The most difficult conversation that this doctor' faces is when she declines to prescribe inappropriate antibiotics for a patient who wants them.
I listened intently to her history - her symptoms, how long they’d been going on, how they’d had an effect on her sleep and activity, and the failure of over-the-counter medications to ease her suffering. Next, I completed a careful exam, looking for clues as to the cause of her ailment. Once finished, I touched her lightly on the shoulder and indicated that she could take her seat. Taking an imperceptible sigh, I mentally prepared myself for the news I had to deliver. She would not like it. She may even express denial and anger. It was entirely possible she would seek a second opinion since I wasn’t going to be able to give her the treatment she specifically requested at the opening of our visit. Steeling myself against her probable disappointment, I began, “You have bronchitis which is usually viral. You do not need antibiotics.”
The no-antibiotics talk with patients is one of the most challenging ones that I face. So much information needs to be conveyed before their minds close and they decide you are a quack. First, I need to reassure my patient that I’ve heard the history clearly. It is imperative that I express empathy. Even though a sore throat is minor on the list of medically bad things that can happen to you, we’ve all been there when our throat is so painful that each breath and swallow is a constant reminder of our suffering. Next, I explain my physical exam findings with both the important negative and positive aspects. Then I will discuss the lack of a role of antibiotics to treat viral infection. Finally, I will list the possible consequences or side effects associated with inappropriate antibiotic prescribing and describe what we can do to help with symptoms.
Reaction is usually mixed. Some patients express relief that you’ve made the diagnosis and have a clear treatment plan. An increasing number of patients have already heard the message that antibiotics have no role in the treatment of viral infections and start nodding before you’ve even completed your explanation. Some will narrow their eyes into slits, silently questioning your competence. A few will become angry, demanding antibiotics or threatening to seek them elsewhere.
Thinking about all the difficult conversations I have with patients about a new cancer diagnosis, a newly diagnosed congenital anomaly in pregnancy, and end-of-life discussions, it is somewhat surprising that the one most likely to cause my stomach to flip-flop is one in which I decline to prescribe inappropriate treatment for a patient who is convinced that is what they need. These conversations can be easier, here are a few important tips.
1. Make sure to listen and complete the examination carefully both to provide good medical care and to demonstrate to the patient that you are being thorough.
2. Express empathy for their experience. While not life-threatening, colds make us feel rotten.
3. Explain your reasoning with confidence.
4. State what you can do to help them feel better.
5. Discuss the potential negative impact of inappropriate antibiotics for them personally (most ill people do not really care all that much about the threat of antibiotic-resistance in the larger population).
6. Above all, do the right thing, so that none of your patients will say to another doctor, “But, Dr. Frank always prescribes me antibiotics for bronchitis.”