From what I’ve seen, any doctor who’s worth a shit will strongly resist any blandishments to give antibiotics inappropriately simply so that a patient can feel like they’re getting their money’s worth. On the other hand, bad patient reviews can and do have strong effects on the doctor and the others in their practice–negative reviews can cause them to lose their panelling with insurance companies, which can mean they have to drop patients. Give the doctors a good strong reason to say no and mean it (“I’m sorry, but your cold does not require antibiotics and I will not prescribe them as the standard of care for a cold is rest and fluids”) while simultaneously removing the onus of being patient pleasers to get good patient reviews and all you have left are the docs so weenie they can’t say no who are also willing to fake a diagnosis in order to continue being weenies. I’m thinking that will be a trivial number. Especially since being caught faking a diagnosis in order to prescribe unneeded antibiotics could result in losing your panelling with the ONLY insurance company that matters.
So you were suggesting that’s how it should/could be, not how it currently is in countries with UHC. That makes more sense.
Well, anecdotally I’ve heard from friends in France, the UK and Australia that it’s just Not Done to prescribe antibiotics willy-nilly and the docs tend to be pretty finger waggy about educating people on what needs them and what doesn’t.
Now if we could just get the idiots who DO need them to take the full scrip we’d be golden. I hear TB is the worst because you have to take the antibiotics for like months and everyone stops after a couple weeks, which of course has given us some super-TB bugs. Awesome.
Bringing this back to the op and its point. The docs with patients in a practice are not the biggest source of the problem right now. It’s “urgent care centers, emergency departments, and the kind of clinics you find in big-box stores and drug stores …”
Their growth and the commoditization of healthcare that they embody comes with more prescriptions (read cost) and poorer stewardship (read a different sort of cost, one possibly more significant).
There is evidence (from CDC/Pew Charitable Trust-sponsored research) that antibiotic overprescription is multifactorial, and that while doc-in-a-boxes are notable offenders, emergency departments, hospital-based outpatient clinics and physicians offices in general are also a major part of the problem. Hospitals are significant contributors as well, especially when it comes to giving unnecessary antibiotics to the elderly (old folks and kids under two are most likely to be given antibiotics they don’t need).
It’s been noted that in higher-income areas, physicians’ offices start generating higher numbers of antibiotic prescriptions when free-standing/urgi-centers move into an area (due to the perceived need to compete).
Pew noted one interesting factor as contributing to overprescribing:
“Assuming that other doctors are the problem. In some cases, even when doctors agree that antibiotic overuse is a major problem or know that the drugs are not appropriate for a specific condition, they may not think their individual practices, or those of peers in the same medical specialty, contribute significantly to the problem. Rather, studies show that physicians attribute inappropriate prescribing to other clinicians or blame other areas of medicine.”
Some physicians have agreed to display a “commitment poster” detailing their adherence to common sense antibiotic prescribing. I would try to support such a practice.
The (limited) good news is that according to the CDC, antibiotic prescribing in the outpatient setting has been declining a little in recent years.
Many of the doctors I know took a mini-course on appropriate antibiotic prescribing and use its excellent “anti infective guidelines for community acquired infections” book. Many of these people are emergency doctors.
The reality is it is not always clear if an infection is viral or bacterial without further tests. For example, a bacterial sore throat is more likely if there are tender lymph nodes, elevated temperature, tonsillar exudates, absence of cough and diarrhea, at an appropriate age and with a history of strep exposure. Canadian places generally lack a rapid strep test, which also has false positive carrier rates.
I go by score and if the patient can understand statistics, use these. I don’t prescribe them if I don’t think they’ll help, even if pressured. I do offer the caveats as listed in my first post.
Almost as important is not using strong ICU type antibiotics for infections where cheap ones with a more limited spectrum would suffice.
Antibiotic stewardship is a problem, as are the use of antibiotics in food animals.
One of the solutions they’ve come up with in Spain is to provide blisters for exactly the course of medication. It used to be that you’d get a whole box (maybe 60 pills, 3x20 blisters) and be told to only take 4; now if you’re supposed to take 4 you get 4, period. In my mother’s case, her pharmacist tells her “and I want to see you bringing that empty blister on [day after end of scrip], you hear?” “Yes Javier.” (You’re supposed to bring empty blisters to the pharmacy, it counts as “medical waste”). I expect he also does it with other customers.
In our case antibiotics are supposed to be prescription-only, a pharmacist can lose her* license if found to be delivering them OTC. But then you have doctors like… heeeey, SiL! Who apparently see no problem in giving “preventive antibiotics” to their own children while telling patients that no, you don’t get antibiotics for a cold.
- Mostly-female profession.
I really like our local urgent care and our pediatrician for that reason: they’re very cautious about antibiotic prescriptions. The last time I took my daughter in to the pediatrician for an ear infection, the doc gave me a prescription for the lowest dose possible for an antibiotic and advised me to wait a couple of days before filling it and to toss it if she was getting better (she got better without it and never needed the prescription). Same for last time I had to go in myself for an infection - they gave me a 5-day supply, which is way different from the usual 10-day supply they used to give.
At this point at both places they have a policy where they check your records to determine whether you’ve taken antibiotics in the last 6 months. If you have, they try really hard to find an alternative.
I have had mixed experiences with this and urgent care.
About 25 years back, I had a case of diarrhea that had gone on for 3+ days. Not the “sploosh” sort, but every hour or more I’d be doubled over with cramps and running down the hall. Definitely not my normal pattern. The guy at urgent care suggested I use Pepto-Bismol and also gave me a scrip for Floxin.
I didn’t think I needed antibiotics so I never took it, and was leery of Pepto, so ditto (though later reading suggests Pepto might have been useful as well).
Well, a few days later, I was no better, so I went to a gastroenterologist - who did bloodwork and a culture. They never ID’ed the culprit but there were white blood cells evident so he gave me antibiotics (a different one… in hindsight I was lucky to miss out on the Floxin) - and within 24 hours I was better.
So - clearly the antibiotics were appropriate for me.
A couple years back, I had a cold that turned into bronchitis. I’d been getting sicker for over a week, probably closer to 2 at that point. Went to the urgent care next door to my primary care’s office, and they said my lungs sounded fine (I frequently get asthma flares due to a bad cold) but did give me oral steroids. No antibiotics.
2 days later, I’m worse and starting to scare myself. The coughing is threatening to damage my innards (seriously - I think I tore a muscle at one point, and I have low-level back pain that wasn’t being helped by this either). That time, they gave me a steroid injection (note: lungs still sounded non-asthma-y), and grudgingly gave me an antibiotic prescription with the caution to not touch it for 24 hours.
Ummmm… yeah. I started the antibiotic that night - and was noticeably better the next morning - as in could almost lie down to sleep.
3 days later I made it to my primary care doc - and was a little better but far from “over it” - the coughing lingered for several weeks. Doc concurred that antibiotics were probably called for.
It’s clear to me what whatever I had may have started viral but quickly brewed a secondary infection. They were not eager to prescribe antibiotics at all - but when the steroids had no measurable effect, it was clearly time. They were erring on the side of caution. To be fair, another time I went in with something that turned into laryngitis and severe ear pain; I didn’t think I needed antibiotics but was pretty sure a couple of days of prednisone would reduce the inflammation (it did).
Then there was the time I developed an asthma flare over the weekend. Called my doc’s office (predates the office mentioned above). Got a colleague who was handling calls - and was VERY reluctant to prescribe steroids over the phone “I’ve seen patients take low doses and wind up with broken hips!”… but prescribed an antibiotic. 3 days later, the antibiotic has done eff-all and my hacking was getting bad - so I got hold of my regular doc who called in a scrip for steroids and a stronger antibiotic; she figured at that point that I probably was brewing something if I hadn’t been before, and the steroid was needed to open things up.
I know some of the problem is people whining for antibiotics - and a reputable place will do things like a rapid strep test (I’ve had that done) - but there must be other guidelines for more susceptible patients like myself. A rapid sputum test or something!
Just a quick caveat-it usually takes 2-3 days to see an effect from antibiotics; if you are better within a day, the antibiotics are not the reason. Also, bronchitis is almost always a viral infection that lasts 2-3 weeks. Doctors cave and give antibiotics too early because it’s hard to deal with a patient calling every day for three weeks.
I would also like to say that I appreciate that some doctors give patients a prescription with orders to “only fill it if you need it”. However, on more than one occasion, I have found that the patient fills it anyway just to have around the house. Then, 6 months later, my patient calls and tells me that she has a UTI and she took azithromycin for 5 days but is no better. I ask where she got it and she tells me that her husband’s doctor gave him a prescription for an upper respiratory infection that he never needed so since she knew that she needed antibiotics, she went ahead and took them. Bonus points if the antibiotics expired more than 2 years ago (happened last week).
One doctor in this area used to give multiple prescriptions-if you’re not better in 3 days take prescription A and if that doesn’t work in another 3 days take prescription B. He made a ton of money because he saw 60+ patients a day because he never actually examined them.
I know I sound touchy but I feel like Don Quixote here, tilting at windmills. The very first patient I saw, in my very first job out of residency came in with a rash on her face after treating a sore with neosporin. After evaluating her, it was clear that she was allergic to neomycin and that was why her rash was spreading. I spent 20 minutes caarefully explaining to her that the best treatment was to do nothing, that she needed to stop her topical treatment and that she did not have an infection and antibiotics would do nothing. She nodded politely, agreed, left and immediately went to my bosses who wrote me up for poor customer service for not giving her what she wanted. I am tired of explaining to people that the congestion, nasal drainage and cough are signs that your body is fighting off a viral infection and that antibiotics only kill bacteria. That’s all they do. They don’t clear up the drainage or the cough. Once they kill the bacteria then your body may not need to fight it off any more, but again that takes a few days. If you are better immediately, you were either on your way to getting better anyway or it is a placebo response.
I’ve now lived in two countries with universal single payer heath care and neither one is that strict on not prescribing antibiotics.
How frustrating!!
In my own defense… as an asthmatic, I tend to develop secondary infections relatively easily. And with the incident I mentioned above, I’d been getting sicker and sicker for 2+ weeks. That was not a normal pattern for me, especially when it was clear the asthma was not at play and steroids had no effect; in fact I felt worse 48 hours after the first round of them started. 2+ weeks into an illness, most people would expect to be getting at least a little better or at least stabilizing.
24 hours after starting the antibiotics, my misery level was maybe down from 10 to 9. 3 days later it was down to 8 or 7. It was most of a month before I felt remotely normal.
Now, I do wish they would routinely do sputum cultures or have some other method of at least attempting to ID what, if anything, I was growing. Why on earth is that not a routine step?
Also in my own defense, I’ve had plenty of times where I needed “help” and knew pretty well antibiotics were likely not needed. The time I had laryngitis and massive ear pain, for example. A very short burst of prednisone reduced the inflammation enough that I could eat.
Not urgent care, but: A friend spent years dealing with one asthma flare after another. Her pulmo finally put her on a low dose of Zithromax long-term. That kept whatever secondary critters she was trying to grow at bay, but he said the other aspect was that it reduced inflammation.
Another thing to consider is a lot of poorer people use “Urgent Care” because they don’t or can’t afford a regular doctor (many are staffed by less expensive Nurse Practitioners).
I recall about 8 years ago when I was out of work, I could afford to see a doctor and he wanted to wait to give me tests, to see if what I had was actually bacterial. I told him I could not afford any tests and could barely afford the cost of the visit.
He gave them to me and it cleared up in a week.
That is also a consideration. A lot of doctors I’ve run across in my day, won’t do anything without expensive tests. I get that, they have to cover themselves, but a lot of people can’t afford it or don’t have insurance to cover it. Or even if they do have insurance, can’t afford the deductible.
So I think you have to consider all sides. No one is going to disagree over prescriptions of antibiotics is a problem but you have to look at all the angle.
Look at AIDS cocktails, they don’t seem to have problems giving that to healthy people who aren’t even sexually active, but may be someday?
And yes, I know bacterial infections are much more common than HIV so resistance is much more of a concern, but the point still should be made.
There was a time when I was in my teens I had strep throat and my doctor said, this is strep throat but he wanted to run some cultures to make sure. Then he looked at me and said that, he’d do it, but there was no point waiting 3 or 4 days to get the lab results back and have me suffer till he was absolutely sure.
I was grateful he gave them to me right off and I didn’t have to put up with it.
So it’s not always so black and white.
One of the nice things about the VA is that beneficiaries develop a relationship with a primary care provider who follows a VA-established, evidence-based standard of care. You don’t like it, you can find (and pay for) your own doctor. On the one hand, it’s awesome for things like reducing antibiotic overuse. On the other hand, providers are limited in what they can do to manage and prescribe, so if your test results are borderline or you need a drug or a service that isn’t on the formulary (i.e., dirt-cheap), you’re in for a hell of a time. (Stuff like this is why I have employer-sponsored health insurance and a family doctor; he can do and prescribe things a VA doctor can’t, and he doesn’t have a problem if I self-refer to a specialist. He also doesn’t believe in prescribing antibiotics for a viral infection and calls us to schedule flu shots.)
That said, I don’t think UHC is going to do a whole lot to reduce improper antibiotic prescription, at least in the office setting. Just for funsies, I checked the explanation of benefits for an office visit in March, when my doctor prescribed a completely new medication. All that he billed was for the actual visit; the prescription was part of that service. If he’d billed separately for the prescription, the insurance company would have denied it as being part of the main service. Therefore, a doctor can prescribe any drug during an office visit, and I can’t imagine how often a doctor prescribes drug x when the visit is for problem y. “Hey, Doc, I know I’m here for my diabetes, but I have this cough I just can’t get rid of. How about a Z-pack?” “Sure, here you go.”
My overall point is this. Standard of care is meaningless without controls in place to ensure that antibiotics (or any drug, for that matter) are prescribed appropriately. As long as patient choice remains a thing, Dr. Friendly is going to give in to Karen’s demands to give Sally an antibiotic for her sniffles because there’s still going to be competition for patients. You can remove or restrict the choice (as the VA does) and guarantee that people won’t get care from doctors they dislike or distrust (which is a problem at the VA) and go to an urgent care center and perpetuate the problem and it won’t solve a damn thing. UHC isn’t a cure-all for every problem; it’ll fix some, and it’s a lot better than what we have now. But it won’t change human behavior.
I’m sure that the dominant trend is patients demanding antibiotics. But my experience has actually been the opposite. I have several times had to persuade doctors to wait a couple of days and see how things play out first.
I have two kids who went through daycare, so we’ve had our share of illness that is ambiguous as to virus or bacteria. I am fairly conservative about antibiotic use, not only because of the problems of over-prescription but because I don’t think we really understand all the consequences for gut bacteria. So I tend to push back on the standard amoxicillin prescription, suggesting we wait a few days and see how things develop. Each time, the problem has lessened significantly or resolved so no script was needed.
This is at my family medicine practice where all of the doctors are no more than 10 years out of med school! I thought at least we would have gotten the medical training bit right by now.