Antibiotics for a Virus? How to Just Say No

Posted by Dike Drummond MD

antibiotics for a virus inappropriate 150x150Antibiotics for a Virus – Effective Communication of “NO”

Studies, medical societies and position papers are unanimous in their condemnation of inappropriate antibiotic prescriptions for an uncomplicated URI … but not a single voice tells us HOW to do that.

So often these office visits are acutely uncomfortable for the practitioner. The easiest thing is to simply write the prescription … and at the same time, antibiotics for a virus are always inappropriate.

Here is just one example of an official guideline (from the AAFP) on antibiotics for a virus. Notice the exquisite detail on the mechanics of diagnosis and the research basis for treatment recommendations … and not a word on how to talk to the patient. Yikes!

Let me give you a three part structure you can use in your patient conversations when they request antibiotics for a virus. I will even give you some exact words to try out.

This structure is adapted from the Parenting literature … another role where Boundaries and Inappropriate Requests are common issues. (“Parenting with Love and Logic”, Cline & Fay, NavPress Publishing, 2006)

The Three “E”s

- Empathize
- Evaluate
- Educate

Know from the start that there are three things going on inside the patient simultaneously when they walk in demanding antibiotics for a virus.

Each has two components:
a) A Primary Experience
b) A Longing

And each of these must be addressed for the two of you to be comfortable at the end of the “antibiotics for a virus” office visit.

1) Your Patient is Suffering

Their Primary Experience is Misery.
Remember the last time you had a snotty cold, bad cough, chills AND you missed work AND all the kids were sick too? You waited 3 days to get over it and still felt terrible. You just have 2 days of sick leave left in the year and it’s only March. You’ve got the picture … yes? Even you might have wanted antibiotics for a virus at that point!

Here is their Longing
They want to be heard. They yearn for your Empathy … because they are not getting it from anyone else. (everyone else is sick, remember?)

There is a saying that is 100% true in this situation:
“They don’t care how much you know, until they know how much you care”

Your job is to Empathize

… show compassion, meet them in that shared place of suffering because you have been in that situation too. In most cases this is a person who doesn’t come to the doctor often. When they think they need antibiotics for a virus … they have been feeling pretty raunchy.

Let me give you some specific phrases you might use:

Wow, that sounds terrible.”
“You sound miserable, how are you holding up?”
“I hate it when that happens, you must be very frustrated.”
“You poor thing, I am so sorry this is happening to you.”

If you have a major challenge working up some empathy one of two things is happening.

- You are experiencing some level of Burnout. Empathy is the first thing to go when You are not getting Your needs met. This is a whole different topic and “Compassion Fatigue” is a well known early sign of significant Burnout.

- You are not fully present with the patient and their experience. In many cases this can be addressed by taking a big relaxing, releasing breath between each patient and consciously coming back into the present before opening the door.

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2) Your Patient is Scared

Their Primary Experience is worrying that “something serious” is going on here … that this is more than just a cold and needs more than just chicken soup.

Here is their Longing
They want a doctor’s opinion so they get treated appropriately for what is REALLY going on. They respect your knowledge and professional diagnosis AND they are scared this is something more than just a “cold”.

Your job is to Evaluate

Take a focused history , do a focused exam and give them a well reasoned diagnosis – no matter how many “cases like this” you have seen this week.

3) Your Patient has an Incorrect Assumption of a Solution

Their Primary Experience is one of thinking they know the solution and you are the source.

Their thought process might be:
“My phlegm is green, which means I need antibiotics” or “Larry down the hall got a “Z-Pack” for the same thing last week and now he is better. I must need one too.”

Their Longing is to have something they can do to simply feel better
The patient’s assumption is not only incorrect … it is potentially very dangerous. We are on solid ground here for a specific educational conversation.

Your job is to Educate

Tell them what you know as a trained and experienced physician.

1) You have a Viral URI … no question about it
2) Here is the normal course of a URI
3) Here’s what you can do to take care of yourself and speed the healing
4) Antibiotics for a virus don’t make a difference in the course of a typical URI
5) Antibiotics can cause diarrhea, yeast infections, allergic reactions and are a major cause of antibiotic resistant bacterial infections. Some of these complications can be fatal. We want to use antibiotics when we know they will work … otherwise the risks outweigh the benefits.
6) Here are the warning signs of a complication of a URI. If these happen, please come back in and let’s take another look.

Do this in words first AND in a handout. Please don’t just hand them a lame, one-page handout, turn your back and walk out of the room.

If the patient is still “demanding” antibiotics
despite following the above conversation guidelines,
this has become a Boundary Issue.

What are your Boundaries around this inappropriate and potentially dangerous request?

Make Sure to Start with Empathy First

It could sound like this:

“I am so sorry you are feeling this way. And I understand how Larry down the hall got antibiotics last week and is better this week. I wish that would work in your case … and it won’t.

I won’t be writing a prescription for antibiotics because they would not help you and might cause a very serious complication. Here is information on how to get better and the signs that you are suffering a complication and need to be seen again.”

Persistent confrontational encounters with a specific patient are signs that the two of you are unable to establish and maintain a “therapeutic relationship”. This is solid grounds to enforce your Boundaries again by asking them to find a different physician.

I encourage you to grab a partner … a colleague, friend, your spouse or significant other and do the most productive thing possible to increase your skill in this important conversation … PRACTICE.

Yes … actually practice these antibiotics for a virus conversations …

  • Have your partner be the sick person.
  • You be the doctor.
  • Try out the phrases above and adapt them to your personal style.
  • Then reverse roles … YOU play the patient.
  • Reverse them again and be the doctor again.
  • Role play this until you are comfortable and your “empathy phrases” are second nature and TRUE for you.
    (BTW, never try to fake Empathy … you can’t do it and you patients will HATE the experience)
  • Empathize

  • Evaluate

  • Educate

Try these out for yourself.

Please leave a comment with your communication tips on this common and difficult clinical interaction.

What works for YOU when a patient requests antibiotics for a virus?


Tags: antibiotics for a virus, inappropriate prescription, just say no

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