A valuable lesson in ‘less is more’ from a Dutch patient

A few weeks ago one of my patients, Eva, asked about the treatment of urinary tract infections. In the course of our conversation I mentioned that in Australia antibiotics are recommended.

Eva had symptoms of a bladder infection and was after a diagnosis, but preferred not to take antibiotics. She was Dutch and said that cystitis in the Netherlands is often initially managed without antibiotics.

We decided to look it up (it has been a while since I practised in my birth country) and I googled the website of the Dutch College of General Practitioners. I had a feeling Eva was correct, as it was Dutch research that concluded middle ear infections can often be treated without antibiotics. The Netherlands, Norway and Iceland also top the charts when it comes to lowest rates of resistance to antibiotics.

Since 1989 the Dutch GP College has developed about one hundred independent, evidence-based guidelines for conditions managed in primary care. It didn’t take long to find the guideline on urinary tract infections, published in 2013.

Indeed, the document stated (freely translated from Dutch):

“Cystitis in healthy, non-pregnant women can be self-limiting. Leaving cystitis untreated seldom leads to bacterial tissue invasion.

But what is the risk of complications, like a kidney infection, I wanted to know after reading the advice to Eva (who didn’t look surprised at all).

“Apparently it is not very high, doctor,” she answered.

In the endnotes of the guideline I found a reference to two studies, indicating that pyelonephritis in non-immunocompromised, healthy women is rare, with no statistically significant difference in the occurrence of pyelonephritis between antibiotic treatment groups (0 tot 0,15%) and placebo groups (0,4 tot 2,6%).

The document further contained instructions about what to discuss with patients:

“The GP discusses the option of watchful waiting (drinking plenty of fluids and painkillers if needed) and delayed prescribing. The patient can then decide to start antibiotics if symptoms persist or worsen.

Some evidence indicates that, without treatment, 25–42% of uncomplicated urinary tract infections in women resolve spontaneously.

Eva was right about the Dutch approach. In healthy people with uncomplicated infections the Dutch College of GPs recommends consideration of no antibiotics.

Are the Dutch unhappy about a health system that often advises against antibiotics? My patient certainly didn’t seem to be. She was relieved when we decided not to treat her urinary tract infection with antibiotics.

The answer appears to be no. For years the Netherlands has led the Euro Health Consumer Index, which measures patient satisfaction with healthcare systems in Europe – including outcomes, access to healthcare and medications.

On the Choosing Wisely Australia website I found one sentence on the topic: “The management of urinary tract infections (UTIs) is changing, although it can still include antibiotics.” Lack of systematically reviewed placebo randomised trials seems to be a key factor for Australia.

Eva’s urinary tract infection cleared up without antibiotics.

I recommend sensible use of local clinical practice guidelines and treatment recommendations. Always seek timely advice from your doctor regarding any medical condition you may have, including urinary tract infections. For privacy reasons the name and details of the patient have been altered.

Shared decision-making is more than asking what patients want

Medical students are sometimes surprised that we don’t always follow the guidelines they have learned in medical school and instead use the patient as our guide when making decisions. Shared decision-making involves exploring patient preferences and what is important to them.

This sounds obvious but it’s actually not easy. As I said before in this blog post, I’m not sure I can always answer the 5 Choosing Wisely ‘questions to ask your doctor’, which form the basis of shared decision-making.

Apparently many doctors believe they already do this when they don’t. For example, a survey of US-based health practitioners observed high confidence in the face of limited understanding. There are many myths about shared decision-making (the 2-minute video below explains the most common ones).

Shared decision-making is more than asking what a patient wants. It also includes providing information about the pros and cons of available options, including the level of evidence around risks and benefits of tests and treatments. If I and many of my colleagues find this challenging, how do patients experience it?

5 questions to ask your doctor (before you get any test or treatment)

The National Prescribing Service (NPS) has made an interesting list of 5 questions patients should ask their doctors. The aim is to be well informed about the benefits and potential harm before you undergo medical tests, treatments, and procedures.

I think the list is useful and I’d encourage people to ask these questions. At the same time I suspect I will not be able to answer all the questions. For example, I don’t know the costs of all available tests, and the exact risks of certain interventions is something I may have to look up.

I have been told NPS is planning to develop resources for doctors so they can better help their patients with these queries. This would indeed be helpful. But in the meantime, feel free to ask! I hope it will lead to less unnecessary interventions.

Here are the 5 questions to ask your doctor before you get any test, treatment, or procedure:

5 questions NPS

Source: Choosing Wisely Australia

2×5 questions you should ask your doctor

There are a 5 simple questions you can ask your doctor about tests and 5 questions about the treatment, to be better informed, and get the outcome you want.

Testing

  1. How certain or uncertain are you about my diagnosis?
  2. Are further tests required?
  3. If so, how good are the tests?
  4. Are there risks or downsides to the tests?
  5. Is testing necessary or are there other options?

Treatment

  1. What treatments options do I have?
  2. How successful is the treatment?
  3. Are there risks attached to the treatment? Eg adverse reactions, interactions with other medications, antibiotic resistance, bleeding, infection.
  4. Is the treatment necessary or are there other options? Eg wait, try lifestyle changes first, do further tests, see another doctor.
  5. Is there anything else I need to know about the treatment? Eg how to administer, when to come back, how to prevent this from happening again.

5 things to remember before a doctor’s visit

It happens regularly: people visit a doctor but have difficulty providing essential details about their health.

Sometimes people incorrectly assume that all information is always at my fingertips. I don’t blame them; the healthcare sector is complicated and going to the doctor is understandably not everybody’s cup of tea.

And in all fairness, it’s not easy to remember when we had our last tetanus vaccination or in which year we were in the local hospital.

I hope the following five tips will help to make the most of your doctor’s visit.

1. Gather information

Write facts down, together with your questions. The doctor may ask a few things such as: when you first noticed the problem, what made it better or worse, and what your main concerns are. Make sure you know what your questions and expectations are.

  • Tip: Feel free to do your research on the Internet and check your findings with the doctor. Remember that online health information may not be applicable to you.

2. Allow enough time

If you want to discuss a complicated issue or a few problems, consider booking a long appointment to avoid running out of time.

3. Ask a friend or family member to join you

Having someone with you is helpful in many ways: to ask questions, to remember what has been discussed, for support and to give you a lift to and from the clinic if you are unwell.

4. Keep a record of all your past and present health problems

This is important. Doctors always need background information about your health. Don’t automatically assume the doctor always has all the required information.

  • Tip: Your own record could include a list of your medical problems, diagnoses, hospital admissions, operations, medications, vaccinations, allergies to or side effects from certain medications, products or food. Outcomes of important tests are always helpful. Keep a paper record or store the information in a safe place on your computer, phone or preferably electronic health record.

5. Never leave things to the last moment

A doctor’s visit just before a holiday trip, or on a Friday afternoon may cause problems – for example if your doctor needs to do more tests or the recommended medications are not available in the pharmacy. Sometimes a last-minute visit is unavoidable but often good planning goes a long way!