Sunday, September 4, 2011

Overtreatment Alert! Antibiotics Fuel Medical Overutilization

A good friend of mine and Whistleblower reader contracted the sniffles and received a prescription for antibiotics at a local urgent care center. Nothing newsworthy here. So far this quotidian event sounds like a 'dog bites man' story. Had antibiotics been denied, this would have been 'man bites dog', as this denial would be a radical departure of standard medical practice, particularly in the urgent care universe.

No doubt, my friend was not assigned the dismissive diagnosis of 'the sniffles', but was likely given a more ominous diagnosis of 'acute upper respiratory infection', a term that sounds so serious that he might have feared that a 911 call had already been made.

Why are antibiotics prescribed so casually and so frequently? Choose from the following answers. There may be more than one correct response.

  • Antibiotics are the appropriate 'shock & awe' response to sniffle syndromes.
  • Patients demand antibiotics and offer evidence of necessity that their prior physician always prescribed them for the exact same symptoms.
  • Prescribing antibiotics is a sure method for increasing patient satisfaction.
  • Antibiotics are extremely safe and only rarely cause adverse reactions.
  • Patients fear that a delay in antibiotics could bring them to the brink of an infectious calamity.
  • Drug reps and direct-to-consumer advertising create a climate to prescribe medications including antibiotics.
  • It takes a physician 10 seconds to zap an antibiotic prescription to the pharmacy, but could take 10 or 15 minutes to explain why they're not indicated.
  • Antibiotic drug samples in physicians' offices encourage written prescriptions for patients.
  • Since physicians can't reliably distinguish viral infections from bacterial attacks, it's safer to prescribe antibiotics just to be sure that a bacterial infection isn't left untreated.
I'm sure that readers could add many other reasons that contribute to the antibiotic avalanche that is burying us, and I hope you will comment below. Infectious disease specialists and primary care physicians know that the majority of infections seen in outpatient visits are viruses - common colds - which do not respond to antibiotics; yet they are often prescribed for these illnesses. Changing this practice won't be easy and will take time. Look how long the public resisted buckling up in the car and using bicycle helmets, which are now universally accepted practices.

Antibiotic overutilization has real consequences.
  • It costs money.
  • It fosters a climate of medical overutilization.
  • Antibiotics can cause severe side-effects including C, difficile (C. diff) infections, which can be fatal.
  • It leads to the proliferation of resistant bacteria - superbugs - which won't respond to any available antibiotic. Care to be infected with one of these germs?
The Chief Complaint in medicine refers to the patient's summary statement explaining the reason for the medical visit. Typical Chief Complaints include:
  • Fever and cough
  • Chest pain
  • Abdominal Pain
  • Trouble breathing
These days, many patients have created their own version of the Chief Complaint (CC). Instead of describing their symptoms, they are now directing the treatment. See below.


Traditional CC: "I have a sore throat and a cough."

New & Improved CC: "I need an antibiotic."

Medical overutilization is my Chief Complaint.

17 comments:

A. Bailey said...

Just curious: do prescribe rifaximin for IBS? Presumptive aging gut syndrome? Presumptive small bowel overgrowth syndrome?

Yes, it is a trick question.

A. Bailey said...

It should read: do you prescribe. Darn iPhones.

Toni Brayer, MD said...

Good post. Even though most intelligent people have heard about "overuse of antibiotics" and "viruses can't be cured with antibiotics"...as soon as they have the "sniffles" or a sore throat they are desperate to get antibiotics as soon as possible. (shock and awe)

What is really irritating is when I do not give antibiotics by phone to a patient with common cold symptoms and they go to the emergency room and get prescribed antibiotics for "an upper respiratory infection" or "sinusitis" (aka: stuffy nose).

See, Doctor, I really am very very sick!

LA Morrison said...

Cost is also a factor. Patients may feel "cheated" if they pay for a visit (even a co-pay), and don't leave with something in hand. Advice and reassurance do not count as purchased products.

Michael Kirsch, M.D. said...

To A.Bailey, the trickster, no I don't prescribe rifaximin for those conditions you listed and am uncertain what 'aging gut syndrome' is. Look forward to your brief synopsis of this condition. Thanks, Toni, for the comment. Of course, when the patient recovers while on unnecessary antibiotics, the drug gets full credit for the cure. To LAM, good point. Unnecessary antibiotics are a symptom of the systemic disease of Medical Overutilization.

Andrew Bailey, M.D. said...

What? Not aware of this paper, and others that support it? www.nejm.org/doi/pdf/10.1056/NEJMoa1004409

Michael Kirsch, M.D. said...

@AB, no aware of these publications for years, just not persuaded that IBS is an infectious disease or a variant of small bowel bacterial overgrowth. I also think there is publication bias on this issue. IBS is so difficult to study considering its murky definition, variable course, response to placebo, etc. Even in the NEJM study you kindly linked in your comment, the benefit of Rifaximin was rather modest, in my view. Best, MK

tired resident said...

the flood of advertisements by big pharma has convinced us that when we have a symptom, there's a pill we should be taking. sounds like the general public has bought into it.

i recently read a book titled "white coat, black hat" which talks about sketchy practices in the medical field. a good portion of the book is about the pharmaceutical industry and how currently, companies are going after blockbuster drugs. instead of designing a drug for a specific purpose and disease, they create a drug with many biological effects, then market the same drug under different names for different diseases. most of these tend to be chronic diseases that people are never cured of so they take the drug indefinitely. the diseases are usually rebranded, common symptoms that tend to affect a large population so as to drug can be applied to a large population. examples include overactive bladder and GERD, which were previously known as incontinence and heartburn. there's a big push by pharmaceutical companies to rebrand certain symptoms as more dangerous sounding diseases so as to facilitate people using the drugs.

Michael Kirsch, M.D. said...

For a 'tired' resident, you seem quite awake and alert. Excellent comments. The rush to pills begins in residency. Interns are constantly called by nurses to alert that them that a patient has nausea or constipation or heartburn insomnia or whatever,and the resident is quickly taught that the correct answer is a drug. Is is sensible that a sleeping pill be part of a patient's standing orders?

Andrew Bailey, M.D. said...

Holy cow. We need to teach interns the following: Sir, you have nausea? Do nothing about it. You might try some ginger root when you get home. Constipation? Load up on prunes, dude. Heartburn? My granddaddy taught me about dilute apple cider vinegar long ago. Give it a try. And you can't sleep in spite of the dementia patient raising hell in the next room and the nurses checking you vital signs hourly (so it seems) all night and you feel awful because of the surgery you had yesterday? Let's try you on some guided imagery. And have a nice stay.

Or you could prescribe the appropriate medication.

tired resident said...

Prunes, apple cider vinegar and ginger root would be great things to try. Unfortunately, patients have an expectation of receiving a pill when they have a symptom. More pills, labs, procedures and imaging equates to better and more thorough medical care in patients' minds today.

If you don't appease them, you're likely to suffer in your press ganey survey scores and you'll have tons of health care administrators breathing down your back and maybe even get decreased reimbursement.

Andrew Bailey, M.D. said...

Hey tired resident,

We are on your side. You will be the one taking care of us as we rapidly age and become senescent.

If you prescribed prunes, ginger root, and dilute apple cider vinegar your provider profile would go down and you would stand to make more, not less money. It's a strange system. Third party payers like it when you provide inexpensive care.

As for patient satisfaction, well....let's just say that if you bring me ginger root and prunes instead of Zofran and Miralax while I'm recovering from my hip replacement, I won't have anything nice to say about you, either.

Michael Kirsch, M.D. said...

@AB, 'become' senescent? Did you use the right tense here geezer? I'm inclined to agree with the tired resident. Patients and nurses believe that all physical complaints - at least in the hospital - warrant a pharmacologic response.

Andrew Bailey, M.D. said...

MK, you're making me uptight with your contrariness. Can I get a pill to relax me a little?

Senescence is a state of mind. That reminds me of a story about senescence being a state of mind. Would you please repeat the question?

A good Sabbath to you and your family. See you Sunday morning.

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Unknown said...

"Prescribing antibiotics is a sure method for increasing patient satisfaction."

i would go for that.

like anti depressants are sure way to calm down, anti biotics are sure way to say cool you are fine now





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profile said...

is it true that frequent drinking of antibiotic make the bad bacteria more immune as the years pass by?

~More Doctors are Now Using EHR: Know their Reasons

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