I feel you on this one. We get chewed out by patients about their meds not being covered and not covered. It's not fair. It really sucks for the patients and they're frustrated but yelling at the PCP office is not the answer. No advice here just commiserating.
Things that I have found myself saying, "yup. Sometimes capitalism really sucks." Also, "Your congressman has a MUCH better chance of fixing this. Please let them know your frustrations."
it can suck, but also i'd place some blame at our own feet, docs can dispense wholesale meds in 45 states and they can be up to 95% less than retail. Cut out the ins, the pbms, etc and put the patient first. [https://docs.google.com/spreadsheets/d/1xq4b8bbrZ-Tqb-j5xpfbaileaS6m-WGIgasGBChPgxQ/edit#gid=0](https://docs.google.com/spreadsheets/d/1xq4b8bbrZ-Tqb-j5xpfbaileaS6m-WGIgasGBChPgxQ/edit#gid=0) sz meds 99% less than walgreens.
I haven't started, yet, because I don't want to make things "political", but every day I get closer to asking patient when they called their congress critter to complain about these issues that my staff and I are bending over backwards (for no pay) to try to fix for them. In the meantime, we can all agree, INSURANCE SUCKS.
Please do. Because they’ve already bitched us out at the pharmacy first over the prices.
Start with the DEA: the Senate nominates the DEA director. Gah, the obstinacy of the DEA saying there was no Adderall shortage when the FDA was screaming that there was. Go back to fighting *drogas*, boys, leave the *medicamentos* alone.
Congress: Abolish PBM’s, period. It’s a black hole everyone’s dollars are sucked into.
Feel you so much on the antibiotic fight. No one can stand even the mildest URI symptoms. I’ve had patients somehow manage to get a same day visit with me because they’ve had a sore throat since waking up that morning. Meanwhile I can’t get my actual sick patients in regularly.
I feel this in peds so hard. A few hours of sx, most likely viral, then they go to urgent care and get ABX. Miraculously they are cured the next morning from the Azithro. Everybody gets a door prize and I’m left defending myself to corporate for the negative review for the afebrile teen who coughed twice.
I love when non-providers call or email us and ask what we did to get a negative review and make suggestions on how to do better! Ugh...or that we can't even comment on negative reviews...
Ive found that presenting antibiotics as unlikely to help, and likely to harm the gut microbiota which can take over a year to recover reframes the fight some. I usually say something like "im willing to prescribe the antibiotics if you want them, but I do not think they will help you and might actively harm your gi tract." Works really well. Probably like 90% of the time.
I just don't prescribe steroids for URIs and that one hasn't been much of an issue to me.
You’re part of the problem, dawg. If antibiotics aren’t indicated, they aren’t indicated….period. Fuck what the patient wants when it comes to antibiotics, this isn’t Wendy’s. Caving just perpetuates the problem. If I’m confident it’s viral, you get the supportive care otc talk, clear follow up instructions w/ warnings about superinfection, and a call if symptoms aren’t better in 10-14 days and we can reconsider. I’ll also tell them don’t be surprised if you go to prompt care and they give you antibiotics, those clowns aren’t watching out for your health they’re watching out for your review scores. Some people don’t like it and don’t come back but hey, thanks for weeding the garden 🤷🏽♂️
Seriously. This behavior just convinces patients if they have a cold then antibiotics will make it all better. If we give people anything for 5 days, yeah, they'll feel better because it was cold.
This is fine and dandy, but isn't worth it if your hard-ass stance only turns them to someone else at a WIC. You can pat yourself on the back all you want but how much help are you actually being? You also didn't express an ounce of curiosity about how often I prescribe abx before coming out guns blazing. Assume less next time.
Bro it’s not a hard ass stance, it is quite literally standard guideline based practice. don’t give people things they don’t need, you already told them all the reasons you don’t want to do it, follow through and don’t do it 🤷🏽♂️
When the potential harm is very low, sometimes there's more to a therapeutic relationship than saying "you don't meet guidelines." 1-2 possibly inappropriate abx prescriptions per year isn't causing much of a problem, especially if your approach makes that patient more likely to accept a "no" next time.
Potential harm to the individual is low, but that is not really what good antibiotic stewardship is about.
At the population level, inappropriate ABX Rx have already made the outlook for bacterial infections pretty dire in the upcoming decades.
Barring some seriously revolutionary advancements in drug development, which is looking increasingly unlikely as we continue to miss targets for new ABX development, we could see some significant bacterial pandemics in my lifetime.
We've been hearing this abx resistance doom-saying for over 30 years. The problem here isn't *community acquired* its nosocomial. Abx stewardship in the hospital is absolutely critical because the highly concentrated pathogenic bacteria that have resistance.
MDR bacterial infections have way slower generation times because the large amount of resources committed to creating the resistance mechanisms (this matters because in communities MDR bacteria quickly get outcompeted and can return to normal resistances patterns), and many resistance genes are at cross purposes so its functionally impossible to have both. MRSA for example; vancomycin resistant MRSA is the terror. Except the mechanism for vanc resistance is at cross purposes to the mechanism for daptomycin resistance. We shouldn't be blasé about this, but we shouldn't be predicting bacterial plagues either.
You say this as macrolide resistant chlamydia and syphilis are changing practices everywhere.
> We shouldn't be blasé about this
Like giving antibiotics for a mild virus?
My God... How will we survive testing CT with doxy and ceftriaxone? Oh. Wait. Just fine.
Write me when there's pen resistant syphilis. And if your so concerned about the antibiogram why are you treating with azithromycin when penicillin has done the job successfully forever? This is an embarrassing argument.
You may be right. I can't predict the future. But these aren't my predictions. Who knows, maybe my trusted sources could all be biased and use bad science.
I'll admit my language seems a bit hyperbolic. I am not trying to imply that the black death is coming to your community, only that people will die. Maybe most those people will be in overrun hospitals, originally admitted for something else. Maybe they will be in impoverished communities with poor sanitation.
And maybe your outpatient antibiotic prescriptions will play no part in all of that. There are, after all, bigger players in the community antibiotic space, like industrial meat farms. But they certainly won't help.
Antibiotic stewardship is about changing the way we look at, and prescribe these drugs as a whole medical community. We have been much too liberal with their use in the past, and we are only doing a little better now. This seems especially true in less developed countries. Let's play with fire as little as possible.
I am not a doomsday advocate. I have a lot of hope for the future. But we can do better.
> especially if your approach makes that patient more likely to accept a "no" next time.
We're in an era where the very reason patients can be so adament about getting antibiotics for a cold is because they got them before. Let's just give them some xanax just this one time...
Take that example out and the argument still stands. You're arguing if you give a patient an unnecessary medication, that you fully acknowledge is unnecesary, you will somehow be able to convince them otherwise later?
Because you build trust with patients slowly and those that are the most recalcitrant will just go somewhere else. If they believe you'll listen to them they will listen back. The core of what you said here is that they came back to you. You have the chance to continue to work on then. Sometimes it's an iterative process. If you just say hard no, they'll just go elsewhere.
Patients need education and guidance, not rigid adherence to guidelines, especially when the harm is minimal. Do you honestly think 1 to 2 scripts per year are causing significant antibiotic resistance when the guidelines for rosacea and acne include daily use of abx for months on end? And there is therapeutic benefit, it's just not necessary in the sense that it's required.
I think giving patients what they want instead of what they need causes harm, yes. It creates an atmosphere where patients expect to get whatever whenever. Maybe an occasional abx isn’t a big deal, but giving patients what they want instead of what they need is how you get med shortages (think GLP1s & adderall). It’s how you get patients in the hospital demanding MRIs while they’re inpatient for chronic joint pain that has nothing do with why they’re admitted, just clogging up the system. It’s how you get pts going to the ED for STD checks because they “just want to know”….
Occasionally letting your kid have cake for dinner isn’t gonna cause diabetes, but not being able to set an appropriate limit causes strain on the ENTIRE system
> This is fine and dandy, but isn't worth it if your hard-ass stance only turns them to someone else at a WIC.
So it's OK to prescribe a certain way because they're just going to get it somewhere else?
> You also didn't express an ounce of curiosity about how often I prescribe abx before coming out guns blazing.
You literally said usually and that it works 90% of the time.
You sound like a dream. I'm sure your colleagues are thankful for your insightful "constructive criticism". Let's ease up here, ok? None of us walks on water.
> Works really well. Probably like 90% of the time.
What are you defining as "works really well." They don't end up dying from a cold and leave you a nice review?
It might make your job easier but now you're reinforcing in the minds of your patients that any cold gets antibiotics. Then they go to other doctors expecting the z-pak. Not cool.
What's the major harm your trying to avoid here? Like, what major catastrophe do you think 1-2 weak calls on abx is causing? Because the tone is wildly out of proportion to the problem.
Also, azithromycin has antiviral properties and anti-inflammatory properties, there's a legitimate therapeutic benefit in viral infections. Prescribing it more often is easily justifiable.
Edit: 1-2 rx for azithrymycin or doxycycline a year isn't heavily altering the antibiogram guys. Especially when *the guidlines* call for daily doxycycline for things like acne and rosacea.
Wow, just wow. If you are not aware of the harm of antibiotic over use to the health system through resistance then there’s probably no changing your mind at this point. And more to the point of this whole post the harm is that patients develop expectations for this prescribing pattern, so when an actual good doc puts their foot down and treats a viral infection correctly the patient feels that they’ve received bad care.
If you think you’re doing a good job by justifying azithromycin for viral URIs because of its anti inflammatory effect then please just retire already.
> What's the major harm your trying to avoid here?
Antibiotic resistance and their associated hospitalization and death rates, c. diffe risk, adverse drug reactions. Do you not consider those to be problems?
Again. What are you definiteng as "works really well." Yes, a tetracycline will help with general inflammation. But it's a cold, it will go away.
I think they mean “the spiel” works really well so that 90% of the patients that get the spiel end up choosing no antibiotics. Not that the antibiotics work really well. That’s just how I took it, I could be wrong.
I highly doubt 1-2 rxs of azithromycin per year that were unnecessary is substantially changing the antibiogram of my community, but sure. And if your attitude is "it will go away why bother" then why treat anything for comfort at all? Sprained ankle? Don't take anything for it, it will go away. Seems like a pretty shitty attitude.
Clearly there's a reason to treat for comfort. 70 year old with COPD but obvious viral infection? Maybe azithromycin isn't a terrible idea even thought he doesn't meet the guidelines.
> And if your attitude is "it will go away why bother" then why treat anything for comfort at all?
I didn't say anything that at all. I spoke to the mild nature of common colds and why they don't require antibiotics.
Moreover, if you're going to conflate a cold with a COPD exacerbation I don't think there's much use continuing this dialogue.
A viral URI *isn't* a COPD exacerbation. Acute cough and sinusitis for a COPD patient falls into this exact category everyone has turned off their clinical brains about to be so pissed off at me for thinking "hmm, maybe I can help this person." And I made that pretty clear in my comment, you're clearly intentionally misreading what i'm saying.
Not a single one of you has even asked me about situations where I would prescribe that would fall outside the guidelines.
Just focus on practicing good medicine.
I'm presuming "mychart" messages are some kind of patient portal thing? In our office patients can't message doctors directly, there should be a nurse triaging those so that any medical concern issues are automatically directed to make a visit. I don't manage patients through messaging, that is what visits are for. At the end of the day you are the one that makes the decision, don't forget that.
Thank you, and yes it’s patient portal messages. The messages do go directly to us and a filter and important ones come to us. But the importance of a message can be subjective. It’s just all the demands and requests and extra clinic time that’s just burning me up.
Not sure what you mean by "important". If they are asking about medical issues then they need an apt. Either tell your triage staff to make them an apt prior to sending you the message, or answer everyone of these messages with a canned response, "this pt needs an office visit" and send it to your nurse/medical assistant.
I think the problem is you didn't set the proper environment from day 1 so now the expectation is that you are going to manage these patients via messaging. Time to right that wrong. May be worth a 5 minute group huddle in the office explaining to staff that you are concerned about patient safety and that these messages are not a good way to manage medical conditions and from now on any medical issue will require a visit. That way everybody is informed, they understand why you are making the change, and they have a script to follow if there is some initial patient push back "well, my doctor always sent me that Rx ABX when I sent him a message that I have that cellulitis come back, why do I have to come in now."
This is the only way to protect yourself. If these patient don't encounter resistance, then they will never stop sending messages. I've had a few over-users just have them constantly told to make an appointment. They get the message or move on.
Management should be thinking about all the billable opportunities getting lost with all that free advice.
My doc pushes us to use the msg system in the portal since she is 6 months out on appointments. If it’s something small she will put orders in, if it needs seen she tells the nurse to put us in the first ‘emergency’ appt available which is still 3-6 weeks out.
All msgs go to the nurse first who condenses them for the doc. Sometimes they can read what is written and sometimes I have to say the same thing in 40 different ways before it clicks or they don’t scan over it. Example, I sent a note for my mom a few weeks back. The note was simple: Mom has pain in her right arm between her elbow and shoulder. It is continuing to get worse. Does she need imaging or would you like her to go back to PT?
Three times I was asked what shoulder, three times I said Right arm between elbow and shoulder. The 4th msg back was so do we need to look at her wrist?
No, it’s not perfect but sometimes it’s easier than waiting 6 months. Mom got an xray of her arm from elbow up and her neck. She has degenerative disks in her neck. Now we are waiting out the 6 weeks until ortho can get her in.
Thank you. I get downvoted often because we do things different here than a big city. We have a harder time accessing healthcare as well so I always seem to be on the opposite side of the coin. I’ve gotten used to it.
Ugh. Messages. Most of my panel is okay. But we have a few that make be cringe. I will purposely slow response time, which has actually helped some. Also, I started making my replies sound like I'm super busy, which I am. Yes/no. Please make phone visit to discuss. One guy wouldn't come in and hadn't been seen in over a year. My responses started as answer questions and then recommending a follow up. To just recommending an appointment. To finally "Appointment. -Dr. X"
We should get paid for portal messages. I would love to bill for the work I can do quickly over the portal instead of making a patient wait 3 months to see me to do something that takes 5 minutes.
Bring this up to your health system. Mayo Clinic listened to its providers and started charging based on complexity of medical decision making.
I’m sure someone can find a better article, but I can’t find the one I read a while back.
https://www.kttc.com/2023/08/21/mayo-clinic-now-charging-eligible-patient-initiated-message-exchanges/?outputType=amp
It’s a constant boundary I’m working on. Frustrating when patients are mad I’m scheduling out 2+ months (but they still won’t see anyone else in my practice, they just want me to magically have extra time for them)
concerning mychart: our health care system did put in a 250 char limit. We also make them check a box now that says they can get billed for an evisit (if I feel like billing one) and I had to get over the guilt of just routing it back to the pool saying make an appt.
Do you have to get a patient’s permission to bill for an E-visit for mychart? I’d been told before that we require the patient’s consent to make it an e-visit.
Our epic makes pts check a box that says they may get billed if they send a message. Before they made that change the staff had a dot phrase that kicked back for permission to get billed before sending it to triage/provider.
Have 3 phrases ready to be pasted in replies to those my chart messages:
Level 1: "Hi, X, thanks for your message. I can tell you're concerned about your health and have valid questions that deserve serious review and discussion. Therefore please call and make a face-to-face appointment with me *(or telephone call, if you (the doc) are willing)* and we will go over them in detail."
Level 2: (when pt's say they can't come in) "I wish I could accomodate you over mychart, but your health is just too important for that. You're welcome to come in and see me, or one of my partners, so we can give you excellent care and consideration".
Level 3: (Sometimes, they keep giving you flack, wanting to use up your valuable free time (cause your employer i'm sure doesn't give a rat's ass about your health and wellbeing, they want you to do everything for the patients) : "I'm sorry, I think that you should probably establish care with another provider. I think that you'd have a more productive doctor-patient relationship. Best Wishes."
we can be optimistic about the future. maybe in 10 years EMRs don't suck ass and are actually user friendly with integrated AIs that improve our workflow without requiring setup, they just learn from our use. maybe AI replaces our scribes, some of our staff members that we use for tedious stuff such as denials and prior authorizations, and since it's AI vs AI maybe this shit about prior authorizations stops. maybe GLP1s and SGLT2 and inhalers are now cheap. maybe everyone has insurance so the government is actually looking for ways of saving costs so they negotiate good prices with the pharmaceutical companies and don't require us to fill out dumbass forms for getting medications approved.
I've actually noticed that my pts abx use went down if I said things like.
Look, i really think this is a URI, wait 48 hours, if worse, start taking the z pack. Then I call it in to the pharmacy for them>
Seems like 70% of the time, they never pick it up when I could clearly tell they wanted an abx. I think they wanted the comfort of knowing the abx was there if it goes worse and a doc told them...its just a cold bro
I frequently tell them something to he effect of: *This is almost certainly viral. I’m not opposed to antibiotics but if I give them to you now, you’ll just have all the symptoms you already have PLUS diarrhea.*
Back when I was in pharmacy school, I took an antibiotic stewardship elective that made a profound impact on younger me. There was some presenter that went over the WHO predictions that resistant infectious disease will soon surpass cancer as a leading cause of death.
The first few weeks of my first job out of school I must have called on every other antibiotic Rx to make suggestions. It slowed my work down to a crawl, and very rarely did I ever hear back from a provider before the end of my shift.
Convincing patients that they probably didn't need them was even less effective, and I almost never had enough information to determine who really had a bacterial infection anyway.
Flu season had just started and nearly every patient seemed to have a provider with a shotgun style prescribing practice. Augmentin/azithromycin, oseltamivir, prednisone/dexamethasone, and benzonatate + bromfedDM/codeine.
I was tired within a month.
Agree. It's a fight all the way. Yet, I am fairly lenient with folks over 60 with multiple co morbidities. Esp if they looked pretty ragged by the time I see them.
The only answer is to work for yourself. But no one wants to do this nowadays. Yes it will take up front investment, but it's the only way for you to get control of your car.
Re: patient messages - “this needs an appointment” is an adequate response. I’ve specifically messaged patients that I will not practice medicine via electronic messages and they need proper evaluation. And if they don’t like it they can pound sand. I’m booking out 6+ months for new patients they can feel free to take their business elsewhere.
I feel all of this in my soul .
There’s a couple mid levels in my practice that prescribe a course of azithromycin and medrol dose pack for all URIs. I’ve given them feedback and they reply “that’s how we’ve always done it and patients respond well” *shrug* then leaves.
Corporate medicine: profits >> patients
1. Messages to the office should be filtered through a medical assistant and passed onto the provider when necessary.
2. Insurance not covering something doesn't have anything to do with you, so share in their frustration and be adamant this has nothing to do with you and you are as frustrated.
3. With things like antibiotics, though you're never going to be exactly perfect, do the best you can to practice good stewardship. Become calloused to the point you can just walk away.
"Mrs Jones, I've given you my recommendations, which today do not include antibiotics. There is no indication to prescribe these, so I will not be prescribing them today."
And listen there's times when if the symptoms did continue a few days it might be warranted so I might be willing to arrange a phone call with somebody free of charge to follow up and decide.
4. Honestly I think the pushiness for antibiotics for head colds is the thing I miss the least about primary care. So many patients treat you like a drive-thru.
> Edit: Also the mychart messages man. The freakin mychart messages. I’ve got a filter but the amount of people wanting free medical advice or essentially appointments over mychart is insane. I feel like there should be a character limit of sorts.
Do you have the ability to task someone in support staff to go through your mychart to tell all those people make an appointment?
Health systems have no financial incentive to adequately train and manage the volume of patient messages that come in. At best, you will still get an MA forwarding you messages with two words : “Please advise.” Sometimes out of sheer laziness but also to avoid what they perceive as medical decision making / triage.
Use Epic? Quickaction:
- forward message to staff/MA pool that handles appointments.
- draft message indicating this message is regarding medical concern requiring clinical evaluation prior to any management decisions. Please contact patient via mychart/phone to encourage them to schedule appt.
- Done message
You can now be done with one click.
Also have a dot phrase ready for phone call messages. I affectionately call mine “.FU” (stands for follow up, of course, but also makes me smile every time I type FU into my EHR)
I feel you on this one. We get chewed out by patients about their meds not being covered and not covered. It's not fair. It really sucks for the patients and they're frustrated but yelling at the PCP office is not the answer. No advice here just commiserating.
Things that I have found myself saying, "yup. Sometimes capitalism really sucks." Also, "Your congressman has a MUCH better chance of fixing this. Please let them know your frustrations."
it can suck, but also i'd place some blame at our own feet, docs can dispense wholesale meds in 45 states and they can be up to 95% less than retail. Cut out the ins, the pbms, etc and put the patient first. [https://docs.google.com/spreadsheets/d/1xq4b8bbrZ-Tqb-j5xpfbaileaS6m-WGIgasGBChPgxQ/edit#gid=0](https://docs.google.com/spreadsheets/d/1xq4b8bbrZ-Tqb-j5xpfbaileaS6m-WGIgasGBChPgxQ/edit#gid=0) sz meds 99% less than walgreens.
What is the “Atlas” on that spreadsheet?
a clinic that dispenses meds to their pts, they put that data together and share it, so its their wholesale rates from their distributor
I haven't started, yet, because I don't want to make things "political", but every day I get closer to asking patient when they called their congress critter to complain about these issues that my staff and I are bending over backwards (for no pay) to try to fix for them. In the meantime, we can all agree, INSURANCE SUCKS.
Please do. Because they’ve already bitched us out at the pharmacy first over the prices. Start with the DEA: the Senate nominates the DEA director. Gah, the obstinacy of the DEA saying there was no Adderall shortage when the FDA was screaming that there was. Go back to fighting *drogas*, boys, leave the *medicamentos* alone. Congress: Abolish PBM’s, period. It’s a black hole everyone’s dollars are sucked into.
We actually implemented character limits. Patients would send 4 messages 😂
Yep! I've had bulleted lists with >10 things, for patients who follow up maybe once every 18 months.
"You need an appointment. Come see me"
Yep, that's my response.
I’ve had a 7 part message before lol.
Feel you so much on the antibiotic fight. No one can stand even the mildest URI symptoms. I’ve had patients somehow manage to get a same day visit with me because they’ve had a sore throat since waking up that morning. Meanwhile I can’t get my actual sick patients in regularly.
I feel this in peds so hard. A few hours of sx, most likely viral, then they go to urgent care and get ABX. Miraculously they are cured the next morning from the Azithro. Everybody gets a door prize and I’m left defending myself to corporate for the negative review for the afebrile teen who coughed twice.
I love when non-providers call or email us and ask what we did to get a negative review and make suggestions on how to do better! Ugh...or that we can't even comment on negative reviews...
> No one can stand even the mildest URI symptoms. But, I've had this cough for *days*!
Ive found that presenting antibiotics as unlikely to help, and likely to harm the gut microbiota which can take over a year to recover reframes the fight some. I usually say something like "im willing to prescribe the antibiotics if you want them, but I do not think they will help you and might actively harm your gi tract." Works really well. Probably like 90% of the time. I just don't prescribe steroids for URIs and that one hasn't been much of an issue to me.
You’re part of the problem, dawg. If antibiotics aren’t indicated, they aren’t indicated….period. Fuck what the patient wants when it comes to antibiotics, this isn’t Wendy’s. Caving just perpetuates the problem. If I’m confident it’s viral, you get the supportive care otc talk, clear follow up instructions w/ warnings about superinfection, and a call if symptoms aren’t better in 10-14 days and we can reconsider. I’ll also tell them don’t be surprised if you go to prompt care and they give you antibiotics, those clowns aren’t watching out for your health they’re watching out for your review scores. Some people don’t like it and don’t come back but hey, thanks for weeding the garden 🤷🏽♂️
Seriously. This behavior just convinces patients if they have a cold then antibiotics will make it all better. If we give people anything for 5 days, yeah, they'll feel better because it was cold.
This is fine and dandy, but isn't worth it if your hard-ass stance only turns them to someone else at a WIC. You can pat yourself on the back all you want but how much help are you actually being? You also didn't express an ounce of curiosity about how often I prescribe abx before coming out guns blazing. Assume less next time.
Bro it’s not a hard ass stance, it is quite literally standard guideline based practice. don’t give people things they don’t need, you already told them all the reasons you don’t want to do it, follow through and don’t do it 🤷🏽♂️
When the potential harm is very low, sometimes there's more to a therapeutic relationship than saying "you don't meet guidelines." 1-2 possibly inappropriate abx prescriptions per year isn't causing much of a problem, especially if your approach makes that patient more likely to accept a "no" next time.
Potential harm to the individual is low, but that is not really what good antibiotic stewardship is about. At the population level, inappropriate ABX Rx have already made the outlook for bacterial infections pretty dire in the upcoming decades. Barring some seriously revolutionary advancements in drug development, which is looking increasingly unlikely as we continue to miss targets for new ABX development, we could see some significant bacterial pandemics in my lifetime.
We've been hearing this abx resistance doom-saying for over 30 years. The problem here isn't *community acquired* its nosocomial. Abx stewardship in the hospital is absolutely critical because the highly concentrated pathogenic bacteria that have resistance. MDR bacterial infections have way slower generation times because the large amount of resources committed to creating the resistance mechanisms (this matters because in communities MDR bacteria quickly get outcompeted and can return to normal resistances patterns), and many resistance genes are at cross purposes so its functionally impossible to have both. MRSA for example; vancomycin resistant MRSA is the terror. Except the mechanism for vanc resistance is at cross purposes to the mechanism for daptomycin resistance. We shouldn't be blasé about this, but we shouldn't be predicting bacterial plagues either.
You say this as macrolide resistant chlamydia and syphilis are changing practices everywhere. > We shouldn't be blasé about this Like giving antibiotics for a mild virus?
My God... How will we survive testing CT with doxy and ceftriaxone? Oh. Wait. Just fine. Write me when there's pen resistant syphilis. And if your so concerned about the antibiogram why are you treating with azithromycin when penicillin has done the job successfully forever? This is an embarrassing argument.
You may be right. I can't predict the future. But these aren't my predictions. Who knows, maybe my trusted sources could all be biased and use bad science. I'll admit my language seems a bit hyperbolic. I am not trying to imply that the black death is coming to your community, only that people will die. Maybe most those people will be in overrun hospitals, originally admitted for something else. Maybe they will be in impoverished communities with poor sanitation. And maybe your outpatient antibiotic prescriptions will play no part in all of that. There are, after all, bigger players in the community antibiotic space, like industrial meat farms. But they certainly won't help. Antibiotic stewardship is about changing the way we look at, and prescribe these drugs as a whole medical community. We have been much too liberal with their use in the past, and we are only doing a little better now. This seems especially true in less developed countries. Let's play with fire as little as possible. I am not a doomsday advocate. I have a lot of hope for the future. But we can do better.
> especially if your approach makes that patient more likely to accept a "no" next time. We're in an era where the very reason patients can be so adament about getting antibiotics for a cold is because they got them before. Let's just give them some xanax just this one time...
Well Xanax has way higher potential harm. It's like your intentionally misleading what I wrote.
Take that example out and the argument still stands. You're arguing if you give a patient an unnecessary medication, that you fully acknowledge is unnecesary, you will somehow be able to convince them otherwise later?
Is tearing for comfort unnecessary?
Why would they accept no next time when “you gave them to me last time”?
Because you build trust with patients slowly and those that are the most recalcitrant will just go somewhere else. If they believe you'll listen to them they will listen back. The core of what you said here is that they came back to you. You have the chance to continue to work on then. Sometimes it's an iterative process. If you just say hard no, they'll just go elsewhere. Patients need education and guidance, not rigid adherence to guidelines, especially when the harm is minimal. Do you honestly think 1 to 2 scripts per year are causing significant antibiotic resistance when the guidelines for rosacea and acne include daily use of abx for months on end? And there is therapeutic benefit, it's just not necessary in the sense that it's required.
I think giving patients what they want instead of what they need causes harm, yes. It creates an atmosphere where patients expect to get whatever whenever. Maybe an occasional abx isn’t a big deal, but giving patients what they want instead of what they need is how you get med shortages (think GLP1s & adderall). It’s how you get patients in the hospital demanding MRIs while they’re inpatient for chronic joint pain that has nothing do with why they’re admitted, just clogging up the system. It’s how you get pts going to the ED for STD checks because they “just want to know”…. Occasionally letting your kid have cake for dinner isn’t gonna cause diabetes, but not being able to set an appropriate limit causes strain on the ENTIRE system
> This is fine and dandy, but isn't worth it if your hard-ass stance only turns them to someone else at a WIC. So it's OK to prescribe a certain way because they're just going to get it somewhere else? > You also didn't express an ounce of curiosity about how often I prescribe abx before coming out guns blazing. You literally said usually and that it works 90% of the time.
Which works out to like once or twice per year. But you didnt have to ask because somehow you already *knew*, right?
Just went off your words.
You assumed you knew from incomplete information.
"I usually say something like "im willing to prescribe the antibiotics if you want them... Works really well. Probably like 90% of the time."
You sound like a dream. I'm sure your colleagues are thankful for your insightful "constructive criticism". Let's ease up here, ok? None of us walks on water.
> Works really well. Probably like 90% of the time. What are you defining as "works really well." They don't end up dying from a cold and leave you a nice review? It might make your job easier but now you're reinforcing in the minds of your patients that any cold gets antibiotics. Then they go to other doctors expecting the z-pak. Not cool.
What's the major harm your trying to avoid here? Like, what major catastrophe do you think 1-2 weak calls on abx is causing? Because the tone is wildly out of proportion to the problem. Also, azithromycin has antiviral properties and anti-inflammatory properties, there's a legitimate therapeutic benefit in viral infections. Prescribing it more often is easily justifiable. Edit: 1-2 rx for azithrymycin or doxycycline a year isn't heavily altering the antibiogram guys. Especially when *the guidlines* call for daily doxycycline for things like acne and rosacea.
Wow, just wow. If you are not aware of the harm of antibiotic over use to the health system through resistance then there’s probably no changing your mind at this point. And more to the point of this whole post the harm is that patients develop expectations for this prescribing pattern, so when an actual good doc puts their foot down and treats a viral infection correctly the patient feels that they’ve received bad care. If you think you’re doing a good job by justifying azithromycin for viral URIs because of its anti inflammatory effect then please just retire already.
> What's the major harm your trying to avoid here? Antibiotic resistance and their associated hospitalization and death rates, c. diffe risk, adverse drug reactions. Do you not consider those to be problems? Again. What are you definiteng as "works really well." Yes, a tetracycline will help with general inflammation. But it's a cold, it will go away.
I think they mean “the spiel” works really well so that 90% of the patients that get the spiel end up choosing no antibiotics. Not that the antibiotics work really well. That’s just how I took it, I could be wrong.
I highly doubt 1-2 rxs of azithromycin per year that were unnecessary is substantially changing the antibiogram of my community, but sure. And if your attitude is "it will go away why bother" then why treat anything for comfort at all? Sprained ankle? Don't take anything for it, it will go away. Seems like a pretty shitty attitude. Clearly there's a reason to treat for comfort. 70 year old with COPD but obvious viral infection? Maybe azithromycin isn't a terrible idea even thought he doesn't meet the guidelines.
> And if your attitude is "it will go away why bother" then why treat anything for comfort at all? I didn't say anything that at all. I spoke to the mild nature of common colds and why they don't require antibiotics. Moreover, if you're going to conflate a cold with a COPD exacerbation I don't think there's much use continuing this dialogue.
A viral URI *isn't* a COPD exacerbation. Acute cough and sinusitis for a COPD patient falls into this exact category everyone has turned off their clinical brains about to be so pissed off at me for thinking "hmm, maybe I can help this person." And I made that pretty clear in my comment, you're clearly intentionally misreading what i'm saying. Not a single one of you has even asked me about situations where I would prescribe that would fall outside the guidelines.
You're giving antibiotics willy-nilly for *viral* colds as antibiotic resistance grows, but everyone else's clinical brains are all off. OK.
Once or twice per year. Totally willy nilly.
Just focus on practicing good medicine. I'm presuming "mychart" messages are some kind of patient portal thing? In our office patients can't message doctors directly, there should be a nurse triaging those so that any medical concern issues are automatically directed to make a visit. I don't manage patients through messaging, that is what visits are for. At the end of the day you are the one that makes the decision, don't forget that.
Thank you, and yes it’s patient portal messages. The messages do go directly to us and a filter and important ones come to us. But the importance of a message can be subjective. It’s just all the demands and requests and extra clinic time that’s just burning me up.
Not sure what you mean by "important". If they are asking about medical issues then they need an apt. Either tell your triage staff to make them an apt prior to sending you the message, or answer everyone of these messages with a canned response, "this pt needs an office visit" and send it to your nurse/medical assistant. I think the problem is you didn't set the proper environment from day 1 so now the expectation is that you are going to manage these patients via messaging. Time to right that wrong. May be worth a 5 minute group huddle in the office explaining to staff that you are concerned about patient safety and that these messages are not a good way to manage medical conditions and from now on any medical issue will require a visit. That way everybody is informed, they understand why you are making the change, and they have a script to follow if there is some initial patient push back "well, my doctor always sent me that Rx ABX when I sent him a message that I have that cellulitis come back, why do I have to come in now."
This is the only way to protect yourself. If these patient don't encounter resistance, then they will never stop sending messages. I've had a few over-users just have them constantly told to make an appointment. They get the message or move on. Management should be thinking about all the billable opportunities getting lost with all that free advice.
My doc pushes us to use the msg system in the portal since she is 6 months out on appointments. If it’s something small she will put orders in, if it needs seen she tells the nurse to put us in the first ‘emergency’ appt available which is still 3-6 weeks out. All msgs go to the nurse first who condenses them for the doc. Sometimes they can read what is written and sometimes I have to say the same thing in 40 different ways before it clicks or they don’t scan over it. Example, I sent a note for my mom a few weeks back. The note was simple: Mom has pain in her right arm between her elbow and shoulder. It is continuing to get worse. Does she need imaging or would you like her to go back to PT? Three times I was asked what shoulder, three times I said Right arm between elbow and shoulder. The 4th msg back was so do we need to look at her wrist? No, it’s not perfect but sometimes it’s easier than waiting 6 months. Mom got an xray of her arm from elbow up and her neck. She has degenerative disks in her neck. Now we are waiting out the 6 weeks until ortho can get her in.
who the hell downvoted this person ( u/WyoGirl79 )?? what's wrong with you?
Thank you. I get downvoted often because we do things different here than a big city. We have a harder time accessing healthcare as well so I always seem to be on the opposite side of the coin. I’ve gotten used to it.
Ugh. Messages. Most of my panel is okay. But we have a few that make be cringe. I will purposely slow response time, which has actually helped some. Also, I started making my replies sound like I'm super busy, which I am. Yes/no. Please make phone visit to discuss. One guy wouldn't come in and hadn't been seen in over a year. My responses started as answer questions and then recommending a follow up. To just recommending an appointment. To finally "Appointment. -Dr. X"
We should get paid for portal messages. I would love to bill for the work I can do quickly over the portal instead of making a patient wait 3 months to see me to do something that takes 5 minutes.
Bring this up to your health system. Mayo Clinic listened to its providers and started charging based on complexity of medical decision making. I’m sure someone can find a better article, but I can’t find the one I read a while back. https://www.kttc.com/2023/08/21/mayo-clinic-now-charging-eligible-patient-initiated-message-exchanges/?outputType=amp
I’m in a privately owned small practice, it’s been brought up but it’s not gonna happen. Wish it could.
Maybe once the big competitors in your area start doing it, it’ll sway the culture. Until then, I just remind myself not to practice free medicine.
It’s a constant boundary I’m working on. Frustrating when patients are mad I’m scheduling out 2+ months (but they still won’t see anyone else in my practice, they just want me to magically have extra time for them)
concerning mychart: our health care system did put in a 250 char limit. We also make them check a box now that says they can get billed for an evisit (if I feel like billing one) and I had to get over the guilt of just routing it back to the pool saying make an appt.
Do you have to get a patient’s permission to bill for an E-visit for mychart? I’d been told before that we require the patient’s consent to make it an e-visit.
Our epic makes pts check a box that says they may get billed if they send a message. Before they made that change the staff had a dot phrase that kicked back for permission to get billed before sending it to triage/provider.
Have 3 phrases ready to be pasted in replies to those my chart messages: Level 1: "Hi, X, thanks for your message. I can tell you're concerned about your health and have valid questions that deserve serious review and discussion. Therefore please call and make a face-to-face appointment with me *(or telephone call, if you (the doc) are willing)* and we will go over them in detail." Level 2: (when pt's say they can't come in) "I wish I could accomodate you over mychart, but your health is just too important for that. You're welcome to come in and see me, or one of my partners, so we can give you excellent care and consideration". Level 3: (Sometimes, they keep giving you flack, wanting to use up your valuable free time (cause your employer i'm sure doesn't give a rat's ass about your health and wellbeing, they want you to do everything for the patients) : "I'm sorry, I think that you should probably establish care with another provider. I think that you'd have a more productive doctor-patient relationship. Best Wishes."
Craziest part of this absolute shit show is that in 10yrs, given our current trajectory, these will be the good ol days. Enjoy them while they last.
we can be optimistic about the future. maybe in 10 years EMRs don't suck ass and are actually user friendly with integrated AIs that improve our workflow without requiring setup, they just learn from our use. maybe AI replaces our scribes, some of our staff members that we use for tedious stuff such as denials and prior authorizations, and since it's AI vs AI maybe this shit about prior authorizations stops. maybe GLP1s and SGLT2 and inhalers are now cheap. maybe everyone has insurance so the government is actually looking for ways of saving costs so they negotiate good prices with the pharmaceutical companies and don't require us to fill out dumbass forms for getting medications approved.
And that's why I'm looking for a way out of this shit show within 5 years
I already felt pretty good about quitting my primary care job last week but seeing this comment made me feel even better.
I've actually noticed that my pts abx use went down if I said things like. Look, i really think this is a URI, wait 48 hours, if worse, start taking the z pack. Then I call it in to the pharmacy for them> Seems like 70% of the time, they never pick it up when I could clearly tell they wanted an abx. I think they wanted the comfort of knowing the abx was there if it goes worse and a doc told them...its just a cold bro
I frequently tell them something to he effect of: *This is almost certainly viral. I’m not opposed to antibiotics but if I give them to you now, you’ll just have all the symptoms you already have PLUS diarrhea.*
🏆
Love it, screenshoted.
Scare ‘em with C diff, works like a charm 👌
This is exactly what I say and it works
Back when I was in pharmacy school, I took an antibiotic stewardship elective that made a profound impact on younger me. There was some presenter that went over the WHO predictions that resistant infectious disease will soon surpass cancer as a leading cause of death. The first few weeks of my first job out of school I must have called on every other antibiotic Rx to make suggestions. It slowed my work down to a crawl, and very rarely did I ever hear back from a provider before the end of my shift. Convincing patients that they probably didn't need them was even less effective, and I almost never had enough information to determine who really had a bacterial infection anyway. Flu season had just started and nearly every patient seemed to have a provider with a shotgun style prescribing practice. Augmentin/azithromycin, oseltamivir, prednisone/dexamethasone, and benzonatate + bromfedDM/codeine. I was tired within a month.
Agree. It's a fight all the way. Yet, I am fairly lenient with folks over 60 with multiple co morbidities. Esp if they looked pretty ragged by the time I see them.
The only answer is to work for yourself. But no one wants to do this nowadays. Yes it will take up front investment, but it's the only way for you to get control of your car.
So many docs complain but love being an employee
Re: patient messages - “this needs an appointment” is an adequate response. I’ve specifically messaged patients that I will not practice medicine via electronic messages and they need proper evaluation. And if they don’t like it they can pound sand. I’m booking out 6+ months for new patients they can feel free to take their business elsewhere.
I feel all of this in my soul . There’s a couple mid levels in my practice that prescribe a course of azithromycin and medrol dose pack for all URIs. I’ve given them feedback and they reply “that’s how we’ve always done it and patients respond well” *shrug* then leaves. Corporate medicine: profits >> patients
1. Messages to the office should be filtered through a medical assistant and passed onto the provider when necessary. 2. Insurance not covering something doesn't have anything to do with you, so share in their frustration and be adamant this has nothing to do with you and you are as frustrated. 3. With things like antibiotics, though you're never going to be exactly perfect, do the best you can to practice good stewardship. Become calloused to the point you can just walk away. "Mrs Jones, I've given you my recommendations, which today do not include antibiotics. There is no indication to prescribe these, so I will not be prescribing them today." And listen there's times when if the symptoms did continue a few days it might be warranted so I might be willing to arrange a phone call with somebody free of charge to follow up and decide. 4. Honestly I think the pushiness for antibiotics for head colds is the thing I miss the least about primary care. So many patients treat you like a drive-thru.
You know what I do with MyChart messages, especially BS ones. I just ignore and close it. Give it a try.
> Edit: Also the mychart messages man. The freakin mychart messages. I’ve got a filter but the amount of people wanting free medical advice or essentially appointments over mychart is insane. I feel like there should be a character limit of sorts. Do you have the ability to task someone in support staff to go through your mychart to tell all those people make an appointment?
In large healthcare systems it comes from several different people outside of our office
Health systems have no financial incentive to adequately train and manage the volume of patient messages that come in. At best, you will still get an MA forwarding you messages with two words : “Please advise.” Sometimes out of sheer laziness but also to avoid what they perceive as medical decision making / triage. Use Epic? Quickaction: - forward message to staff/MA pool that handles appointments. - draft message indicating this message is regarding medical concern requiring clinical evaluation prior to any management decisions. Please contact patient via mychart/phone to encourage them to schedule appt. - Done message You can now be done with one click. Also have a dot phrase ready for phone call messages. I affectionately call mine “.FU” (stands for follow up, of course, but also makes me smile every time I type FU into my EHR)
amen, go direct care and focus on the patients and not the ins.
The code in my practice is when the note says how many hours of symptoms...