Choosing Wisely Canada recommendations

Emergency medicine recommendation 10

Do not use antibiotics in adults and children with uncomplicated acute otitis media.

What shared decision making strategies or tools have you implemented in your practice around this recommendation?

I use a delayed prescription for antibiotics. This is based on a conversation with patients to introduce the idea that antibiotics are not always the right strategy for conditions they once automatically received a prescription for—like ear infections. It creates a verbal contract: if the ear infection has not started to improve in 48 hours, they should fill the prescription. My approach is similar to the Using Antibiotics Wisely campaign’s Delayed Prescription^* tool put out by Choosing Wisely Canada and the College of Family Physicians of Canada.

What makes shared decision making around this topic challenging or rewarding?

In shared decision making, we seek to find “common ground.” But sometimes there is not enough common ground to make a plan! Some patients or parents are set on the idea that they need an antibiotic to get better. This narrative persists in large part owing to the old habits of our own profession. Our understanding used to be that otitis media was caused by bacteria, and therefore antibiotics were needed. We sent messages such as, “Your child has an ear infection. You came just in the nick of time—without an antibiotic, your child might never have recovered!” We were practising based on the knowledge and belief systems of the time. We were not bad or wrong. But now, I think we have a responsibility to help correct the messaging. And when we do this, we can create tension between the old narrative and the new. Patients need time to consider the new idea, and to resolve that tension.

The delayed prescription serves several purposes. It communicates a new idea (that ear infections can heal without antibiotics); it provides time to reflect (because a 10-minute appointment might not be enough); it makes the patient the decision maker; it communicates trust; and it respects the doctor-patient relationship. These are all core concepts for me in my practice.

If a patient waits 48 hours before filling the prescription—or does not fill it at all—that is a great success in terms of decreasing the global antibiotic problem. But studies show that a few parents rush out and get the prescription immediately. This outcome is still a success, in that the seed of a new idea has been planted, and our relationship is intact. When they next have an ear infection they might be more receptive to the new narrative.

Why is shared decision making around this specific Choosing Wisely recommendation or clinical topic essential to you?

Over many years, patients came to expect antibiotics for self-limiting illnesses, and physicians played a role in shaping that expectation. One undesirable consequence of this has been an increase in antibiotic-resistant organisms.

It takes a long time to turn a big ship around. If we consider the culture of antibiotics this way, we see it can take a long time to change course!

I started practice in 1990, when antibiotics for ear infections were the norm. By 1995, I shifted my strategy and integrated elements of the delayed prescription into conversations. There was already a movement afoot to use antibiotics less often.

Today many of my patients are aware that antimicrobial resistance is a problem and that they can help by not using antibiotics unnecessarily. I am proud that in family medicine we have come a long way in shifting patient understanding of the benefits and risks of antibiotics for many conditions.

As a physician, my overarching goal is to participate in a culture shift where there is established common ground that antibiotics are not “the norm.” I strive to help create a new narrative. And I strive to turn this big ship around.