Friday, June 27, 2014

Rational Foolishness: mis-communication, mis-perceptions and the over-prescription of antibiotics

According to the Centers for Disease Control and Prevention, more than 2 million people in the United States suffer infections due to bacteria that are resistant to antibiotics each year, and 23,000 die as a result of these infections. These statistics are worrisome and sobering.  Particularly since this problem is, to a large part, a direct consequence of the unnecessary over-prescribing of antibiotics by physicians.  This begs the question: why do doctors prescribe antibiotics when they are not needed?
I’ll offer my answer to this question at the end of this article but first consider this: a recent survey of clinicians and patients shed some light on this phenomenon.  Just 5% of physicians surveyed said they never prescribe antibiotics when they are not absolutely sure that they are not necessary, and 11% said that “antibiotics won’t hurt if not needed and could help the patient sooner if I’m correct.”
Twenty-eight percent of clinicians surveyed stated that the patient’s request for an antibiotic was the reason for prescribing it when they are not certain that one is necessary, and 10% will prescribe an antibiotic to satisfy a patient’s request when they know it is not indicated.
Satisfying perceived expectations of patients is one of the most often cited reasons pediatricians give for dispensing unneeded antibiotics. Yet, the perception of parental expectations on the part of pediatricians can be completely unfounded as shown by a landmark study published in Pediatrics in April of 1999 (Mangione-Smith et al – The Relationship Between Perceived Parental Expectations and Pediatrician Antimicrobial Prescribing Behavior).  Some of the findings of this study were as follows:
  •  About half of the parents reported that they expected to be prescribed an antibiotic   when they brought their child in with symptoms of the common cold.  
  •  The physician’s perception that the parent expected an antibiotic was the only reliable predictor of prescribing an antibiotic for a viral condition (in which an antibiotic is not expected to be of any use).  Doctors prescribed antibiotics 9% of the time for viral infections when they did not think the parent wanted an antibiotic, but did so 52% of the time when they believed the parents expected one.
  • Surprisingly – or maybe not so surprisingly, if you read my book, Suffer the Children  -- when pediatricians perceived that parents wanted an antibiotic they were more likely to diagnose a bacterial infection.  Let me repeat that.  The physician’s perception of parental expectations drove the diagnosis rather than the patient’s presentation and physical exam findings.  An ear infection was diagnosed 49% of the time if they thought the parent wanted an antibiotic and only 13% of the time when they felt the parent didn’t want one.  Overall, pediatricians made a bacterial diagnosis in 70% of children with upper respiratory symptoms if they thought the parent wanted an antibiotic compared to 31% when they felt the parent did not desire one.
  •  But doctors were often wrong in their assessment of parental expectations.  Twenty-seven % of the time they believed a parent wanted an antibiotic when the parent did not desire one, and they correctly surmised that a parent wanted an antibiotic only 41% of the time when the parent did expect a prescription.
  • Though the desire to satisfy patients is often quoted by physicians as a reason for prescribing unnecessary antibiotics, in this study, failure to provide antibiotics when the parent expected a prescription did not affect satisfaction.  The only predictor of dissatisfaction was poor communication.
Good communication between physician and patient is a cornerstone of high-quality medical care.  Which is why some proponents argue that the best way to reverse the trend of over-prescribing antibiotics is to improve physician communication skills.  One approach is to ask the patient direct questions in regards to their expectations. Yet physicians balk at this, claiming that doing so may exacerbate direct confrontation if the patient were to cling to an unreasonable demand.
“You’re not in a negotiating stand,” a general practitioner interviewed for one study said with regards to when a patient has a high expectation for an antibiotic when one is not warranted. (Mustafa et al, Managing Expectations of Antibiotics for Upper Respiratory Tract Infections: A Qualitative Study)  “You are very much in a direct conflict stand, which doesn’t help anyone.” As a result, practitioners surveyed for this study disclosed that they resorted to indirect ways of eliciting a patient’s expectations, contrary to the advice of many communication’s efforts.
What can parents do to avoid receiving an unnecessary prescription for an antibiotic?  Try to do your best to communicate your expectations with your physician.  Rather than offering “candidate diagnoses” (“I’m worried Johnny has a sinus infection”) try to stick to describing the actual symptoms.  The mention of candidate diagnoses by parents increased the likelihood of antibiotic prescription in one study.  If the doctor determines your child has a viral infection that will not improve with an antibiotic, it’s perfectly appropriate to ask her how she came to this conclusion, what to expect in the coming days, what you can do to help alleviate the symptoms, and what to look for as far as worrisome symptoms that might require follow-up.  Disputing the diagnosis, on the other hand, will often lead physicians to cave in and prescribe a medication your child will not need.
I told you earlier that I would offer my own explanation as to why physicians are so prone to prescribing antibiotics when they know they are unlikely to help.  Isn’t it irrational for highly trained professionals to prescribe treatments that are counter to accepted guidelines of care?  
Actually, the unnecessary prescription of antibiotics is perfectly rational from their point of view of the physician – what one might term, rational foolishness -- and can best be understood in terms of potential risks and rewards.  Risks and rewards for the physician, that is, not for the patient.
Though on a population basis the over-prescribing of antibiotics constitutes a public-health risk, with regard to the individual patient, it is hard for the physician to envision any imminent harm (unless the patient suffers an unanticipated allergic reaction to the medication).  Thus, the way the doctor sees it, the risk of not prescribing a medication (missed diagnosis, lawsuit, unsatisfied patient, loss of time and unpleasantness resulting from a discussion of why an antibiotic is not needed) outweighs the risk of prescribing (rare allergic reaction, unlikely that MY patient will get a resistant bacterial infection from just one teeny antibiotic script).  Besides, we doctors don’t have to pay for the medication.

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