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Tell me your “no antibiotic needed “ spiel


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I feel like patients are getting more and more rude/demanding or maybe I’m burnt out from urgent care shifts this time of year. 

What’s your typical spiel after you’ve told them they don’t need antibiotics and they start up with the  “I know my body” type statement/upset about not getting abx?

I feel like some encounters end poorly at this point and there is a disconnect between me and my patient. They leave thinking they didn’t get what they came for but also can be  flat out rude towards the provider. How can i do better at this? 

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3 hours ago, FriarMedic said:

I feel like patients are getting more and more rude/demanding or maybe I’m burnt out from urgent care shifts this time of year. 

What’s your typical spiel after you’ve told them they don’t need antibiotics and they start up with the  “I know my body” type statement/upset about not getting abx?

I feel like some encounters end poorly at this point and there is a disconnect between me and my patient. They leave thinking they didn’t get what they came for but also can be  flat out rude towards the provider. How can i do better at this? 

No, they are getting more rude and more demanding- the customer is always right.  I would avoid prescribing antibiotics and telling them to take them if no improvement in x hours- first, I have a suspicion most of these ding dongs just take them anyways, and second, if you didn't think it was bacterial in the first place, would it "turn into" a zpack solvable problem in a few days?  What is your differential and how did you rule it out if you didn't see them?

Here's my thought:

" be nice... until it's time... to not be nice"

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Some things aren't worth the effort.

 I typically give them an explanation about why I think they don't need them, and advise them about the truth of getting better while taking antibiotics most likely being coincidental (it was likely to happen anyway, and now you are giving credit to the antibiotics instead of the body's immune system working as it should).

If they still look at me like I have two noses, I ask them a simple question:

"Tell me my motive for not providing you with the best care?"

If needed, I elaborate, "What do I stand to gain by not taking good care of my patients?  It costs me nothing to write a prescription for anything at the end of a visit, whether it be antibiotics, pain medication, muscle relaxers, steroids, blood pressure meds...etc.  Why would I risk your health by denying treatment that I felt you needed, and open myself up to investigation, ridicule, lawsuits, etc?"

Sometimes you can see the little light go on, other times you have a little drink when you get home, and ponder why you chose medicine instead of engineering.

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Had a pt who is a nurse (in my anecdotal experience MAs and RNs make the worst pts when it comes to ABX) who saw me last week with RAD/post viral cough. (Antecedent URI, no FCS with paroxysmal cough etc.) I gave her reassurance and tessalon. 4 days later she is not better (of course) and went to a doc in a box place that gave her a Zpack. Then she went over my head and emailed my CP. She was saying how she got better after taking the Zpack and that I was negligent because I should have "swabbed me or took a sample to confirm it's a bacterial infection.". She likely just got better on her own since it was at the end of the course. Or Macrolide anti inflammatory effect but I'm betting on the former. He told her that he would talk to me about "individualizing" her care.

 

I told my CP I am not changing my approach to such cases regardless who the pt is. He said "I know it was just 'for the customer service effect'"

 

Having said that it looks like I will be leaving Family med soon... (shhh[emoji6]) details to follow! [emoji16]

 

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37 minutes ago, Joelseff said:

Had a pt who is a nurse (in my anecdotal experience MAs and RNs make the worst pts when it comes to ABX) who saw me last week with RAD/post viral cough. (Antecedent URI, no FCS with paroxysmal cough etc.) I gave her reassurance and tessalon. 4 days later she is not better (of course) and went to a doc in a box place that gave her a Zpack. Then she went over my head and emailed my CP. She was saying how she got better after taking the Zpack and that I was negligent because I should have "swabbed me or took a sample to confirm it's a bacterial infection.". She likely just got better on her own since it was at the end of the course. Or Macrolide anti inflammatory effect but I'm betting in the former. He told her that he would talk to me about "individulaizing" her care.

 

I told my CP I am not changing my approach to such cases regardless who the pt is. He said "I know it was just 'for the customer service effect'"

 

Having said that it looks like I will be leaving Family med soon... (shhhemoji6.png) details to follow! emoji16.png

 

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You should've bronched her since what she coughs up has nothing to do with what is actually cultured from the respiratory tract.  If anyone questions this, I ask them "Why do we no longer ask you to honk up something into the cup, unless I were to think that you have TB?"  One of the better findings over the past half-century in a study in my opinion.  Sputum doesn't correlate to causative agent.

With regard to the antibiotic question and how to address it; in my snot/cough clinic I waggle my index finger around their head and throat and say "approximately 10 days, give or take a day or two".  I then split my index/middle fingers and point at their chest and say "two to four weeks on average to get back to normal."  I then provide them a sheet spelling out what to expect for chest colds/coughs, sore throats w/o an obvious source, and head/sinus complaints.  In each it details the circumstances for which antibiotics are indicated.  Cough?  You don't have pertussis or pneumonia so no.  Sore throat w/o an obvious source and I don't think you have tonsillitis/bacterial pharyngitis?  One week after sx. onset.  Rhinosinusitis?  Bolded and the last sentence states <4% likelihood of bacterial etiology but I provide them the four concurrent symptoms which might imply a bacterial source.  In my setting where I only get to see them once per illness, I provide the antibiotic after stressing above and tell them not to fill it at time of visit in over 95% of cases.  If they fill it, and don't get better after being told what to expect then it's on them.  Previous off the cuff inquiries at time of call back showed ~65% compliance.

Concur that medical providers are some of the worst as well.  BTW, don't forget to suggest a trial of OTC generic store-branded liquid antacid (<$2) h.s. to help alleviate the acidic irritation to the pharynx and help to dispel the throat tickle that induces the h.s. cough.  You guys try it yourself first and see what happens and just remember that you may have heard it here first.

Edited by GetMeOuttaThisMess
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During exam of well appearing people with chief complaint of a cold I tell them (or parents) that I am "looking for a bacterial source of their infection."  As I spent 60 seconds examining them I tell them my findings: "Heart sounds good, Lungs are clear so I doubt pneumonia, ears look clear, oh...I see cobblestoning in the back of Jonnies throat which points to a viral cause.  No nausea, vomiting, diarrhea, or rash?  Good.  Well, Jonny DOES have an infection, but its viral, which is great news because we dont have to RISK all the complications of antibiotics! "

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I’ve petitioned to have this put in the rooms at the UC clinic I work at...

 

Typically I like to educate on antibiotic resistance and it usually falls on deaf ears but some do respond and at least act like the understand it. I like to follow that up with “Now just because you don’t have a need for an antibiotic doesn’t mean we cant try to manage your symptoms while your body does its work” and it seems to work. Tessalon, atrovent nasal spray, coricidin, ect ect... 

 

AF29C78B-9454-4320-B011-D23920C83EA7.jpeg

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I don't know why people with colds even present for care. 

I don't know why parents will have a child vomit once and present for care.

What have we become? We were once a nation of rugged individualists that carved a nation out of the wilderness. Now we are a pack of helpless, fat imbeciles.

Had a pt yesterday who presented with ONE episode of HA last week that resolved with ONE dose of 325 APAP and it has not recurred nor does she have a hx of HAs. She wanted to "discuss headaches" to make sure "I don't have something wrong with my head..." this stuff just writes itself...

 

I am so done with Primary care.

 

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1 hour ago, Joelseff said:

Had a pt yesterday who presented with ONE episode of HA last week that resolved with ONE dose of 325 APAP and it has not recurred nor does she have a hx of HAs. She wanted to "discuss headaches" to make sure "I don't have something wrong with my head..." this stuff just writes itself...

Wait....isn't that what primary care is for?  At least she didn't come to the ED.  Wait....I think I saw her 3 days ago.  I told her to follow up with her PCM.

MODERATORS....can we PLEASE get rid of the delay in posting for confirmed posters??

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1 hour ago, Joelseff said:

Had a pt yesterday who presented with ONE episode of HA last week that resolved with ONE dose of 325 APAP and it has not recurred nor does she have a hx of HAs. She wanted to "discuss headaches" to make sure "I don't have something wrong with my head..." this stuff just writes itself...

 

I am so done with Primary care.

 

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There is something wrong with her head!!

 

1

 

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Having witnessed two deaths related to ABX one of which was my mother, I inform the pt of the lack of indication for  ABX rx at this time. As it's my professional & legally binding responsibility to prescribe medications appropriately, I do believe the line "the patient wanted them" won't hold up in court or in front of the disciplinary board.

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I tend to go off a little bit in the realm of C-diff, massive lifelong diarrhea and death.....  all from an ABX

 

Then just move on.  I no long give much thought to it - it is just what it is

 

Thinking about working in the recent stat that 75% of ALL ABX scripts are not needed....

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26 minutes ago, CAdamsPAC said:

Having witnessed two deaths related to ABX

Have not witnessed a death from it yet, but seen several bad reactions.  Had throat prepped and scalpel in hand for a cric on one case for augmentin rx'd day before by UC for.....sinusitis.  Awesome CRNA got tube passed and transferred to tertiary where she spent about 2 weeks on a vent.  

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50 minutes ago, Boatswain2PA said:

Have not witnessed a death from it yet, but seen several bad reactions.  Had throat prepped and scalpel in hand for a cric on one case for augmentin rx'd day before by UC for.....sinusitis.  Awesome CRNA got tube passed and transferred to tertiary where she spent about 2 weeks on a vent.  

Interstitial nephritis leading to Acute Renal Failure from Cipro took my mother and massive GI Bleed form C Diff took down one of my patients. Quinolones are no joke on the side effects!

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3 hours ago, ventana said:

Ah. No.  

 

ME are calling due to the opioid deaths in mass.  They would not call for a med not written.  This would be an attorney after the fact. 

uhhmmm no, you are wrong

they would call why a bacterial infection was not treated with antibiotics, maybe they are calling you about opioid deaths in mass because you over prescribed, haven't received a single call about opioid death

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