10 Sep 2014
Written by Jonathon Tomlinson
The Longitude Prize will launch in the autumn with the aim of rewarding innovative diagnostic solutions that contribute to a reduction in antibiotic resistance in bacteria. One of the major perceived causes of resistance is ineffectual or inappropriate prescription of antibiotics; last month’s survey of General Practitioners highlighted a few of the challenges of prescribing effectively in primary care. While any test that helps to more easily form a diagnosis is helpful, a GP’s job is much more than simply telling a patient what is wrong.
A common medical saying is that one should ‘treat the patient, not the test result’. We know, for example, that even in the presence of streptococcal infection, sore throats usually resolve without antibiotics. This was behind some of the scepticism with which doctors greeted the introduction of a rapid antigen test in general practice. My experience of using Centor criteria (a scale used to identify the presence of bacterial infection for sore throats) to guide antibiotic prescribing is that it lowers the threshold at which I am likely to offer antibiotics, so I rarely use it. Doing tests to reassure patients is intuitively appealing, but the evidence suggests that it can be ineffective if the patient’s underlying concerns are not sensitively handled. A simple diagnostic tool could help in many situations, but a decision to prescribe is made within the complexity of clinical practice, which is bound up in human relationships and social contexts.
In one study from 1976, GPs were found to be far more likely to prescribe antibiotics if they expected patients to have difficulty getting to the practice, if they had an exam or travel commitments the next day or if a sibling was in hospital with pneumonia. I used to look after an opera singer who expected antibiotics within hours of every sore throat, and was very upset when I attempted to challenge this. I was relieved to read in a study published this year that I wasn’t alone in prescribing antibiotics to avoid an unpleasant confrontation with patients. I work with an ethnically diverse group of patients who have very different cultural expectations due, among other things, to widely varying rates of antibiotic prescribing in their home countries. It would be interesting to know more about why this happens.
One way that doctors try to avoid conflict is to use examinations to build a rapport with patients – the strength of the rapport influences whether they are able to take control of the decision to prescribe. The clinical examination is often used as a time for reflection or an opportunity to uncover patients’ hopes and fears. In a study from 2002, GPs who were least likely to prescribe antibiotics were more likely to be older, to spend longer with patients and be more interested in their relationships with patients. Those who prescribed more often described their role with patients in terms of a ‘professional service’ or a business exchange. Interestingly they were also more likely to describe themselves as being ‘firm believers in evidence based medicine’ than their peers who prescribed least. Low prescribing doctors had a more relaxed attitude to evidence, being less likely to attend educational meetings and were less concerned with labelling symptoms with a diagnosis.
Continuity of care enables doctors and patients to get to know and trust each other and also increases the likelihood that antibiotics will be prescribed prudently. Continuity and mutual trust can make a brief consultation successful, but lack of continuity can eliminate the effects of knowledge and professional skills. One reason that parents expect antibiotics when they (or their children) have a cold or a sore throat is that they lack confidence in their ability to cope. A negative test result doesn’t make a pale, feverish and lethargic child suddenly well, but a known and trusted doctor might be able give parents the confidence they need to cope without a prescription.
The Longitude Prize is offering a very important contribution to the goal of more prudent antibiotic prescribing, but every test is applied to a unique individual in a complex social context – entrants should be able to demonstrate an understanding of the complexities of real-life clinical decision making.
