4th June 2015

Antibiotic Police

This article in Modern Healthcare, Telemed docs more likely to prescribe broad-spectrum antibiotics,begs the question about how practice type may impact antibiotic selection and use. In my post on concierge medicine, I wrote about force vector diagrams for various practice types. Maybe this can help us to consider antibiotic use as well.

In the ER there are strong pressures (force vectors) to solve problems quickly and to prevent “bounce backs.” Patient satisfaction surveys shove us along as well. While I give many patients my phone number in case they have questions or problems after they leave, I’m well aware that the majority are gone forever when they exit the ER. Unfortunately, most follow up comes not in the form of thanks, but rather “do you remember that patient you sent home the other day?….”

As such, I have no doubt my neurotic subconscience pushes me to overprescribe antibiotics from the ER. Since I’m semi-aware of this I often write for antibiotics, and then advise patients to use them only if worse after 24-72 hours. That’s my feeble approach to save them a second visit. Happily, no monetary force vectors push me toward prescribing antibiotics because I’m paid by the hour… unless you consider my inner lawsuit fears. (Pharm reps have long been flushed from ERs where I work in case you’re curious. That was a whole ‘nother force vector back in the day.) Urgent care forces are fairly similar, though the pressures to rapidly move patients along to make room for sicker patients are far less.

The telemedicine article doesn’t surprise me at all. Talking someone through his or her infectious disease problem from a distance is just not as easy as it is in person. So using broader spectrum (bigger hammer) antibiotics actually makes sense. As such, I much prefer the house calls component of Pre-R now.

Concierge medicine is probably even worse, though I can’t prove it. Concierge medicine doctors are strongly incentivized to cater to their patients’ wants and needs. As with any membership model business, the goal is to sell many memberships to people who will rarely use the service. It can be done well or very poorly. Such a service is wonderful for patients with diabetes and hypertension, because their doctors are incentivized to tune their meds closely. But for infectious problems, prolonged conversation about antibiotic resistance can mean disappointed patients and lost revenue. I could be wrong, but it would not surprise me to discover that concierge medicine docs use the broadest spectrum antibiotics. (Michael Jackson’s doc represented the extreme end of concierge medicine. No doubt Michael not only received Propofol for sleep, but also the biggest, baddest antibiotics for every illness. So beware: Extreme wealth does not = extreme health.)

The Pre-R force vectors are entirely different from each of the above. I can spend plenty of time with each patient and I get tons of follow up. This is the best part of Pre-R for neurotic me. Actually, I don’t leave my patients alone until they’re clearly out of the woods. Plus I’m incentivized to do so. But here’s the one flaw I’ve discovered with our “pay what you think we’re worth” model – Patients don’t value and reward conversation as much as prescriptions. I’ve actually never been in a setting where I’ve been so financially incentivized to overprescribe.

Does anyone here know the Freakonomics guys? I want them to do some analysis. I’m not about to abandon our Pre-R model. In all other respects I love it. But frankly, I want to swim even further upstream for a social thought experiment starting with this question: Why are doctors the antibiotic police anyways? Neighboring countries offer antibiotics over the counter. Our chickens and cows are marinating in antibiotics. Rivers and oceans have notable levels from all the expired meds we flush down our toilets. Am I really qualified to be the gatekeeper to save the world from antibiotic resistance with so many opposing force vectors on me?

How would the world look in a parallel universe if each hospital (or Walmart even) had a vending machine with a variety of antibiotics? What if insurance never covered antibiotics? And what if I was paid hourly just to stand there and give bits of science/experience based advice, which patients could take or leave. “I think you have a virus and you’ll be wasting your money here.” “That antibiotic will probably help your UTI in 3 days, maybe 7.” “That one next to it costs more, but is a little stronger and you don’t have to take as frequently.” “That one will make you puke.” “That one may cause C. diff. enterocolitis.” “That one has sulfa in it so beware if you’re allergic.”