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Independents' Day

New antibiotic rules just highlight the magic of the prescribing pad

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History taken, throat examined: now you brace yourself for the ‘virus’ spiel.

‘We look for certain things when considering if a sore throat is likely to be caused by a bacteria or virus.

‘You’re 52, have a cough, you’ve not had a fever, you have no pus on your tonsils and you have no swelling to the gland in your neck.  This means that your sore throat is 90% likely to be caused by a virus. 

‘The great news is you don’t need antibiotics, which can cause diarrhoea, rashes, vomiting and thrush. Even when we do feel this is a bacterial infection, the body will clear the infection in seven days with no treatment. We would have to treat 4,300 patients with antibiotics to prevent one quinsy developing.’

This is a wordy variant of the explanation I give when a patient with a sore throat clearly has a cold.  It’s evidence-based and it makes the patient aware they may be harmed, not helped, by an antibiotic. 

As a good Catholic, I’m not unfamiliar with confessions. So here comes one: even when I’m over 90% sure this patient has a cold, I have still prescribed penicillin V. Now, if that statement results in a punishment – 10 Hail Marys, 50 lashes, a custodial sentence – then I deeply apologize to my patients and partners, because I have been guilty of serious malpractice.

To be fair, most patients accept the mini-lecture and wander off with some advice about painkillers and gargles. If they’re a real FP10-ophile, I might push to a difflam script. 

But some of them – the demanding, experienced, previously hospitalized – won’t take no for an answer. They won’t be educated.

Because there is something magical about a doctor’s prescription. It is the most potent of placebos. We hand over delayed scripts, but they’re generally cashed in moments later. What’s more, the Health Secretary says he just can’t address patient demand.

We’ve all been lectured about the facts:

- Some 60% of acute otitis media sufferers will improve within 24 hours, 80% within three days, without antibiotics.

- Sinusitis may last three weeks, and 70% of patients don’t need antibiotics.

- Bronchitis is self-limiting, and lasts three weeks. 

But although we know all this already, we’re still obligated to prescribe.

Back when I was a GP trainee, I thought it’d be fun to email the eponymous Dr Bob Centor at the UAB Huntsville School of Medicine.

I was flattered when the Sore Throat Don emailed back the same day. I’d asked him how he broke news to his patients that a script wasn’t required. He favoured the ‘good news, you don’t need antibiotics’ strategy. 

But even though it comes from the Man Himself, patients aren’t convinced. 

How can CCGs or MMCs possibly determine if a GP’s prescribing behaviour is punishable? Some GPs are soft, some are hard as nails. Some patients are lovely, some are bullies. Some literally will not leave the room without the glorious green chit. It’s nigh-on impossible to be scientific and scrupulous with every antibiotic hopeful.

Consultations for sore throats can be excruciating for GP and patient. But Bob’s email finished on a positive note: ‘I continue to be amazed that I became an eponym – but if [my criteria] are helpful to physician practices, then I smile at every injury.’

They’re useful indeed Bob. But they rarely make any of us smile.

Dr Tom Gillham is a GP in Hertfordshire and specialty doctor in A&E. You can follow him @tjgillham

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Readers' comments (9)

  • Azeem Majeed

    A good article which illustrates some of the difficulties in trying to implement evidence-based medicine in general practice.

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  • Where are the days when doctor knew best? Today mum and google forums know best. Politicians and the media making us out to be worthless, lazy and overpaid dont help. Please, please someone convince my wife that Oz is a great country!

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  • Tom I'm afraid the magic of the prescribing pad is what has got us into this mess in the first place. It has created a society of doctor dependent people who cannot accept self limiting illnesses or take personal responsibility for their lifestyle related ailments. And before anyone jumps down my throat, it is not patients who are to blame. Doctors and the government have allowed this to happen.

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  • That green pad is the catharsis for all the demons that we as doctors carry throughout our lives.

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  • The problem is - standard medical thinking assumes patients go running to the doctor for any little sniffle.

    In my case I deal with frequently occurring viruses at home without troubling the doctor.

    On the infrequent occasion that I do attend with an infection, after having self-managed and self-triaged for weeks, I would like to be taken seriously and provided with treatment.

    But doctors are unaware of context, they just simplistically assume that everything patients present with is a cold, until such point that the patient is hospitalised with sepsis.

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  • Patient have been educated over the years. now they come with cough for more than 3 weeks , ear ache for more than 4 days and sore throat more than 10 days . Where you go from here?

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  • @Anonymous | 25 August 2015 1:50am who wrote "The problem is - standard medical thinking assumes patients go running to the doctor for any little sniffle. "

    Depends where you work.My council estate punters who are all on the dole do turn up for every little sniffle.They are all young single parents with different kids from different fathers and no family networks to support them.So who do you think they turn to?

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  • 'The problem is - standard medical thinking assumes patients go running to the doctor for any little sniffle. '

    Anon - you read Pulse. You are probably better-educated than 95% of the UK population (I'm guessing you're a GP or associated professional). You probably pay for your scripts and probably work, so time is a priority.

    None of these factors apply to many of our more frequent presenters - the elderly, the young parents, the unemployed and the never-been-employed - they have lots of time, little education, few coping skills and not a great deal of money. The GP is therefore the 'can't be too safe' default, with the possibility of getting OTC drugs for free also.

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  • Continuity is one answer for much of this ( but that currency does not seem to matter to our political leaders) provided of course that your first ever patient refused an antibiotic does not 'croak' - as they say in Australia and you then end up with litigation on your hands. We are always sat there in the consulting chair and can hopefully reason with our clientele over a life-time. I am also conscious that the little green chit has a 'dollar value' in unscrupulous transactions!

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