How to say no to inappropriate antibiotic requests

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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.