Blog | Wednesday, September 5, 2012

A plague upon unneeded antibiotics

With regard to antibiotics, physicians and the public have each been enablers of the other. Patients want them and we doctors supply them. There's nothing evil about this arrangement. Antibiotics are one of medicine's towering achievements and have saved millions of lives. Shouldn't we prescribe them to patients who need them? Of course we should. But why do we prescribe them to patients who don't?

Before you race to the comment section to accuse me of being a self-righteous preacher, realize that throughout this blog, I have confessed my own mistakes and shortcomings, and will continue to do so. (Yes, many commenters have enthusiastically assisted me in this effort.) So, when I throw a stone at the medical profession, I am also in the line of fire.

I have since the heady days of medical internship, been a conservative practitioner, preserving my soul even after completing training where medical overtreatment was worshiped. In medicine, less is so much more. I wish that more patients and more of us subscribed to the philosophy of medical parsimony.

Why would a physician prescribe an antibiotic that is not needed?

First, there are times when the medical situation is murky, and the physician may be unsure if an antibiotic is truly needed. If there is concern about this patient, then the doctor may understandably prescribe the antibiotic, just in case the illness is a bacterial infection. (Antibiotics are effective against bacterial infections, but are not effective against more common viral infections including common colds.) Doctors often must make recommendations and decisions based on incomplete information. Wouldn't it be nice if we knew with 100% certainty if a sick patient needed surgery, as many medical malpractice attorneys believe?

However, I am not referring to prescribing antibiotics when the clinical situation is unclear. I refer to situations where they are clearly not indicated, and should not have been prescribed.

Over the years, I have seen numerous cases of "diverticulitis," "sinusitis," "touches of pneumonias," upper respiratory infections, coughs, colds and various sore throats all treated with antibiotics. Many of these patients received a second course of antibiotics when the condition persisted or recurred. In many of them, these drugs were simply not needed. Don't think that antibiotics were mere placebos. Unlike true placebos, antibiotic have real medical risks and can cause harm.

Of course, it's possible that my medical judgment is flawed and that these patients truly needed antibiotics, and it was lucky these folks had sharper physicians who recognized this. However, ask any doctor, including yours, if the antibiotic trigger is pulled too quickly. If the doctor says no, then get a second opinion.

So, why does this happen?
--Patients demand it, convinced that they need it. This belief is strengthened if prior physicians have provided them with antibiotic "Kool Aide" for the same viral symptoms.
--Patients who are told only to rest and drink fluids may not believe they received sufficient medical care. "He did nothing for me. Who needed this appointment? For this I took off work?"
--It may take 15 minutes to convince a patient that antibiotic are not needed, and only 10 seconds to prescribe one. Additionally, some patients can't be convinced by any argument.
--Physicians want to keep their patients satisfied. This will become more relevant when patient satisfaction reporting will be tied to physician reimbursement. Won't that be ironic if lower quality care that patients approve of will reward doctors?
--Physicians may falsely believe that prescribing an antibiotic reduces their legal vulnerability, arguing that the antibiotic is evidence of active treatment against the condition. For some reason, physicians don't fear being sued if an unnecessary antibiotic causes a medical complication or a serious side-effect.

--Overutilization of antibiotics costs money and exposes patients to unnecessary risks. I'm also philosophically hostile to any treatment or medical test that is not needed. Additionally, medical experts have warned us for a few decades that the tsunami of antibiotics that are prescribed so casually is breeding out superbugs that resist our available antibiotics. It is tragic when a patient is severely ill from a true bacterial infection, and the necessary antibiotics won't work because the germ overpowers it.

--So, the next time you have the sniffles and you're in your doctor's office, make sure you demand the right treatment. And, if you leave without a prescription, don't feel that the doctor did nothing for you. He may have done quite a lot for you. And, that's nothing to sneeze at.

This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.