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Antibiotic resistance: don’t blame patients

BMJ 2019; 364 doi: (Published 19 March 2019) Cite this as: BMJ 2019;364:l1218

Antibiotic use: don't blame doctors for trying to address patients' expectation

I read with interest the article by Glover et al, which claimed there is little evidence that patients are unreasonably pressuring GPs for antibiotics.[1] By the same token, there is little evidence that patients’ expectation is a non-factor in doctors’ decision making process. Similarly, there is little evidence that doctors are always “blaming” patients for antibiotic resistance.

As Glover et al stated, there are patients whose “expectation” is to receive antibiotics. UK doctors are often taught to address patients’ expectations using the ICE (idea, concern, expectation) model.[2] Canadian doctors are also taught to address patients’ expectation using the FIFE model (feeling, idea, function, and expectation).[3] Although it does not mean antibiotic prescribing would then be warranted, a caring doctor would at least address patients’ expectation rather than ignoring it. Patient’s specific factor often plays a huge role in a doctor’s consultation. A study of 613 consultations showed good use of the ICE model reduced unnecessary prescribing, but was not conducted specifically on patients who expected prescriptions of antibiotics.[4]

If financial incentive is the determining factor of antibiotic overprescribing, wouldn’t the fee-for-service doctors decline antibiotic prescribing, so that they can claim one more fee for a follow-up assessment? In fact, Glover et al showed that antibiotic prescribing is used as a mean to terminate consultations. Nevertheless, I agree with Glover et al’s suggestion to avoid the blaming culture for antibiotic overuse and encourage doctors and patients to work together to tackle the problem. We should continue to harmonize patients’ expectation and doctors’ clinical judgment in a professionally appropriate way. For instance, Rxfiles, an academic detailing program for Canadian doctors, has designed “prescription pads” of non-antibiotics for upper respiratory tract viral infection in multiple languages.[5]

All things considered, we should acknowledge that antibiotic overuse is multifactorial, rather than blame solely doctors or patients for the problem.

[1] Glover, R.E.; Dangoor, M.; Mays, N. Antibiotic resistance: don't blame patients. BMJ 2019, 364, l1218, 10.1136/bmj.l1218.
[2] Anonymous. I never asked to be ICE'd. BMJ 2016, 354, i3729, 10.1136/bmj.i3729.
[3] Klein, D.; Nagji, A. Assessment of communication skills in family medicine. Canadian Family Physician 2015, 61, e412-e416.
[4] Matthys, J.; Elwyn, G.; Van Nuland, M.; Van Maele, G.; De Sutter, A.; De Meyere, M.; Deveugele, M. Patients' ideas, concerns, and expectations (ICE) in general practice: impact on prescribing. Br. J. Gen. Pract. 2009, 59, 29-36, 10.3399/bjgp09X394833.
[5] RxFiles Viral Prescription Pad. (accessed Oct 1, 2016).

Competing interests: I have been paid for working as a physician, but not for writing this letter.

26 March 2019
Eugene Y.H. Yeung
Lancaster, UK, LA1 4RP