How not to harm patients (and control antibiotic use while you're about it)

So I am often asked, as a microbiologist, what I would do if it were me, or my kids, with a sore throat/sinusitis/cough and so on. People seem surprised when I say I would have some paracetamol (maybe with a little whisky and lemon obviously). As though I know that antibiotics are really what's needed, for an individual patient, but that I put public health concerns above this when advising others. Taking this approach, as a doctor I would have to weigh up the benefits of giving an antibiotic (24 hours less symptoms perhaps) but then try to factor in some professional responsibility to 'do the right thing', even if that is in direct conflict with what the patient might want.

But of course a patient wants more than just to get better. They also don't want to be exposed to potential harm. And antibiotic use is not benign. Data presented at ECCMID shows that there are high rates of colonisation with resistant organisms after antibiotic treatment. Clinically relevant? Who knows... But as a patient I might like to know that it might happen. People know that MRSA is not a good thing to have on your skin. And of course there are myriad other risks. From drug reactions to irreversibly altered gut flora (with who knows what consequences).

So looked at this way, over prescribing is not patient centred medicine triumphing over the paternalism of population health. Rather it is a complete failure on behalf of the medical profession to properly consent patients for the things we do to them. So let's start sharing our uncertainties with patients in more honest and open ways.

I was thinking of an analogy. You are driving from A to B. You could do so very fast, breaking the law, increasing the chance of death to you and others; or you could do so more sedately, arriving a bit later, but safely. We might normally do the second, but in some situations, say if time is tight, we might do the first. To make that choice requires 'consent' by considering all consequences, both short and long term, and weighing them up. The answer we get to may not always be rational to others, but perhaps by focusing on rationality we lose the argument? So perhaps the answer to problems of antibiotic stewardship is purely designing ways of sharing risks and benefits with patients and then letting them make the call with us as their impartial advisors.