Avoiding unnecessary antibiotics, my answer to a student question:

This student posted a general question about why doctors over-prescribed antibiotics and I responded that I did not.  So then the little bugger asked me "How do you handle patients that insist on needing them?"  My response:

Variously.  And being not-flip, I have on occasion prescribed antibiotics I suspected were not needed. One of my tactics is to schedule a follow up appointment. Patient comes in, has had "sinusitis" or "Bronchitis" for 10 days. I suspect it will be better in another 10 days, or then they may need antibiotics. So I schedule another appointment and tell them to cancel if they're all better. I work in a setting without co-pays. If I were in a different set up, I would have them call the nurse in 10 days, or I might have the nurse call them with a checklist of questions.

I NEVER prescribe the newest and greatest in the outpatient setting. Most people in the outpatient setting will get better with or without antibiotics. I remember when azithromycin cured everything (it now cures very little but it has an anti-inflammatory effect). When I see folks treated with Levoquin for an uncomplicated urinary tract infections I want to scream.

People with COPD (Chronic Obstructive Pulmonary Disease) are different as well; they are more likely to need/benefit antibiotics. I was taught to keep a rotation of basic antibiotics with them, but when I looked into it recently there don’t seem to be any studies supporting this, but the antibiotics involved are all old and out of patent so it might be hard to get them funded. Note: When reading a study that says new, expensive antibiotic works best on outpatient issue, be VERY suspicious.

Two things I was taught, one is never work harder than the patient. This is why symptom diaries rock. If the patient isn’t willing to fill them out, it can’t be that bad.

The second: The medical art is to distract the patient while nature cures the disease. (L'art de la médecine consiste à distraire le malade pendant que la nature le guérit.) Voltaire (1694 - 1778)

I write prescriptions for fresh ginger, lemon and honey hot drinks. I smile and make silly jokes. I tell them I get paid to do the worrying will they will kindly leave it to me and me to it.

I also tell the story of my aunt, killed by inappropriate use of antibiotics at the dentist. (This is a true story. She was 80 and ended up septic due to C. dif.)

I also keep in mind that I could be wrong. I give them things to watch out for and tell them to call me if that happens. Patients are remarkably forgiving if you care. (You can’t fake it. You have to really mean it, if only for the time in the room. And the nastiest most difficult ones are the ones most afraid that you don’t care.) And in the long term I build a practice of patients who trust me. The ones I can’t educate or who don’t develop confidence in me move on to someone else. And that’s okay.