Just want to vent on abx overuse

[DogLovingPA]

Saw a patient this past weekend (I'm in UC).  Healthy middle aged female with 3 days of head congestion, completely normal exam.  Reassured her it was all viral and will resolve.  She apparently goes to another UC the next day, is told she has a dreaded "sinus infection" and is given abx.  Calls our office today complaining about how awful we are, how we misdiagnosed her and that she is going to dispute the visit with her insurance company. 

Now I'm not worried about any of that.  But damn I'm mad at the other UC.  I get that this is part of the territory when you work in UC/ER but grrrrr.......    Some days medicine is just damn frustrating.  

Just wanted to vent,  I realize the folks on this forum are not the ones over prescribing just to appease patients. 

[sk732]

If it makes you feel any better, I've been on my backside with an actual sinus infection - 3 days of fever that's now resolving, just been treating with my NeilMed and lots of fluids, seem to be on the upswing finally.  Will be funny when she goes back to the place within 24 hours wondering why she isn't any better :-D.

 

SK

[DogLovingPA]

If we could convince everyone to use NeilMed rinses I think we'd put ourselves out of business!

[sk732]

29 minutes ago, DogLovingPA said:

If we could convince everyone to use NeilMed rinses I think we'd put ourselves out of business!

I honestly wished they had things like that when I was a teenager - I endured horrible sinus issues.  I doubt they'd put us out of business though - there are other things out there that cause antibiotic seeking behaviours...

 

SK

[jmj11]

This is a real problem in society. We must somehow (I doubt if possible) speak with a unified voice. I read about an experiment in Iceland a few years ago (closed and smaller society) where they had a uniform approach in treating URIs without Abx and it worked out great. But each time I'm at a social function (eg. Thanksgiving dinner) I hear people saying the same thing. "I had a sinus infection for a couple of days, went to the ER,  and the idiots DID NOTHING.  Then I went to my doctor and was put on abx the next day." 

[lkth487]

It's a huge problem in pediatrics as well.  We get kids all the time that were treated at outside EDs/Urgent Cares and prescribed antibiotics every time for clearly URI or bronchiolitis (as well as cough medicines, don't get me started on those..).    The problem is that kids get URIs like 6-10 times per year....and now parents have the expectation that their kid will get antibiotics every time he or she has a runny nose and fever.   It's pretty bad.  Especially when I am working in the Pedi ED and parents come in with these expectations...

[sk732]

When I was in FM, there was a mom that literally brought all three of the kids over as soon as one got a sniffle, as "all of them will have ear infections if you don't do something"...to which I said - "If they develop an ear infection, then I'll look at them again - today, one has the sniffles (and under my breath, you are just plain snivelling) and it's viral."  There have been days when I have just looked at people and told them "People like you are the reason antibiotics are prescription drugs"...and they should be reminded that 9/10 times, they likely aren't trained in prescribing them, so stop demanding them.  One dude, about this time 2 years ago, "borrowed a friend's amoxil" when he got the sniffles and wanted more...he'd been sick less than 8 hours.  I gave him a NeilMed sampler and he just looked at me and said "I've waited here for 8 hours and this is all I get?".  I looked at him and said "Since you appear to be a glass half empty sort, then I'd say yes...if you were a glass half full type, you'd have realized you're not nearly as sick as you thought you were and you're being treated appropriately...waiting time=/="reward" with antibiotics for a cold."  That attitude really irkes me actually...I could probably write a book just based on that.

Everyone is in that  "I don't have time to be sick" crowd and want a silver bullet that doesn't exist (even colloidal silver doesn't work all that fast...much less at all, lol).  I called in sick for the first time in over 6 years today because I'm just now getting out of the febrile stage and being able to speak reasonably well and I managed a few hours sleep last night - I knew if I went in today, I wouldn't be on my game fully, might make some sicky sicker and, frankly, would be a lot crabbier than I normally am...though in EM, that's sometimes helpful :-D.

 

SK

[thinkertdm]

After working for the past 9 months in a walk-in clinic, I am convinced that these types of clinics, while making gobs of money, are contributing to the "get better fast" mindset.  In the olden days, you called your nurse, she checked with your doc, who said, "eh, sounds like nothing, wait it out", or "come on in next week".  So you did, and oh my gosh, it was gone.  Now, however, OMGimsickibetterseesomeonerightaway.  Its surprising how many people consider a sore throat an emergency but couldn't care less about their blood pressure.

[sk732]

The BP is a big pharma conspiracy thing...didn't ya know?  Lol

SK

[Boatswain2PA]

8 hours ago, jmj11 said:

This is a real problem in society. We must somehow (I doubt if possible) speak with a unified voice. I read about an experiment in Iceland a few years ago (closed and smaller society) where they had a uniform approach in treating URIs without Abx and it worked out great. But each time I'm at a social function (eg. Thanksgiving dinner) I hear people saying the same thing. "I had a sinus infection for a couple of days, went to the ER,  and the idiots DID NOTHING.  Then I went to my doctor and was put on abx the next day." 

I interject there....you went to the EMERGENCY DEPARTMENT....where they treat EMERGENCIES.  They don't specialize in whether or not your green snot is a bacterial or viral, because either way it won't kill you.

The EMERGENCY DEPARTMENT is for when you think you may be having an EMERGENCY, like a heart attack, a stroke, or you have bone sticking out through your skin.

You wouldn't take your car's battery problem to a tire guy would you? Why did you take your COLD to an EMERGENCY DEPARTMENT!

I don't know if it help or not.....

[Boatswain2PA]

7 hours ago, thinkertdm said:

After working for the past 9 months in a walk-in clinic, I am convinced that these types of clinics, while making gobs of money, are contributing to the "get better fast" mindset.  In the olden days, you called your nurse, she checked with your doc, who said, "eh, sounds like nothing, wait it out", or "come on in next week".  So you did, and oh my gosh, it was gone.  Now, however, OMGimsickibetterseesomeonerightaway.  Its surprising how many people consider a sore throat an emergency but couldn't care less about their blood pressure.

It also has more to do with our culture that provides "free" healthcare to a growing percentage of our population.  If you would have to pay $300 for that clinic visit, you would probably be fine with the nurse telling you to "wait it out" or "come on in next week."  But if your visits are FREE (to you), then suddenly you are less inclined to "wait it out", and instead demand to be seen TODAY!!!

 

[thinkertdm]

35 minutes ago, Boatswain2PA said:

It also has more to do with our culture that provides "free" healthcare to a growing percentage of our population.  If you would have to pay $300 for that clinic visit, you would probably be fine with the nurse telling you to "wait it out" or "come on in next week."  But if your visits are FREE (to you), then suddenly you are less inclined to "wait it out", and instead demand to be seen TODAY!!!

 

Yeah, 99% of the patients are some kind of state sponsored no copay.  And they bring their emergencies to the walk-in, I had a fellow with an spo2 of 81 ( a week earlier it was 98%) arguing with me about going to the ED.  He's in the icu right now, no doubt cursing me because I wouldn't give him his steroids. His son had the gall to ask me to clarify that I wasn't going to do "anything"- yes, I'm going to call ahead to the er. 

It's actually frustrating because my previous job at the VA was a similar to an urgent care, I could order labs and actually use my brain, I loved it, I was seeing people who really needed my help...the stories I could tell-like the 25 yo with pericarditis then I saw some lab abnormalities which turned out to be leukemia of some sort.  The only problem is that the pay was minimal, and I had what I thought would be a great opportunity making nearly double- and I hate it.  Not hate it like I hate creamy peanut butter, but hate it to the point I nearly throw up just thinking about going in the n xt day. I see forty to sixty patients a day, all of whom want antibiotics for their "sinus".  I've been screamed at by a "nurse" who wanted a zpack for her granddaughter, who was not sick.  Real nurses know how to use a thermometer, so sorry lady.

Right now I prescribe a lot of tessalon.  Don't get me started on the Robitussin ac, that's what pcp's are for. 

 

[Guest ERCat]

1 hour ago, Boatswain2PA said:

It also has more to do with our culture that provides "free" healthcare to a growing percentage of our population.  If you would have to pay $300 for that clinic visit, you would probably be fine with the nurse telling you to "wait it out" or "come on in next week."  But if your visits are FREE (to you), then suddenly you are less inclined to "wait it out", and instead demand to be seen TODAY!!!

 

THANK YOU! 90 percent of the patients I see in the ER for the sniffles are patients with “free” healthcare. Sorry if this offends anyone but it’s the honest to God truth.

My strategy for avoiding antibiotics for viral URIs is to act like I am SO relieved to not have to give antibiotics (well, I really am relieved but I really play it up). I will say something like “GOOD NEWS!!! Your Strep test was negative and it looks like this is a virus. The great news about this is we can avoid antibiotics - antibiotics kill off all the good bacteria in the body and can also lead to resistant infections so this is a great thing that we can avoid them!” Then I usually prescribe stuff that they can buy like diclofenac instead of ibuprofen. Terrible but often times in the ER if the patients don’t leave with a prescription they get pissed off like they leave Costco without a free sample.

[CAdamsPAC]

10 hours ago, jmj11 said:

This is a real problem in society. We must somehow (I doubt if possible) speak with a unified voice. I read about an experiment in Iceland a few years ago (closed and smaller society) where they had a uniform approach in treating URIs without Abx and it worked out great. But each time I'm at a social function (eg. Thanksgiving dinner) I hear people saying the same thing. "I had a sinus infection for a couple of days, went to the ER,  and the idiots DID NOTHING.  Then I went to my doctor and was put on abx the next day." 

I'm past disgusted with providers who pass out ABX for left & right for "sinus infections" who are doing something! I couldn't do ER/UC any longer over the incessant demands for ABX and controlled  agents and their "Suits" allies wringing their hands over Press Ganey scores!!

[Anachronist]

After getting a few years into my BS in biology, I realized just how little I understood, and that is growing up in a family of MDs and PhDs. I have come to the conclusion that the greatest failing of the scientific community is the failure to effectively disseminate information the the general public. One of the primary jobs IMHO of any healthcare provider from a MA to a MD, is to educate and communicate with patients (within one's scope of practice of course). You may forget your 10 min interaction with a patient by the end of the day, but they may carry it with them for years. And just a fyi, "doctor" is Latin, and the translation is quite literally "teacher." 

When I find myself being questioned about antibiotics by patients, I always explain that "all medications have unwanted side effects, and common among antibiotics are diarrhea, abdominal cramping, and upset stomach, even in some cases yeast infections and thrush. Further, certain antibiotics work on some bacteria but not others, so it is important to know what bacteria is being treated. So our physicians don't prescribe them unless they are sure of what is causing your symptoms." This is usually acceptable for most patients. But, I did have one who was emphatic that they be prescribed penicillin because "I'm from the generation where penicillin works on everything, I'm not like you, I need penicillin and that new stuff won't work on me." Can't win em all. Also, they did not get penicillin. 

On the "free healthcare patients," the bigger picture isn't that they have free access, it is for most, the "why" they have free access, a profound lack of education is strongly correlated, and I would argue that for many, is causative. Ever the more reason to take the time to help them understand what you are doing and why you are doing it. If you want change, it will come very slowly, and will be the result of providers effectively educating patients. 

[Febrifuge]

I have several really well tuned, carefully written patient info sheets that give the big picture and then go into detail about how no, green doesn't mean bacteria (myeloperoxidase is cool!) or that if you've been sick for a day and a half and you're draining thin clear stuff, you don't have a bacterial sinus infection. But I get good mileage just saying "I mean, the thing is, if I gave you antibiotics today, then you'd have this cold, plus diarrhea, and no real benefit to show for it." 

Similar approach for people who think they need a chest x-ray: "today's Thursday. You've been sick since Monday. I think you sound just fine, you don't have a fever, and your saturation is 100%. If you roar back into your usual good health over the weekend, we would have done an x-ray today for no good reason. If you feel worse next week and it seems like a good idea to get an x-ray then, I'd really feel better about ordering it if it's not your second one in 10 days, y'know?" 

People appreciate knowing that I have a thought process. I cheerfully acknowledge that I'm open to the idea I might be wrong, and in fact it seems to disarm them to find I'm not just some a-hole insisting I must be right. That's followed with the idea that dammit I'm advocating for your health, even if you're not getting what you think you wanted. I'm not going to cause you problems with side effects or unnecessary radiation because I was being a chicken about it. 

People get confused. They sometimes pause, like they know they're supposed to be upset, but they feel cared for and listened to. They seem to kind of admire the way I just denied them without making them feel dumb (because they also suddenly understand they were being dumb). It's a cool thing to see, when it comes together.

[DizzyJ]

I sometimes wish we could report providers for over prescribing antibiotics as we could with narcotics.  Some of the things I see just blow my mind.  Recently I saw a provider document clear URI/cough symptoms and 100% normal exam findings in a young, otherwise healthy, adult.  Did a strep, back up strep PCR, mono, CXR, AND sent patient out on amoxil.  All tests negative.  WTF!  Another provider has prescribed cipro twice in the past two weeks for uncomplicated UTIs in a young, healthy, non pregnant, female.  WTF! Z packs prescribed over and over again for sinusitis and bronchitis.  When patients come in specifically saying "I'm here for a z pack", I want to scream.  Had a provider at another clinic a few weeks ago call my office and ask me what to use for strep if penicillin allergy?!?!? WTF!!

[TWR]

I was let go from a family practice because I didn't given antibiotics out like candy.  "Dr. XYZ" always gives me abx and I get better."  He said I was costing him money because patients said they were going to go somewhere else!!

[sk732]

8 hours ago, Boatswain2PA said:

It also has more to do with our culture that provides "free" healthcare to a growing percentage of our population.  If you would have to pay $300 for that clinic visit, you would probably be fine with the nurse telling you to "wait it out" or "come on in next week."  But if your visits are FREE (to you), then suddenly you are less inclined to "wait it out", and instead demand to be seen TODAY!!!

 

I work in Canada, so people don't have to pay to walk in the door...and the Canada Health Act prohibits me from telling people that aren't actual emergencies to frig off.  In this day and age, if people are getting a bit run down at 0830, they want to be better NLT 0900 - not only unrealistic, but outright developmentally delayed.  When someone asks me for a Z-Pack, I just look at them and laugh - where I used to work we couldn't use it as a first line agent for dinky doo unless it was part of a double coverage, because so many prescribers and prescribees are morons.  I was dealing with a person a week or two ago that had never heard of using a NetiPot for a sinus cold - their doctor never told them to, they'd just give the old person Co-Tridin syrup (Actifed with Codeine - not the best thing in the world for a moldy person with a significant cardiac history and on other things that make them sleepy).  I stand by my old "You Have A Viral Illness" Rx pads I used to use in FM, courtesy of your wonderful CDC.  I'd have the 8.5x11 versions that I'd just photocopy and hand out during flu season with my suggestions written in the "Rx" portion with the diagnosis.  As someone noted, our job is largely education and part of that is telling people stuff they don't want to hear.  When things get a bit hairy, I remind people that I'm not allowed to self prescribe/diagnose for several reasons - what makes them any different?

SK

[GetMeOuttaThisMess]

8 hours ago, thinkertdm said:

Yeah, 99% of the patients are some kind of state sponsored no copay.  And they bring their emergencies to the walk-in, I had a fellow with an spo2 of 81 ( a week earlier it was 98%) arguing with me about going to the ED.  He's in the icu right now, no doubt cursing me because I wouldn't give him his steroids. His son had the gall to ask me to clarify that I wasn't going to do "anything"- yes, I'm going to call ahead to the er. 

It's actually frustrating because my previous job at the VA was a similar to an urgent care, I could order labs and actually use my brain, I loved it, I was seeing people who really needed my help...the stories I could tell-like the 25 yo with pericarditis then I saw some lab abnormalities which turned out to be leukemia of some sort.  The only problem is that the pay was minimal, and I had what I thought would be a great opportunity making nearly double- and I hate it.  Not hate it like I hate creamy peanut butter, but hate it to the point I nearly throw up just thinking about going in the n xt day. I see forty to sixty patients a day, all of whom want antibiotics for their "sinus".  I've been screamed at by a "nurse" who wanted a zpack for her granddaughter, who was not sick.  Real nurses know how to use a thermometer, so sorry lady.

Right now I prescribe a lot of tessalon.  Don't get me started on the Robitussin ac, that's what pcp's are for. 

 

We obviously weren’t at the same VA.  Good lord, folks would drop in if within 10 miles just for an isolated sneeze or one minor cough, but only after clogging the entrance to enjoy one last cancer stick before walking in.  Now, there were some serious folks like the leukemia that I found on one of my first patients on whom the rotating residents had failed to note the progressively increasing WBC count over 20K.  The problem was the darn patient didn’t trust US to know what we were talking about because he felt fine.  It took a paranoid OCD attending and then finally an oncologist to convince him that he was actually sick.

[GetMeOuttaThisMess]

15 minutes ago, sk732 said:

I work in Canada, so people don't have to pay to walk in the door...and the Canada Health Act prohibits me from telling people that aren't actual emergencies to frig off.  In this day and age, if people are getting a bit run down at 0830, they want to be better NLT 0900 - not only unrealistic, but outright developmentally delayed.  When someone asks me for a Z-Pack, I just look at them and laugh - where I used to work we couldn't use it as a first line agent for dinky doo unless it was part of a double coverage, because so many prescribers and prescribees are morons.  I was dealing with a person a week or two ago that had never heard of using a NetiPot for a sinus cold - their doctor never told them to, they'd just give the old person Co-Tridin syrup (Actifed with Codeine - not the best thing in the world for a moldy person with a significant cardiac history and on other things that make them sleepy).  I stand by my old "You Have A Viral Illness" Rx pads I used to use in FM, courtesy of your wonderful CDC.  I'd have the 8.5x11 versions that I'd just photocopy and hand out during flu season with my suggestions written in the "Rx" portion with the diagnosis.  As someone noted, our job is largely education and part of that is telling people stuff they don't want to hear.  When things get a bit hairy, I remind people that I'm not allowed to self prescribe/diagnose for several reasons - what makes them any different?

SK

I preface my recommendation by pointing out the Neti pot on their information sheets that I keep in the rooms and referring to it as the #1 recommended holiday gift idea, and then turn around to watch them frown.  Hmm, must not be TOO sick then.

[DogLovingPA]

Glad I'm in good company.  At least I am lucky enough to work in a place where there is no such thing as patient satisfaction scores.  I am sure my medical director will take a look at the complaint, read my chart, see there was no problem on my end and move on. 

But this aspect of medicine definitely gets exhausting.  But I imagine from a patient perspective, in someone who has zero understanding of medicine it would be highly confusing why one provider gives abx and another one does not.  Which is why I blame the providers, not the patients.  JMJ11, I agree, a unified voice would be amazing, but will likely never happen. 

[BruceBanner]

When you are seeing upwards of 20 colds a day, the temptation to give abx for something even quasi-bacterial gets strong.

I consider myself a fairly conscientious provider, but sick visits suck and are truly one of my least favorite things to do. And some of them are so nebulous. It's not always as black and white as a 2 day cold or a 14 worsening day sinus pressure, pain, etc.

What really never ceases to amaze me is how many people come to the fvcking doctors office for cold symptoms. I am continually amazed at the low level of tolerance for URI sx.

[EMEDPA]

4 hours ago, BruceBanner said:

What really never ceases to amaze me is how many people come to the fvcking doctors office for cold symptoms. I am continually amazed at the low level of tolerance for URI sx.

I have no problem with folks going to see their pcp for a cold. that's better than when they come to the EMERGENCY department at 3 am for 2 days of sniffles...and then complain about the wait...

[BruceBanner]

35 minutes ago, EMEDPA said:

I have no problem with folks going to see their pcp for a cold. that's better than when they come to the EMERGENCY department at 3 am for 2 days of sniffles...and then complain about the wait...

For sure, even worse. I just cant understand that in 2017 people still think there is something the doctor can DO about their cold. I partly blame antibiotic overuse for this mentality.