A wise man once said that treatment was something the physician gave the patient to keep the patient amused while nature took its course and healed the illness. This certainly applies to prescribing of antibiotics.
"We [the medical profession] screwed up, and we ought to say so and apologise. Doctors were handed the wonderful gift of antibiotics but are destroying them through indiscriminate use. We don't need another committee. We know what to do: we should just use antibiotics less." These words were part of an address by Dr Norman Simmons, a medical expert in the field of infectious diseases, to an international conference on antibiotic resistance in Copenhagen last year.
For years, antibiotics have been grossly over-prescribed by the medical profession. While doctors promote themselves as a very scientific group, the truth is that the majority of antibiotics are prescribed for reasons which are far removed from science. The over-prescribing of antibiotics by doctors over the past 30 years is one of the greatest scandals of 20th-century medical practice.
Resistance to antibiotics is health care's equivalent of global warming, according to the British Medical Journal. Condemning the misuse of antibiotics, an editorial last September pointed out that this abuse of antibiotics is driving us slowly but surely back to the status of a pre-antibiotic society.
Eighty per cent of all antibiotics are prescribed by GPs. The majority of these antibiotics are for respiratory tract infections, most of which do not require treatment with antibiotics. Every doctor knows that antibiotics should only be used for bacterial infections, that they are totally ineffective against viral infections, such as colds, flus, most throat infections, and many chest infections. Yet antibiotics are widely prescribed by doctors for these and other infections which do not need antibiotic treatment.
Infectious disease experts estimate that at least 50 per cent of antibiotics prescribed in Irish hospitals and by GPs are unnecessary, exposing these patients to the risk of drug toxicity with no therapeutic benefits. A study involving half of the Republic's GPs earlier this year showed that up to 99 per cent of patients presenting with a sore throat received antibiotics. In at least one third of these cases, no antibiotic was necessary. Other research has shown that, in a study of more than 700 people with throat infections, those who were not prescribed antibiotics recovered just as quickly as those who were prescribed them.
Why do doctors over-prescribe antibiotics in this way? Many people, when they get a heavy flu, expect a course of antibiotics from their GP, and they usually get them. In practice, it is often the expectations of the patients which dictate whether or not they receive a course of antibiotics.
Up to 60 per cent of our population have to pay their GP every time they visit. Many GPs believe that patients may not feel they're getting value for money unless they walk out of the surgery with a prescription.
Prescribing the antibiotic can be reassuring for both patient and doctor: the patient feels happier, because he knows this powerful medication should make him better; the doctor feels that the patient's condition is less likely to deteriorate, that all the bases are covered. In the words of one doctor, it is always easier to prescribe than not.
Prescriptions are usually for five to seven days. This gives the doctor up to seven days' breathing space, during which the vast majority of infections would have healed anyway without an antibiotic. The patient's recovery is attributed to the doctor and the antibiotic he or she prescribed, reinforcing the patient's misguided reliance on antibiotics as a cure-all. There is a tendency to blame patients for misusing antibiotics, on the basis that they're looking for a quick-fix solution to minor ailments. The truth is the patient goes to the doctor for expertise and advice. It is the doctor who writes the prescription, not the patient. If the doctor does not believe an antibiotic is necessary, he or she should have the courage to say so.
But many doctors do not have the courage to stand by their beliefs. The GP may worry that the patient will not be satisfied and go to another GP, where he may well get the antibiotic from a doctor prepared to put the wishes of the patient before his best medical judgment.
What happens if the patient gets worse that night? At least if he is on the antibiotic, the GP will feel somewhat secure, and less likely to be called by the patient. But if the patient is not on any treatment, the GP may have to see the patient that night, or if the GP is off duty, the patient may have to see his deputising doctor, who will charge the patient a second fee. The GP may want to avoid this risk by prescribing an unnecessary antibiotic at the first consultation.
An Australian expert in medical behavioural science, Dr Jill Cockburn, found that patients who expect a prescription are up to 10 times more likely to get one than patients who are open-minded about whether or not they get a prescription.
The real danger of the chronic over-prescribing of antibiotics is that bacteria which cause many serious illnesses are becoming immune to antibiotics. These bacterial organisms adapt very well to the environment they find themselves in. They have been bombarded with antibiotics so indiscriminately that they have developed ways of becoming resistant to antibiotics. There is a real concern within modern medicine that these "superbugs" may soon develop resistance to all antibiotics. As one medical specialist in infectious diseases put it, the pace of antibiotic development is lagging far behind the speed at which bacteria are becoming resistant to antibiotics. This is particularly worrying since, according to medical experts, there has been a marked reduction in the amount of research into, and development of, new antibiotics.
Due both to the increased resistance of bacteria, and forceful marketing by pharmaceutical companies, doctors are increasingly prescribing newer, often very expensive antibiotics for infections which 10 years ago would have been cured by far cheaper antibiotics, to which the bacteria have now become resistant. For years, the medical profession has known that bacteria quickly develop resistance to antibiotics. But the profession has done nothing about it on the ground - in the doctor's surgery, where the antibiotic prescriptions are written. The medical profession has come up with no effective way of persuading doctors to reduce their antibiotic prescribing.
If antibiotics do become less and less effective against bacterial infections - as many experts say is already happening - then the blame for this scandal lies fairly and squarely at the feet of the medical profession.
Dr Terry Lynch is a GP in Dooradoyle, Co Limerick