Can patient-clinician engagement save us from a time when antibiotics will not be able to resolve infection?
In 1945, the medical community was first warned of the danger of antibiotic overuse and resistance. Alexander Fleming, the man who gave us penicillin left us with this powerful message about overuse: “In such cases, the thoughtless person playing with penicillin is morally responsible for the death of the man who finally succumbs to infection with the penicillin-resistant organism. I hope this evil can be averted.1”
There is a clarion call from the Center for Disease Control (CDC) to move quickly on strategies to halt overuse of this drug or face an era they have called “post antibiotic.”
We have just such an example, carbapenem-resistant Enterobacteriaceae (CRE) today. CRE is resistant to ALL first-line antibiotics now and some strains do not respond to any of the antibiotics today. Grim words from the CDC’s Dr. Srinivasan point to 50% mortality when this bug enters the bloodstream.2
The implications of a “post antibiotic” era are staggering. We can reflect on a time our grandparents and their ancestors knew. A wound that became infected was a harbinger of death for many. This left the clinician and family with only supportive care and prayer for the loved one with the infection.
Uncertainty: a Driver for Over Use of Antibiotics
A recent survey by Medscape in collaboration with WebMD, offers important insights into perceptions surrounding use of antibiotics by providers and patients.
The role of uncertainty is a key takeaway from the survey and it speaks directly to the purpose of patient engagement. Although the term patient engagement requires clarification according to the care situation, communication is at its core. How we express ourselves verbally to one another and how we listen to what is spoken is the strength (or the weakness) of communication.
In speaking about the value of listening, the Institute of Medicine says: “By listening first and listening fully, patient and caregiver voices are integrated fully into every possible level of decision making3”
Can Patient-Clinician Engagement Deal with Uncertainty?
Uncertainty is a factor for many illnesses that bring people to their provider’s office. We do not yet have a wide range of rapid tests for differentiating bacterial and viral infections, and uncertainty about the cause makes both clinician and patient uncomfortable. In a clinician’s office uncertainty surfaces because clinicians are educated “to know”. Therefore, being uncertain about the actual cause of Mrs. Jones’ low-grade fever, general malaise, aching joints, cough and congestion is uncomfortable. Clinicians are taught to use “watchful waiting”—advise to wait a day or two, use the supportive interventions to relieve symptoms—but in a face-to-face encounter this approach is not always easy.
Mrs. Jones feels lousy, is trying to run a small business with little help and recently lost her husband to cancer. So, from the clinician’s perspective, maybe this is the time to “be better safe than sorry” and prescribe the antibiotic “just in case”. After all, she’s had a great deal of stress in the last year so her illness could have started viral but now be bacterial.
Mrs. Jones has read articles and heard reports on the news about antibiotic being used too often when not necessary. She understands this problem, intellectually. Right now, however, she is hurting and would like some relief and some sleep.
A Glimpse of the Report
In the Medscape survey, 21 percent of clinicians report prescribing antibiotics between 25-49% of the time when they are uncertain of the cause. Twelve (12) percent of those surveyed did so over 50% of the time. Whereas 23% of patients tell us they request an antibiotic when they are uncertain if it is needed. We also learn from this survey that top priorities for patients are these:
- How to manage their symptoms and get some relief
- How to monitor their progress and what they should expect
- Explanation of why antibiotics are not needed.
Ironically, these are the same three educational points clinicians say they are providing.
Can Patient-Clinician Engagement Deal With Uncertainty?
The implication of sharing in decisions about care are that we must confront our own uncertainty about the outcomes that may result from a decision. In order to do that, both clinician and patient must be “engaged” in listening. This is often a tough thing to do in a busy office and in the press of direct clinical care in the hospital.
As the Institute of Medicine points out, it is a learning curve for everyone:“Patient engagement is a skill, not a trait. Being an engaged patient and actively engaging patients are not intuitive skills. Patients and clinicians learn these skills over time and through partnership with a supportive team.2”
A Strategy for Mrs. Jones and Her Provider
After the assessment, the discussion about approach to managing the illness comes forward. Patients and clinicians have a responsibility to not overuse antibiotics, and dealing with an uncertainty about viral or bacterial cause is not easy. The clinician does not want to cause harm and the patient wants to feel better, so moving to the “try chicken soup first” approach is not easy for either. Here are three responses to press the conversation.
|How certain are you that this illness is cause by a bacteria?||We’re not certain at this point. I would like to explain both the benefit and harm of taking an antibiotic when we are not certain if the illness is caused by a bacteria. May I do so?|
|Should I wait another day or two and see if I improve?||It would make sense. How comfortable are you waiting a day or two to see if you symptoms improve?|
|If I am not improving how easily can I get a Rx without returning to the office?||We can make it easy. Is that your biggest concern about waiting or do you have a greater concern?|
Perhaps, we could move more quickly if we paraphrased Fleming’s words: “I want to be morally responsible for the death of the man who finally succumbs to infection with the penicillin-resistant organism?”
1How can we turn the tide against inappropriate antibiotic prescriptions? Spellberg, B. , Bartlett, J, Gilbert, D., August 18, 2014, www.medscape.com
2Antibiotic Overuse a ‘Huge Threat’ to Patient Safety, Says CDC, Cheryl Clark, August 18, 2014, http://www.healthleadersmedia.com
3Partnering with Patients to Drive Shared Decisions, Better Value, and Care Improvements, Institute of Medicine, August 2013,http://iom.edu/Reports/2013/Partnering-with-Patients-to-Drive-Shared-Decisions-Better-Value-and-Care-Improvement