In my clinical practice, I have encountered patient aggression typically with narcotic medications, in particular with the refusal of a refill due to evidence of concerning behavior, like a positive drug screen for drugs not prescribed. Aggressive behavior can include yelling, threatening physical violence or intimidation. I have had less trouble with narcotic-related aggression nowadays especially with media coverage of the dangers of narcotic abuse and especially since a lot of my patients who are on chronic narcotic therapy are managed by pain specialists. In the past couple of years, however, I have started to experience this level of aggression with another type of medications: antibiotics. Until recently, I have dreaded fall and winter months because they are peak months for demand for antibiotics for a common cold.
My established patients are aware that I do not give antibiotics for the common cold. These patients trust that I care about their health; it’s what I do. But then there are the new patients or the patients of other providers that bring back the need to have this challenging conversation about the correct use of an antibiotic. I have had to endure the frustrated look of disbelief, the accusations of being a bad doctor who does not care about them feeling better and who wants them instead to wait until they feel worse to get treated. Month after month, however, I do endure these insults because it is my duty not only to care for my patients but to educate them about their health.
We would not have this level of demand for antibiotics (and the resulting acceleration of antibiotic resistance crisis) if physicians or advanced care practitioners do not prescribe medications inappropriately or against their own documented assessment: it is not uncommon for me to see a patient’s urgent care visit note that says viral infection and yet the management plan is followed by a prescription for azithromycin or augmentin. The “nocebo” effect is real, and a patient’s perception of their ability to heal correlates positively with their clinical recovery. A patient who does not believe they will get well with the non-antibiotic you have prescribed may not get better, leading them (and you) to conclude that they need an antibiotic to get better. We must break this vicious cycle, this inappropriate dependence on antibiotics, and help patient trust in their care plan which, for a routine common cold, should not include an antibiotic.
Health care providers need to understand that integrity and ethical behavior are compromised when medications are prescribed inappropriately and specifically when directly against one’s clinical judgment. The inappropriate antibiotic prescription has some serious negative implications and does cause tangible harm. I am starting to see patients where I have needed to give parenteral antibiotics for simple infection just because of prior multiple exposures to unnecessary antibiotics. According to the CDC and WHO, antibiotic resistance has been associated with increased mortality, prolonged hospital stay, increased health care cost, and increased morbidity.
Of course, if you practice medicine long enough, you will have the occasional patient who seemed to have a viral URI for a few days and who, a few days later, develops full-blown pneumonia or other complication. It is important to acknowledge to ourselves and to patients that we are doctors, not God. We use our best clinical judgment at the time based on information that we have about the patient’s current presentation and we cover for the most likely cause and we re-assess if the patient is not progressing as expected. The patients that have something else develop will usually be detected if they follow their discharge instructions.
Now, in the age of convenience care and consumerism where patients get care at the time that works best for them, I am aware that patients are also demanding care their way, with their plans. This new trend has some possibly dangerous consequences, especially when physician quality and productivity metrics are now often tied to patient ratings and patients’ perception of care. Physicians, though they do serve their patients, are not, however, to be confused with a waiter who takes your order and delivers them just the way you like it, with a smile. It took over ten years of training to be able to bear that title of physician, and I daresay that even the formidable Dr. Google is not able to surpass the clinical expertise of a well-trained physician. The commercialization of medicine and the consumerist focus should have some limits, for patient safety sake. It is incongruous to want physicians to practice good, evidence-based medicine and yet link their compensation, bonuses, or facility privileges to the patients’ perception of the providers’ care and plan. Of course, patient feedback is important and provides opportunities to improve a facility or clinic’s practice. I have been a patient, too, and I want my opinion to matter to my health care team. My dissention is when this consumerist shift places undue stress on the physician to please the patient as this may lead to detrimental care. Physicians are human and they have their own families and financial interest to take care of. It can be very tempting to give a patient an antibiotic that they do not need just to please the patient and get them out of your office so you can see the next patient (production bonus, anyone?) than to spend an additional 15 minutes talking to the same (discontented) patient.
I am a doctor; as such, I try to be a patient advocate and patient educator. I love what I do, and it is a privilege to live my childhood dream. In this age of consumerism and patient satisfaction scores, I do not want to forget who I am and the importance of the role I play. Let us, as health care providers, encourage one another towards good deeds and take the pledge to educate our patients.
Rosemary Eseh-Logue is an internal medicine physician.
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