How to say no to inappropriate antibiotic requests

Studies, medical societies and position papers are unanimous in their condemnation of inappropriate antibiotic prescriptions for an uncomplicated URI … but not a single voice tells us how to do that.

Let me give you a three part structure you can use in your patient conversations in the future – and some exact words to try out.  This structure is adapted from the Parenting literature, another role where boundaries and inappropriate requests are common issues.

The Three “E”s

  • Empathize
  • Evaluate
  • Educate

Know from the start that there are several things going on inside the patient simultaneously. Each has two components:

  • a primary experience
  • a longing

And each of these must be addressed for the two of you to be comfortable at the end of the office visit.

1. Your patient is suffering

Their primary experience is misery.

Remember the last time you had a snotty cold, bad cough, chills and you missed work and all the kids were sick too? You waited 3 days to get over it and still felt terrible. You just have 2 days of sick leave left in the year and it’s only March. You’ve got the picture … yes?

Here is their longing.

They want to be heard. They yearn for your empathy, because they are not getting it from anyone else.

There is a saying that is 100% true in this situation: ”They don’t care how much you know, until they know how much you care.”

Your job is to empathize first, show compassion, meet them in that shared place of suffering because you have been in that situation too.

Let me give you some specific phrases you might use:

“Wow, that sounds terrible.”

“You sound miserable, how are you holding up?”

“I hate it when that happens, you must be very frustrated.”

“You poor thing, I am so sorry this is happening to you.”

If you have a major challenge working up some empathy one of two things is happening.

You are experiencing some level of burnout. Empathy is the first thing to go when You are not getting Your needs met. This is a whole different topic and “compassion fatigue” is a well known early sign of significant burnout.

You are not fully present with the patient and their experience. In many cases this can be addressed by taking a big relaxing, releasing breath between each patient and consciously coming back into the present before opening the door.

2. Your patient is scared

Their primary experience is worrying that “something serious” is going on here … that this is more than just a cold and needs more than just chicken soup.

Here is their longing.

They want a doctor’s opinion so they get treated appropriately for what is really going on. They respect your knowledge and professional diagnosis.

Your job is to take a focused history , do a focused exam and give them a well reasoned diagnosis – no matter how many “cases like this” you have seen this week.

3. Your patient has an incorrect assumption of a solution

Their primary experience is one of thinking they know the solution and you are the source.

Their thought process might be:

“My phlegm is green, which means I need antibiotics” or “Larry down the hall got a “Z-Pack” for the same thing last week and now he is better. I must need one too.”

Their longing is to have something they can do to feel better.

The patient’s assumption is not only incorrect … it is potentially very dangerous. We are on solid ground here for a specific educational conversation.

Tell them what you know as a trained and experienced physician.

  • You have a viral URI … no question about it.
  • Here is the normal course of a URI.
  • Here’s what you can do to take care of yourself and speed the healing.
  • Antibiotics don’t make a difference in the course of a typical URI.
  • Antibiotics can cause diarrhea, yeast infections, allergic reactions and are a major cause of antibiotic resistant bacterial infections. Some of these complications can be fatal. We want to use antibiotics when we know they will work, otherwise the risks outweigh the benefits.
  • Here are the warning signs of a complication of a URI. If these happen, please come back in and let’s take another look.

Do this in words first and in a handout. Please don’t just hand them a lame, one-page handout and walk out of the room.

If the patient is still “demanding” antibiotics despite following the above conversation guidelines, this has become a boundary issue.  What are your boundaries around this inappropriate and potentially dangerous request?

Make sure to start with empathy first.

It could sound like this:

“I am so sorry you are feeling this way. And I understand how Larry down the hall got antibiotics last week and is better this week. I wish that would work in your case … and it won’t. 

“I won’t be writing a prescription for antibiotics because they would not help you and might cause a very serious complication. Here is information on how to get better and the signs that you are suffering a complication and need to be seen again.”

Persistent confrontational encounters with a specific patient are signs that the two of you are unable to establish and maintain a “therapeutic relationship”. This is solid grounds to enforce your boundaries again by asking them to find a different physician.

I encourage you to grab a partner — a colleague, friend, your spouse or significant other — and do the most productive thing possible to increase your skill in this important conversation.  Practice.

Have them be the sick person. You be the doctor.

Try out the phrases above and adapt them to your personal style. Then reverse roles … you play the patient. Reverse them again and be the doctor again.

Role play this until you are comfortable and your “empathy phrases” are second nature and true for you.

  • Empathy
  • Evaluate
  • Educate

Try these out for yourself.

Dike Drummond is a family physician and provides burnout prevention and treatment services for healthcare professionals at his site, The Happy MD.

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  • Anonymous

    Thanks for the good ideas, but it’s not always quite that easy.  If you work for an HMO or other such closed system you might not be able to fire the patient.  Of course you will  be able to get an angry complaint to your higher-up. 
    That said, I’m still fighting the good fight against inappropriate antibiotic and most patients do  cooperate.

    • http://www.thehappymd.com/ Dike Drummond MD

       You bet BKS … the key I have always found is to start with empathy. You remember the last really snotty cold you had, when everyone in the house was sick … start with empathy and things go much better. The wheels come off the cart of this kind of visit when the burned out doc is feeling put upon, does not empathize, does not do a good exam (patients can tell) and just says “no” … and not a lot else.
      These simple guidelines always worked well for me … that and the assurance of follow up.
      Keep breathing,

      Dike
      Dike Drummond MD
      http://www.thehappymd.com

  • Anonymous

    What can you offer patients that want to feel like they are receiving a “Treatment”– or therapy. The ethics of deception and obecalp aside, are there ways for you to be upfront with the patient and offer them a treatment that will make them feel better emotionally if not physically, in the place of a pill? 

    • http://www.thehappymd.com/ Dike Drummond MD

      Here is my prescription. Empathy … two naps a day … plenty of citrus fruit and your favorite chicken soup (I make mine from scratch with a Costco roast chicken carcass and LOTS of garlic).

      Back in the day they used to prescribe pills called Lipragus – that’s “sugar pill” spelled backwards. The placebo effect is powerful and real and a whole different topic.

      Dike
      Dike Drummond MD
      http://www.thehappymd.com

  • Ginger

    When I would take my kids in to see the doctor I was often “longing” for some kind of help to get them feeling well enough to go to daycare so I could (bad parent alert here) go to work, since I didn’t have a lot of available leave.

    My particular jurisdiction required a note from the doctor to administer OTC medications. Making suggestions about OTC medications and issuing a note, without the unneeded antibotics, could be helpful!

    • http://www.thehappymd.com/ Dike Drummond MD

       Hey Ginger … would be nice if there was any evidence that OTC meds work too. We are looking for something we can do … aren’t we? I can’t see any harm in your recommendation. Challenge is that fluids and rest are what you “do” to cure this illness and most of us see that as “doing nothing” or “just waiting it out”. And what most moms need in this situation is a nanny for a couple days to take the load off.

      Thanks for your comment.

      Dike
      Dike Drummond MD
      http://www.thehappymd.com

      • ORMD

        Actually, zinc is good OTC remedy with some good baseline research.  Check out the Cochrane Review: http://summaries.cochrane.org/CD001364/zinc-for-the-common-cold

  • Anonymous

    This article seems to overstate your ability to differentiate between viral and bacterial URIs.  True, 90-95% of your patients will have no response to antibiotics because they do indeed have viral infections.  But the others do have bacterial infections and will respond to antibiotics with very low side effect rates.  I don’t think patients are intransigent for the fun of it.  I think few of them are willing to take a 5-10% risk that they will suffer needlessly for 3 weeks, have to take another sick day and pay another co-pay to allow you to come to a certain diagnosis before treating them.  Physician reluctance in the face of this cost-benefit balance doesn’t make sense in the larger context of their medical care where expensive, invasive, unpleasant screening is often recommended on far less evidence and the broader context of profligate antibiotic use in livestock.

    Might a compromise be to educate patients, and if they still want it, write them a prescription but suggest that they hold off on filling it for a few days to see if they improve?  That way patients don’t feel like they’re just setting themselves up for having to take yet another day off work to come back and see you if things don’t improve?  

    • http://www.thehappymd.com/ Dike Drummond MD

       Hey CBRN … we don’t need to differentiate between bacterial and viral. The normal URI syndromes do not respond to antibiotics … this is the gist of the many practice recommendations on the subject. They are keyed on recognizing a symptom complex … not an etiology. So … runny nose, sore throat cough without fever, chest pain, vomiting … it does not matter what is causing it (and the vast majority are viral) … antibiotics will not modify the course of the disease and they will produce resistant bacterial flora in the patient.

      The key here is how do you communicate with the patient in this common interaction in a way that honors their experience and does not prescribe antibiotics? You can see my thoughts.

      Dike
      Dike Drummond MD
      http://www.thehappymd.com

  • http://twitter.com/DocRockne Michael Mirochna, MD

    Dr. Drummond, thank you for your insight.  It’s hard to stay empathetic when the Chief Complaint is “I need my Z-pak.”  The newly updated ISDA guidelines for sinusitis state that z-pak resistance has become too high to use it for such.  Other studies have shown that even treating bacterial sinusitis doesn’t help.  The ISDA guidelines have strict criteria

    CBRN brings up a few points I see often.  
    1) We can’t diagnose bacterial vs viral URI’s perfectly.  I’d propose that it doesn’t matter.  People don’t die of straight away URI’s.  IF it is bacterial, before it escalates, we have time to follow and treat appropriately with antibiotics.  
    2) Paying for the treatment you receive and follow-up if needed, that appears to not be fair.  Why should I have to pay twice for the same thing?  I’d suggest its good medical care.  Unfortunately, not everything can be solved in one visit.  
    3)  Antibiotics really aren’t that harmful.  Obviously, as Dr. Drummond mentions, they really are.  First do no harm is one of our first mandates as physicians.  Prescribing an antibiotic for a cold is doing harm. We are giving you a placebo that could HURT the patient.  

    I’d also offer that beating your physician up until they write an antibiotic doesn’t mean that it’s the right thing when they sometimes cave to the demand the patient who plays their own doctor.

    • http://www.thehappymd.com/ Dike Drummond MD

      It is not a question of being able to differentiate between viral and bacterial sources when we are talking about common URI presentations. The natural course of the illness is not modified by antibiotics. I could quote any number of exquisitely researched practice recommendations that come to a similar conclusion.

      Even the return visits – the one where the doc “gives in” and writes for the prescription – don’t modify the course of the disease. They just make everyone feel like they are doing something productive.

      AND every time you prescribe an antibiotic you produce resistant bacterial flora in the host that can – and will – cause trouble down the road.

      The most effective and least dangerous route is observation, two naps a day, and chicken soup. And the key is communicating that effectively while honoring the patients primary experience of misery.

      Dike
      Dike Drummond MD
      http://www.thehappymd.com

      • http://twitter.com/DocRockne Michael Mirochna, MD

        Thanks for the help!

  • Anonymous

    As a patient what I’d like to see an article on how to
    tell your doctor that you don’t want unnecessary medications. For example, I
    went to see my doctor a few months ago for  reoccurring back muscle pain.  I know from experience that if I get in
    quickly to a physical therapist the pain can be cut in half.  I’ll go for about three weeks of therapy and
    the problem will be fixed.  I told my
    doctor right up front that I don’t like to take medicine unless it is
    necessary.  She and I then had a
    conversation about what was wrong and then she proceeded to write me a
    prescription for high dose pain killers when I told her my pain was 2 on a
    scale of 1-10.  I had to remind her that
    I don’t like unnecessary pain medications and I didn’t think the prescription
    was necessary.  Since I am the only one
    who can judge my pain it surprised me when she questioned whether I really
    wanted to go without it.  Another example
    was when I went to the doctor for flu symptoms and the doctor gave me a
    prescription for an antibiotic.  I was
    surprised by this and asked him if antibiotics would work on flu
    symptoms.  He said probably not but many patients want to take them anyway.  I said No Thank you and then we had a
    discussion about what I could do to feel better.  So I think it’s not only the patients who
    need to be educated but the physicians as well. 
    Not all of us want to be medicated.

    • http://www.thehappymd.com/ Dike Drummond MD

       I totally agree Shikseh … some docs will take the shortest route. They will Diagnose, write the Rx and move on to the next patient. I would submit to you that the doc in question is most likely feeling hurried, behind and stressed on that day. Burnout effects on third of MD’s every day and this is how it often shows up. They are looking for the shortest route to the next patient … and you are not “typical” in your desire to avoid meds.

      The bottom line for me is that these conversations over time set the two of you up for a “therapeutic relationship”. I would get to know you and what works for you. We would get better at meeting your (appropriate) needs over time.

      Keep telling them what you want … and hopefully they will keep listening.

      Dike
      Dike Drummond MD
      http://www.thehappymd.com

    • http://empoweredpractice.com/ Trista

      Very cool to see your insight on this. Most patients trust that their doctors are treating them as they would treat themselves and their families. As Dr Drummond points out, burnout, stress, packed schedule all play into how doctors treat their patients. And you are an exception to the rule. Some doctors are so worried about patient satisfaction scores that they are quick to succumb to the patient’s request. As the potential for reimbursement to providers riding on such scores rises, this could possibly become an even bigger problem unless the medical staff is properly trained and educated on how to successfully communicate with patients. Empathy, evaluation and education are only one very important step in this.

  • http://empoweredpractice.com/ Trista

    I am quickly growing fond of your posts. It seems as though you have it all figured out :)  
    EmpathyEvaluateEducate
    What profession couldn’t benefit from this? It is all about the education and how you present it: Coaching the patient. Opening up the conversation with empathy, acknowledge how they feel, validate that it is normal. The patient can only make decisions based on what they know, so it is the doctor and team’s responsibility to help their patients make the best decision. They may not always turn their beliefs and ways of thinking around to agree with you, but now they are well informed. Of course, in the case of prescribing meds it isn’t necessarily that you can let them choose. 
    -Trista

  • Beanoville

    Most colds are self limiting no matter how lousy you feel.  I wouldn’t even
    consider taking up a doctor’s time without giving it a chance to run its course.
    Most treatments for colds are worse than the cold itself.

  • gloriousglo2

    When I was in private practice (IM here) I found it useful to manage patient expectations up front, so we would give all new patients an info sheet that included our practice’s philosophy on several common issues. One of these was a paragraph about antibiotic Rxs and appropriateness. Frankly, this worked great, and often the conversation from the patient’s end might end up with a comment like, “Probably don’t need an antibiotic, right Doc?” Education is the best thing.

  • UnhappyToaster

    I have to say – this article sounds rather baloney. I often get sinusitis directly after a cold or a flu. Perhaps I blow my nose too hard, which causes my sinuses to become lodged. Afterward, it’s a tight compressed feeling my my cheeks and forehead, normally including a heavy cough. For the dozen of times this has happened in my life, the z-pac has worked to eliminate these symptoms in 1-2 days (ALWAYS). This is whether I go to the doctor immediately or wait 3-4 days for an office appointment to open up. For the times I’ve waited a week for it to go away on its own, or tried amoxycillin, the symptoms would never go away. More than a dozen times where only the z-pac actually solved the problem (even waiting up to 2 weeks).

    How could the z-pac not be working? Do I just magically remove symptoms the day or two after taking the z-pac (whenever I take it) simply because it’s viral and viruses all respond to my opening my mouth for a z-pac?

    I’d love to see the ‘studies’.

    • http://www.thehappymd.com/ Dike Drummond MD

       Hey Unhappy Toaster … the studies are overwhelming in their unanimous recommendation to avoid antibiotics in an uncomplicated URI. AND if you really would like a sampling of the research you can get started here http://www.aafp.org/afp/2006/0915/p956.html

      Having said that … your situation brings up the value of having a primary care doctor. Studies will always address pooled data on a large group of people. In every group there are outliers and you appear to be one. If your facial fullness and heavy cough simply will not go away no matter how long you wait … until you get a Zpak … that is a pattern worth knowing. Perhaps you are one of the rare people with a true bacterial sinus infection. And this pattern is something you and your regular doctor should be aware of. And for every person like you there are 50 for whom the no antibiotics rule is the best course of action.

      Dike
      Dike Drummond MD
      http://www.thehappymd.com

      • UnhappyToaster

        Thanks Dike! And yes, thanks for the link. I’m currently undergoing my big sinus infection of the year (3 weeks) now, which is why my post was rather ornery and pointed. But yes, the education helps quite a bit too. As a relatively young person starting out on my career, I’ve switched jobs/insurances/physicians a lot. So each new doctor I’ve had to explain my history, then try to keep it together when I’m refused what I’ve considered to be the magic pill – the z-pac.

        I’m entirely willing to concede that I’m prescribed this too often, and that viral infections in my history would have gone away on their own. Indeed – for my current sinus infection, it would appear that I’ve burned through my course of amoxycillin and my non-magic z-pac. Now it’s just a wait and see for a few more weeks I suppose. All in all, thanks for the response and the education. Doesn’t relieve sinus pressure, but at least I can be more composed in future doc visits.

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