Antibiotic Resistance

Antibiotic resistance is a problem throughout the world that is rapidly progressing, but not at the same rate in all areas. Multi-drug resistant bacteria such as Methicillin-resistant Staphylococcus aureus, more commonly known as MRSA, is a problem in several nations including the United States, but not as prevalent in other places such as in the United Kingdom. The effect of antibiotic resistance on patient care is important to consider, especially dealing with a multicultural population that may or may not contribute to the spread of such "super bugs" as MRSA.

Introduction and Questions
One of the greatest challenges in modern medicine is the rapid development of multi-drug resistant bacteria. It is becoming more and more difficult to find antibiotics that can kill these “super bugs.” Many people contribute their increase in number to patients’ noncompliance with antibiotic regimens. '''In regard to cultural competency, how do physicians explain the importance of following pharmaceutical directions to foreign patients? '''

Many recent immigrants and refugees are of lower socioeconomic status and thereby this may complicate the problem. I have seen some patients who do not complete an antibiotic course so that they can save the medication for themselves or family since they may not be able to afford it again. How can we avoid this situation?

Finally, many traditional healers are not as specific with their directions or quantities of medications. Does this play a role in noncompliance with our medication regimens?

Discussion
Why not spend the time to talk to the patient and educate them. Telling a patient that they have something that they clearly do not to be PC or to trick them into doing what you want is unethical. Yes, one should be sensitive to others cultures, but this does not include lying to them. Honesty and integrity are some of the most important parts of medicine.

Both parties involved in the case had to find a compromise for Miguel to get well. The mother came to a western doctor because the Healer's Rx did not work and her kid was still sick. She sought a second opinion. In her mind the Healer is probably as qualified as the MD. She went to the Healer first because of several reasons: easy access, similar backgrounds, and the ease of communication. But since the Healer's Rx did not yield results the MD got a shot at treating Miguel.Results matter.

The MD is at a significant disadvantage in this encounter. As seen in the 1st movie it is very easy to poison the Pt-MD relationship. He needs to gather and then present a recommendation in a way that the Pt understands and then accepts. This is true in any Pt encounter but with this scenario the MD has to validate his position to the Pt by knowing enough about the Pt's culture and beliefs to avoid offending the Pt and to come off as someone whose opinion is valuable.

Both parties need to sacrifice a little to get through this encounter. Time and the amount of information exchanged is sacrificed. The manner in which information is exchanged necessitates this fact. Using a translator is a little like playing the telephone game in elementary school. The longer and more complex the message the more room for error one introduces.

The education of the Pt does not mean the dismissal of their belief system. If the MD can provide a positive outcome on this visit the Pt will seek the MD's opinion prior to that of the Healer the next time someone is ill and that is when the MD can start to educate the patient in the western approach to medicine. There will never be a perfect exchange of information between MD and Pt in any situation, what we need to aim for is good enough exchange to get compliance.

The problem with cross cultural exchange is that both parties think their belief system is the right one. Neither side wants to concede their system is wrong. If one gets too focused on re-educating the patient one might lose out on compliance.

In conclusion, final outcomes matter. To get these results the patient must believe you know what you are talking about and believes your treatment will work, a little bit of cross cultural knowledge helps bridge the divide and helps sell the treatment.

In my opinion, when physicians take time to explain the importance of following directions, patients are more likely to adhere to the regimen. This issue is not specific to the foreign patients. Going back to having a good rapport with the patients, physicians may be able to understand the reason why the patients may be non-adherence, they can address the issues better. “Next time you or your friends and family have similar illness, they can see the doctor at free clinic (if they are uninsured) and they can still get the medicine relatively cheaply ($4?) or free.” We must explain to them that some patients are allergic to certain medications and that taking someone else med can cause serious medical problem. Also, it is important to reiterate that not all illnesses with similar signs and symptoms are the same.

I think part of the “super-bug” problem is the physicians prescribing antibiotics unnecessarily. My pediatrics preceptor was awesome in that he will not prescribe the med if not indicated. But I have met physicians who will acknowledge to me that it is not necessary, but since the patient came to see the physician “to take something home” they are willing to give antibiotics even after educating the patients antibiotics are not necessary. Call it social reasons. It’s of course more complicated than I have described. But, we as providers should practice evidence-based medicine and not by outside pressures. Clearly, by giving unnecessary antibiotics, we will be violating “do no harm” principle.

As for the traditional healers, I personally think the ways they treat have little to do with the adherence issues. Again with proper education, and acknowledging that alternative medicine may not require strict regimen, I think patients will follow the regimen.

It’s all about the education and rapport in my opinion. And of course, evidence-based medicine.

The only way to promote patient compliance is with effective communication. This might entail spending more time with a patient if they are not from a western culture, but it is the only way to prevent antibiotic resistance. If the patient understands why it is so important to take all of their prescribed antibiotics they will be more likely to take them. Being culturally competent allows us to communicate with everyone in a fashion that is not offensive. We as physicians have an obligation to distribute knowledge to our patients to do our part in preventing antibiotic resistance.

I agree that education about medical treatment (for example, the use of antibiotics) is very important for patient adherence. Even myself, being a medical student, I find that I follow doctors instructions more correctly if they clearly and carefully explain 1. the diagnosis, 2. the treatment and treatment plan, and 3. why following the treatment plan correctly will help resolve the medical issue. When doctors are not clear, or do not educate, patients are less likely, I think, to follow through with the treatment plan.

This is certainly seen with use of abx. In terms of abx use specifically, as mentioned in this discussion, patients sometimes want to save abx for later use, not understanding that they are contributing to mutations of bacteria, leading to resistance. I think also, that a lot of times, patients discontinue abx early, because they feel better after only a few doses. They may assume, incorrectly, that they are cured, and so not feel the necessity to continue the full regimen, again contributing to antibacterial resistance. This is another reason why physician education of diagnosis, treatment, and prognosis is so important.

Finally, as seen in the video, the doctor offered the combination of western therapy and the continuation of warm oils to tx Miguel. One way to facilitate trust in multi-cultural patients, as others have said, is to learn about their cultures/medical treatment. I think a physician can gain a patient's trust and respect by treating them with western therapy AND allowing them to continue their folk remedies, AS LONG AS the folk remedies are not harmful to the patient or interfere with the western treatment.

I know that many hospital systems utilize computer programs to print out discharge information with multiple languages available for translating the written documents. Maybe having a written document with specific and clear directions in their primary language will help convey the importance of compliance and taking a full course of antibiotics as well as the dire consequences that could occur if other people take their medications.

I think the first major thing is to be sure to explain to the patient the need to finish the course the antibiotics. I have seen a good amount of doctors hand out prescriptions for antibiotics and not reenforce the fact that all the pills must be taken even if the patient is feeling completely better. While some patients may save the pills for financial reasons, I think a bigger concern is that patients begin to feel better and therefore do not see the need to finish the prescription. We need to remember to tell every patient about that. I think sometimes our jobs become so routine that we can forget the basics. Of course, we also need to stress the reason behind why the antibiotic must be taken in full. This like any other medical explanation, be it disease, treatment options etc, needs to be done at the most appropriate level for that patient. If in doing so you sense there are reasons the patient may want to save the antibiotic then I think that should be addressed head on. If it is financial then offer ways to help find a solution for the financial problems. Reassure them that there is need based assistance and other ways to get medications in the future. Like we have all said it boils down to communication. We should start with the basic instructions, our reasoning and then discuss the obstacles they may have in complying.

One of the greatest challenges in modern medicine is the rapid development of multi-drug resistant bacteria. It is becoming more and more difficult to find antibiotics that can kill these “super bugs.” Many people contribute their increase in number to patients’ noncompliance with antibiotic regimens. In regard to cultural competency, how do physicians explain the importance of following pharmaceutical directions to foreign patients? Many recent immigrants and refugees are of lower socioeconomic status and thereby this may complicate the problem. I have seen some patients who do not complete an antibiotic course so that they can save the medication for themselves or family since they may not be able to afford it again. How can we avoid this situation?

Finally, many traditional healers are not as specific with their directions or quantities of medications. Does this play a role in noncompliance with our medication regimens?

I want to bring up a point about antibiotic use in other countries. I have the impression that one can purchase antibiotics in many latin american countries over the counter. With that said, I believe that many patients from these countries are very familiar with antibiotic regimens. I would think these patients may be more aggressive in demanding an antibiotic regimen when presented with any sort of GI symptoms. I believe we need to educate all patients about the consequences of over prescribing antibiotics.

Another thing to understand is the prevalance of certain illnesses in other countries. In terms of GI symptoms we tend to encounter more viruses in the states. On the contrary, people deal with a lot more parasites in latin american countries. Hence, this would probably necessitate the use for antibiotics. However, patients should be aware of this so that they know when an antibiotic can be put to good use.

Recommended Resources
Speaking of cutting antibiotic use. Here's an article from the AAFP website on Sinusitis Practice Guidelines from the American Academy of Otolaryngology-Head and Neck Surgery aiming to improve diagnosis and cut antibiotic use.

http://www.aafp.org/online/en/home/publications/news/news-now/clinical-care-research/20070921sinusitisgdln.html

Links to Cases
Back to Miguel or Case studies.