Right now our little town is in the grip of the swine flue pandemic. Its officially an epidemic.  The reported rate of influenza presentations in the last two weeks in the 6 practices has sky-rocketed, being about 5 times the normal seasonal rate of influenza presentation. (Its winter here)

There are many lessons that we have already learnt, with clearly significant success from the “stay at home” message for at least in our practice we are only seeing the reasonably sick patients and alas those who can't read or hear the public health messages. We haven't been overrun with patients yet....Clearly good practice and public health organisation has allowed the development of systems to cope with the high number of sick fortunately only about 1% of whom require intervention. A great practice for a more virulent epidemic.

Talking with other medical centres, it seems that good practice management is key to handling the problem, particularly focusing on barrier hygiene and isolation techniques. You have to combine this with skilled reception staff and excellent phone nurse triage but it works. 

Funny thing is that a little over a couple of months ago the idea of barrier techniques was being  laughed at by most docs including the author. That was until my practice manager and I visited a couple of practices in Toronto where the SARS epidemic had such an impact on primary care. To see practices where curtains were not used for patient privacy was a little surprising until our good host from McMaster Uni pointed out the reservoir of viruses and bacteria that such niceties provided.

This evening, at a public health meeting for all primary care, the hygiene strategy was emphasised. However the idea that we should removed curtains was laughed down as being “over the top” although I note that we were discouraged from having seats with “furry” seat covers. Now I admit that there is a significant difference between seat cover material and curtains, but I have a faint suspicion that we will come to change our views on this. History does not repeat itself, just that doctors make the same old mistakes.

Another interesting observation from the epidemic to date has been the fact that the “hard to reach” have become the most likely to suffer. The non European population, especially itinerant workers here to prune the 1000s of hectares of grapes in the valleys suffer more because of both language and also cultural problems. The former issue is blindingly obvious, but some of the social behaviour, especially “sickness behaviour” such as whole families visiting when someone becomes sick, clearly facilitates infection spread. Interestingly one important cultural group has already altered the practice of kissing greeting at meetings in response to the epidemic.

There must be other models of this type of social change out there.

“To think it, wish it, even want it — but do it! No, that I cannot understand. “

I recall this quote from Peer Gynt, Henrik Ibsen's famous play, being used by a Norwegian professor at a WONCA meeting many years ago. We were talking about the evidence/clinical performance gap. This was in 1995 if I recall correctly. 14 years on, last week to be precise, things have not changed for I reviewed a paper on antibiotic prescribing  ( http://www.globalfamilydoctor.com/search/GFDSearch.asp?itemNum=10223&ContType=JournalWatch )  showing a wide variation in antibiotic prescribing amongst GPs in Europe, with a coinicidental finding that Norway had the lowest antibiotic prescribing rate and low prescribing of amoxycilllin. Obviously more analysis needs to be done before we can identify more accurately what this means, but for a little comparison I pulled out my antibiotic prescribing analysis for the last 3 months (in NZ this data comes from a national body called BPAC) and saw the same wide variation in antibitoic prescribing amongst my collegaues, both locally and nationally. We have all been through the justifications over the years that doctors have “different populations” and “different environments” but most likely the “differing environments” are largely a result of the behaviour of GPs, something very evident when a new patient transfers from a high antibiotic prescribing colleague.

We all know (or should know) that the evidence on antibiotic prescribing, for most conditions in general practice, shows harms largely outweight benefits. Severity is a useful indicator of possible  effectiveness but even in some severe conditions (e.g. COPD) the benefit is not large. So why are antibiotics still prescribed by some doctors in such large quantities?

Quoting out of context is a universal sin, and thespians will know that I am not innocent in this regard, for Peer Gynt was referring to a boy who cut off his finger to avoid serving in the army. But the quote is poignant for antibiotic prescribing. Many reasons are given for this prescribing habit, probably the most common being meeting perceived patient demand (perceived by the doctor that is ) aligned with justification that it is acceptable to use a placebo (ignore the dictum “primum no nocere”). Which is where informed consent comes in (refer last week's GFD Blog).

Have you ever tried to justify to a patient prescribing a placebo antibiotic?
“Here Mrs Smith. Take this triciprochlorcillin for your cough and cold. It has about a 1 in 50 chance of reducing the duration of your cough by 3 hours and about a 1 in 17 chance of giving you thrush, 1 in 50 of leading to subsequent antibiotic resistance and about 1 in 1000 of cause anaphylaxis.”

Trouble is not one actually does this in medicine.

Now wouldn't it be really nice to have a good sound reason for being a high antibiotic prescribing doctor. Even better would be research supporting this.