Family Medicine Recommendation #2: Do not use antibiotics for upper respiratory infections that are likely viral in origin, such as influenzalike illness, or self-limiting, such as sinus infections of less than 7 days’ duration.
Choosing Wisely Canada: What shared decision making strategies or tools have you implemented in your practice around this recommendation?
Dr. Guylène Thériault: Shared decision making tools have a central place in my practice because they simplify my explanations and make patients aware of the potential implications of their choices. When it comes to upper respiratory tract infections (URTIs), I use visual and interactive aids more than formal shared decision making tools. Online resources can be helpful to fuel discussion and are accessible to patients on their own. I use a Centor score calculator collaboratively with patients who come in for a sore throat to help them understand how I came to my diagnosis and to make them a part of their care plan from the time they step into my office; I present them with the finding and my diagnosis, and we discuss what to do next. Another helpful prop I often use is a diagram showing how long bronchitis symptoms last. For viral infections, I use the follow-up sheet suggested by the Institut national d’excellence en santé et en services sociaux,* which explains to patients what they have and how to alleviate their symptoms. I think using these tools, along with the Choosing Wisely Canada poster Four Questions To Ask Your Health Care Provider† that I have put up in the office, helps to let patients know that I practise evidence-based medicine and that it is okay to ask me questions about their care plans.
CWC: What makes shared decision making around this topic challenging or rewarding?
GT: It can sometimes be difficult to talk about treatment choices for URTIs because there is a widespread myth in our society that these infections need to be treated with antibiotics. We need to break down this popular belief so that we can engage patients in a dialogue about the treatments that are actually recommended for their condition. It is up to physicians not to assume that patients expect to be prescribed antibiotics.
I take the time to discuss my patients’ needs and work with them to come up with the best strategy to relieve their symptoms. More than anything, patients are looking for reassurance and the knowledge that we can quickly reevaluate their options if their condition does not improve.
Working this way is rewarding because it means that I can provide my patients with the information they need and clear their doubts so they can stick to their chosen treatment plan. Last winter, a 54-year-old patient came to see me for a case of acute bronchitis that would not go away despite the antibiotics prescribed by the first physician whom she had received treatment from. The patient and I talked about the different possible treatments, as well as the potential harms or consequences associated with them, and we agreed on a care plan that included drinking a certain amount of water every day, irrigating her nasal cavities with a saline solution, and using throat lozenges. When the patient left my office, she said that she felt extremely relieved that she did not have to take another course of antibiotics to cure her infection, and empowered to manage her own symptoms.
CWC: Why is shared decision making around this specific Choosing Wisely recommendation or clinical topic essential to you?
GT: Shared decision making is essential to breaking the cycle of misinformation about URTIs. By arming patients with knowledge, encouraging them to start a dialogue with their physicians, and helping them identify their care preferences, we can improve the quality of medical practice at large.
This article first appeared in Canadian Family Physician. The interview was prepared by Dr Kimberly Wintemute, Primary Care Co-Lead, and Hayley Thompson, Project Manager, for Choosing Wisely Canada.