Here's What I Will Do
When patients seek antibiotics that aren't indicated, Colgan and Powers recommend that clinicians stick to their guns and apply the triad of education, empathy, and alternative treatments for symptomatic relief. Sounds like good advice, but does it work?
In EDs, where rates of antibiotic prescribing are often the highest, clinicians are hampered by not knowing the patient. "We don't have the luxury of an ongoing relationship with patients. Along with building that bond and level of trust, education and communication are the most important elements in managing patient expectations," says Dr. Glatter, who recommends making a pact with the patient as an alternative to prescribing immediately. "A pact is an agreement between patient and provider that says that we will monitor and reassess. We are looking for these signs and symptoms, and if they occur, this is what will happen." Dr. Glatter believes that patients are becoming more amenable to this. "Patients are starting to learn about the evils of antibiotics."
Many clinicians have carved out a middle ground with postdated prescriptions. The practice of handing the patient a prescription for use, if needed, a few days after the evaluation visit is a way of dealing with a situation that combines diagnostic uncertainty with patient insistence on antibiotic therapy. The Medscape survey found that 49% of clinicians occasionally write postdated prescriptions, and another 4% report doing this most of the time. In contrast, 47% never write postdated scripts.
The latter figure is somewhat surprising. Dr. Bartlett comments that delayed prescribing is one of the few effective strategies for reducing patient demand for antibiotics and lowering prescribing rates, although a policy of not writing prescriptions for antibiotics at all and advising patients to return if symptoms do not improve results in the lowest rates of antibiotic use. Dr. Bartlett also suggests placing a sign in the waiting room stating that "Dr. Jones will prescribe antibiotics only according to current guidelines" as a measure to manage patient expectations. The only downside, says Dr. Bartlett, is that clinicians need to be familiar with the details of those guidelines.
One clinician uses postdated prescriptions "to appease patients," always giving instructions for using or not using the prescription. Research, however, doesn't necessarily support the assertion that patients will be happy with postdated prescriptions. A recent Cochrane Review of delayed prescribing for respiratory infections concluded that patient satisfaction was no higher in patients who were given delayed prescriptions than in those who received no prescription at all.
A nurse practitioner provides "delayed prescriptions for antibiotics when I am not certain that an illness is viral, as I work in an urgent care setting and cannot depend on my patients seeking appropriate follow-up. Patients dislike having to return and pay again for an urgent care visit when they don't improve as expected."
Delayed prescriptions, however, are at best a temporary stop-gap solution. Dr. Spellberg sees this strategy as "a rational work-around to the real problem, which is that we don't know what we are treating. But it is a work-around nonetheless. The problem is that you don't know whether patients will actually wait to fill their prescriptions, and if the patient does have a bacterial infection, 3 days are lost before stating treatment. The real solution to the core problem is the availability of rapid diagnostic tests that will actually tell doctors and patients what is causing the infection."
"The most important thing is to have a conversation with each patient about the potentially adverse effects of overprescribing, which not only may contribute to bacterial resistance, but can cause allergic reactions and C difficile infection as well," says Dr. Glatter. "Having a rational discussion about why an antibiotic might not be helpful will lead to a better clinician-patient relationship in the long run."