“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.
c5b284f7-d54f-4b9c-bb22-20babff1bc6d|1|5.0