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
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?