Doctors, why aren’t you on twitter yet?

Dr Ashleigh Witt is a Melbourne based doctor who is training to be a geriatrician and writes about her experiences on her blog. Follow her on twitter. If you work in healthcare and have a blog topic you would like to write for doctorportal, please get in touch.

Our presence as doctors online is no longer optional. This is a lesson the college of obstetricians and gynaecologists (RANZCOG) learnt on January 2. The Australian Doctor posted this, and the internet exploded:

Doctors, why aren't you on twitter yet? - Featured Image

Unfortunately, as RANZCOG had no media presence and very few actively tweeting fellows, there was no one to rebuke the claims that the college was ‘sexist, misogynist and ignored trainees human rights’. RANZCOG is actually the college that allows the most flexible training regime for doctors becoming parents – but on twitter, as in real life, you can’t defend yourself in a conversation you’ve declined to participate in. The best summaries of the events are here by Dr Eric Levi and here by Dr Nikki Stamp.

We’ve all seen the dangers of using of social media, but to me this highlights the risk of not using it. Whilst there are many ‘guidelines’ available, very few do anything to convince doctors to join the conversation. A few of these guidelines include the AHPRA guideline, this 2011 MJA article, and the RACGP guideline (the only one of which, actually alludes to the benefits of social media).

I am a GenY doctor, which I define as doctors who are in training between the years of 2005 and 2025. More than 90% of GenY’s log into social media every single day and we’ve never gone a day as a doctor without our mobile phones. But despite social media’s huge role in our lives, it is almost non-existent in medical education, with just one lecture in all of my training which involved someone reading out the ‘social media guidelines’.

In my opinion, this isn’t teaching, this is risk management. After all, how can you teach something as living and breathing as social media with something as rigid as a guideline?

Guidelines seem to at worst insult our intelligence, and at best state the obvious. ‘Don’t post photos of yourself doing illegal things’ and ‘Don’t post identifiable information about patients’ are covered by common sense. I once saw a poster in a hospital that said ‘Never post anything related to work online’. What does that mean? Don’t mention medicine?

I have friend in IT who would say that it’s impossible for two doctors to talk about anything other than medicine when they get together. So then, is it best to avoid Twitter and if we do use it, not post about medicine?

This is where the guidelines betray us. They imply that extreme caution and ideally abstinence from social media is the best course of action. I disagree entirely.

Let me tell you about twitter

Last week, I participated in a robust discussion about why we hate using the word ‘acopia’ in reference to frail patients presenting to ED. This topic was passionately debated between a geriatrician, a palliative care physician, a med reg, 2 GPs, a medical student, an anaethetist, an ED reg, 2 paramedics and a surgical HMO. We all walked away having learnt new phrases, new skills and new ideas to improve our care.

The night before we discussed mental health in doctors. A week before we discussed opiate rotation in palliative care. Other recent discussions have included euthanasia, the review to MBS, when to have children during training, antibiotics in septic joints and bullying in medicine.

Every time I log in to Twitter I am presented with a discussion on par with a National Conference Panel. If we don’t know an answer, we tag in someone who does. Doctors from every speciality and every country are represented, as well as nurses, administrators, allied health and researchers.

The benefits don’t end there. I recently wrote a blog that was read over 20,000 times, just from sharing it on twitter. Another time I was contacted by the editor of a state newspaper to ask if they could publish a blog I’d read on twitter. I was also contacted via twitter to speak at a conference.

I often read journal articles long before any of my work colleagues because they’ve been posted on twitter by the doctors in that speciality. Imagine social media where whilst ‘wasting time online’, you got caught up on all the latest evidence based practices – that’s what twitter is.

I read tweets from frustrated patients who want such simple things from their doctors. I read the frustrated tweets of colleagues in different departments and have discussed many times what each speciality want to hear in a referral. I really think these things make me a better doctor.

If I were allowed to teach med students or doctors how to use Social Media, I’d have everyone make a twitter account with the following for homework then meet again after a week:

Start off your account by adding a photo and a bio
Follow 5 new health professionals per day whose timelines interest you
Retweet something at least 1 tweet per day
Tweet 1 original tweet that includes a link per day
Contribute something to a medical hashtag or participate in a ‘tweetchat’ like #hpm or #nephjc
Ask a question and participate in the discussion that follows

I suspect this would teach them more than a rigid guideline could. I’d also give them my post ‘Dr Ash’s Twitter rules‘

This blog was previously published on Dr Ashleigh Witt’s blog and has been republished with permission. If you work in healthcare and have a blog topic you would like to write for doctorportal, please get in touch.

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Severe ulcerative herpes zoster

A 78-year-old man presented to a regional emergency department with a severe progressive rash, on a background history of chronic lymphocytic leukaemia, dementia and malnourishment.

The rash was multidermatomal, with patchy areas of ulceration, crusting, excoriation and necrosis (Figure, A and B). Active bleeding, seborrhoeic discharge and occasional vesicles were also noted, extending to the left pelvis. Subsequently, the patient developed concurrent Pseudomonas aeruginosa cellulitis and bacteraemia.

Punch biopsies were non-specific with dermal necrosis, excoriation and possible lichenoid reactivity. However, swabs revealed varicella-zoster virus. The patient was successfully treated with intravenous piperacillin–tazobactam, intravenous acyclovir, normal saline (0.9% sodium chloride) washes, and 50% liquid paraffin with 50% white soft paraffin cream (Figure, C and D). Multifactorial immunodeficiency was deemed to be the aetiology.

Figure

Public hospital performance stagnating due to lack of funding: AMA

The Australian Medical Association has launched its Public Hospital Report Card 2016, and says results point to an imminent crisis.

The report card shows key performance measures such as emergency department waiting times, elective surgery waiting time and bed number ratios have either deteriorated or are stagnant.

AMA President Professor Brian Owler said these results are a direct consequence of reduced funding from the Commonwealth.

“The States and Territories are facing a public hospital funding ‘black hole’ from 2017 when growth in Federal funding slows to a trickle,” Professor Owler said.

“From July 2017, the Commonwealth will strictly limit its contribution to public hospital costs.

“Growth in Commonwealth funding will be restricted to indexation using the Consumer Price Index (CPI) and population growth only.

“Treasury advised the Senate Economics Committee that this change will reduce Commonwealth public hospital funding by $57 billion over the period, 2017-18 to 2024-25.

“As a result, hospitals will have insufficient funding to meet the increasing demand for services,” Professor Owler said.

The current report card shows that:

Hospital bed to population numbers have remained constant despite there being an increased demand for hospital services
68% of emergency department patients classified as urgent were seen within the recommended 30 minutes. The target for this is 80%
Under the National Emergency Access Target (NEAT), 90% of patients should be treated within four hours of presentation to an Emergency Department. In 2014/15, only 73% were treated in this time frame.
Under the National Elective Surgery Target (NEST), 100% of all urgency category patients waiting for surgery should be treated within the clinically recommended time however in 2014-15, 78% of elective surgery category 2 patients were admitted within the clinically recommended time (within 90 days).

Professor Owler believes it’s a lack of focus on public hospitals since the 2014 budget that has led to poorer outcomes.

He told ABC Breakfast: “The incentives and funding was there for infrastructure and [indistinct] ward funding was all taken away. And, naturally enough, we’ve seen these performances stripped backwards.”

He also said emergency departments are under increased stress with an increase of patients.

“We’re seeing more and more patients present to emergency, and they’re not GP-type patients; these are higher triage category patients, they’re sicker patients. These are the patients that are actually – represent the growth in the presentations to our hospitals.”

Related: Hospital cuts cloud reform outlook

Opposition health spokeswoman Catherine King said the government’s decision to walk away from Labor’s funding agreement with the states and territories would lead to further increase in emergency department wait times and big increases in elective surgery wait times.

“Patently, the current arrangements are inadequate and demonstrate that this government has no interest in health reform or ensuring every Australian has access to high quality hospital care,” she said in a statement.

Health Minister Sussan Ley has previously denied the AMA’s claims that multi-billion dollar “black hole” for hospitals.

“What we are focused on in the Federal Government — and what all governments should be — is efficiency,” she said in April 2015.

“Let’s get the best bang for our dollar, wherever it goes.”

The AMA Public Hospital Report Card 2016 is available at https://ama.com.au/ama-public-hospital-report-card-2016

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From riches to riches: the effect of affluent medical students on patients

Thousands of bright-eyed and bushy-tailed students recently found out whether they had been accepted into Australian medical schools.

Selection is a highly competitive process, requiring an impressive combination of high secondary school results (ATAR/GPA), high results on various medical admissions tests (UMAT/GAMSAT), cogent personal statements and/or performance in multiple mini interviews. Only the most successful students are selected.

As selection interviewers for an Australian medical school, one of our scripted questions was “How have you helped disadvantaged people?”. A memorable candidate began, “well, our family has a maid…”.

Other applicants told stories of well-intentioned overseas trips to help “poor people” in other countries. Strikingly, of the nearly 20 aspirants we interviewed, none told stories of socioeconomic disadvantage involving themselves, family or friends.

Although we cannot say whether these students were selected, it is likely some of them were. These well-to-do students will become the future of our medical system.

About two-thirds of Australian medical students come from affluent backgrounds. Fewer than one in ten come from low socioeconomic status backgrounds. This is unsurprising as selection criteria such as ATAR and personal statements are known to be biased against low-socioeconomic-status candidates.

Universities have created special access schemes, and tests such as the Undergraduate Medical Admissions Test (UMAT), Graduate Australian Medical School Admissions Test (GAMSAT), personality tests and interviews which are supposed to reduce bias against low-socioeconomic-status candidates.

However, low-socioeconomic-status applicants are still less successful than their high-socioeconomic-status counterparts at getting into medical schools, perhaps due to the lack of access to role models, support, and opportunities necessary. Females from low socioeconomic backgrounds are the most disadvantaged.

Consequences for patients

Socioeconomic status is associated with important differences in values and beliefs.

Two families recently delivered very premature newborn babies who needed life support. If the babies survived, they were faced with a high chance of disability requiring lifetime care.

The families came from different socioeconomic backgrounds, and expressed different concerns. The parents who were struggling with money said they would not be able to afford the high costs of looking after a disabled child.

The well-off parents expressed they were worried the child’s disability was going to be so severe their child’s quality of life would not be worth putting the child through the intensive and traumatic treatments.

Although both sets of parents wished to withdraw care, they were perceived and treated differently by their health team. One set of parents was eventually referred to child protective services, and the other family had their wishes carried out.

This example highlights the difficulties in shared decision-making when values and priorities are different, and the extent of their impact. People with lower socioeconomic status consistently have poorer health and are more likely to die earlier than their more affluent counterparts, and are less involved in medical decision-making.

Conversely, patients with higher socioeconomic status tend to be more assertive, take an active role in their medical management and receive more explanations.

Selecting a medical community with such differences in socioeconomic status to the Australian population (in which only 25% of people are classified as affluent) holds the risk that the patients they serve have contrasting priorities, values and life situations to their own.

It is human nature to feel more comfortable with, and be more persuaded by patients who hold similar values and articulate them in a familiar way. Patients who have divergent preferences or goals of treatment may have their intentions misconstrued or experience conflict with their doctors.

What can be done?

Medical schools should continue refining medical selection processes to give students with lower socioeconomic status a fair opportunity to become doctors. The medical fraternity and patients would be better off with a broader representation of doctors from different backgrounds.

Doctors do not need to have the same backgrounds as their patients to deliver good care, but they should strive to understand and respect their patients’ needs, expectations and values when delivering health care. Doctors should be aware of the effects socioeconomic status has on the doctor-patient relationship and that patients’ intents and styles of communication may vary from their own.

Much emphasis has been placed on “cultural competency”, but this is often framed in racial, linguistic, ethnic and religious differences. The medical profession is more aware of the possibility of value conflicts when patients speak a different language or have a different ethnic, racial or religious background to their own.

However, when a patient shares the same language or culture, there is an unsaid assumption that there will be common understandings. Expanding these lessons to socioeconomic status is essential to creating a system that serves those who need it most.

Evelyn Chan, Medical doctor (paediatrics and public health), Royal Children’s Hospital and Paul Leong, Doctor, Monash Health

This article was originally published on The Conversation. Read the original article.

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Sepsis early intervention saves lives, NSW study finds

An emergency room program that helps speed up the time it takes for patients to be treated with sepsis has been found to be successful.

The ‘SEPSIS KILLS’ program aims to reduce sepsis deaths by recognising the condition early and managing it promptly.

The program was introduced in 2011 to 97 NSW emergency departments and data from 13 567 patients were collected for the period 2011–2013.

According to research published in today’s Medical Journal of Australia, the sepsis death rate decreased from 20% in 2009 – 2011 to 14.1% in 2013 thanks to the introduction of the program.

Sepsis was involved in 17.5% of in-hospital deaths in 2009 in NSW and is one of the most common causes of clinical deterioration, causing more deaths than prostate cancer, breast cancer and HIV/AIDS combined.

Related: Act fast on sepsis

Authors Mary Fullick, Sepsis Program Lead at the Clinical Excellence Commission (CEC) in Sydney, Professor Mary-Louise McLaws, at the University of New South Wales, and colleagues wrote in the paper: “The focus of the program is to recognise risk factors, signs and symptoms of sepsis; resuscitate with rapid intravenous fluids and antibiotics; and refer to senior clinicians and teams.”

Since 2011, the changes include:

Proportion of patients receiving intravenous antibiotics within 60 minutes of triage increased from 29.3% in 2009–2011 to 52.2% in 2013
The percentage for whom a second litre of fluid was started within 60 minutes rose from 10.6% to 27.5%.
The number of sepsis patients being treated immediately had increased from 2.3% in 2009 to 4.2% in 2013.
The number of patients treated within 10 minutes of arrival increased from 40.7% in 2009 to 60.7% in 2013.
There were also significant declines in time in intensive care and total length of stay.

As a result, NSW public hospitals have begun extending the SEPSIS KILLS program to inpatient areas and have introduced a 48-hour management plan for ward patients.

The authors conclude: By focusing on the principles of “Recognise, Resuscitate, Refer” it is possible to reduce the time it takes to start antibiotics and fluid resuscitation. This program could be applied in other jurisdictions and its integration with antimicrobial stewardship requirements should be considered.”

Read the research in the Medical Journal of Australia.

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New prostate cancer clinical guidelines launched

Australian health professionals will now have access to evidence-based recommendations for using the prostate specific antigen (PSA) blood test to assess prostate cancer risk in patients.

The PSA Testing and Early Management of Test-detected Prostate Cancer: Guidelines for health professionals were developed in partnership with the Prostate Cancer Foundation of Australia (PCFA) and Cancer Council Australia and have now been approved by the National Health and Medical Research Council (NHMRC).

PCFA Chief Executive Officer, Associate Professor Anthony Lowe said contention about the PSA test has made it difficult for health professionals to take a consistent, evidence based approach to the test.

“The guidelines cut through the contention and provide guidance in relation to an individual man’s circumstances and on how to manage a patient if he requests and consents to taking the test,” he said.

The recommendations include:

Men considering a PSA should be given information about the benefits and harms of testing.
Men with an average risk who have decided to undergo regular testing after being informed of the benefits and harms should be offered PSA testing every 2 years from age 50-69. If the total PSA concentration is greater than 3ng/mL then further investigation should be offered.
Men over 70 who have been informed of the benefits and harms of testing and who wish to start or continue regular testing should be informed that the harms of PSA testing may be greater than the benefits of testing in their age group.
Men with a father or one brother who has been diagnosed with prostate cancer has 2.5 – 3 times higher than average risk of developing the disease. If these men have decided to undergo regular testing after being informed of the benefits and harms, they should be offered PSA testing every 2 years from age 45 to 69.
Men with a father and two or more brothers who have been diagnosed with prostate cancer have at least 9 to 10 times higher than average risk of developing the disease. If these men have decided to undergo regular testing after being informed of the benefits and harms, they should be offered PSA testing every 2 years from age 40 to 69.
In a primary care setting, digital rectal examination is not recommended for asymptomatic men in addition to PSA testing however this may be an important assessment procedure if referred to a urologist or other specialist for further investigation.
Mortality benefit due to an early diagnosis of prostate cancer due to PSA testing isn’t seen within less than 6-7 years of testing so PSA testing isn’t recommended for men who are unlikely to live another 7 years (subject to health status).
A PSA testing decision aid for men and their doctors is under development by PCFA and Cancer Council Australia.

Other recommendations also include further investigations if the PSA concentration is above 3 ng/mL; prostate biopsy and multiparametric MRI; active surveillance and watchful waiting.

The report says there is no evidence to support a national PSA screening program to all men of a certain age group.

Cancer Council Australia CEO, Professor Sanchia Aranda says use of the guidelines will hopefully reduce the level of over-treatment.

“The NHMRC’s Information Document for health professionals, recommended as a companion document to the guidelines, estimates that for every 1000 men aged 60 with no first degree relatives affected by prostate cancer who take the test annually for ten years, two will avoid a prostate cancer death before the age of 85 as a result. Yet 87 men will receive a false-positive PSA test result and have an invasive biopsy that they didn’t require –28 will experience side-effects, including impotence and incontinence, as a result of this biopsy, and one will require hospitalisation.”

PSA Testing and Early Management of Test-detected Prostate Cancer: A guideline for health professionals is available for download at www.pcfa.org.au and wiki.cancer.org.au/PSAguidelines.

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Stillbirth risk twice as high for disadvantaged women

Women from low socio-economic families have twice the risk of delivering a stillborn baby than those from wealthier backgrounds, an Australian-led international study has found.

The Lancet’s Ending Preventable Stillbirths series reports that over 200,000 stillbirths worldwide could have been prevented in 2015.

Although Australia ranks 15th lowest in the world, it has a stillborn rate that is 2.7/1000 total births, double the rate of Iceland which comes in at the lowest rate of 1.3 stillbirths/1000.

Experts in the field believe that more can be done to help prevent stillbirth and over 200 stillbirths each year could be prevented in Australia.

Philippa Middleton from the University of Adelaide said migrants, Indigenous peoples, people on low income, those with low education and early teenagers all were found to have double the risk of stillbirth.

“During pregnancy it might be about how good your access to antenatal care is, whether you have to travel to get good care and whether your mental health is all that it might be,” she said.

The causes are varied, including the fact that some disadvantaged women aren’t as empowered to make choices.

Associate Professor Vicki Flenady from the Mater Research Institute at the University of Queensland said the lack of appropriate care is a big factor.

“The lack of provision of culturally sensitive care that results in women not attending for care and complications not being picked up. We know poor antenatal care is certainly a risk factor for stillbirth.”

There are other major risk factors that are also at play, including smoking, being overweight or obese and fetal growth restriction which many care providers don’t know enough about.

Professor David Ellwood, a Professor of Obstetrics & Gynaecology at Griffith University, said an increased understanding of risk factors among care providers and the community could help the stillbirth rate.

He said surveys have demonstrated there is an underestimation of risk on certain risk factors including increased maternal age, multiple births and an increased risk of pregnancies attached to IVF.

A third of the population attributable risk comes from three risk factors which are maternal age, maternal overweight or obesity and smoking.

While smoking has become less of a burden, Dr Ellwood said it’s being replaced by overweight or obesity.

“It’s important to emphasise when we’re talking about risk factors, it doesn’t mean that everybody of a certain age is at high risk, it is characterising a group that collectively is at increased risk and require some additional surveillance or some other form of antenatal care,” he said.

The researchers also highlighted the role health care providers can play in helping a family who is dealing with stillbirth.

Associate Professor Fran Boyle from the School of Public Health at the University of Queensland said one thing that GPs can do is to acknowledge the loss.

“To understand that parents will be grieving their baby, to understand that recovery is a very long term process. It’s not something that happens in just 6 to 8 weeks.”

There are also issues in caring for women in subsequent pregnancies who may be anxious, and referring families to additional support services and parent organisations if needed

“It’s about recognising the loss and hearing from parents what they need,” she said.

Sands CEO, Andre Carvalho applauded the call to action on stillbirth prevention and said more needs to be done to support healthcare professionals.

“Sands will be developing new services to support this aim, including the development of new national care guidelines and training for front line staff,” he said.

Read the executive summary of the Lancet study or the full study.

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Australia lagging in lung cancer screening: experts

Lung cancer kills more Australians than breast and colon cancer combined, however we are lagging behind other countries in researching and implementing targeted screening, experts argue.

In an article published today in the Medical Journal of Australia, consultant physician at the Sir Charles Gairdner Hospital in Perth Dr Fraser Brims and his coauthors write that the majority of lung cancer deaths are occurring in former smokers.

“In Australia, there are about 2 200 000 current or former smokers between the ages of 55 and 74 years who may be eligible for lung cancer screening,” they write.

In the US, low-dose chest computed tomography (CT) has been shown to reduce lung cancer mortality by 20%.

They said combined with smoking cessation initiatives and validated risk-prediction screening methods, targeted screenings can be cost-effective.

“The costs of treating advanced lung cancer are greater than the costs of treating the early stage disease”, Brims and his colleagues write.

They believe that in the absence of a coordinated approach, ad-hoc screening should be strongly discouraged.

Related: Screening needs ‘balance’

“The challenge facing Australia is the translation of international results into sustainable, cost-effective clinical practice, ensuring that the desired benefit outweighs the known harms, at the same time as enhancing tobacco control policies”, they conclude.

Read the full article in the Medical Journal of Australia.

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Low stress resistance leads to type 2 diabetes: study

A recent study published in Diabetologia (the journal of the European Association for the Study of Diabetes) has found 18-year-old men with low stress resistance have a 50% higher risk of developing type 2 diabetes in their lifetime.

The population based study examined all 1,534,425 military conscripts in Sweden during 1969–1997 who underwent psychological assessment to determine stress resilience. They had to have had no previous diagnosis of diabetes.

They were followed up for type 2 diabetes from 1987–2012 with the maximum attained age being 62.

After adjusting for body mass index, family history of diabetes, and individual and neighbourhood socioeconomic factors, the research found 34,008 men had been diagnosed with type 2 diabetes.

The study found the 20% of men with the lowest resistance for stress were 51% more likely to have been diagnosed with diabetes than the 20% with the highest resistance to stress.

Authors Dr Casey Crump, Department of Medicine, Stanford University, Stanford, CA, USA, and colleagues in Sweden and the USA admit lifestyle behaviours related to stress including smoking, unhealthy diet and lack of physical activity could be related to the increased risk of diabetes. The study also could not make any assertions about women as it only included male army cadets.

The authors conclude: “These findings suggest that psychosocial function and ability to cope with stress may play an important long-term role in aetiological pathways for type 2 diabetes. Additional studies will be needed to elucidate the specific underlying causal factors, which may help inform more effective preventive interventions across the lifespan.”

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Long courses, confusion and culture: why we’re losing the fight against antibiotic resistance

Doctors often tell patients to take a “course” of antibiotics, because a partially treated infection may result in relapse with antibiotic-resistant bacteria. But where does this advice come from?

As Lyn Gilbert has pointed out on The Conversation, there isn’t good evidence behind many of these recommendations. For GPs, the main determinant of the duration of antibiotics is the size of the pack they come in.

In hospitals, we also have some odd rules about antibiotics:

Prime numbers for durations of up to a week (three, five or seven days)
Even numbers for more serious infections that take weeks to eradicate (two, four or six weeks)
Multiples of three for really tenacious infections such as bone infections (three months) or TB (six months).

Of course, there is nothing magical about these numbers. I doubt anyone was harmed by stopping their treatment on day 89 instead of day 90.

Although this seems rather silly, it highlights the serious point that we often don’t know exactly how long is necessary to treat many infections.

The evidence base for these recommended durations comes from the duration used in previous studies. But shorter courses often haven’t been tested. Clinical trials that test shorter durations of treatment aren’t as sexy as those testing a new antibiotic, but are also important.

If we could safely treat infections with shorter courses of antibiotics, this might help reduce the risk of antibiotic resistance developing in bacteria. On the other hand, inadequate treatment of infections can increase the risk of resistance, so the optimal treatment length is “just enough”.

Grey areas in clinical diagnosis

One of the most difficult areas for new doctors is dealing with uncertainty. It is easy to catastrophise: every headache could possibly be meningitis, every cough could be pneumonia, every fever could be the harbinger of an overwhelming infection. The problem is, sometimes they are. The junior (and senior) doctor’s worst nightmare is to miss a serious diagnosis, be responsible for a patient’s death and end up in court.

Given this uncertainty, it isn’t surprising that doctors sometimes over-prescribe antibiotics. Despite clinical guidelines not to prescribe antibiotics for viral infections – and knowledge that antibiotics don’t benefit patients who have bronchitis – it is easy to rationalise why “my” patient might be different.

Patients don’t present to their doctors with a diagnosis; when doctors make the decision to prescribe antibiotics they rarely have the results of a test for viral flu, or a chest x-ray to diagnose pneumonia. Even in hospitals, where access to diagnostic tests isn’t really a problem, the results of the test may not be available until well after the decision to prescribe antibiotics is made.

Another example is in sinusitis. The clinical trials that looked at the role of antibiotics in sinusitis largely focused on those presenting to GPs in the community. They show little or no benefit for patients given antibiotics compared to those who did not receive antibiotics.

But what about patients who need to be hospitalised with sinusitis? What about a patient with sinusitis who responded well to antibiotics last time? What about a patient with sinusitis who had a heart transplant and is on medication to heavily suppress her immune system? Or the frail elderly patient with multiple chronic illnesses who probably wouldn’t survive a serious infection?

One way we have been combating this problem in hospitals is to have “post-prescription” reviews. A team of pharmacists and infectious diseases specialists checks the notes and tests of patients who are prescribed broad spectrum antibiotics two to three days after they are started, with the sole aim to see if something better could be used.

This recognises that simple rules for prescribing don’t account for how complicated patients can be, and that not all the information may be available when the initial decision is made.

Benefits for the individual, harm to others

Antibiotic resistance is, in many ways, a lot like global warming. We want to be warm and well fed, live comfortably in large houses and take holidays in exotic locations, but don’t want to think about the consequences for the environment.

As Alex Broom wrote on The Conversation, doctors want the best for their patient, and giving antibiotics to treat or prevent infection provides a potential benefit for the patient. It is hard enough deciding on the balance of benefits and harms for the patient in front of you, let along the potential “harms” to the wider community.

Cultural factors may be particularly important in clinical decision-making. When I worked in the United States, there was a strong feeling among many doctors that the individual being treated was the patient, and the impact on other patients was very much a secondary consideration. I once heard a doctor saying he used new, broad spectrum antibiotics because he wanted his patient to benefit from them before the bacteria became resistant to it.

On the other hand, the northern Europeans are well known for their low rates of antibiotic use and resistance.

I once worked in a hospital in Denmark and had a patient who was rather unwell with sinusitis, which had caused fever for more than two weeks. I explained to him that while the evidence generally didn’t support the use of antibiotics for sinusitis, prolonged illness was a situation where we might consider using antibiotics. He said to me that he would prefer to wait a few more days, just to see if he might avoid the need to take antibiotics.

In addition to the obvious cultural differences between Americans and Europeans, this suggests that education is required for both doctors and patients. Australia’s National Prescribing Service is running a Resistance Fighter campaign to raise awareness of the dangers of unnecessary antibiotic use.

Research findings that antibiotic use actually increases the risk of resistance in the patient, and isn’t just a hypothetical problem in a far-off future, is also an important message.

It is easy to make excuses for poor prescribing and no doubt a significant proportion of antibiotics are not required. We could do more by researching the optimal durations of treatment for different infections, setting up systems to deal with clinical uncertainty and educating both doctors and patients about the trade-off between antibiotic use and resistance.

Allen Cheng, Professor in Infectious Diseases Epidemiology, Monash University

This article was originally published on The Conversation. Read the original article.

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