Expectations versus reality when Choosing Wisely
“So…are you going to prescribe me the antibiotic, doc?”
He was an otherwise healthy male in his 40s seen in after-hours care and I had just diagnosed him with a viral upper respiratory infection. I was in my first month of my family medicine residency and there were six other patients waiting to be seen for other urgent issues. I was falling behind in clinic and I had a whole day of clinic notes to catch up on. Suddenly, the years of my training in Choosing Wisely recommendations all seemed trivial.
During my summers in medical school, I had the opportunity to work at the Choosing Wisely Canada central office on two projects. As a result of this experience, I am a passionate advocate for the campaign. My first project evaluated patient education materials (one of which centred around antibiotic use in viral upper respiratory infections) in Family Health Teams throughout the Greater Toronto Area1. I also helped to co-create STARS (Students and Trainees Advocating for Resource Stewardship), a student-led campaign across all of Canada’s medical schools in support of Choosing Wisely Canada 2.
As I looked at the patient in front of me, I was aware of the numerous drivers for why clinicians prescribe medically unnecessary antibiotics and I felt like I was about to be driven down that path. Time pressures are always on our minds. As physicians we want our patients to leave the clinical encounter satisfied, and sometimes it’s easier to send the patient home with a prescription than to have a potentially time-consuming conversation about why the antibiotic is not necessary 3.
One of my mentors in family medicine has taught me that in our short visits, one of our goals is to find out the “patient’s agenda”. Two weeks into my residency, I felt tested by this situation where the patient's agenda and mine were so far apart. I thought back to my education in medical school where we learned that antibiotics are not benign drugs. By prescribing an unnecessary antibiotic, we are fueling antibiotic resistance and creating the possibility that the antibiotics I prescribe for him today will not be useful tomorrow4.
All of this quickly ran through my mind, and I responded to the patient “no, let’s talk about why you don’t need an antibiotic prescription today.” The confidence to say no was challenging for me as a resident, but once the patient and I started talking about the risks and harms of an unnecessary antibiotic, I felt that I had made the right choice. I had used communication strategies such as offering treatment of symptoms and I counselled when to follow up if his condition changes5. This took longer than just writing a prescription, but both the patient and I left that encounter feeling satisfied, and I felt that I had done the right thing as a clinician.
As I progress through residency, I have begun to appreciate the importance of teaching resource stewardship at both the undergraduate and postgraduate level. Having strong allies amongst our faculty can also foster appropriate prescribing practices and give trainees tools to integrate these into their practices. At Mount Sinai’s Family Health Team, we have an annual session about antibiotic stewardship led by one of our staff family physicians and our primary care pharmacist. We learn when to prescribe antibiotics, that broad coverage is usually not needed, how long to prescribe, and where to find best practices for local resistance patterns. In addition, we practice counselling techniques to guide us when facilitating these important discussions. As part of this session, faculty and residents have pledged an oath towards appropriate antibiotic prescribing practices. All of these supports can help students Choose Wisely in practice, which as I learned that day in clinic can be very challenging. Having the confidence to say no, and to have a conversation about why more isn’t always better takes time but was rewarding as both my own agenda and the patient’s agenda were met.
Elliot Lass is the Co-chief Family Medicine Resident at Mount Sinai Hospital in the University of Toronto Department of Family and Community Medicine. He is in the Integrated 3 Year Family Medicine Residency and an MSc Candidate at the Institute of Health Policy Management & Evaluation with a focus in System Leadership & Innovation at the University of Toronto.
References:
1. Silverstein W, Lass E, Born K, Morinville A, Levinson W, Tannenbaum C. A survey of primary care patients’ readiness to engage in the de-adoption practices recommended by Choosing Wisely Canada. BMC research notes. 2016 Dec;9(1):301.
2. Lakhani A, Lass E, Silverstein WK, Born KB, Levinson W, Wong BM. Choosing wisely for medical education: six things medical students and trainees should question. Academic Medicine. 2016 Oct 1;91(10):1374-8.
3. Korenstein D, Kale M, Levinson W. Teaching value in academic environments: shifting the ivory tower. Jama. 2013 Oct 23;310(16):1671-2.
4. Meeker D, Linder JA, Fox CR, Friedberg MW, Persell SD, Goldstein NJ, Knight TK, Hay JW, Doctor JN. Effect of behavioral interventions on inappropriate antibiotic prescribing among primary care practices: a randomized clinical trial. Jama. 2016 Feb 9;315(6):562-70.
5. Légaré F, Labrecque M, Cauchon M, Castel J, Turcotte S, Grimshaw J. Training family physicians in shared decision-making to reduce the overuse of antibiotics in acute respiratory infections: a cluster randomized trial. Canadian Medical Association Journal. 2012 Jan 1:cmaj-120568.
