white coated, and very male doctor delivers his diagnosis in a voice of supreme confidence: “Acute sinusitis.” And what does he get? A prescription that will “help with your mucus”. A prescription for YOU GUESSED IT an antibiotic.

And the guy is abso-fricken-lutely delighted. Of course he is! After all, that’s what he paid $49 for, right? He’s oh so sick, and far too busy and important to just deal with being sick like the rest of us mere mortals, so he wants to be able to lay out some cash in exchange for the pleasure of being told a) his congested misery is somehow more badass than everyone elses’ (because “acute sinusitis” sounds far more badass than “common cold”) and b) I’M GOING TO FIX IT. Here’s the fix-it pill, right here. Augmentin will solve all your problems. You’ll be back to the board room in no time! (Guy totally looks like he spends way too much time in board rooms.)

But wait. What about the evidence that shows that even patients who meet clinical criteria for acute bacterial sinusitis don’t get better any more quickly with antibiotics than without? What about that?

So I’m sitting here, watching this video, getting all bothered about some well funded group of smoothies selling the illusion of quality care, and I decide I want to find out whether telemedicine visits produce more antibiotic prescriptions per visit than in-person visits. And it turns out that, surprise surprise, they do! Because OF COURSE they do. The implied transaction being offered is cash for antibiotic, not cash for cracking The Mystery of the Stuffy Nose. Mr. Board Room didn’t cough up his $49 to get advice about how to use a Neti pot.

But let’s be real. Over 90% of in-person visits for “sinusitis” end in an antibiotic prescription too.

And this is why this post isn’t really about telemedicine. It’s about how it can be really hard, and frustrating, and sometimes lonely, figuring out how to provide the type of care that people want – treating our patients like consumers, as we’re being increasingly encouraged to do – when that care comes in direct conflict with what the enormous and growing evidence base of medical knowledge indicates they need.

Because I think most health care providers are more customer-service-oriented than we let on. We WANT to heal and help and please people! That’s why we’re doing this in the first place! So I really and truly get why so many of us fall prey to the feel-good trap of overdiagnosis/overtreatment, particularly when our patients make it clear that’s what they want, and, of course, when they get better (which, remember, they will, whether or not they take antibiotics).

I don’t LIKE the feeling of entering an exam room ready to engage in rhetorical battle, when the chief complaint is “sinus infection x 2 days; wants antibiotics”, any more than anyone else does. It feels yucky.

But I also don’t like feeling as though I’m being less than honest with my patients. I’m uncomfortable with the idea of putting on my best “authoritative confidence” voice to deliver a plan, and a prescription, that I know isn’t supported by the evidence.

So I guess for now, I’ll keep doing what I’m doing, particularly since I know that usually, most of the time, the patient gets that I’m on their side and we all leave the visit feeling warm and fuzzy.

However, if it turns out that there’s actually some world of knowledge I’m not privy to – maybe it involves a private club with a secret handshake (and fabulous cocktails, and three piece suits, and wait how did I end up inside a Mad Men episode?) where everyone laughs about how antibiotic overuse isn’t actually such a big deal after all and we should all keep prescribing to everyone who walks through the door so our patients continue to think we’re THE BEST EVER –

Can you please let me know?

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16 thoughts on “The care we want vs. the care we need

  1. You bring up some good points. When it comes to sinusitis or sinus pressure, most patients don’t understand the difference between “infection” and “inflammation”. Inflammation addresses the underlying cause while infection is temporary and explains why antibiotics often don’t fix the problem in the first place. It’s a difficult sell!

    • Absolutely right. And I think most of the time providers in that moment, when the patient is in front of them, weigh their options – hand over an rx, or spend 5 minutes teaching about the difference b/t inflammation and infection, viral and bacterial – and opt for the former, because it takes less time, and feels less confrontational. It is most definitely a tough sell – not only to patients, but to providers!

  2. I think rather than a secret club, what you are finding is the general reluctance of the medical community to admit the problem (and the real severity of the problem) despite a huge and ever-increasing body of evidence.

    Also, there’s the reluctance of the medical community to asmit that the way they’ve been rreating URIs for decades is actually wrong. Patients think: “what do you mean I don’t need an antibiotic? My doctor always gave me one, so I obviously needed it.” And implied is: who are you to tell me he was wrong?

    One doctor I worked with essentially told me to give patients antibiotics when they came in for URI sx because, in essence, when they feel sick enough to come in, they expect something (a prescription) in return.

    This made me so, so mad. So mad, for several reasons:
    1. He liked to tell me what to do even though my treatment approaches were better (yes Iam biased).
    2. He is discrediting the patients ability to understand the problems with this approach.
    3. He is failing to correct an error in treatment but rather propagating it.
    (I could go on)

    The thing is, patients are not forced to come see you. The do because they are looking for medical input. That the content of that medical input has changed from what their beloved family doctor used to do, and now it is left to us young, non-physician providers to correct is a crappy situation- one which many of them continue to put us in even now.

    Don’t let it intimidate you- the eyes glazed over, the subtle accusations and even the open disrespect. We have the knowledge- and that is why prescriptive authority lies with us. Whether or not a patient chooses to hear you is not within your control- but whether or not you write a prescription you feel is inappropriate is. None of us would ever consider doing that in a situation that could be dangerous, and more and more evidence is indicating that even if that abx script is not directly dangerous to the patient (which it could be as in w/ c.diff), it is dangerous to the population at large. We have to start thinking this way, even if our collegues aren’t willing face these realities yet.

    • The hard part about this is that sometimes, that’s true: there are definitely patients who come in wanting a specific thing, usually a prescription, because we’ve created this set of expectations wherein your misery has been quantified, justified, etc by being handed a prescription by a medical provider, whereas if you just stay home and drink tea and sleep, your level of misery is somehow less valid.

      We need to deconstruct this. I don’t know how, but it needs to happen.

      Also, this does not apply to all patients. Even those that come in thinking – and stating – that they want antibiotics, often they really just want someone to explain why they’re feeling the way they feel, and what they can do to feel better, and that they’re going to be okay.

  3. (I also shouldn’t propagate the frustration with physicians from non-physician providers- I don’t mean to, but in my situations (one female APRN working with three male physicians), we fell regularly into those dynamics. I know, though, that this isn’t helpful to general medical provider dynamics, and don’t want to be contributing to the problem, even though my experiences seem to. No professional designation is immune to these human and interpersonal struggles that are part of all medical providers’ experiences!)

  4. And in response to the MD above re: infection vs inflammation (the often chicken-and-egg dilemma): YES!!!

    Also I find patients are generally open to learning this, provided we take the time to explain it and answer their questions (time- which none of us has enough of-).

  5. p.p.p.s.
    re: telemedicine-
    Perhaps it is because I am still a relative novice, but I feel that though the history is so, so, so crucial in the diagnosis, the physical exam is also absolutely essential. How do providers comfortably practice telemedicine without feeling like they may be providing significantly compromised care? Maybe I will not understand until I’m a veteran NP (when I’m all NP grown up- aw).

    • I couldn’t agree more. Especially with things like coughs and colds: I just can’t feel comfortable dismissing someone’s cough as viral and self-resolving without a physical exam. And even diagnosing strep: yes, maybe you can get a bit of a peek at the throat with a camera phone, but how can you evaluate for the presence or anterior and/or posterior lymphadenopathy without an exam? Serious question!

      • I always learn something by talking to patients. For instance, a young male with chest tightness was showing me his breathing pattern by grabbing his chest and let me know that’s when it hurt. Does it hurt when taking a deep breath for spirometry? That explains his low lung function and his costochondritis!

      • Agreed! I think of the patient as the one with the answers – they’re the experts on how they’re feeling, after all – and it’s up to me to ask the right questions so that I can learn from them.

    • I know, right? It’d be interesting to ask this service’s providers about their thoughts on antibiotic overuse, though I’m assuming from the little I know about their business model that they must not think much about it at all. Super.

  6. Appreciated the timely entry. My colleagues and I just had this same rant earlier today. I find that for me, it is not my own patient base of 2000 that roll their eyes and think I’m purposely withholding meds from them. For me, it is usually the “walk-ins” of colleagues that may not know me as well, so it takes more time to educate them. At any rate, it is nice to read of others in the trenches fighting the good fight. 🙂

    • I’ve found the same thing. It’s usually the patients I’m seeing for the first time that are the toughest, since we haven’t had the opportunity yet to develop that mutual-trust-thing that happens in a patient-provider relationship over time. SO frustrating. But at least it’s reassuring to hear I’m not alone! 🙂

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