“For every complex problem there is an answer that is clear, simple, and wrong.”
-H. L. Mencken
As I sit in an apartment full of unpacked boxes and grumpy children, only a few days removed from driving 1,600 miles to a 3rd floor walk-up and a better life just outside of Boston, I find the task of writing a post somewhat daunting. But I must admit that this new town is not without the potential for inspiring future musings. In fact, I find myself surrounded by irregular medicine of all shapes, sizes and dilutions.
Next door is a chiropractor who cures Tourette’s syndrome and, according to the pamphlet available outside the clinic entrance, only uses the in-house x-ray machine on select patients who truly need it. A few buildings down from me is an acupuncturist that treats athletic injuries with ear acupuncture and Kinesio-tape while liberally sprinkling references to his practice of “sports medicine” and “orthopedics” throughout the clinic’s promotional material. But at least I was reassured that acupuncture is completely harmless because it is a natural medicine. Finally, a block further down the road, completing my welcome committee of woo is a clinic that uses homeopathy to treat just about every real and fictional condition under the sun. I checked out their website and it’s a good thing that the walls are well insulated or my neighbors would have surely been forced to ignore the sound of my forehead pounding a wooden desk like a flagellant monk hoping for divine intervention.
So for the sake of time and sanity I am aiming at some pretty low-hanging fruit with this post. How low you ask? The inappropriate prescription of antibiotics for apparent viral infections is listed first on the American academy of Pediatrics contribution to the Choosing Wisely campaign. I’ve mentioned Choosing Wisely briefly in a prior post but it was explained in a little more detail in a discussion by SBM’s own science-based drugslinger Scott Gavura a little over a year ago. I of course mean that term in the cool, Roland of Gilead from The Dark Tower novels sense that I hope he appreciates.
Sadly it seems as if the campaign has been largely ignored since awareness of it appeared to peak in February when 17 groups, the AAP being one of them, contributed lists of clinical no-noes. And there has even been some backlash as well that frankly I find rather silly. Hopefully, there are plans in place to ramp up public and physician awareness in the near future.
One criticism that certainly isn’t valid is that the issues raised by the AAP aren’t pertinent to real world practice. The AAP went through lengthy process to determine their “Five Things Physicians and Patients Should Question”:
The American Academy of Pediatrics employed a three-stage process to develop its list. Using the Academy’s varied online, print and social media communication vehicles, the first stage invited leadership of the Academy’s 88 national clinical and health policy-driven committees, councils and sections to submit potential topics via an online survey. The Second stage involved expert review and evaluation of the management groups that oversee the functions of the committees, councils and sections. Based on a set of criteria (evidence to document unproven clinical benefit, potential to cause harm, over-prescribed and utilized, and within the purview of pediatrics) a list of more than 100 topics was narrowed down to five. Finally, the list was reviewed and approved by the Academy’s Board of Directors and Executive Committee.
So I am confident that they represent concerns that are important, require addressing urgently, and adequately represent the opinions of the vast majority of pediatricians. But are we just talking the talk?
Despite some decent evidence that overall prescriptions for antibiotics in pediatric populations have decreased over the past two decades, the trend appears to have plateaued and fairly widespread overuse is still occurring. This overuse primarily comes in the form of recommending antibiotics for what are in reality self-limited viral infections of the upper and lower respiratory tract and ear infections, which remain the number one diagnosis resulting in a prescription for antibiotics despite the majority of cases resolving without intervention other than TLC or chiropractic care. Misuse, if not overprescription, also comes in the form of writing for newer and broader agents when older and narrower antibiotics are equally, and often more effective, but that is a topic perhaps for another post.
Inappropriate use of antibiotics results in significant unnecessary medical costs, increasing rates of infections with resistant organisms and frequent adverse events ranging from fairly benign loose stools to life-threatening/altering skin conditions (Stevens-Johnson syndrome) and deadly allergic reactions. Antibiotics may have saved countless lives, and hopefully will continue to do so far into the future, but despite what many seem to believe they are not risk free.
So what is the deal with us pediatricians? Why can’t we keep our Hannah Montana brand non-latex examination mitts off of the prescriptions pad every time little Timmy has a runny nose or a cough? Why don’t we listen to the well-meaning experts from the AAP and our own inner voices? To put it bluntly, it’s because medicine is hard. It’s messy, it’s complicated, and it is practiced by humans beleaguered by the same propensity for bias and intellectual laziness as everyone else.
Pediatrics, in my biased opinion, is particularly difficult. Our patients can’t or won’t (teenagers) even talk to us most of the time so we must rely on second-hand accounts of symptoms. Our patients, I admit, don’t tend to get sick as seriously or as frequently as the average adult patient, but there is something fundamentally albeit subjectively different about a gravely ill or dead 9-year-old compared to a gravely ill or dead 90-year-old. Maybe that balances things out. Trust me it’s no picnic for any physician caring for the sick and/or dying, and of course it isn’t really a contest. But you never hear people say that it was just Timmy’s time and that he lived a good life, or that he did it to himself with lifestyle choices.
There is also something very different about dealing with a parent. Again, kids tend to be pretty healthy, and the most common ailments are usually self-limiting. Obviously there are many exceptions but children usually just get sick but not sick-sick, as the kids like to say. At least I think that they say that. I’m pretty sure some kids say that but I’ll need to re-watch season 3 of Good Luck Charlie to be certain. Very few of my patients watch Game of Thrones or even The Sopranos. This is the life I chose.
One of my favorite broken-record-quotes that rarely will fail to elicit groans of familiarity from the nurses during teaching rounds is that kids will usually get better despite what we do, not because of it. But parents often don’t see it that way. Many parents seem to interpret every sign or symptom as a distant but rapidly approaching death knell. Thus it can be considerably more difficult to explain why it is better to do nothing rather than something and to dispel the assumption that we are gambling with their child’s life. “Don’t just do something, stand there”, that’s another good one. “Masterly inactivity” is too. Somewhere a pediatric nurse I’ve worked with just rolled his eyes.
Then there are times when it seems as if our patients’ parents are evenly split between folks who present a list of demands and folks who refuse to end their cell phone conversations while you try to take a history or give treatment recommendations, but I admit that there is likely some selective recall bias at play here. Many parents are just scared and uncomfortable with a “wait and see” approach. But while I recognize the pressure that parents place on pediatricians and the reality that prescription writing patterns can be influenced by that pressure, I personally refuse to accept that it is a valid excuse for overprescription of antibiotics. One of many possible reasons perhaps, but not an excuse. Ultimately it is our signature on the pad, not the parent’s.
I hear a lot of talk about defensive medicine from my colleagues and the media but I don’t buy it as a major motivator either, at least not for the overprescription of antibiotics. More of a post hoc rationalization perhaps, but maybe that is a narrow perspective based on my own pediatric experience. There are far too many other more reasonable culprits in my opinion.
I doubt that any pediatricians set out to overprescribe antibiotics. Yet I personally am unaware of any pediatrician, including myself, that has never at some point in their career knowingly prescribed an antibiotic for what they were fairly confident was a viral process. I don’t believe that any of us is above reproach in this regard. I do know many pediatricians, however, that will pick their battles, recognizing when to just write for what the parent wants and when to stand their ground, with the latter being significantly more common.
As a hospitalist I tend to discontinue antibiotics as frequently as I start them and I’ve made many parents uncomfortable doing it. I’ve made my partners uncomfortable at times. But there have absolutely been occasions where, based on the specifics of the case and my interactions with the family, I have agreed to continue what I felt were unnecessary antibiotics.
Some pediatricians, unfortunately, drift towards the other end of the spectrum. There are bad pediatricians just as there are bad plumbers. The first pediatrician I shadowed during medical school had prefilled prescriptions for Augmentin (a broad spectrum antibiotic commonly prescribed for upper respiratory infections) that he gave out at almost every sick visit. I remember cringing at the intellectual contortions he worked himself into when coming up with reasons to hand that barely legible chicken scratch-covered piece of paper over to the caregiver with a smile. “Just in case” was his favorite excuse though. And in pediatrics, at least with new prescriptions, adherence appears to actually be pretty decent. Close to 90% of those antibiotics were probably taken, or at least started.
I think that extreme cases like this are an exception. We certainly don’t learn to treat viruses with intramuscular ceftriaxone in residency, often for fear of being taken to task by an attending or questioned into submission by a fellow resident or ambitious medical student. We learn good evidence-based practice and conserving antibiotics is a major part of our educations. So what goes wrong?
For some, I believe it is a path of least resistance that is taken after some time practicing in the real world. It is easier to do something rather than nothing. It is easier to write a prescription than to give reassurance and detailed instructions on expectant management. It is easier to treat than to learn how to accept, deal with and communicate uncertainty, skills which are not necessarily honed during medical training.
How long it takes an individual practitioner to fall into the unfortunate pattern of handing out antibiotic prescriptions for nasal drainage that looks “a little yellow” depends on many factors. Without more senior members in a practice that are supportive of antibiotic stewardship and science-based practice, for instance, it can be very difficult for recently graduated residents practicing without a safety net. Involvement with a local academic hospital, or with teaching students/residents, and constant effort to maintain one’s fund of knowledge and familiarity with current practice guidelines are all protective as well. But that takes a considerable amount of time and energy, things which many pediatricians have dwindling supplies of as they struggle to juggle work and family.
So while there are exceptions, I firmly believe that the most compelling and by far the most common reason why pediatricians write antibiotic prescriptions for viral infections is that they think that they are treating a bacterial infection. It is as simple as that. Naturally, the explanation for why we might think this is quite complex.
Sometimes it is impossible to tell the difference between viral and bacterial infections based on symptoms alone. Viral and bacterial pneumonia, for example, can present in a pretty similar manner in the average 15-month-old child: high fever, cough and infiltrates on a chest x-ray. Group A streptococcal infection of the throat (“strep throat”) is virtually indistinguishable from viral pharyngitis. 14 days of persistent runny nose and intermittent fever can be caused by acute bacterial sinusitis or back-to-back colds. These are just a few quick examples.
If the patient actually has strep throat or pneumococcal pneumonia rather than a viral mimic, the patient will generally get better more quickly, avoid potentially deadly complications and show up for the next well check if they are prescribed a course of an antibiotic. If it was a virus all along, the patient will also get better and no one will be the wiser for it. Either way, the parent will be happy with the care their child received.
The negative aspects of overprescription are unlikely to make a significant impact on the practice of an individual pediatrician. Parents have become conditioned over the decades to expect their child to have a little diarrhea or upset stomach while taking an antibiotic so it doesn’t really register as a reason to avoid antibiotics unless truly necessary. And despite the potential for serious complications when looking at large populations, the risks to any one child of a serious allergic reaction, an idiosyncratic process like Stevens-Johnson, or infection with Clostridium difficile remain pretty low. Resistance issues also don’t tend to affect the individual pediatrician in the office enough to serve as punishment for sloppy practice. They affect me in the hospital however.
So it is easy to see how a pediatrician can, over time, develop a nasty habit of handing out antibiotics carelessly. In order to avoid falling into the habit of prescription creep, a pediatrician can sometimes rely on the rational use of testing in certain clinical scenarios, such as the rapid detection of Group A streptococcal antigens. But more often than not determining the source of an infection comes down to historical variables and exam findings.
Pediatricians need to trust their clinical skills and be comfortable following evidence-based practice guidelines. They need high level critical thinking skills. They also need to be expert communicators and educators, with the ability to convince a distraught parent that antibiotics are not always the answer and that often watchful waiting is safe and appropriate. Not every pediatrician is capable of this but it doesn’t mean they can’t improve their skills and increase their prescriptive accuracy. There are many resources available to do just that.
There will always be some degree of overprescription of antibiotics. It isn’t realistic to expect us to get it just right, although people are working on it. There are many scenarios in pediatrics where a “shoot first, ask questions later” approach is justified. There is certainly room for much improvement and educating the public to question the use of antibiotics is probably the key to achieving this. If we can get parents to simply question why their child is being prescribed an antibiotic and if it is truly necessary it will make a big impact. Hopefully efforts like Choosing Wisely will gain more momentum.
So there you have it. A solution to a complex problem that is fuzzy, complicated, full of excuses and thus almost certainly correct…sort of.
Speaking of changing parental behavior, here is some good information from the AAP and Choosing Wisely on when kids need antibiotics for sore throat, cough, or runny nose and when they don’t.