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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#AbxScore Week 2

This was a less than successful week when it comes to rocking the AbxScore. Quick rundown of my progress this week (and to refamiliarize yourself with how scoring works, visit my initial and more optimistic post here):

Day 1: 1/2

Day 2: 0/1

Day 3: 1/1

Day 4: 1/2

First off, you can see right away that for whatever reason, I haven’t been seeing so many of the garden variety upper respiratory infections this week. Plenty of other fun stuff, don’t you worry, but the URIs were few and far between.

Which was just fine by me, because the ones I did see had me feeling like I was banging my head against a wall. Total AbxScore of 3/6, or 50%. Sad face.

Longer post to follow, wherein I go on far too long about responsible prescribing and ethical practice and telemedicine and some other stuff. Because I can, because it’s my blog. Lucky you!

 

#AbxScore: Week 1

yuck

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.