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Have any of you guys started withholding abx? I've wanted to, but it's just not common practice where I'm from and Id be the odd one out.
Have any of you guys started withholding abx? I've wanted to, but it's just not common practice where I'm from and Id be the odd one out.
"Never be the first person or the last person to adopt a new treatment/strategy/procedure/etc" is a good rule to live by. This seems to be pretty early on. Like the poster above, not really standard of care yet.Have any of you guys started withholding abx? I've wanted to, but it's just not common practice where I'm from and Id be the odd one out.
Have any of you guys started withholding abx? I've wanted to, but it's just not common practice where I'm from and Id be the odd one out.
What is the deal with all of these letters or words at the end of your posts?-jiggaman
Hopefully most people aren't prescribing them for colds or at least are making an effort not toIf you want to try to cut back on abx usage, there is a lot lower hanging fruit than this. Like, colds.
But my last doctor gave me a zpack when I had the same symptoms and I got better!Hopefully most people aren't prescribing them for colds or at least are making an effort not to
You're in for a treat when you leave residency...Hopefully most people aren't prescribing them for colds or at least are making an effort not to
I'm not quite there with no abx for a ct proven diverticulitis.
I do believe the evidence is decent that there is no benefit, but if they have complications, you are going to be on the hook.
I have however become less likely to get a ct if that's what I think is going on. No ct,
No proof, no abx.
I'm also more likely to send tics home, since I don't believe the hospitalization and iv abx will add anything to their care.
Hopefully most people aren't prescribing them for colds or at least are making an effort not to
Patients love him though
Well, yeah. This one is pretty clear. Outpatient treatment of diverticulitis is common.And your peer review is fine when they bounce back with complications after a documented tender abdomen?
I'm doneYou're in for a treat when you leave residency...
Outpt treatment that doesn't include abx? Your hospital's peer review committee must have a different make up from mine. Most are medicine subspecialists that only remember things outside their field at a med student level and the rest are surgeons that vividly remember every single soft admit they've ever taken and are incredulous whenever anything bounces back because they think we admit everyone.Well, yeah. This one is pretty clear. Outpatient treatment of diverticulitis is common.
"Doing something" doesn't prevent complications, and can create some if done wrong.
Ah, my apologies - I thought your status said Resident.I'm done
Oh, you weren't clear about the Abx or no Abx.Outpt treatment that doesn't include abx? Your hospital's peer review committee must have a different make up from mine. Most are medicine subspecialists that only remember things outside their field at a med student level and the rest are surgeons that vividly remember every single soft admit they've ever taken and are incredulous whenever anything bounces back because they think we admit everyone.
Would be nice to expect more than a McDonald's cashier attitude towards the patient.Your choice is give abx and everyone is happy (5 min) vs not giving in 95% of URI and having 1/3 of those pts thinking you suck, complain, or get worse then get abx (15 min trying to educate)
I will let you decide your practice. You do realize that people who are actually educatable will not go to the ED for URIs. Those that comes want abx.
Thats like a mcdonalds cashier telling 75% of the customers that they don't need fast food b/c thats the vast majority of their customers. I never go to mcdonalds and if I was FAT, I would appreciate someone not selling me a big mac. But those that shows up to Mcdonalds are uneducatable. No different than the ED.
My sanity/well being is of utmost importance to me.
Would be nice to expect more than a McDonald's customer attitude *from* the patient.Would be nice to expect more than a McDonald's cashier attitude towards the patient.
It would, although the McDonald's cashier is getting a lot less money out of the transaction and the McDonald's customer is paying a lot less than the patient. The idea that 1/3 of patients get pissed about not getting abx for a URI or that it takes 15 min to explain why you're not giving them is BS, though. If you want to make tons of money off them coming back every 3-5 days until their cough resolves you could definitely template something like:Would be nice to expect more than a McDonald's customer attitude *from* the patient.
Semper Brunneis Pallium
Honestly, I find 80% of people are just fine being told their URI is viral and that we have a long list of things that might help their symptoms, but it is very likely abx will only-->
cost them money
give them a rash
give them a yeast infection
make them prone to MRSA and CDIFF
Get them better in six days, instead of half-a-dozen days.
So suggest symptomatic relief, if needed Rx an albuterol inhaler or Ibuprofen 600mg, or cough-med-which-isn't-better-than-honey-but-looks-like-medicine. And if they work a hateful, difficulty job give them a work note for 1-2 days.
And frankly 10% of patients probably do deserve abx (big smokers, symptoms >1 week, etc).
Which leaves about 10% who will potentially piss-and-moan. I haven't found these people create enough racket with admin and press gainey to worry about. Abx stewardship is a topic of interest, and responsible prescribing with occasionally irritated patients is A-OK.
I find the diverticulitis question very different, vis-a-vis our current knowledge base and practice standards. Maybe in 15 years we'll be typing what I wrote above about Cipro/Flagyl for divertic...
Truthfully, I get much less irritated with EM docs giving out antibiotics more freely than I do with us PCP types - y'all don't have an established relationship, they can't get back in touch with you in 2-3 days if they aren't any better, and are likely already ticked off being in the ED in the first place. Plus, in terms of sheer numbers your prescribing is a drop in the bucket compared to ours.I often start my URI encounters by saying something like "I reviewed your chart and I see that you've got a really bad cough. I want to ask you some questions and do an exam so we can see if you need antibiotics, or if it's the sort of thing that antibiotics won't help." This doesn't work for everyone, but I've found that acknowledging the gorilla in the room at the beginning helps a lot of patients accept the no ABX discharge at the end.
If you saw the pt 2 days later, and they were not better, you would NOT give antibiotics? That is what you are saying. That seems to go against (my) common sense.If I were to see the pt in 2 dys in the ED if not better, I likely would forgo abx.
Shared decision making is a GREAT thing. I can frame things pretty well if I dont want to scan a 70 year old with fibro with belly pain.
I think he is saying that if he knew he could just see the patient again in 2 days if not better he would avoid abx on the initial visit but since he can't he treats them all.If you saw the pt 2 days later, and they were not better, you would NOT give antibiotics? That is what you are saying. That seems to go against (my) common sense.
Then again, the guy above who says, "if I think it's maybe diverticulitis, I don't get a CT", that, to me, is some severe degree of confirmation bias, or anchoring bias, or just plain crazy. If I was the guy with a perf or abscess in my belly, and the doc who saw me didn't image or write abx, and I ended up with a colostomy or ileostomy, man, I'd be calling the first piece of **** ambulance chaser I could find.
What I think is crazy is just getting a ct on every belly pain without knowing what you are looking for.If you saw the pt 2 days later, and they were not better, you would NOT give antibiotics? That is what you are saying. That seems to go against (my) common sense.
Then again, the guy above who says, "if I think it's maybe diverticulitis, I don't get a CT", that, to me, is some severe degree of confirmation bias, or anchoring bias, or just plain crazy. If I was the guy with a perf or abscess in my belly, and the doc who saw me didn't image or write abx, and I ended up with a colostomy or ileostomy, man, I'd be calling the first piece of **** ambulance chaser I could find.
What I think is crazy is just getting a ct on every belly pain without knowing what you are looking for.
The patients who I wouldn't scan would be a young healthy person with a benign exam and story.
Bad exam, worse symptoms, old or other risks, scan and all the other stuff.
I'm just saying I don't hunt down this diagnosis with every vague belly pain.
It's like the doc who looks for pe in every lame cp story. They won't miss many but I don't think their patients are being well served.
What I think is crazy is just getting a ct on every belly pain without knowing what you are looking for.
The patients who I wouldn't scan would be a young healthy person with a benign exam and story.
Bad exam, worse symptoms, old or other risks, scan and all the other stuff.
I'm just saying I don't hunt down this diagnosis with every vague belly pain.
It's like the doc who looks for pe in every lame cp story. They won't miss many but I don't think their patients are being well served.
I'm not quite there with no abx for a ct proven diverticulitis.
I do believe the evidence is decent that there is no benefit, but if they have complications, you are going to be on the hook.
I have however become less likely to get a ct if that's what I think is going on. No ct,
No proof, no abx.
I'm also more likely to send tics home, since I don't believe the hospitalization and iv abx will add anything to their care.
I have been involved with several patients where this happened (although it was usually their PCP that did it) although they did usually get antibiotics, not that that prevented them coming back with complicated disease and needing to see me (surgeon).How many 28 y/o diverticulitis puts have you seen? When someone says "diverticulitis", my first thought is a 60 year old. I just can't get my head around "no CT, no proof, no antibiotics", even after you say, just before, that you will be on the hook for complications. So, you have a pt with LLQ pain, fever, and diarrhea, and you don't CT? (That's a deliberately provocative absurdity.) You don't consider admission? Call me over cautious, or you cavalier, but, either you are not being SO cavalier, or you are, and that sounds pretty scary to me.
In the first post, you were 2 or 3 SDs off the median, but, following, you seem to hew back to the middle.
All the PCPs I've ever known do much less imaging (and there's that "fallacy of anecdote" again) then we do in the ED. Virtually all of what I post, unless otherwise specified, is EM-specific.I have been involved with several patients where this happened (although it was usually their PCP that did it) although they did usually get antibiotics, not that that prevented them coming back with complicated disease and needing to see me (surgeon).
Uh, there's a lot of enteritis where I live. If their abdomen isn't surgical, then they don't need the CT on the first visit. Similar to kidney stones. I know that I'm an outlier for not thinking the 24 year old with history of stones needs her 20th CT in my EMR, not counting the ones at other hospitals.How many 28 y/o diverticulitis puts have you seen? When someone says "diverticulitis", my first thought is a 60 year old. I just can't get my head around "no CT, no proof, no antibiotics", even after you say, just before, that you will be on the hook for complications. So, you have a pt with LLQ pain, fever, and diarrhea, and you don't CT? (That's a deliberately provocative absurdity.) You don't consider admission? Call me over cautious, or you cavalier, but, either you are not being SO cavalier, or you are, and that sounds pretty scary to me.
I don't think I've met a 70 year old belly pain that I didn't want to scan.
If the system actually rewards good medicine rather than punishing it, I would love to do the right thing. But you are swimming up the stream if you don't play the game.
Admin and the medical society can care less about good medicine. When is the last time I got a pat on the back when I practiced quality medicine? almost never. All they care about is metriccs, patient sats, and nice yelp comments.
When I don't give pain meds or abx, I get complaints. When I give abx, I never get complaints. Guess what I am going to do?
I accuse pts of drug seeking when they have a pharm sheet a mile long and seen 10 different docs with 50 narc scripts in the past year. I sure dont get a compliment. I get a board complaint I have to waste my time defending. While my fellow partners are candy men and never have to deal with this crap. Guess which path is easier.
I get more headaches "doing the right thing"
I am not bitter at all, just being frank. And I would say I order less tests than my fellow docs. I actually use common sense and not shot gun every patients although i get less RVUs.
It seems like the most important thing to you in the practice of medicine is what is easiest for you.
"Easiest" is not having to worry about getting fired for doing good medicine.
Do y'all really have to write responses to complaints about not writing antibiotics for colds? You get fired if you practice EBM to the chagrin of some PCP? What is wrong with your medical directors and who do you work for?
Maybe this is unique but we get these baseless nonsense complaints as regularly as anyone, I imagine. And they are given the attention they deserve (minimal) while not firing anyone, nor requiring some sort of written response.
It's funny. I'm still a resident. But I've heard so many people complain (both IRL and on here) about the groups losing contracts at hospitals. You would think they would encourage their CMG leaders to do almost anything to protect a contract. It seems there is no winning?Every complaint at some hospitals I've worked for gets "investigated" regardless of the legitimacy. The customer is always right, and I typically have to give my director or admin a written response as to why I didn't give narcs, antibiotics, admit a patient or do a test.
Additionally any PCP or medical staff member can refer my case to be reviewed by the peer-review committee. I then have to spend time writing a response, regardless of whether or not anything incorrect was done.
Administrators generally don't like squeaky wheels. Get too many complaints, and they will encourage your group to get rid of you. Because the CMGs are all run by spineless idiots that are afraid of losing contracts, they won't put up too much of a fight against admin on your behalf.
Therefore it's best to stay below the radar and avoid complaints even if it means doing the wrong thing.