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Innovation Blog

Blog posts are written by Russell Kohl, MD, FAAFP. Dr. Kohl is the Chief Medical Officer at TMF Health Quality Institute. He works across the company to support quality improvement efforts, leads the Innovation Team and has served as lead physician for the Comprehensive Primary Care initiative.

 

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No Single Raindrop Believes It Is Responsible for the Flood

Nov 9 2017 - Russell Kohl, MD, FAAFP
In an academic sense, prescribers understand the principles and importance of antibiotic stewardship—but we don’t live or practice in an academic sense. We share in the wonder that our patients have for the truly miraculous effect of antibiotic medications. We may not remember the pre-antibiotic days where simple infections frequently led to death, but we each have a story of the rapid recovery of an appropriately treated patient. Our nervous concern about the patient’s condition and the fear in the eyes of the patient’s family are forever emotionally attached to their rapid recovery and the grateful smiles received the next day. That kind of dopamine-surge induction is hard to overcome with charts and protocols. The odd thing is that we rarely think about the other episodes: the Stevens-Johnson syndrome from Bactrim use or the strong smell of a Clostridium difficile infection following a course of antibiotics in a fragile patient. The key question underlying much of antibiotic stewardship isn’t about the use and efficacy of antibiotics. It’s about what we are really using the antibiotic for and how that risk versus benefit calculation plays out in our head.

Antibiotics are a poor treatment for anxiety. I won’t say they’re ineffective, because doing so would ignore the significance of placebo effect, but I have to wonder how frequently they are actually being prescribed for that diagnosis. Voltaire once said “the art of medicine consists of amusing the patient while nature cures the disease.” I surmise that antibiotic prescriptions in upper respiratory infections and many otitis media cases are the practical extension of this theory. We think “just this one time” won’t affect antibiotic resistance rates, and a single case in a large set of statistics would likely support that contention. The problem is that it isn’t “just this one time.” It is just one raindrop in the storm that leads to a flood. We accept the “small risk” of antibiotics as a time saver in an already busy day. As our teams at TMF work on antibiotic stewardship, we realize that patients and caregivers play a huge part in antibiotic stewardship, and we are working to help give you better ways to treat their anxiety than a quick antibiotic prescription.

I still have a well-worn and outdated Sanford Guide that lived in my lab coat pocket as a student and resident, now more as a memento than a reference. The days when a hard copy national reference on antibiotic selection was the best answer have passed. Knowledge of your local pathogens and antibiograms are critical steps toward appropriate prescribing. The “bugs” in Vinita, Oklahoma, have faced different selection pressures over the years than those in Austin, Texas, supporting Darwin’s theories, but also require me to localize my knowledge and treatment plans. However, my efforts alone aren’t enough. I have to talk to my peers, share my experience and knowledge, and remain vigilant. Holding an umbrella over my patients alone won’t stop the flood—it will only stop when each raindrop begins to take responsibility.

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