Find yourself a physician who is stingy with prescriptions

Find yourself a physician who is stingy with prescriptions

Antibiotic use is the direct cause of the rise of untreatable superbugs that are killing people.

Antibiotic use is also the cause of most cases of C. diff colitis in kids, a potentially life-threatening, difficult-to-treat gut disorder. Antibiotics have also been linked with recurrent wheezing  in infants and inflammatory bowel disease. They can also trigger allergic reactions that can be severe or life-threatening. (I was going to link to photos of Stevens Johnson Syndrome, but decided not to be cruel. Go ahead and Google at your risk. Don’t say I didn’t warn you.)

Most infections in children are caused by viral infections. This includes all common colds, most coughs, most sore throats, most nasal congestion, and most fevers. It includes most bronchitis, most pneumonia, and most wheezing. Croup, laryngitis, tonsillitis, upper respiratory infections: They’re all viral. They are caused by viruses.

There is no circumstance where any antibiotic medication helps anyone with a viral infection get better. They don’t make viral infections go away faster, and they don’t prevent the development of later bacterial infections. They just don’t work.

Even “bacterial” infections often don’t need antibiotics to get better. Most ear infections will resolve without antibiotics, and good studies have shown that antibiotics, overall, are not effective in treating sinus infections.

So, the potential for great harm. And no upside. If you’ve got an accurate diagnosis of a viral infection, you know that the antibiotics aren’t going to help. Zero benefit. Some real risk. You’d think this would be a no-brainer kind of decision.

And yet, every single day I feel this struggle with some parents who just want antibiotics. It’s really strange, in a way: I listen to the story, I do a careful exam, and if possible I get a confident diagnosis. I talk about what will help the child feel better, and red flags to look out for to contact us if things get worse. And I get back a stare. “Can’t I just get an antibiotic?” or “He needs an antibiotic for his sinus” or “My doctor just gave me an antibiotic. He has the same thing.”

It’s our own fault, I know. Doctors have been way too quick to write antibiotic prescriptions. It’s much faster to whip out the prescription pad than talk about viruses and bacteria. And, more nefariously, writing antibiotic prescriptions creates a culture of dependency that guarantees future business. Patients, at least some of them, seem more satisfied if they just get a magic antibiotic prescription. Why anger people, why fight it, why not just give out the pills and move on to the next patient? Happy parents, happy cash register.

Besides: I know there’s a good chance they’ll go right to the QuickieClinic in the drug store across the street and get their peniwondercillin prescription anyway. (And then I’ll be the one called with the weird allergic reaction or when Junior didn’t get better because he needs a “stronger” antibiotic. QuickieClinic doesn’t offer 24/7 access to their doctor. They don’t offer any access to any doctor. But I’m getting off topic here.)

Why fight it? Because I’m your kids’ doctor. I’m not here to make you happy, or give you what you think you need. I’m here to try to get an accurate diagnosis and to do the best thing for my patient. I’m here to give solid advice about how to help your kiddo feel better, and to tell you when to worry, and when not to worry. I will not always get it right, but I’m going to try my best every time, even when that means I’m not giving you the prescription you want. And I’ll be here to help when things take an unexpected turn, because symptoms and diagnoses change. I can’t guarantee when your child will get better, but I’ll do my best to do the things that can genuinely help.

You want a burger your way? Go to Burger King. You want a quick antibiotic prescription? Go to the retail clinic in the drug store, or one of those docs or practitioners who see 60 kids a day. You want someone to use their professional skills and judgment to help your child? Find yourself physicians who’re stingy with the prescription pad.

Roy Benaroch is a pediatrician who blogs at The Pediatric Insider. He is also the author of Solving Health and Behavioral Problems from Birth through Preschool: A Parent’s Guide and A Guide to Getting the Best Health Care for Your Child.

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  • NewMexicoRam

    Now, seriously, how many patients will listen to this advice? Very, very few.
    Most patients will only hear the voice of the adults in Peanuts cartoons: “Wah– wah– wah, wah, wah.”

    • Patient Kit

      (1) That’s a pretty low opinion of most patients and (2) assuming you are right about many patients, isn’t it the doctors’ job to educate patients, especially since docs are largely responsible for miseducating them about antibiotics? It’s “do the jaded thing” attitudes like this that seriously erode my trust in primary care docs.

  • Patient Kit

    I wish more docs thought like you. Seriously, doctors have collectively done a lot of harm with their rampant writing of unnecessary antibiotics scripts. And, correct me if I am wrong but, most unnecessary antibiotics have come from primary care docs. And, frankly, I think it may have eroded my trust in primary care docs a bit.

    Personally, I take antibiotics very infrequently. And I’ll take it a step further by saying that I rarely see the point of going to the doctor when I have a cold, flu, sore throat, earache, cough, etc unless it hangs on for an unusually long time and I just can’t seem to shake it.

    Why should people go to the doctor as soon as they get a sore throat? I’m actually amazed that so many people do. Not only are antibiotics unnecessary but it’s also unnecessary to see a doctor for many ordinary things. Personally, I find it reassuring to feel my immune system kicking in and fighting off a virus. I know it will take a few days, but I can feel my body fighting back. All I — or a doctor — can add at that point is common sense, fluids, rest, etc. If I really can’t kick it within a reasonable time, that’s when I’ll call my doc.

    • rtpinfla

      I wish more patients thought like you but the fact is that a lot do not. I still try to dissuade patients from unnecessary antibiotics and am grateful when a patient agrees but the fact is but many of them are hell-bent. Indeed, the ones that make the unnecessary appointments you mention are often there for one purpose only- to get that Z-pak. I try to educate them why they only need Tylenol and a little Sudafed for a few days. I usually get that arms-crossed -screw-you look very early in that conversation. The other docs on this board know that look. I once offered an angry patient a sinus CT to see if there was actually an infection to treat( I was convinced she had a simple tension headaches so didn’t need an antibiotic). She refused it, stating it wasn’t necessary. She left very angry and told the front staff to never, ever schedule with “that man” again. Several of my patients have switched doctors within my practice because I don’t “do anything” for them. One called me a “terrible doctor” in front of my staff. I haven’t seen her back and assume someone down the street now gives her all the antibiotic she wants.
      Frankly, it gets old fighting with these patients. It is exhausting, draining, and takes too much time to fight that battle. Even when I know I am right, it sucks to have a patient stare lasers of hate at me for denying them what they believe is their life saving and God given right, the Z-pak. Eventually you learn to recognize these patients about 10 seconds into a visit and you have to decide; do you want to spend 15 extra minutes trying to convince this person to try another route and have them verbally abuse you or just write the Z pak and move on.
      So although we can all agree that antibiotics are overprescribed, to simply say that doctors are just being lazy or greedy or just not trustworthy over simplifies the matter.

      • Patient Kit

        I don’t want to oversimplify a serious and complex problem and I certainly acknowledge that this is a huge issue at this point in time and that it’s not easy for docs to deal with. I especially feel for younger docs who didn’t have a role in creating the problem but who now have to deal with it. But didn’t doctors have a big role in creating this rampant unnecessary antibiotics situation? Shouldn’t doctors be part of the solution? Or is the only “solution” really to just keep writing them? If so, yeah, it does erode my trust in doctors.

        • rtpinfla

          You clearly get it and I think most docs would be glad to have a patient like you (myself included). But man, those that don’t really suck the life out of me.
          It seems that the trust issue is kind of chicken or egg thing. A patient that already trusts me is more likely to take my advice, especially if I leave the door open to come back or call if things get worse. Unfortunately, the opposite is also true- if a patient doesn’t trust me they automatically think I’m a quack for not writing the rx. Their suspicion od my incompetence is reinforced. And of course, they think I’m an anus-hole so they won’t come back to work on that relationship that results in trust. Oh my God this is starting to make me dizzy….

          • Patient Kit

            Thank you. I try not to be an annoying patient. Hopefully, my docs don’t scream and pull their hair out once I leave. ;-). I try to stay well-informed and bring my wicked sense of humor to the exam room.

            I consider a good doc-patient relationship to be a partnership and a very valuable thing and trust is one of the most valuable — and fragile — things of all. But once I lose trust in someone, it’s very difficult, maybe almost impossible, to get it back. In general, I respect what docs do very much but I don’t put docs on pedestals, as you may be able to tell from my comments.

            I agree that both the antibiotics and trust issues can be vicious circles. I guess I assumed that your OP about the antibiotics issue implied that you believe that there is a solution. I hope there is.

      • guest

        From the other side of the fence, I think sometimes there is the assumption that if a patient has come to the doctor’s office they must want a prescription. Not so. I’m not a doctor, so I don’t always know if I have a cold or an infection. I try and treat the symptoms for a while, but if I cannot kick it I go in for an opinion. Not being a doctor, I don’t always know when to go in and when to stay home. I don’t want a doctor assuming that just because I have come, I want a drug.

        My sister once took her child in to an urgent care center because she was screaming in pain and tugging on her ears. She thought that it was probably something that didn’t require a medication, but she also thought what if I am wrong and I’ve ignored something and harmed my child. My sister is not a doctor, so she didn’t know what to do. She didn’t demand anything for her child. She just wanted the doctor’s opinion. The doctor, assumed she was going to be a demanding parent and he took out his bad experiences on her. He said, “I can give her an antibiotic and she will get better, or I can not prescribe an antibiotic and she will get better. What do you want?” Her response, “I want you to do what you think is right.”

        • Arby

          I know that those types of answers don’t go over so well either. My PCP once asked me when I wanted to come in again and I told him “I don’t know, you tell me when you want to see me again.” After he just stared at me, I expounded and said “I mean, what is SOP for my issues?”. Weird end of the conversion overall.

    • SpringTexan

      I too am always shocked by the things my co-workers take to doctors. Why on earth? Seems silly and also sort of reckless. They would do much better to go to bed (what I do).

  • Patient Kit

    A prevailing attitude among primary care docs seems to be “if I don’t prescribe unnecessary drugs, somebody else will, so I might as well do it and keep the business (I mean, patient).” As you said, not good medicine.

    If overwhelmed, overworked primary care docs is such a huge problem, maybe we need a public health campaign to educate patients about the difference between viruses and bacteria. We could probably cut out a huge chunk of unnecessary visits to primary care docs for things like colds, sore throats, flus, earaches and those docs could concentrate on patients who really need them. I’m guessing that such a campaign will not be coming from primary care docs any time soon.

    • PrimaryCareDoc

      It already exists. It’s the CDC “Get Smart” campaign. I’m not going to link it because that’ll block my comment, but you can google it.

      As for primary care docs not doing that campaign- well, I beg to differ. I have posters and handouts all over my office. I even have special “prescription pads” for viral infections that I use to write out OTC and symptom relief methods.

      • SteveCaley

        That’s been standard medical school dogma for 20 years – Patient Education about Respiratory Viruses.
        You can’t teach what people don’t want to know.

        • Arby

          Exactly that.

      • Lisa

        I don’t see my pcp for every cold, sore throat, cough, skin rash etc, but will see him if something seems to be hanging on too long or getting worse. When I do see him, I want to know if I am developing a secondary infection and if it should be treated with antibiotics. I am happy to be told I don’t have a secondary infection and to be sent on my way, without a prescription, and some information about what to watch out for.

  • NewMexicoRam

    I wish patients listened to the advice. 90% of the time I will say antibiotics are not needed, and 90% of the time the patients insist on getting them.
    That is from experience, not heresay.

  • Jenny Jackman

    “I’m not here to make you happy.” Actually, that’s exactly what you’re there for. Pills = higher patient satisfaction scores = higher reimbursement = job security. That’s the only relevant equation here. If you tell a patient that they have a viral illness and there’s nothing you can do to make it go away, you’re just a crap doctor who doesn’t do anything in their minds and they’re going to change their PCM as soon as they walk out of your clinic. The patients who actually follow your advice are a very small percentage of the entitled public. Everyone else wants their miracle pill, STAT.

    • Patient Kit

      The ONLY RELEVANT equation for this issue is how it effects your reimbursement rate? Wow. Seriously? Even if I accept that premise (which I don’t), do you feel like doctors have any responsibility for creating this antibiotic mess in all the years prior to patient satisfaction surveys effecting your income? Another really low opinion of “most” patients from a doctor. Great. :-(

      • Jenny Jackman

        I should clarify by stating that I’m not a doctor and am not pretending to be one. I do work in the healthcare field, have done so for 19 years, and it is my personal experience that patients arent interested in being told that pills arent the cure for everything. On a separate note, I think the agricultural industry is doing exponentially more to cause antibiotic resistance than anything doctors are doing.

        • Patient Kit

          Thank you for the clarification. It really sounded like you were speaking as a frustrated doctor. While I agree with you about the agriculture industry and it should also be stressed that Big Pharma has a huge role in this antibiotic mess, I’m still not willing to let doctors completely off the hook for their dominant role in creating the problem.

          • Jason Simpson

            The reason doctors write antibiotics for colds is because they are the only doctors left.

            All the “good” doctors who told their patients that medicines/antibiotics are unnecessary have gone out of business.

            So what you have left is the doctors who hand out antibiotics like candy.

          • Patient Kit

            I don’t buy that at all — that there are no good doctors left. That is a ridiculous statement. There are plenty of good docs left. When, exactly, do you think all the good docs went out of business? The antibiotics issue has been going on for years.

          • Lisa

            I don’t think doctors who refuse to write scripts for unnecessary antibiotics are all out of business. My pcp does not write scripts for antibiotics unless clearly necessary and he is still in business.

  • Patient Kit

    I agree. I know that I rarely go to my doctor for viral things like colds, flus, sore throats, earaches, unless I really can’t shake them within a reasonable time. What is the point of going to a doctor for stuff like that? Which begs the question: Do some docs keep writing unnecessary antibiotic scripts to keep patients coming in? If so, I’m sorry, but that really is a huge problem.

  • NewMexicoRam

    Did I have to say that these are about patients either seen in the office, or who call me? I know many don’t come for common colds. If I’m giving advice, that means THEY contacted me.
    Who said I write for unnecessary antibiotics? I said that is what patients want. I understand the pressure, but don’t give in to it. Others, they are on their own.

    • HJ

      So how many patients listen to this advice? Clearly all those that didn’t come to your office.

      Is it the same people who continue to come in for antibiotics or do you have a rotating patient panel?

  • SteveCaley

    On Wondercillin:
    Had a patient with skin abscess. Could not I&D in office; saw next day and sent to local hip’n’slick surgeon. Had treated with dicloxacillin (retails at 75¢ a pill) for ten days. One day’s worth of treatment, and the systemic symptoms and erythema went down.
    Got patient back WITHOUT I&D, but with $100 worth of Avelox (Patient dutifully threw away the diclox). Patient was annoyed he didn’t get “the stuff that kills everything.”
    There’s a reason not to use the stuff that kills everything. I tried to explain that. Dicloxacillin was useless except for killing the skin infection bugs.
    Did I get a collegial phone call? Naw.
    PS: I bet anyone 75¢ that we’ll have a performance measure “did you get the antibiotic you asked for?” pretty soon. Hope to be retired.

  • betsynicoletti

    Some of you may know that I teach E/M coding. About ten years ago I had a sinus infection and begged my PA (unsuccessfully) for an antibiotic. I said, “Tony, if you give me antibiotics this moves the visit from a three to a four, and it’s a win-win for everyone.” He was unmoved.

  • Patient Kit

    I wonder whether I’m ever going to get one of those patient satisfaction surveys to fill out. So far, none have arrived. I’m feeling a little left out here. :-( If one ever does, my plan is this: Always excellent across the board for docs I love (even if they’re only very good in one aspect or another). And for docs who I only like or who I have some issues with, the patient satisfaction survey goes into the garbage unanswered.

  • TheresaWillett MDPhD

    I do a lot of just in case rx; I spend the extra time to educate, talk side effects and supportive home care, and leave it up to the parents. For ears, eyes and sinuses in breastfeeding babies, I will even suggest breastmilk (really) and watchful waiting. I have no doubt that I amoverprescribing, but at least a good number of families end up not using those antibiotics, and I gave them the control and removed a second visit for them. Of course, that means it is hard for me to see more than 20 patients a day, and the fewer easy follow up visits hits my productivity. I will keep trying to do the right thing by all, but makes it hard to stay employed in the status quo system. :-(

  • Suzi Q 38

    It took me a few years to figure out that not getting the RX for whatever was a good thing.

  • bill10526

    Do you have data that retail clinics are worse than doctor practices with regard to antibiotics?

    Prepared garlic is a potent antibiotic that has been used for centuries. Yet our species survived and many ou us actually evolved to like the stinky spice. Still antibiotics should be used sparingly and certainly not to appease idiotic patients.

  • RenegadeRN

    Press Ganey can go stuff it. They are ridiculous and a liability to good medicine.
    Sorry, total knee jerk reaction to your comment!

  • Jennifer Jonsson

    Guys, I get it. I understand all the concern about superbugs, and I don’t for a minute like what antibiotics do to my body (vomiting, sleep difficulties, interfering with other meds I’m taking). But the truth is, I have chronic sinus infections, the kind that DO respond rapidly to antibiotics, and if we “just wait and see”, I’m likely to end up with bronchitis or pneumonia. I’ve already got damaged lungs after my last bout with pneumonia ten years ago. I’d rather not damage them again, if you don’t mind. And yes, I have had the sinus surgery. It made me better, but it didn’t make me perfect. When I’m coming down with this thing once every year or so, I know I’ve got it. It would really help if you’d treat me with something that’s effective. And I hate explaining all this to you every single time it happens.

    • SpringTexan

      My mother was like you and I agree there really are some people who seem to pick up infections easily. She had a terrible time shaking things and really did need the antibiotics.

      I’m definitely against antibiotic misuse but it’s like with pain medication, you don’t want to just always say no.

  • SpringTexan

    I don’t in any way need to find a doctor like that. Because I am a patient that doesn’t want unneeded antibiotics and have probably taken about 3 courses in my entire life (one of which was the first time I ever took them — 30 years ago in my 30′s — and oh my it was indeed a miracle drug for what I had). But I won’t want surplus ones.

    So I’m choosing a doctor based on other factors.

  • Beth Miller

    hit the nail on the head! However – on topic of the “over concerned parent” and the ” I just need and antibiotic parent” Schools and daycares are part of the problem. I cannot tell you how many times I have had to take my son to the office – knowing full well the issue is allergies – in order to get a physician note stating as such – so they would not have to miss class/ daycare.

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