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In Defense of (Over)prescribing Antibiotics

Cesarine, Joseph, MD

doi: 10.1097/01.EEM.0000554301.86523.af
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The patient sitting in front of you looks uncomfortable, which is explained away by his slight fever and bilateral, rip-roaring pharyngeal exudates. You perform a rapid strep test, which is negative.

An identical patient walks into your ED every day of the week and twice on Sunday. He also presents to every other ED and urgent care across the country and the world every day. One unifying feature among these patients is that many of them will leave with a prescription for some of the finest amoxicillin our great nation has to offer. We live in an era where those individuals with a microphone lambast nearly all antibiotic prescribing patterns except those targeted against bacterial infections with the pinpoint accuracy of a Navy SEAL sniper, so a major driver of antibiotic prescribing ought to be acknowledged, defended, and potentially even encouraged. Defensive medicine is that driving force. The origination and propagation of defensive medicine practices are incredibly complex, but it can be argued that they are disseminated throughout nearly all facets of the medical world and likely confer some benefit to the physician and the patient.

Physicians, faced with the harrowing reality that one in 14 of them will be sued every year, go on the defensive, as many as 93 percent when surveyed. (New Engl J Med 2011;365[7]:629, http://bit.ly/2BCRWzp; JAMA 2005;293[21]:2609, http://bit.ly/2P7Te8O.) Defensive medicine is intuitively defined as deviating from sound medical practice because of the threat of liability. Intelligent individuals who study the behavior of physicians state that defensive medicine comes in two flavors. The more common practice is known as positive defensive medicine or assurance behavior. Positive defensive medical practices add no or marginal medical value to the patient's care. An example of this would be ordering that more-advanced-but-unnecessary imaging test or adding on that not-so-indicated course of antibiotics. These measures are draped like a Kevlar vest around the patient's chart and are aimed at preventing adverse outcomes, deter patients from filing a malpractice suit, and persuading the legal system that the standard of care was met. Negative defensive medicine, or avoidance behavior, is behavior geared toward distancing physicians from legal risk, such as not treating or performing a procedure or surgery on a high-risk patient.

Taken alone, defensive medicine practices seem like a natural and beneficial defense mechanism evolving in response to the increased pressures from practicing in a high-risk malpractice environment. These are practices that likely reduce a physician's chance of being sued (continue reading). The identification of life-threatening pathology and treatment of serious bacterial infections hiding in the shadows are also patient-oriented promises of defensive medicine. But defensive medicine is not cost-free. An estimated $60 billion of health care costs per year are attributed to defensive medicine practices. (BMJ 2015;351:h5786.) Increased antibiotic resistance, medication side effects, and procedural complications are other noteworthy damages. For a style of practice that incurs such great cost, why is defensive medicine so viral?

More than 80 percent of physicians responding to a survey admitted to practicing defensive medicine in one state, 93 percent in another state. A national survey found that more than 60 percent of physicians attempt to reduce liability by ordering more tests and consultations, and 30 percent of imaging tests and 13 percent of hospital admissions are considered to be defensive. (BMJ 2015;351:h5516.) A staggering 30 percent of antibiotic prescriptions are deemed unnecessary. (CDC: Antibiotic Use in the United States, 2017: Progress and Opportunities; http://bit.ly/2TUBaD1.) It seems that practicing defensively is woven into the fabric of modern medical practice.

Publications have long chronicled the increasing magnitude of defensive medicine, yet no one has definitively answered whether it actually results in decreased liability. One analysis of a massive databank from Florida spanning a decade and examining 24,637 physicians, 18 million hospital admissions, and 4,342 malpractice claims found that greater health care spending correlated with a statistically significant lower risk of being sued. This trend was observed across multiple arenas of medicine, occurring in six of the seven specialties examined. The probability of a malpractice suit was 1.5 percent for internists in the lowest fifth of resource utilization compared with 0.3 percent for internists in the highest fifth of spending. The message is clear: Doctors who spent more and ordered more consults were five times less likely to be sued. (BMJ 2015;351:h5516.)

It should be noted that this article used resource utilization and health care spending as surrogates for defensive medicine, and it is unknown whether those increased costs were a result of defensive medicine practices. It is also unknown whether increased spending led to a reduction in adverse events or improved patient outcomes, though a significant reduction in risk of malpractice was seen with increased resource utilization. Still, a logical and appropriate Bayesian inference of this study would claim that defensive medicine does lower the chance of being sued.

The malpractice crisis, record-breaking ED visits, and administrative throughput pressure test physicians' ability to deliver optimal medical care and threaten their mental and physical health, and defensive medical practices seem quite defensible when they reduce the risk of malpractice. Up to 93 percent of physicians would agree as they write for amoxicillin.

Dr. Cesarineis an emergency physician at the Crozer-Keystone Health System in Chester, PA, and at the Virtua Health System in southern New Jersey. Follow him on Twitter @CesarineMD.

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