Dictating treatment 

It must have happened to you many times that an anxious parent came to your clinic for follow up with his daughter suffering from fever and telling “Doctor it has been two days she is suffering from fever. Why are you not giving her some STRONGER antibiotic that acts FAST and heal her fever?” Even she has a sore throat. “What’s the need for swab test? It’s must be a strep throat. Give some antibiotics.“ And Finally, the parent leave with a prescription of antibiotic in hand. That is how the doctor often fails to convince the patient and get dominated regarding treatment. The number of patients demanding a fast relief from their disease and dictating the course of their treatment has increased in numbers in recent times. There can be several reasons for that such as increasing patient education, easy access to information (?) over the internet, increasing medicolegal knowledge of patient are prompting them to dominate physician in deciding the treatment. Do all bugs really need drugs? Sore throat As in the case of above example, sore throat is symptomatic prior to recovery is four to seven days, whether or not strep is found and regardless of whether antibiotics are used. Further, physicians do not even. Many physicians also wonder that why antibiotics for strep throat became and remain the “standard of practice” to prevent rheumatic fever. Rather, one million prescriptions for antibiotics for a sore throat may prevent one case of rheumatic fever. But they may cause 2,400 cases of significant allergic reactions up to and including anaphylaxis, 50,000 to 100,000 cases of diarrhea, and some 100,000 cases of skin rash and above all may contribute to generating a few drug-resistant strains. According to a study, roughly one-quarter of pediatrician office visits resulting in antibiotic prescriptions were for acute respiratory tract infections in which antibiotics are not appropriate. Sinusitis Similarly, there is a lot of evidence suggesting that acute sinusitis of fewer than 10 days duration usually resolves without antibiotic therapy in about the same time and with about the same severity of complications as with antibiotic therapy. The outcome of an episode of acute sinusitis that has not been present long is therefore about the same with or without antibiotic therapy. Still, you will find patients demanding antibiotic for sinusitis symptoms, either to a physician or over the pharmacy counter. Ear infection Patients with ear infections are more likely to be harmed by antibiotics than helped. While the pills may cause a small decrease in symptoms (for which ear drops work better), the infections typically recede within days regardless of treatment. The rampant antibiotic therapy itself can lead to significant morbidity, both the individual treated and to the larger community. Complications like antibiotic resistance and C. difficile-related pseudomembranous colitis is becoming more common. But how to make the patient understand all this data and results of evidence-based studies? What is the proper way? If you can’t heal, let the child sleep! There are several reports that cough syrups are actually harmful to children and they do not really work. To be very clear, cough remedies have never been proven better than a placebo, either for adults or children. Yet they are largely used and demanded in clinical practice. Physicians periodically get requests from parents to prescribe cough medicine for their child that contains codeine. Besides the codeine, the drug contains alcohol, naturally leading to a better night’s sleep for child and, hence, relieving the exhausted parent. Can a surgery help? Back and spine surgeries to relieve pain are, in the majority of cases, no better than non-surgical treatment. Yet in the US doctors perform 600,000 of these surgeries each year, at a cost of over $20 billion. The number will be quite equivalent even in India. A good number of people undergo arthroscopic surgery to correct osteoarthritis of the knee. However, studies show the surgery to be no better than sham knee surgery, in which surgeons “pretend” to do surgery while the patient is under light anesthesia. It is also no better than much cheaper, and much less invasive, physical therapy. Most of the patients are actually reluctant in the recommended physiotherapy or rehabilitation therapy and think only surgery can heal or rejuvenate their problem. It is endorsed by my HERO It is not even uncommon to get pressurized by patients about a drug or cosmetic product endorsed by a celebrity in media. Although in India, advertising the scheduled H and X drugs are not allowed, many herbal remedies or cosmetic enhancement products are claiming “magical remedies” [Which is again prohibited by The Drugs and Magical Remedies (Objectionable Advertisements) Act, 1954]. Thus, demands for such remedies to be prescribed are increasing adding to the distress of physicians. Why doctor says YES when they actually meant NO They are running mostly behind schedule, with a waiting room full of impatient people-patients and pharma representatives, and a desk full of sticky-notes for appointment and phone calls. This ambiance does not even allow them to spend time and energy for the conversation or confrontation with patients. They just put the pen on paper, rip the page off from their prescription pad and escort the patient to the exit with an everlasting smile. Physicians who encounter a patient with such a specific request also report these visits to be stressful and unsatisfying. Moreover, doctors have noticed that if they do not listen to patients requests the general reactions from patients are as follows They rate their physician lower They are less likely to adhere to their doctor’s recommendations They are prone to try health care resources to get their request met, such as getting unreliable information from the internet, moving to a “quack” with a warranted result of their therapy. How doctors should react? The art of negotiation is a business skill that physicians will have to master as we move towards an era of patient-centered care. If both patient and doctor can get to the root of the request, they can, in many cases, discuss it and figure out a third way. If one delve deeper it might be found that a patient who comes in with headaches wanting an MRI to be ordered, actually had a friend or relative who died of a brain tumor or one with a cough who wants an antibiotic who knew someone hospitalized with pneumonia as prophylactic treatment was not started in time. This fear psychosis may lead them to such demanding behavior. The critical question that looms for health care reform is whether patients, doctors, and experts are prepared to set aside ideology in the face of data. They must believe in evidence-based research rather than traditional and ideological therapies. Surgeries to repair the knee should work. A syrup to reduce a cough should help. Calming the straining heart by a beta-blocker should save lives. These traditional beliefs may be alluring but the uncomfortable truth is that many expensive, invasive interventions are of little or no benefit and cause potentially uncomfortable, costly, and dangerous side effects and complications. Therefore, doctors must devise a strategy to cope up with these demanding patients. After all, we must remember medicine is taught as “science” but practiced as an “art”. Sources Adam L. Hersh, Pediatrics Vol. 128 No. 6 December 1, 2011 pp. 1053 -1061 (doi:10.1542/peds. 2011-1337) Garbutt JM, et al “Amoxicillin for acute rhinosinusitis: A randomized controlled trial” JAMA 2012; 307(7): 685-692. Believing in treatments that don’t work. By Tara-Parker Pope, Well blog, 2009 What demands from patients you encounter most in your daily practice?

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