The RTI clinical iceberg

In their NICE study on expectations for consultations and antibiotics for respiratory tract infection in primary care, the authors describe the point of view from the patients in an RTI clinical iceberg; the authors come to the conclusion that most who ask for antibiotics are prescribed them.1

In the triade patient–doctor–society, from the point of view of the society, as mentioned by the authors, more and more countries do national public campaigns to promote appropriate use of antibiotics in the community.

Otherwise, from the point of view of the doctor, one can also ask questions about the ICE (Ideas, Concerns, Expectations) of patients in general practice consultations, and their relation with medication prescribing. Now, do most patients expect antibiotics? Surely not.

In a study on ICE, an analysis of 350 new contacts showed that the expression/unveiling of expectations of patients (P = 0.009, OR = 2.0, 95% CI = 1.2 to 3.4) was associated with not prescribing new medication (dichotomised into the categories present/absent); in a subgroup analysis of respiratory complaints (n = 90), evidence was even found for fewer antibiotic prescriptions when two or three ICE components were present, compared to the group with no or only one ICE component, namely 6/36 versus 20/54 prescriptions of antibiotics (P = 0.056, OR = 0.34; 95% CI = 0.10 to 1.04).2

The conclusion of McNulty et al, may give the impression that patients especially expect antibiotics and this is not the truth. As many patients who contact their GP surgery expect advice and reassurance rather than antibiotics, there is an opportunity for GP practices to give more advice about how patients may relieve symptoms. Systematically disclosing the patients’ real expectations and concerns could lead to less unnecessary use of antibiotics.

There remains an important link between the stages of the ICEberg, namely how the GP deals with request of patients for antibiotics.

• © British Journal of General Practice 2013