About the BookVideosContact Us
Spandorfer J, Pohl C, Nasca T, Rattner SL, eds. Professionalism in Medicine : A Case-Based Guide for Medical Students. Cambridge: Cambridge University Press; 2010.

Video: Commitment to Honesty with Patients | Commentaries


A Faculty Perspective

Acute upper respiratory infections are the most frequent reasons for seeking medical attention in the United States. Although most of these infections are viral in origin and self limited in nature, they account for up to 75% of total antibiotic prescriptions written yearly1, 3, 4. Many randomized, placebo-controlled trials of upper respiratory illness have found no benefit for patients taking antibiotics compared with placebo. Yet, of 51 million visits for "colds", upper respiratory tract infections and bronchitis in the United States in a year, 50-66% culminated in an antibiotic prescription2. The consequence of this excessive use of unnecessary antibiotics has been an epidemic spread of antibiotic resistance not only in the United States, but worldwide1. Why physicians continue to prescribe antibiotics when they are not clearly indicated is a complex issue.

Though guidelines for diagnosis and treatment of upper respiratory infections have been developed, physicians often prescribe antibiotics that are not clearly indicated5. It is difficult for a physician to be in a position where an illness might be made worse by inaction or a where a chance to relieve symptoms might be missed. Though we can stratify patients based on symptoms and estimate the probability of bacterial infection, symptoms are often nonspecific and we are still left with uncertainty. Some clinicians prescribe antibiotics believing that a fraction of their patients will obtain benefit. By prescribing antibiotics, we hope to prevent the remote case of a bad outcome1. How do we know how to proceed? Very often we don't. Medicine is an uncertain art and clinical judgment develops with time and experience.

In many cases, the physician's decision has more to do with the physician-patient relationship than the physician's diagnostic skills. The concept of antibiotic resistance is abstract and the patient's perceived need is immediate. Giving an antibiotic is a personal act, one which shows the patient that the doctor is involved and that he or she cares. It also means that the physician has made a diagnosis and knows what to do to make the patient better. It has been said that "the drug prescription prolongs the physician-patient encounter by enabling the patient to ingest a "dose of the doctor" several times a day"2. Patients can be quite vocal with demands for an antibiotic, especially if they have received one in the past. Sometimes it is easier to avoid a confrontation by giving in to a patient's demand for an antibiotic.

Also it is time consuming for the physician to explain why an antibiotic is not indicated and to reassure the patient that this is the right decision. Writing a prescription for an antibiotic is much faster. It completes the encounter and terminates the visit.

Yet, as a physician in practice, I feel that my integrity is at stake when I prescribe an antibiotic, or any intervention, that is not indicated. The risk of doing harm and of further increasing worldwide antimicrobial resistance must take precedence. As stated in the above student commentary, studies have shown that patient satisfaction is correlated with physician time spent and with the patient's understanding of their diagnosis to a greater extent than the receipt of a prescription for an antibiotic4. In my practice, I find that patients truly are more satisfied and actually more appreciative when I listen to and understand their concerns. Their trust is reinforced when I hold true to my principles and explain to them my clinical reasoning. Rather than an unnecessary antibiotic, I can offer them a decongestant for symptomatic relief, and re-assurance of my availability in the unlikely event that they do not improve.

References:

  1. Gonzales R, Bartlett j et al. Principles of Appropriate Antibiotic Use for Treatment of Acute Respiratory Tract Infections in Adults: Background, Specific Aims, and Methods. Ann Intern Med. 2001; 134: 479-486.

  2. Avorn J, Solomon D. Cultural and Economic Factors that (Mis)Shape Antibiotic Use: The Nonpharmacologic Basis of Therapeutics. Ann Intern Med. 2000; 133:128-135.

  3. Scott J, Cohen D, Dicicco-Bloom B et al. Antibiotic Use in Acute Respiratory Infections and the Ways Patients Pressure Physicians for a Prescription. J Fam Pract 2001; 50:853-58.

  4. Mostov P. Treating the Immunocompetent Patient Who Presents with an Upper Respiratory Infection: Pharyngitis, Sinusitis, and Bronchitis. Prim Care Clin Office Pract 34 (2007) 39-58.

  5. Snow V, Mottur-Pilson C, Gonzales R. Principles of appropriate antibiotic use for treatment of nonspecific upper respiratory tract infections in adults. Ann Intern Med 2001: 134 (6): 487-9.

Carol Reife, M.D.
Clinical Associate Professor of Medicine
Jefferson Medical College