Parents will take explanation over antibiotics

In response to numerous campaigns urging more judicious use of antibiotics, many doctors have just been saying no -- or at least trying to.

But telling a patient, "no antibiotics for you" might not be an effective way to cut unnecessary prescriptions, said a study presented at the Pediatric Academic Societies annual meeting in San Francisco this month.

The paper suggested that a more positive approach with suggestions of what could be done, rather than the negative, no-prescription mantra, might be a better way to cut down the number of antibiotics prescribed.

"It's much better to focus on what you can do than what you're not going to do," said Rita Mangione-Smith, MD, MPH, lead author and assistant professor of pediatrics at the Mattel Children's Hospital at the University of California, Los Angeles. "The take-home message is to really recognize that the child is sick, and here are some things we can offer to help, even if it's just symptomatic stuff."

Researchers videotaped more than 500 encounters between pediatricians and parents who brought their child in because of cold symptoms. Parents were more likely to disagree with physicians who focused on the fact that antibiotics should not be prescribed, and this disagreement seemed to result in more prescriptions. Satisfaction with care was not affected by whether the parent received an antibiotic prescription or not. But it was affected by whether physicians gave recommendations to alleviate the child's symptoms.

Authors of the paper say this suggests that doctors should take a more positive approach. "The negative approach was only being used by about 25% of doctors. The majority of physicians were using the positive approach," Dr. Mangione-Smith said. "Our goal is to get rid of that 25%, because hopefully that would get rid of a lot of inappropriate prescribing."

The study also highlights the potential this technique offers as a tool for physicians. "This gets at the heart of ways that doctors can really influence treatment," said John Hickner, MD, who has written several guidelines about appropriate antibiotic use and is a professor of family medicine at the University of Chicago. "Most of us have developed a spiel that we use to tell patients that antibiotics are not necessary, but some of us forget to go on and talk about positive things."

Others offer this study as evidence that shifting physician communication patterns and directly addressing patient concerns can lead to improved outcomes.

"This makes a whole lot of sense. A patient comes to a doctor with problems, and they want help," said Paul Haidet, MD, MPH, an expert in patient-physician communication issues and a staff physician at the Michael E. DeBakey Veterans Affairs Hospital in Houston. "The negative approach defines the problem as a viral illness for which there is no cure, and it feels like abandonment. In the positive approach, the problem is defined as distressing symptoms, and here's a strategy for addressing those symptoms."

Study critics warned, though, that the subject requires more attention before recommendations to change a physician's communication style are added to strategies for reducing antibiotic use.

"It could be the case that the doctors who happen to have a more positive approach were doctors whose patients tended to be more satisfied with them, and it might not be because of the positive approach," said Ted Ganiats, MD, who has authored several antibiotic-related guidelines and is a professor of family and preventive medicine at the University of California, San Diego. "This doesn't prove that all doctors should change how they talk to patients."