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How do we stop the war over antibiotics next winter?

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She was quite insistent and becoming irate:

Look I am a busy woman. Every time I get these symptoms I come in and get antibiotics and it gets better. Whenever I wait it just gets worse. I don’t have time to mess about so can you just look at the previous notes and prescribe what I usually get?

She had an upper respiratory tract infection. Her throat was mildly inflamed and she had a runny nose. No pyrexia. She sat bolt upright and ready for an argument.

It doesn’t happen that way every time. The patient is usually prepared to allow her doctor to make the call but occasionally it’s not that easy. According to the literature, a third of the public still believe that antibiotics work against coughs and colds. We have seen quite clearly that offering a prescription with the advice to take the antibiotics if the symptoms don’t improve rapidly may help reduce the numbers who take antimicrobials unnecessarily. We know that in at least one study 38% of people may be prescribed an antibiotic this year.  More than one in ten will not complete the course.

How many take the drug as prescribed, e.g. three times a day? And why is it that younger people are less likely to complete the course all the while acknowledging that they understand the importance of taking the medicine as prescribedThe context in which people seek antibiotics may help to inform how doctors manage the call for antibiotics. The answer to the challenge thus far is to mount a public health campaign:

We could focus a ‘Do not recycle antibiotics’ message towards the higher educated, young women who are more likely to store and take antibiotics without advice. McNulty et al

An upper respiratory tract infection is an unpleasant experience. Having a ‘cold’ that lasts a few days may seem trivial to some healthcare practitioners or policy makers but to the patient, it is very far from trivial. In a brilliant paper describing work with 719 people, Longmier demonstrated that neither doctors nor patients can accurately predict how long an upper respiratory tract infection would last or how severe the symptoms are going to be. In an intriguing conclusion to their study they said:

Clinicians should not use their predictive assessments or their patients’ predictions when advising patients on the expected course of a URI (Upper Respiratory infection).

The average duration of symptoms  for URI is 7–10 days, with a minority of patients experiencing symptoms for more than 3 weeks. Antibiotics will do nothing to improve symptoms. Therefore, the problem can be framed quite differently. How you feel on the day you consult your GP is not a good predictor of how long you are going to be miserable with this ‘virus’. Your GP might tell you it’ll all be better in a week and that might sound okay alternatively she might say this will go on for two weeks or more and that might sound disastrous. In any case, she is not likely to be right.  So we go back to the scientists who suggest:

As we cannot accurately predict when the URI will end or how bad it will be, our best clinical tools for patients with URIs are empathy, reassurance and education on the self-limited, short-duration nature of viral upper respiratory tract infections. Longmier et al

To my patient my sympathetic demeanour and rehearsed speech about viruses was not satisfactory. What this patient wanted more than anything else was to be free from her symptoms. I was curious as to why but she was not in a mood to talk about it.  It seems that regular paracetamol in combination with chlorphenamine and phenylephrine may be helpful as are nasal decongestants.  Over the counter cough medicines are not. No doubt there is more literature on the topic of effective symptom relief however, no papers suggest that any treatment entirely rids the patient of symptoms immediately. The key question still remains- why do people insist on and or stop antibiotics before completing the course? If we could demonstrate that people stop antibiotics because their symptoms improve after regular use of effective symptom relief then such evidence may be helpful in any discussion with patients about antibiotics. We then reframe consultations on URIs to offering advice on symptom relief. We offer a solution more aligned to the context in which the patient is presenting. Let’s acknowledge that a cold is an unpleasant experience and not as seems to be suggested to the public a minor nuisance not worthy of our attention.

Picture by Marquette Laforest

The context is often private and confidential

7257592240_6759efd5a5_zThe consultation between a doctor and patient is private. Innovators hoping to improve outcomes in that context can’t observe the exchange directly because some presentations are very uncommon and because neither the doctor nor the patient welcomes the intrusion. There are many outcomes of the encounter between patient and doctor that we still don’t fully understand. Why are some patients’ cancer symptoms not recognised as early warnings? Why do carers of patients with a life-limiting illness fail to have their own medical problems addressed? Why do people living with some chronic conditions continue to have problems with intimacy?

People deploy verbal and non-verbal cues to communicate. They choose when and how to disclose their ideas, concerns and expectations. However in an average consultation in my country, the patient has fifteen minutes to ‘spit it out’. Similarly, clinicians vary in their ability to pick up cues or to probe with the right question, assuming they get the right answer. Hence errors of omission and or commission.

Lean medicine is about being intuitive, creative and agile. Lean innovators, clinicians, are already on site. Therefore, they can reproduce the context in a way that can be observed and where they can be tested with other clinicians. Video technology and a fusion of skills across disciplines allow the depiction of those encounters in such a way as to present the critical decision point for close examination. Do you prescribe, refer or investigate in these circumstances? What do you say to the patient?

How do you explore hard to reach elements in your practice or business? How can you hope to innovate for encounters that are strictly private and confidential but where mistakes or misunderstanding can be very bad for business. Who has the insight to show you? How can you generate valid hypotheses? How do you test ideas without a real risk of casualties?

Picture by Urbanbohemian