In his Bad Science column of 11 February, Ben Goldacre has published a powerful reminder of the need to avoid using antibiotics as much as possible.1 It's easy to be casual about the individual decisions, and to forget what they add up to collectively (I do it myself all the time), and it's important to understand the problem from all possible angles and continue to restrict our own prescribing. In the editorial on page 164, Morton Lindbæk restates the problem for GPs: how to pick those who will benefit from antibiotics from the large numbers who can safely be left without them.
The conclusion of the study on page 176, examining the consequences of treating or not treating children with acute otitis media, is that we should feel confident we are not harming them by not treating, but to be careful with children with a previous history of recurrent otitis media. The paper on page 170 has measured the decline in the numbers of patients consulting with acute otitis media between 1991 and 2001, and suggests this is one of the benefits of not giving antibiotics, although it notes that the trend is not seen among those consulting with glue ear. The study from Belgium reported on page 183 confirms that doctors' perception of patient demand for antibiotics is one of the drivers for prescribing; an echo of work first published in 1981 by Ann Cartwright, when she showed that GPs tended to overestimate patients' desire to receive antibiotics.2
Patients' expectations and wishes for treatment takes us straight into modern policy making. There is much discussion of the need to consult patients and put them in control of the services in the White Paper published at the end of January, discussed on page 163, and page 231. We also publish two papers that underline both the importance of trying to elucidate patients' preferences, and the difficulties it may present.
On page 198, a qualitative study of women recruited to a randomised controlled trial of different strategies for early miscarriage emphasises that different people hold completely different values about what matters most to them, and this is likely to be partly related to their previous experience (although there did seem to be a widely shared desire to stay out of hospital). The study on page 206 reports on a consultation exercise to identify the wishes of a group of patients with diabetes. The results won't surprise, but the study emphasises the sheer effort that will be required if there is to be real consultation every time an innovation or research project is planned; and will also illustrate some of the unrealistic expectations that can be encouraged.
The authors of the paper recognise the need to consider costs when deciding where to focus research efforts, a cautionary approach notably lacking from the White Paper (see again page 163). The next big area of research is of course genetic epidemiology, and on page 214 there is a paper exploring the various ways in which primary care researchers could and should be involved. Tom Shakespeare is rather more wary of all the hype, and is of the opinion that GPs' most useful role will be not as researchers but as patient advocates, making sure that patients genuinely understand and agree to whatever it is they are being asked to get involved with (page 167).
Even when a study sets out to respond to patients preferences, the result may disappoint. The leader on page 166 summarises the evidence about the interventions that have been shown to encourage breastfeeding, yet rates of breastfeeding in the UK remain shamefully low. Sadly, the trial on page 191, of peer support to nursing mothers, was unable to report resounding success despite doing everything right, and a recruitment period of, by modern primary care standards, epic length. Perhaps this is another example of the limits of what medical intervention can achieve on its own, and a salutary reminder that the medical profession should remain modest and humble about what it can achieve on its own.
- © British Journal of General Practice, 2006.