Patient expectations influence Doctors’ treatments

Some months ago I wrote a column about the overuse of antibiotics causing widespread antibiotic resistance, hence we now have the emergence of superbugs that are resistant to all antibiotics.

The same scenario was played out in the overuse of chloroquine, which led to universal resistance to this cheap antimalarial, necessitating switching to much more expensive categories of antimalarial drugs.

Last week I had a conversation with a doctor from one of the big medical insurance companies who informed me that the continuing overuse of antibiotics has also significantly increased the cost of insurance claims – to the extent that all the health insurance companies are losing money.

This is bad for everyone because such companies have only two options: either they go out of the health insurance business completely, or they raise the cost of their medical insurance premiums. Apparently the average claim from clinics to the insurance companies has risen by 30% due to the overuse of expensive IV antibiotics for ‘bacterial infections’.

Several years ago when a patient went to a clinic he would tell the doctor he had ‘musuga’ which can be translated as fever or malaria, thus effectively giving the doctor the diagnosis, so the doctor was expected to give treatment for malaria. However, with the advent of rapid tests and treated mosquito nets, it has become obvious that much of this musuga is not due to malaria, thus the clinic cannot simply dole out quinine.

This gives a problem for both the patient and the doctor, because patients go to clinics with the expectation that their symptoms will be diagnosed, and then cured by the doctor. Thus if a patient has fever, he expects the doctor to examine him, run some tests, make a diagnosis, and give him treatment which cures him. This is possible when the diagnosis is something such as malaria, or tonsillitis, because treatments exist which can cure each of these conditions. However, when the patient comes with fever, and the test shows it is not due to malaria, the doctor still feels under pressure to find a diagnosis that will satisfy the patient.

Hence doctors have come up with the diagnosis of ‘bacterial infection’ for which the treatment is antibiotics. In effect there is tacit collusion between the patient and the doctor: the patient gets a diagnosis, and the doctor gives IV antibiotics, (for which he can charge more). The patient leaves the clinic feeling that he made the right decision to go to that clinic, because he was given ‘serious’ treatment.

Hence we see many patients going to clinics, getting the diagnosis of ‘bacterial infection’, and walking around with cannulas inserted in the back of their hands. From the patient’s point of view it all makes sense, but from a scientific point of view it is at best pseudo-science and at worst misdiagnosis. Firstly, the diagnosis of bacterial infection is non-specific and does not define which site of the body the bacteria have infected, nor which bacteria, so it is not an actual diagnosis. For example, if I have a sore throat and a doctor swabs the throat and finds Streptococcus, I know I have a bacterial infection of my tonsils caused by streptococcus, (a strep throat) for which the cure is penicillin V.

If a patient has a urethral discharge (from the private parts), which is swabbed and the gonococcus bacteria is cultured, then he has gonorrhea, which will be cured by the administration of specific antibiotics.

Doctors are treating patients’ expectations, and justifying such diagnoses on the basis of small changes in the white cell count; they are not using scientific evidence. There are various reasons for fever, but minor fevers are commonly due to self-limiting viral infections. These are not curable through taking antibiotics, but they are self-limiting, and will resolve, with or without the intervention of a doctor.

In such cases the best course of action is to treat the symptoms, as we wait for the virus to run its course, and the best treatment to bring down a fever is paracetamol (Panadol). But when a doctor gives a patient paracetamol, the patient feels insulted that he has been given this ‘simple’ drug, and goes to another clinic for another opinion.

In many cases the second clinic tells him that he has a serious infection such as typhoid, and puts him on IV drugs. This is all due to patient expectations; some people have grown up knowing that minor illnesses are caused by viruses, so they understand symptomatic treatment when it is explained to them.

On the other hand, others have grown up being familiar with tropical diseases such as malaria, and expect a specific diagnosis with a specific treatment attached. The first goes to a clinic to eliminate the possibility of a serious condition, while the second goes expecting a certain treatment.

The major mistake that doctors make is in treating the expectations of the patient, not treating according to scientific evidence. And life is made more difficult for those doctors who treat scientifically, by patients who do not agree with the diagnosis, and then find another doctor who treats them according to their expectations.