In this cough, runny nose and colds season, I cannot find any more befitting time to publish this article, that I first wrote for kevinmd.com last month in honor of the National Antibiotic Awareness week here in the US (November 12-18) It has become such a huge problem, that I am planning a TEDx talk on this topic in 2019 (stay tuned). I feel helpless sometimes, worse still, I feel hopeless most times when I think about the future of our world, our universe with antibacterial resistant germs aka superbugs. As a pediatrician, I have continued to experience a huge pushback from parents, and it is mostly NOT their faults. WE, care providers (Doctors, Midlevels, Pharmacists, Nurses, Medical Students, Residents) have all played major roles in what I call “excessive antibiotic prescription syndrome, or excessiveantibioticprescriptionitis“, #ANOTHEROPIOID-LIKEEPIDEMICANYONE?
These days, no one waits for the body’s immune system to work anymore, no one waits to see if the child or adult for that matter, can fight the infection anymore, no wonder our generation is getting less and less able to fight even the most mundane of infections. We are ALL in a rush to get better, real fast, so we continue to perpetuate the behavior.
For those of you who have been following my story since this summer of 2018, you will remember that I quit my nine-to-five job to pursue a carrier in public speaking on a more semi-permanent basis. I started working part-time with a National Telemedicine company. I am extremely excited about the opportunity and I am very satisfied with the options it has given me to stay home, as I complete my Executive MBA, as well as spend time with the family, a rare opportunity that I have never had in my entire adult working life of almost 30 years. I have realized that there is more to life than working for the man. I have gotten to know my children again. For instance, my eldest son who is a junior at Stanford University came home for 2 weeks this summer and I was able to spend time with him one-on-one. I got to meet the man that he has become and got to know him on a totally different level. In essence, he left my home almost three years ago as a boy and came home this summer as a man. And I am eternally grateful for the opportunity, but I digress.
Unfortunately, this blog is not about me and my children, it is about the fact that in the last 16 weeks, with this new and fun experience of independence and a new way of practicing medicine (for me), has come a new revelation that is rather disturbing. The following, are 11 quotes from my telemedicine patient/parent encounters that have recurred pretty much since my days in private practice but more so in the past few weeks.
“Hello, doctor, my son has had a fever for 4 days now, is there a way we can get an antibiotic for that, please? Thank you.
“Ma’am, I know my body very well, and I know that when I get like this, the only thing that fixes it is an antibiotic”
“Her cough is really deep, and she has greenish-yellow mucus, I think she needs an antibiotic”.
“My children have been running fevers off and on for about 3 days now, the last time they were like this the other doctor gave us an antibiotic and it worked, can we have it again this time?”
“All the other doctors we have spoken to have given us antibiotics I don’t understand why you won’t”.
“Are you saying you’re not going to treat my child?”
“…and what if his stomach doesn’t get better in two days, does he now get an antibiotic at that time?”
“So, how long does he continue to cough before he gets an antibiotic?”
“Can my little girl get an antibiotic for a pink eye? I know it’s a virus but I feel like an antibiotic will help, it did the last time”
“Sir, simply look back at our records, you will see that she gets antibiotics every time she has a ‘sinus infection’, that is the only thing that works for her when she gets like this”
As doctors, we all know that antibiotics are good, but they can also cause life-threatening problems when used recklessly, or when used excessively. However, in my opinion, I do not believe that we have done our due diligence in educating our patients and their parents appropriately to this point, hence their constant reliance on antibiotics for improvement of symptoms regardless of etiology. Even if we have done a fair enough job so far, I believe there’s a need for persistence and insistence on daily teaching of ourselves, our mid levels, our patients, trainee residents, and the entire medical team about the dangers of antibiotics, and especially, the dangers of their over-prescription. At this point I feel like we have to proceed with reminding ourselves; one doctor at a time; one trainee at a time; one pharmacist at a time, and one midlevel provider at a time, about the need for hypervigilance in this matter. I dare add a quick reminder that Sir Alexander Flemming himself said “ The greatest possibility of evil in self-medication with penicillin is the use of too-small doses, so that instead of clearing up the infection, the microbes are educated to resist penicillin and a host of penicillin-fast organisms is bred out which can be passed onto others until they reach someone who gets a septicemia or pneumonia which penicillin cannot save. In such a case the thoughtless person playing with Penicillin treatment is morally responsible for the death of the man who finally succumbs to infection with the penicillin-resistant organism. I hope this evil can be averted”.
I find this quote extremely inspiring, however, even though his original fear was for under-dosage of penicillin, our problem today entails both underdosing and overusing. As much as I worry about my patients who have confided that they “shared the Amoxicillin meant for one child among the three children” or they “used the left-over Omnicef from last time, this time, because little “Misty” had the exact same symptoms as little “Joe” did the when he was sick”, hence perpetuating underdosing behavior, this write-up is mainly about overuse of antibiotics, and not only in humans, but also in livestock (something I rarely think about) In a 2015 paper, Business Insider wrote that in her TED talk, Maryn McKenna, a journalist, had cried out about the excessive use of antibiotics to fatten farm animals and prevent them from getting sick, thus causing widespread presence of antibiotics in circulation, leading to bacterial exposure to inappropriate doses, and therefore, resistance.
In a recent article published by the Journal of Antimicrobial Chemotherapy titled “antibiotic treatments and use in hospitals and long-term care facilities” it was observed that 30% to 50% of antibiotics prescribed in hospitals are unnecessary or inappropriate”, thus underscoring our own contribution to the situation. In that article, they refer to the term “antibiotic stewardship” as a process of evaluation and optimization of antibiotic use. It is being increasingly promoted as a means to reduce antibiotic resistance, adverse events, treatment complications and costs within institutions. Unfortunately for us practicing physicians, the recent WIRED article from March 2018 titled; The Yelping of the American Doctor by Maryn Mckenna, indicates that 2 million Americans are sick yearly from antibiotic related issues, and calls out us doctors as being part of the problem, when we write antibiotics for viral infections and or we give low-doses, the wrong dose, the wrong directions for use, or the wrong antibiotics for the ailments. It further points out that all of these factors contribute to the patient being sick, and developing antibiotic resistance and that antibiotic resistance costs the US 2.2 billion dollars in medical expenses yearly. Pressure and fear of bad online patient satisfaction scores are the main reason given by doctors that were surveyed for writing unnecessary antibiotics, as evidenced by the just-released NPR article titled Patients Give Doctors High Marks for Prescribing Antibiotics for Common Sniffles which notes that patients felt more satisfied with their doctors’ visits when they received antibiotics for upper respiratory tract infections, whether they needed it or not. As a result, doctors are now writing prescriptions for the patients who for the most part do not know what they’re asking for or why. Some of the other reasons cited include physician fatigue at the end of the workday and “just-in-case” situations like those that arise at the urgent care settings or with a new patient in the office.
The struggle is real for us doctors. One time I found myself arguing with a patient’s mother on the phone, who according to her, knew her child’s body and knew that “only an antibiotic would fix the problem”. She got really upset because I essentially refused to give her 17-year-old daughter an antibiotic prescription for a maternally diagnosed “sinus infection” after 4 days of symptoms of nasal congestion and cough. She challenged me and actually threatened to lodge a complaint against me, to which I gingerly informed her that I would be glad to do the same, and I did. I stood my ground and refused to give her what she wanted, strictly because her child did not need it, prompting her to declare that she would simply call back and get another doctor and would get her way!
Luckily for me, these experiences have not deterred me, over time, I have persisted and continued on my mission to educate my patients, and more and more of them are now doing better with listening to me and trying to understand my reasoning. Many of them actually thank me, happy that someone took some time to explain the proper reasoning to them. On my part, I always end the talk by empowering them to take a moment next time their provider prescribes antibiotics for themselves or their children, to respectfully ask that burning question: “doctor, does my child really need those antibiotics?”
As a Nigerian-born physician, the plight of my people in the third world countries has not escaped my mind. In Nigeria, like in most developing countries, people still generally walk up to the chemist or pharmacy and purchase medications over-the-counter, antibiotics included. That behavior, in addition to the lack of effective government regulations amongst other issues with healthcare delivery, puts us all in even greater danger of antibiotic resistance and further underscores the fact that in September of 2017, the World Health Organization described antimicrobial resistance as “a global health emergency”.
Finally, I am writing this piece as a gentle reminder to each one of us to remember our Hippocratic oath “to first do no harm”, to educate the patients repeatedly until it sticks… and never tire in doing so. This, I say is one time we MUST all stick together and speak with one voice. Otherwise, it puts some of us who still do so, in a weird light. Sometimes it might be necessary to be firm and insist on doing what is right in order to practice good medicine. And in case you are thinking otherwise, always remember that never has it been known that a defendant told his defense attorney exactly how to defend him in court. Our patients should neither be telling us how to treat them, nor threatening us, nor grading us better, based primarily on antibiotic prescriptions.