When it comes to medical decisions, it stands to reason that the more information a patient has, the better he or she will be at making the most appropriate choices for their care. The whole idea of informed consent rests on the concept that fully explaining the risks and benefits of any particular treatment or intervention allows people to make the soundest decision they can.
Unfortunately, a new study raises questions about the effectiveness of efforts to educate the public about the proper use of antibiotics. Researchers from George Washington, Cornell, and Johns Hopkins universities surveyed over 100 patients at an urban hospital, and asked them about the use of these medications. As reported in the journal Medical Decision Making, they compared two different kinds of thinking that might cause patients to want antibiotics unnecessarily.
On the one hand, patients may not understand that viruses are the cause of most cold symptoms this time of year. Antibiotics only work against bacteria, a totally different kind of pathogen, and have no benefit for most upper respiratory tract infections. The authors categorized responses that indicated a misunderstanding of possible benefit as “germs are germs” beliefs. On the other hand, patients may not perceive much downside to taking the medications, even if they may not help much. “Why not take a risk?” was how the study termed this thinking.
The results showed that even those who understood the difference between viruses and bacteria were still inclined to seek antibiotics, even if there were to be no benefit. According to Dr. David Broniatowski, lead author of the study, “More than half of the patients we surveyed already knew that antibiotics don't work against viruses, but they still agreed with taking antibiotics just in case.”
The study also showed that most efforts to educate patients focus on the limited benefit of medications, the “germs are germs” side of things, without much attention to the risks. Though it’s important not to draw too many conclusions from a single study with a limited sample size, it does seem to indicate that efforts to educate the public about the appropriate use of antibiotics may be taking the wrong tack.
The problem is that there are indeed serious risks to giving antibiotics to patients who don’t need them. For the individual patient, there is the potential for side effects or adverse reactions. But the risk extends far beyond any given person. The more antibiotics are used inappropriately, the greater the risk of bacteria growing resistant to them. Already I am seeing more and more patients coming in with skin infections that are caused by bacteria resistant to medications designed to kill them, specifically methicillin-resistant staphylococcus aureus (MRSA). While there are a couple of antibiotics that usually work, if they are overused they, too, may cease to be effective.
The World Health Organization warns that a “post-antibiotic era,” in which once-treatable illnesses become serious health threats, is a real possibility for this century. While Ebola has grabbed all the headlines recently despite sickening a mere handful of people in the United States, antibiotic resistant illnesses are a genuine concern for people in this country. The Centers for Disease Control reported that last year over 2 million people Americans were infected by resistant bacteria, and at least 23,000 people each year die of one, mainly hospitalized patients or residents of nursing homes.
That is the answer to the “Why not take a risk?” question. These medications will not continue to work when we need them if they are handed out like candy.
We are in the throes of cold and flu season, and the patients coming to see me these days are apt to be there for some combination of runny nose, sinus congestion, cough, and sore throat. The overwhelming majority of them have viral illnesses, and get the same vaguely resigned answer from me—this will simply have to get better with time. A fair number explicitly ask for an antibiotic, to cover the possibility that it is “bronchitis” or a “sinus infection.” I still tell them no, even if it means that some of them leave as unsatisfied customers.
The good news is that, when I take the time to explain about things like antibiotic resistance, as well as the distinction between viruses and bacteria, most of my patients understand why I am sending them home without a prescription. It takes more time and effort (which is why getting a script may not mean you’re getting better care, just that your medical provider is lazy and/or pressed for time), but in the end it usually pays off. Unlike with vaccine refusers, who are apt to cling to their benighted beliefs in spite of increased education or even outbreaks of illness in their area, I’ve found that many people can be convinced to let their immune systems do their work when given enough information.
The GWU study didn’t examine this kind of more personalized education, merely efforts to educate the public at large. Perhaps more information focused on the threat of antibiotic resistance will be more effective in reducing the demand for needless medication. But even if changes in how the information is disseminated broadly fail to make a dent in the number of requests I get, my approach will remain the same. Antibiotics are too precious a resource for me to give them out for illnesses that don’t warrant them, and I’ll say it as often as I need to.