ASK DR. BAUGHAN                                                         September 25, 1997

DANGEROUS COLLUSION

Every time a patient meets with a doctor, the doctor (consciously or unconsciously) tries to determine what the patient expects.  If what the patient expects is what the doctor thinks the patient needs, then there is no problem.  However, if there is a spoken or unspoken disagreement about what treatment is necessary, then the stage is set for either patient dissatisfaction  or unnecessary medical treatment.  One of the sobering lessons of the 1990s is that unnecessary treatment with antibiotics can not just be wasteful, it can be dangerous.

Last week’s issue of the Journal of the American Medical Association (Sept. 17, 1997) features the lead article “Antibiotic Prescribing for Adults with Colds, Upper Respiratory Tract Infections, and Bronchitis by Ambulatory Care Physicians” and a companion editorial “Preventing Emergence of Antimicrobial Resistance.”  The article documents how 21% of prescriptions for antibiotics (12 million in 1992) were given for diagnoses of colds, upper respiratory infections and bronchitis.  These illnesses are due to viruses 95% of the time.  Antibiotics will not affect viruses.  But what’s the harm?  There is always the risk of an allergic reaction, minor or major.  The risk that is creating the public health clamor, though, is the growing resistance of bacteria to many antibiotics.  Bacteria are always present in the human body, competing with each other.  When we use antibiotics unnecessarily, we kill off some of the antibiotics.  The bacteria that are resistant to the antibiotics survive and multiply abundantly.  Bacteria out of balance can then cause infections and illness that are harder to treat.

Why would physicians prescribe antibiotics when they are not needed?  I hate to give away trade secrets, but the reason is this:  Doctors are people first and scientists second (Surprise! Surprise!).  A study in the Journal of Family Practice asked physicians why they prescribed antibiotics when they diagnosed colds.  The most common reason was because they thought patients expected them.  To not give them would risk causing patient conflict or dissatisfaction.  The researchers also asked patients if indeed they did expect antibiotics.  The vast majority did.  But here’s the punch line.  When they asked the patients if they were satisfied with the visit, who was satisfied?  Patients were just as satisfied if they did not get antibiotics but did get a good explanation as they were if they did get antibiotics!  I heard the echo of one of my mentors from residency training, “You often decide within the first 30 seconds if you are going to write a prescription or talk to the patient.”

Patient expectations and doctors’ habits may change slowly.  If every crisis is an opportunity, maybe resistant bacteria are teaching us this:  We need to slow down, not expect quick fixes, take care of ourselves and (revolutionary concept!) talk  to each other more.