Choosing Wisely Canada recommendations

Family medicine recommendation 2

Do not use antibiotics for upper respiratory infections that are likely viral in origin, such as influenzalike illness, or self-limiting, such as sinus infections of less than 7 days’ duration.

How have you implemented this recommendation in your practice?

Recent data provided by Choosing Wisely Newfoundland and Labrador (NL) showed that NL has a 30% higher antibiotic prescribing rate than the rest of Canada has. I work mostly in the emergency department (ED) of our rural hospital. It is an hour’s drive from St John’s, NL. We serve approximately 26 000 people through our ED annually, and also do a lot of primary care, as there is currently a local shortage of family doctors.

As cold and flu season approached this year, we aimed to create a culture of more judicious antibiotic prescribing. We also wanted to continue to better manage ED wait times given our recent increase in patient visits. We started using 2 new patient handouts provided by Choosing Wisely NL. One explains the differences between bacterial and viral infections, and the other is a mock prescription that details red flags or symptoms to watch for that would prompt patients to seek re-assessment. Patients hate leaving empty-handed and it is difficult for them to remember the details of our conversation, so we provide them with handouts that detail the reasons for our watch-and-wait approach, what to expect with a viral illness, and when to seek re-assessment. We have gotten good feedback from patients that they found this to be helpful.

How have you brought the Choosing Wisely principles to your relationship with patients?

Outlining expectations and duration of illness is critical. Patients and clinicians alike can put unrealistic expectations on interventions like antibiotics. I had someone say to me last week, “Can you believe I’ve had this cold for 3 weeks?” Meanwhile, I personally had had a runny nose for a month in October! I told him that if I thought an antibiotic would have helped, I would have taken one, and would give one to him too! Leading by example is one of the best ways we can encourage others to choose wisely.

Newfoundland and Labrador has an aging population and a lot of chronic disease. As health care providers shift prescribing patterns, patients with chronic obstructive pulmonary disease especially require reassurance when they do not need antibiotics. We cannot expect the public to understand and appreciate the effect of antimicrobial resistance. But we can use language they understand, such as “It will interact with your other medications” or “If you use antibiotics too much, they might not work for you in the future when you really need them.”

When you have many patients waiting, it is hard to be met with resistance around not prescribing an antibiotic. So you think, “I’ll just quickly scribble down a prescription for amoxicillin so that I can get to the rest of my patients.” But you really have to step back and say, “Would I do this if it were another medication that had more serious potential adverse effects? Is this the best I can do?” I sometimes compare antibiotics to antihypertensive medication. I think, “What would I do if the stakes were higher?” I would monitor and re-assess the patient. So that is what I do with my patients with upper respiratory tract infections.

What does Choosing Wisely mean to you as a family physician?

The key ingredients to Choosing Wisely for me are providing clear communication and education for my patients around the various disease processes, and informing them when they might need to seek re-assessment. Also, it is important for me to ensure my prescribing practices are judicious and I always find myself reevaluating and ensuring that I am practising to the best standards I can. If I am not going to give a patient active treatment, I need to reassure both the patient and myself that I have made the right choice. I frequently invite patients to come back to see me if they have any concerns, and I try to clearly communicate to patients why I am not doing a particular investigation or writing them a prescription. I tell my patients, “I’m concerned, I’m going to follow you through this, and I’m not going to lead you astray.” Again, going back to my hypertension example, patients with a potential diagnosis of hypertension might need to be reassessed up to 3 times before they are started on a medication. Why should antibiotics be any different? It is a process.

The right investigation or medication for the right person at the right time is how I practise medicine in general, but I believe that these principles are also the foundation of making better choices. As a result of the practice data we received last year and our new patient resources, our community is now choosing a little more wisely.