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.

6 great podcasts for primary care

 

6 great podcasts

Here are six free podcasts made with tender loving care by a variety of people and organisations. I enjoy listening to these online broadcasts because they are relevant to my daily work in general practice. I download the episodes on my iPhone at home when I’m on WiFi – and listen on the way to work.

The first two podcasts are aimed at health professionals and mainstream audience, the others are more suitable for health professionals only. There are many other awesome podcasts out there; if you know of any in particular, please share your tip in the comment section below.

Do you want to know how to set up podcasts or how to get started recording your own? Here is a good explanation by GP Dr Tim Leeuwenburg.

#1: Health Report (ABC)

In-depth quality reports by Norman Swan and other ABC reporters on topics such as breast cancer & screening, contraceptive options other than the pill and science topics like the future of DNA-sequencing. Well put together with often several national and international experts in one episode.

Audience: Mainstream and health professionals. Episode duration: 28 minutes. Download on iTunes

#2: Inside Health (BBC)

Inside Health
Inside Health with UK GP Dr Mark Porter

Great podcast discussing a few topics per episode – with UK GP Dr Mark Porter. Demystifying myths about vitamins, glucosamine, testosterone, statins, e-cigarettes and much more. One episode about the doctor’s gut feeling inspired me to write this blog post.

Audience: Mainstream and health professionals. Episode duration: 28 minutes. Download on iTunes

# 3: Broomedocs Podcast (Dr Casey Parker)

High quality grassroots podcast by Australian GP & ED Doctor Casey Parker. All sorts of topics relevant to general practice and emergency medicine, such as resuscitation techniques, snake bites, vitamin D deficiency, contraception, overdiagnosis and suicide. The podcast could do with a professional iTunes logo to make it stand out on mobile devices amid other podcasts.

Audience: Health professionals. Episode duration: 15-50 minutes. Download on iTunes

#4: Best Science Medicine Podcast – BS without the BS (Dr James MCormack and Dr Michael Allen)

Entertaining Canadian show discussing evidence-based drug therapy. Lots of myth busters and many topics relevant to general practice such as vaccines, osteoporosis and the treatment of common cold.

Audience: Health professionals (GPs). Episode duration: 20-40 minutes. Download on iTunes

#5: Australian Family Physician Audio (RACGP)

Interesting interviews with authors of articles in Australian Family Physician, the journal of the Royal Australian College of General Practitioners. The podcast is a great way to follow the journal if you don’t have the time to read everything, or if you want to hear more from the authors. Episodes are presented by various AFP editors, and include topics like multimorbidity, systemic lupus erythematosus, multiple myeloma, SSRIs & adolescents, and obesity in general practice.

The quality of the recordings varies between episodes. It is occasionally necessary to read the article to gain full understanding of the topic. The podcast needs a professional iTunes logo to make it recognisable on mobile devices amid other podcasts.

Audience: Health professionals (GPs). Episode duration: 10-30 minutes. Download on iTunes

#6: HBR Ideacast (Harvard Business Review)

HBR IdeacastManagement and business skills are not taught sufficiently during the medical training, even though doctors often find themselves in leadership positions. The Harvard Business Review podcast features tips and ideas by inspirational leaders – ready to be implemented at work. Food for thought for business owners and (practice) managers.

Listen to topics like: how to spread excellence when opening another practice, and online training videos for new staff members. Want more tips? Download the free Harvard Business Review management tip of the day app on your phone.

Audience: Managers & business owners. Episode duration: 10-20 minutes. Download on iTunes