Protect doctors so they can say no to improper requests for antibiotics

The evolution and perpetuation of methicillin-resistant Staphylococcus aureus is not due to physician ignorance causing the over-prescribing of antibiotics.

Educating physicians is a misplaced effort, as virtually every physician already understands the problem. Educating the populace is a dream destined for utter and frustrating failure. The collective attention span is just too brief and superficial. The hot topics of anthrax, Ebola, West Nile, and SARS that gripped us yesterday are distant concerns today.

MRSA is caused by fear. Doctors overprescribe because of two real fears.

First is the fear of being sued, should they miss a more serious process. Second, they fear not satisfying the customer. The dissatisfied customer, who did not get what he thought he should have gotten for his now ill-spent co-pay, will lose faith in the physician and may even leave the practice. After marching to the urgent care, the patient will carp, "That doctor, who spent only two minutes with me, knew what he was doing,because I got over it after a week's worth of antibiotics."

The 10-minute lecture by the family doctor on viruses did not dazzle and reassure the patient. Even when the doctor is completely correct at the time of the visit, time changes things, and not infrequently a patient will develop a complication like otitis, sinusitis, pneumonia or, rarely, meningitis from a triggering viral process. If unfortunate and severe enough, a malpractice claim is levied on behalf of the deceased.

Fear also afflicts the patient. The Institute of Medicine does its job quite well of perpetuating the fear of medical mistakes made by incompetent doctors, sleep-deprived interns, unsupervised students and faulty medical systems. Ailing patients falling from their previous level of health just want a reassuring parachute in the form of an antibiotic. In fact, the very fear of MRSA that currently captivates the public likely will feed upon itself and cause an increase in the over-utilization of more antibiotics.

The solution is physician protection from the consequences of the correct and difficult use of the word "no." This takes legislation. It should be mandated that any time that the ICD-9 code 460 (acute nasopharyngitis) or the ICD-9 465 codes (acute upper respiratory infections) are used, the physician cannot be held liable for any tort linked to that visit. Reasonable, tax-generated victims' funds should be created to cover the cost of the care or losses incurred by the few unfortunate victims of unforeseen complications.

Lastly, to assure that the patient who wasted his money on a cold is not transformed into an angry and dissatisfied customer, all insurers must cover the co-pay in total for these codes. To be fair, since many patients hit up the doctor for more than one complaint, the insurer would be accountable for the total co-pay divided by the number of total but unrelated diagnosis codes submitted.

Considering the cost in dollars and lives caused by MRSA, the health insurance CEOs shouldn't miss these co-pay costs from their annual multimillion-dollar bonuses and stock options.

The cure for MRSA is not education. The simple solution comes from correcting the motivating fearful factors that generate the inappropriate behaviors. Sixty years of inappropriate antibiotic use would end, and resistant strains of bacteria would fade in the presence of happy patients and fearless doctors.

Mark D. Schmidt, MD, West Carrollton, Ohio

Note: This item originally appeared at http://www.ama-assn.org/amednews/2007/12/24/edlt1224.htm.