Antibiotics and the breakdown in the patient-doctor relationship

A July 2017 article in The Washington Post has patients and family medicine doctors debating whether it’s really necessary to take the full course of antibiotics a doctor prescribes.

The topic was surfaced by an opinion piece published in the BMJ in which researchers discuss antibiotic duration and clinical effectiveness. While the publications bring to light interesting and important points about evidence-based prescription of antibiotics, the real issue is building trusting, honest relationships between doctors and patients.

Clearly, doctors often tend to overprescribe antibiotics, with some studies showing that nearly one third of antibiotic prescriptions may be unnecessary. This occurs for a variety of reasons, including increased pressure from patients to “give them something” for their ailments, as well as unwillingness to separate from long-standing guidelines in favor of new best practices for prescribing antibiotics. These departures from evidence-based best practices have been responsible in part for the rise of antibiotic-resistant superbugs – bacteria that have become immune to medications that once killed them.

So, what are doctors and patients to do in the face of this growing issue? The way I see it, the first step to curbing inappropriate antibiotic prescription is to focus on the way we, as prescribers and patients, communicate and collaborate to determine “doctors’ orders.”

Doctors should rely on science, not emotion

In medicine, as in many fields of study, traditional consensus often persists even when data are presented to prove otherwise. Take, for example, the “flat Earth” theories that remain even though it has been proven without doubt that Earth is round.

Antibiotics – and all drugs, for that matter – should be prescribed in the simplest form for the briefest effective duration. But many doctors prescribe higher dosages of antibiotics for longer courses than necessary or prescribe them for viral infections that can’t be cured with antibiotics.

Prescriptions should be written in the context of a solid patient-doctor relationship. We must consider the patient’s unique situation, including what we know about a person’s personal circumstances, their medical history, and our patient’s attitudes about medication that would likely affect prescription compliance.

Doctors have two avenues to get this information about patients: the vast electronic medical databases and records at our fingertips and thorough conversations over time with the patient in front of us. The latter is generally the area in which many physicians struggle.

Factors that affect inappropriate prescription of antibiotics

Sick people want to feel better, and doctors want patients to feel better as well. However, the path to “getting better” can sometimes be at odds with “high-quality care” thanks to an influx of medical information available online.

Personally, I’m always pleased when patients are educated about their conditions and want to participate in their own care. However, some misinformation online can lead patients to feel as if they need to leave with a prescription in hand to receive adequate care.

Conversely, physicians may feel pressured to do something “official” by prescribing an antibiotic or other medication to improve the perceived patient experience, while they feel that their limited time with the patient leaves them little opportunity to generate a more nuanced patient experience. For example, if the doctor’s schedule is off-kilter because of several late or extended appointments, the doctor’s time with each subsequent patient is reduced. It might take five to 10 minutes to have a thorough conversation about a recommended drug, but it might take only 20 seconds to write out a prescription.

I’ve practiced in private practice and in an academic setting here at UT Southwestern. In both environments, I understand how a doctor or a patient may be frustrated at feeling rushed in the clinic. But these conversations are too important to rush through. These discussions help patients understand why they did or didn’t receive the care they expected and also lay the groundwork for an open dialogue that builds a trusting doctor-patient relationship.

When a good relationship exists – or, at the very least, when we have a thorough conversation – I don’t feel pressured to prescribe unnecessary, extended, or potent courses of drugs. Likewise, I can share my thinking process with the patient, explaining why I didn’t write a prescription, how the patient can feel better without one, and how not prescribing a drug that won’t address the illness anyway helps in a small way in the fight against superbugs and antibiotic resistance. We refer to this as good antibiotic stewardship – it’s our role as doctors to not only care for but also educate our patients about our recommendations to help them in the short term and the entire community in the long term.

How doctors and patients can work together

Collaborative, effective healthcare can be achieved only when patients and doctors establish an open, honest dialogue.

For patients, that means being forthcoming with questions and asking doctors to explain their drug recommendations:

• Is this the simplest medication that is effective for my illness?
  
• Is this the shortest course necessary?
  
• Is this particular drug and dosage right for me?
  

For doctors, the responsibility is twofold. First, we must create a collaborative environment for patients. We must ensure patients don’t feel rushed, dismissed, or criticized when they ask questions, and we shouldn’t assume they have no questions if they don’t ask on their own. It’s up to us to invite questions and make our patients feel comfortable enough to ask.

Second, we must be consistently committed to evidence-based practice, using the ample decision-support tools available to us to support this practice. In the academic medical setting at UT Southwestern, clinicians have the benefit of on-site access to a range of lectures and presentations about the latest in guidelines and research.

In the clinic at the point of care, we have EPIC, an electronic medical record and care tool that securely stores patients’ medical history, allows us to document our medical care, and offers on-demand diagnosis support – current best practices that help us select the best medication, dosages and durations. Evidence-based care is built right into our recordkeeping system. We serve our patients and the community best when we use these tools to safely and effectively diagnose diseases and prescribe medications.

Today’s doctors must strike a balance between authority and compassion to successfully care for people in our communities. We must commit to inviting patient-doctor collaboration and incorporating patient-specific needs while remaining confident in our knowledge and the tools we use to provide the best care.

Best practices and guidelines are always changing and improving. Doctors and patients must be willing to re-examine what we once thought was “the best care” on an ongoing and dynamic basis. Doing so will foster a more positive doctor-patient relationship, which can help prevent medical crises such as antibiotic overprescription and resistant bacterial strains in the long term. 

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