Try a 3-prong communication plan
To counteract these pressures, Dr. Stivers recommends a three-prong communication plan to influence the consultation:
- Foreshadowing, where suggesting that the cause of the patient’s symptoms is likely to be viral is introduced early in the consultation. This approach was found to reduce antibiotic prescribing to 33%, compared with 59% without foreshadowing (P < .05). Resistance may also be reduced.
- Affirmative nonantibiotic treatment plans, where specific positive recommendations given early (e.g., “I’m going to put you on some medicine to try to dry that out”) are less likely to be resisted than is vague negative advice at the end of a consultation.
- Persuasion, which involves explaining the diagnosis and nature of a cough and cold, educating about viral and bacterial differences, and presenting the risks of antibiotics. When persuasion is employed, antibiotic prescribing is reduced to 33%, compared with 63% (P < .05) without persuasion. In general, effective foreshadowing and affirmation should avoid the need for persuasion.
Dr. Stivers’ research suggests that these techniques work, but to do so, they should be delivered naturally as part of routine practice. Interestingly, her data showed that physicians rarely foreshadowed, and when they encountered resistance, they adopted persuasion in 53% of cases. By comparison, affirmative recommendations were used in 89% of cases, but their effects were reduced by the physician being vague and nonspecific.
In conclusion, Dr. Stivers said that addressing inappropriate prescribing requires awareness but that is not enough. The challenge is to reconsider health policies and ways of communicating about antibiotics. There is no downside to foreshadowing a likely viral origin, delivering affirmation, or using persuasion. She added, “If we can make even a 5%-10% reduction [in prescribing], wouldn’t it be worth it?”
Questions answered
A question-and-answer session followed Dr. Stivers’ presentation, and points raised included:
- Physicians have a desire to please. Dr. Stivers countered this point by saying that satisfaction is not tied to antibiotic prescription, and that physicians often misjudge what patients want. It’s important to communicate other treatment options because patients often just want “something they can do.”
- Decision fatigue is often a factor. Evidence shows that antibiotic prescription is more frequent toward the end of a shift. Doctors should avoid negotiation because it increases consultation time. Here, foreshadowing early on may help. Setting may also be important – prescription is more frequent in the ED.
- Vaccine-resistant parents often want active treatment. Here, conversations can be challenging. Trying to persuade may be a less successful than giving positive instruction (e.g., “we’ll give you a vaccine today.”) Resistance is likely to be lower.
- Concern was expressed about manipulating patients ahead of a firm diagnosis. Could this lead to missing a serious bacterial infection? Dr. Stivers acknowledged that this was a gamble. She recommended a “neutral” early foreshadowing statement such as “we are seeing a lot of viral infections at the present.”
- Cultural differences can have an effect. In China, for example, the argument between parents and physicians no longer focuses on antibiotics versus nonantibiotics but rather on oral versus intravenous administration.
- Litigation is a factor in prescribing, especially in the United States. Dr. Stivers stated that her proposed approach to prescribing should not interfere with appropriate management. The clinical picture can change, and antibiotics should be prescribed where needed.
- Audits improve prescribing in the short term. These results were based on recorded consultations, and that factor may have influenced management. In unrecorded consultations, inappropriate antibiotic prescription would be higher.
- Increased point-of-care testing can reduce unnecessary prescribing. This has been documented in countries such as Sweden. Evidence from China suggests that many patients will still receive antibiotics even if a bacterial cause is excluded.
When patients dictate treatment, sometimes we must tell them what is best. Dr. Stivers closed her presentation by emphasizing that, “how you say things will matter.”
Louis Bont, MD, PhD, chair of this session and pediatric infectious diseases specialist at the University Medical Center Utrecht (the Netherlands), commented: “Antimicrobial resistance is a global health threat which jeopardizes sustainable health goals. The World Health Organization has declared that antimicrobial resistance is one of the top 10 global public health threats facing humanity. Resistance to ciprofloxacin varies from 8%-93% in Escherichia coli and 4%-80% in Klebsiella pneumoniae. Colistin is the only last-resort treatment for life-threatening infections caused by carbapenem-resistant enterobacteriaceae.”
Dr. Stivers stated that she has nothing to disclose.