I have often had to smile at the irony of the situation when patients fail to turn up for a consultation because they are ill. An even greater number ought to fail to turn up because they are well – well enough, that is.
Photo: Einar Nilsen
«Ask your doctor!» is repeated ad nauseam in TV commercials for prescription drugs, in countries where such things are permitted (
1). The objective is to persuade potential patients to visit their doctor. This may appear legitimate, since it is never wrong to go to the doctor. Or is it?
The key risk factor for overdiagnosis and overtreatment is to seek out the health services. Or, when applied to the field that I know best: the key risk factor for being handed an unnecessary prescription for antibiotics is to go and see your doctor.
In Norway, we tend to think that doctors are restrictive in their prescribing and that this explains our relatively low use of antibiotics and thereby also our fairly limited problems with resistant microbes. There is a certain truth to this, but it is still only a partial explanation. GPs still prescribe antibiotics in three out of four consultations for acute sinusitis and in three out of five consultations for acute bronchitis (
2). In Southern and Eastern European countries, the corresponding rate for acute bronchitis tends to be four out of five ( 3). This small difference cannot explain why these countries consume 2 – 3 times more antibiotics than Norway ( 4).
After a worrisome increase, the prescribing of antibiotics in British general practice declined considerably during the second half of the 1990s (
5). This could easily be interpreted as reflecting a more restrictive attitude on the part of the GPs. On closer inspection, however, it turned out that the decline was largely caused by the population: the doctors’ prescribing rate declined by 15 %, but the consultation rate for respiratory infections in the population declined by a full 35 % ( 5).
The primary health services have their own disease panorama, which differs considerably from the disease panorama in the second-tier services. This is one of the reasons why knowledge from hospital-based research is not necessarily transferable to general practice. Moreover, we need to keep in mind that the disease panorama in general practice does not correspond to the actual illness picture in the population. The primary health services filter out patients for the second-tier services, but the most rudimentary filtering does not take place in the GP’s office; it takes place in the home.
So what determines the population’s consultation rates? The authors of the British study believed that the explanation for the considerable drop in consultation rates was an increasing awareness of how self-care was preferable to seeing a doctor (
5). The causes of this increasing awareness are difficult to identify. Patient-directed campaigns on sensible antibiotics use had been launched in approximately the same period. The doctors’ prescribing practices will also have an impact on the patients’ consultation rates: if patients with a sore throat are prescribed antibiotics instead of no prescription or a wait-and-see prescription, they will be more likely to visit their doctor the next time they have a sore throat ( 6). It has also been shown that if parents are given information on the natural, untreated progress of a respiratory infection, they will be less likely to take a child to the doctor for such a condition ( 7). A large number of people are unaware of the fact that it is quite common – and not a cause of concern – to have a cough for several weeks in case of acute bronchitis.
Directly advising not to see a doctor is questionable. We will never see a situation where only those who definitely need an active medical intervention actually come to the doctor. The home-based filtering will never be this good. This notwithstanding, this advice was dispensed during the influenza pandemic of 2009. Those who were «slightly ill» were told to stay away from GPs’ offices and A&Es (
8). During the pandemic period, the consultation rate in A&Es for afflictions such as otitis and acute sinusitis declined by approximately 30 % compared to the three previous years ( 9), and antibiotics use in 2009 was 4 % lower than in the preceding year ( 10). Better hygiene as a result of the authorities’ advice was seen as an explanation of why fewer people went to see their doctor ( 9). Another equally likely hypothesis is that people actually followed the advice of not seeing the health services.
The hospital doctor must keep the disease panorama in general practice in mind. The GP, on the other hand, must be aware of the total, unselected disease panorama: what has disposed this specific person to become a patient? By providing accurate information and avoiding unnecessary interventions, the home-based filtering can become even better.