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New antibiotic rules just highlight the magic of the prescribing pad

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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