How to say No when antibiotics won't help

Here are some proven techniques to persuade stubborn patients. New public education campaigns should also help.

By Ken Terry
Managed Care Editor

Internist Geoffrey H. Gordon recalls the stiff argument he got from a patient at the VA hospital in West Haven, CT. The doctor had declined to prescribe an antibiotic for the man's cold. "He was being really nasty about it, and it got my hackles up," says Gordon.

When the patient kept on, Gordon finally asked him why he was so insistent on getting an antibiotic. It turned out that while he was serving in the military, his mother had contracted pneumonia and died before he could return home. He'd been told that if she'd been seen sooner and had been put on an antibiotic, she might have survived. "He was angry and frightened about that."

After hearing his story, Gordon started writing the prescription, but the patient told him, "If you don't think I need it, that's fine."

This is one example of how to handle patients who demand antibiotics they don't need, notes Gordon, who's associate director of clinical education at the Bayer Institute for Health Care Communication. "You should ask, 'What would not getting this antibiotic mean for you? What concerns you the most about that?' "

But the tale also explains why many physicians avoid discussions about the dangers of overusing antibiotics: It takes too much time. When you combine patients' desire for antibiotics with the economic pressures to see more patients, some doctors would rather just write the prescription.

Several national campaigns are starting to educate the public and help physicians convince their patients that antibiotics are not required to treat most respiratory infections (see "New campaigns target antibiotic overuse"). In addition, the American College of Physicians-American Society of Internal Medicine recently weighed in with consensus guidelines that detail the latest medical thinking on antibiotic prescribing.

Experts urge physicians to do their part, noting that public education campaigns can succeed only if doctors support them. Some argue that it's not really that hard to persuade most patients that they don't need an antibiotic. "We're all strapped for time in the clinic," says practicing internist Vincenza T. Snow, who's senior medical associate in scientific policy for the ACP-ASIM. "But I've found that once you tell patients that they want something that doesn't work, and you mention the added cost and the risk of side effects, most of them are very understanding."

On the other hand, many physicians remain deeply skeptical of the new clinical approaches to upper respiratory infections. "I wonder what happens when the child of one of these experts has a temperature of 102. Does he just sit there and wait or he does manage to slip an antibiotic into the child?" says FP Scott R. Helmers of Sibley, IA. "However, when I'm convinced it's a viral infection, I try to explain to the patient that an antibiotic won't help."

Why doctors prescribe too many antibiotics

Physicians currently prescribe antibiotics to about half of patients with upper-respiratory infections, and for about 70 percent of those with bronchitis. The Centers for Disease Control and Prevention figures that about 40 percent of these prescriptions are written for patients with purely viral infections.

In otherwise healthy patients, moreover, most upper-respiratory infections will subside without antibiotics. "For most healthy adults, the best treatments for bronchitis, sinusitis, pharyngitis, and nonspecific upper-respiratory tract infections are over-the-counter remedies and salt water gargles to relieve symptoms," states the ACP-ASIM.

Snow notes that studies showing the viral origins of most bronchitis and sinusitis cases appeared only about 10 years ago. Until then, she says, "many of us still believed that if you had green phlegm, you had a bacterial infection. So we prescribed antibiotics believing we were treating a bacterial infection, and we weren't."

According to the ACP-ASIM guidelines, you shouldn't diagnose a bacterial infection in a case of acute sinusitis unless the patient has had the condition for at least a week. And once pneumonia has been ruled out, antibiotics are not indicated for bronchitis. But the guidelines are just starting to be widely disseminated, and many physicians would still rather err on the side of safety.

Diagnostic uncertainty and the fear of unforeseen complications are especially problematic in the emergency room. Shelmar R. O'Connell, an ER physician in Tacoma, WA, says she gives antibiotics to most patients with upper respiratory infections partly because she knows she won't see them again.

Keeping patients happy doesn't mean giving in

The biggest reasons for overprescribing are patients' expectations and doctors' desire to satisfy them. But patients don't necessarily have to get a prescription to feel satisfied when they leave your office. They'll be most satisfied, according to one study, if they feel you spent enough time explaining their illness and your choice of treatment.

Finding the time is less of a problem if you have long-term relationships with a lot of your patients. "It's much easier and faster to explain when they're people you know," notes FP Richard E. Waltman of Tacoma, WA. Good relationships also increase satisfaction, he adds. "Most of the people who come to my office want me, not medication. Medication is just a throw-in."

You might want to avoid tangling right away with people who insist on antibiotics, advises internist Sheldon Greenfield, an expert on doctor-patient relations, who teaches at Tufts University School of Medicine in Boston. "If someone seems like a tough nut, and you have a busy day, write the prescription for that patient and suggest you have a discussion about it next time."

Waltman takes a similar approach. "Sometimes when people demand antibiotics, I tell them this is almost certainly a viral process, and I give them the antibiotics anyway. They get better slowly, the way I told them they'd get better. Then they're more comfortable when they come back and I say, 'Let's try it without the antibiotic.' "

If the patient doesn't change his mind, says Geoff Gordon of the Bayer Institute, try to find out why he's so set on getting a prescription. That's what Gordon did with the patient whose mother died of pneumonia.

Communicate your concern about the patient's condition, and ask all the appropriate questions. Says Gordon: "Usually when somebody leaves the office without a prescription, he complains that the doctor never inquired about who else is in the house or whether anyone had had a serious infection lately, or other things he thinks the doctor should have asked. So you have to ask, 'Is there a special reason why you want the antibiotic? What should I know?' Don't assume you know it all."

If the patient is still dissatisfied, Gordon suggests saying, "Mr. Jones, I can understand you want to feel better right away, and you're willing to take the risk of some side effects or antibiotic resistance in yourself or the population at large. But my job as your doctor is to do what I think is best. And any benefit you might get from these drugs doesn't outweigh the risk."

What do you say to a patient who wonders why you've given him antibiotics before? Gordon suggests this: " 'We've prescribed so many antibiotics for so long that resistance is becoming a major problem. We're now seeing resistance to things that in all my training and practice I've never seen resistance to.' "

Interim strategies work with some patients

There are also more-subtle ways to avoid overprescribing. For instance, Waltman's office keeps a list of patients with chronic lung disease, heart disease, and diabetes. If a patient with a cold or a sore throat calls for an appointment and her name is on the list, she'll get an appointment that day. If she doesn't have a chronic disease, particularly if she's young, the front desk asks her to come in a day or two later. "Patients are usually getting better by then, so they might not have to come in," Waltman says.

You can also explain why the patient doesn't need an antibiotic, but leave the door open to prescribe one later. "I tell patients that if things get worse, I want them to get back in touch with me and we may need to add some medication," says Helmers. "I think withholding the antibiotic goes over a bit better if patients know that I might prescribe it later if they're not doing so well."

Internist Catherine R. Landers of Wheeling, IL, says: "I tell them what I'd look for before giving them antibiotics. If someone comes in and his nose is running, but it's not keeping him up at night, I say, 'I want you to call me if you start running a fever or you start getting yellow or green drainage.' I paint a picture of what it would do to get me to change my mind about antibiotics. And that usually works."

The only problem with this approach, says Gordon, is that "by the time most people call for or land an appointment, their illness has gotten to the point where they want something done."

But that something doesn't have to be an antibiotic prescription, say Waltman and Landers. Both doctors advise patients to get an over-the-counter decongestant, antihistamine, or nasal spray to relieve their symptoms.

To support physicians in this approach, the CDC offers a "viral prescription pad" that has been used successfully by pediatricians. The physician writes the names of his recommended OTC medications, along with his instructions, and the patient leaves with a "prescription" in hand.

Informational handouts are also available, both from the CDC and specialty societies. But Tufts' Sheldon Greenfield says that these aren't effective when used alone. While it's okay to use them for backup information, he says, "it's a delusion to think patients are going to educate themselves from handouts."

Most patients care more about getting better than about the welfare of the population. While you can cite studies showing that patients who take a lot of antibiotics increase their own or their families' chance of contracting resistant infections, this argument may not work with some patients.

On the positive side, more and more patients—especially educated ones—are asking doctors not to give them antibiotics because they've read or seen stories about the perils of pathogenic resistance.

Meanwhile, says Gordon, there's nothing wrong with refusing to write a prescription. "Part of a doctor's job is to say No. And if you can say No in a way that makes you feel good and doesn't make the patient feel ashamed or ignored or disrespected, there won't be a problem."

New campaigns target antibiotic overuse

For the past several years, the Centers for Disease Control and Prevention has been aiming its campaign to reduce the prescribing of unnecessary antibiotics at pediatricians and parents. But now, amid signs that pediatric antibiotic use is starting to ebb, the CDC is partnering with medical societies, health plans, and state health agencies to get the message across to adults and their physicians.

In the first stage of this new campaign, the CDC sponsored a series of guidelines that were approved by the American College of Physicians-American Society of Internal Medicine, the American Academy of Family Physicians, and the Infectious Diseases Society of America. The guidelines were published last March in the Annals of Internal Medicine. Developed by a panel of internists, FPs, and emergency medicine and infectious disease specialists, the guidelines address the appropriate use of antibiotics in nonspecific upper-respiratory tract infections, acute sinusitis, pharyngitis, and bronchitis in adults. (The guidelines can be obtained online at www.acponline.org/sci-policy/guidelines/recent.htm. )

Around the same time, the Coalition for Affordable Quality Healthcare, a group of 26 health plans whose members insure more than 100 million people, kicked off a nationwide campaign to raise awareness of the antibiotic problem. Working with the CDC, the ACP-ASIM, and other medical societies, the coalition is trying to get the word out through a variety of media, including nationwide radio interviews.

In three locations—Connecticut, Norfolk, VA, and San Diego—coalition companies have formed groups encompassing nonmember insurers, local health departments, hospitals, and academic medical centers. They've mailed the consensus guidelines and educational materials to all physicians in Connecticut, and are about to do the same in Norfolk and San Diego. Nationally, the coalition is placing educational articles in newsletters that go to physicians and patients.

A number of other campaigns are under way to reduce antibiotic prescribing, notes internist Vincenza T. Snow, a senior medical associate in scientific policy for the ACP-ASIM. She cites the Appropriate Use Partnership, a group of health plans and employers that include Intermountain Health Care, Kaiser Permanente, and Ford Motor. Sponsored by the Ortho-McNeil Pharmaceutical subsidiary of Johnson & Johnson, this coalition is boiling down the CDC-sponsored guidelines into an educational pamphlet for patients and will mail letters to employers, employees, and plan subscribers, says Snow.

Many organizations are starting to realize the urgency of the fight against antibiotic-resistant pathogens. The CDC counted 25 campaigns in 2000, and there are now about 50 such efforts, according to the health plan coalition.

It's too early to tell whether these campaigns are reducing antibiotic use by adults. But David M. Bell, antimicrobial resistance coordinator for the CDC, says there's some evidence that antibiotic prescriptions for children are declining.

Pediatric infectious disease specialist Margaret C. Fisher, who regularly speaks to doctors on this subject on behalf of the American Academy of Pediatrics, notes that about one-third of the pediatricians who attend her lectures say that parents are asking them not to prescribe antibiotics for their sick kids. That wouldn't have been true five years ago, she points out.

"Good media coverage has made people aware that antibiotics are being overused," she says. "I think it's changed parents' attitudes and made them much better consumers."

 

Ken Terry. How to say No when antibiotics won't help. Medical Economics 2001;19:73.