As clinicians, we are aware of the potential harm that antibiotic overuse creates, including the development of antibiotic resistant infections and adverse drug events. The World Health Organization has designated antibiotic resistance as “one of the biggest threats to global health, food security, and development today.” Despite our awareness of these risks, we clinicians continue to overprescribe antibiotics.

When discussing unnecessary antibiotic prescriptions with physician colleagues, we have heard various rationales for why a given antibiotic was prescribed inappropriately. The common theme is the difficulty we all face as providers when saying “no.” This is not something that is taught in most training programs. We learn how to deliver bad news and how to comfort a patient’s family in difficult times, but we never learn how to say “you don’t need that treatment.” The conversation when deciding not to prescribe an antibiotic could be structured as an informed consent discussion, similar to explaining the risks and benefits of a surgical intervention.

As healthcare providers, we often associate “treating” a patient with prescribing medications. There are times, however, such as viral respiratory infections, where the best management we can provide is not to prescribe.

So how do you say “no” to patients who are seeking, possibly insisting, on an antibiotic prescription? Below are some communication tips we’ve found useful to provide a patient-centered, successful visit:

1. Validate Symptoms and Provide Symptomatic Treatment Recommendations: Never use the phrase: “It’s just a virus.” It makes patients feel you are not an empathic physician. Say warmly instead, “Although your symptoms are due to a viral infection that won’t respond to antibiotics, it doesn’t mean you aren’t sick. Viral infections are often as painful as bacterial infections. I would like to provide you with treatment recommendations that can help you feel better while your body’s immune system fights the virus.”
2. Considerate Substitution: Many patients want “something strong” prescribed for their symptoms. Some patients will accept an over-the-counter recommendation, but others feel that if you didn’t prescribe something, you didn’t help. Non-antibiotic prescriptions may be an appropriate compromise, and may even lead to higher patient satisfaction.
3. Take Your Time: Saying something like: “I’m in no hurry, let’s talk more about how we can make you feel better,” can be useful in disarming an upset patient. Taking a bit more time to educate the patient on antibiotic stewardship may improve patient satisfaction.
4. Point to a Higher Power: Even if a patient does not yet know or trust you, we have found that many patients respect the scientific reputation of known organizations, such as the Centers for Disease Control and Prevention (CDC). Consider saying: “The research shows antibiotics are over-prescribed by many physicians.” You may even simplify the guidelines by mentioning that “the CDC has a ‘10-day rule,’ meaning that when symptoms have been present for less than 10 days, more than 90 percent of the time, they’re caused by a virus. Viruses, unfortunately, don’t get better with antibiotics.”
5. Share a Story: “A patient came to me once who had diarrhea for five weeks due to a toxin that grows in the colon after taking an antibiotic. While listening to her story, it became clear that the antibiotic wasn’t needed in the first place because she her symptoms were due to a chest cold, which is caused by a virus.” Reviewing potential adverse events related to antibiotic use can be helpful to show you are recommending against antibiotics to prevent the patient from developing symptoms that might make them feel worse.
6. Express Concern, Even When a Patient is Upset: Sometimes, when a patient is distrustful and feels unwell, it can cause bad behavior. Think about how you would want a doctor to talk to your family member in this situation. Try to diffuse anger by remaining calm and monitoring your words carefully. Remember, you are the professional and you can set the tone of the conversation by example.
7. Respect your Physician Colleagues: Careful here. Some patients may say, “Well my previous doctor, Dr. Smith, always gave me an antibiotic whenever I felt this way and I always felt better!” Criticizing good old Dr. Smith directly is likely to be a losing option. Instead, consider taking this opportunity to educate the patient about the usual duration of viral illnesses. For example: “We used to think that antibiotics worked for the symptoms you have, but we found that the course of antibiotics was actually given at the same time your body was fighting off the virus and you would have gotten better without the antibiotic.“
8. We’re In This Together—I’m On Your Side: We know, of course, that we are on the patient’s side. Simply reminding a patient of this can go a long way, especially when you are not providing a treatment the patient was expecting. It is also helpful to give the patient a backup plan. You might say something similar to: “Thank you for being understanding and partnering with me. Let’s plan to see each other again in X days if your symptoms do not get better.”

In our experience, most patients respond favorably to these empathetic communication tips. At the end of the day, it is important for us to convince patients that we put their best interests first—even when we agree to disagree. And always remember, we took an oath to “Do No Harm.” Giving in to an unnecessary antibiotic prescription-seeker may do more harm than good.

Useful Resources:

Centers for Disease Control and Prevention: Antibiotic Prescribing and Use

Consumer Reports: When to Say No to Antibiotics for Infections

Consumer Reports: Antibiotic Side Effects in Children: What Every Parent Should Know

Disclosures: Kristin and Prentiss practice with Doctor On Demand Professionals, a national medical group that provides direct-to-patient telemedicine visits. Kristin is board-certified in Family Medicine and Prentiss is board-certified in Internal Medicine/Preventive Medicine. They are small shareholders in Doctor On Demand, and have mutual funds in retirement accounts that hold shares of CVS, Walgreens, Walmart, Humana, Anthem, Intuitive Surgical, Johnson and Johnson, and other healthcare companies.

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