Sunday, August 5, 2012

The Plague of Unnecessary 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 (ATB) that is not needed?

First, there are times when the medical situation is murky, and the physician may be unsure if an ATB is truly needed. If there is concern about this patient, then the doctor may understandably prescribe the ATB, just in case the illness is a bacterial infection. (ATBs 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 ATBs 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 ATBs. Many of these patients received a 2nd course of ATBs when the condition persisted or recurred. In many of them, these drugs were simply not needed. Don’t think that ATBs were mere placebos. Unlike true placebos, ATB 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 ATBs, and it was lucky these folks had sharper physicians who recognized this. However, ask any doctor – including yours – if the ATB 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 ATB ‘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 ATB 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 ATB reduces their legal vulnerability, arguing that the ATB is evidence of active treatment against the condition. For some reason, physicians don’t fear being sued if an unnecessary ATB causes a medical complication or a serious side-effect.
Overutilization of ATBs 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 ATBs that are prescribed so casually is breeding out superbugs that resist our available ATBs. It is tragic when a patient is severely ill from a true bacterial infection, and the necessary ATBs 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.

9 comments:

Anonymous said...

so, how about unnecessary procedures? How do you justify those? The NYT ran an article a few days ago about unnecessary cardiac procedures. Also, how about uninsured people? how come doctors don't care about those?

Michael Kirsch, M.D. said...

The subject you raise is important and has been addressed throughout this blog. I have even indicted myself in performing unnecessary procedures. Here are two relevant posts you may wish to review. Thanks for your comment.

http://www.mdwhistleblower.blogspot.com/2010/06/unneccesary-medical-tests-tort-reform.html

http://www.mdwhistleblower.blogspot.com/2012/04/how-many-tests-do-doctors-need-to-make.html

Classof65 said...

As I understand it, farmers routinely feed their animals antibiotics mixed with grain so that humans receive antibiotics and, possibly, steroids or other drugs through the meat they eat. Americans need better and more oversight by the FDA to limit or eliminate our unnecessary exposure to all these chemicals.

Michael Kirsch, M.D. said...

I am against the overutilization of antibiotics in all creatures.

Medical malpractice lawyer Maryland said...

It was nice reading your blog... Thanks for sharing...

Anonymous said...

In the last paragraph, you admonish patients. Most of this post is about doctors who prescribe antibiotics when they shouldn't. Shouldn't you be admonishing doctors?

Michael Kirsch, M.D. said...

@anonymous, I agree with you that physicians should be admonished. I had hoped that this sentiment came through on the post along with an explanation of why this does not occur often enough.

spanishmedman said...

Thank you Dr Kirsch. As a premed student headed towards primary care, I appreciate the insight on prescribing (and over prescribing) antibiotics. Physicians walk a fine line of keeping patients happy and yet doing what is actually best for them.

Michael Kirsch, M.D. said...

To spanishmedman, thanks for the comment. I hope you will be mindful of overdiagnosis and overtreatment after you are released into the real world.

Add this