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No, antibiotics aren’t always needed. Here’s how GPs can avoid overprescribing

<a href="https://theconversation.com/profiles/mina-bakhit-826292">Mina Bakhit</a>, <a href="https://theconversation.com/institutions/bond-university-863">Bond University</a> and <a href="https://theconversation.com/profiles/paul-glasziou-13533">Paul Glasziou</a>, <a href="https://theconversation.com/institutions/bond-university-863">Bond University</a> The growth in antibiotic resistance threatens to return the world to the pre-antibiotic era – with deaths from now-treatable infections, and some elective surgery being restricted because of the risks of infection. Antibiotic resistance is a major problem worldwide and should be the concern of everyone, including you. We need to develop new antibiotics that can fight the resistant bacteria or antibiotics that bacteria would not be quickly resistant to. This is like finding new weapons to help the immune system fight the bacteria. More importantly, we need to use our current antibiotics – our existing weapons against the bacteria – more wisely. <h2>Giving GPs the tools to say no</h2> In 2022, more than <a href="https://www.safetyandquality.gov.au/publications-and-resources/resource-library/aura-2023-fifth-australian-report-antimicrobial-use-and-resistance-human-health">one-third of Australians</a> had least one antibiotic prescription, with <a href="https://www.safetyandquality.gov.au/publications-and-resources/resource-library/analysis-2015-2022-pbs-and-rpbs-antimicrobial-dispensing-data">88%</a> of antibiotics prescribed by GPs. Many people <a href="https://pubmed.ncbi.nlm.nih.gov/28289114/">mistakenly think</a> antibiotics are necessary for treating any infection and that infections won’t improve unless treated with antibiotics. This misconception is found in studies involving patients with various conditions, including respiratory infections and conjunctivitis. In reality, not all infections require antibiotics, and this belief drives patients requesting antibiotics from GPs. Other times, GPs give antibiotics because they think patients want them, even when they might not be necessary. Although, in reality they are <a href="https://pubmed.ncbi.nlm.nih.gov/17148626/">after symptom relief</a>. For GPs, there are ways to target antibiotics for only when they are clearly needed, even with short appointments with patients perceived to want antibiotics. This includes: <ul> <li> using <a href="https://pubmed.ncbi.nlm.nih.gov/32357226/">decision guides</a> or tests to decide if antibiotics are really necessary </li> <li> giving <a href="https://www.safetyandquality.gov.au/our-work/partnering-consumers/shared-decision-making/decision-support-tools-specific-conditions">patients information sheets</a> when antibiotics aren’t needed </li> <li> giving a “<a href="https://pubmed.ncbi.nlm.nih.gov/33910882/">delayed prescription</a>” – only to be used after the patient waits to see if they get better on their own. </li> </ul> All these strategies need some <a href="https://www.nps.org.au/assets/NPS/pdf/NPS-MedicineWise-Economic-evaluation-report-Reducing-Antibiotic-Resistance-2012-17.pdf">training</a> and practice, but they can help GPs prescribe antibiotics more responsibly. GPs can also learn from each other and use tools like <a href="https://pubmed.ncbi.nlm.nih.gov/24474434/">posters</a> as reminders. To help with patients’ expectations, public campaigns have been run periodically to educate people about antibiotics. These campaigns <a href="https://pubmed.ncbi.nlm.nih.gov/35098267/">explain why</a> using antibiotics too much can be harmful and when it’s essential to take them. <h2>Giving doctors feedback on their prescribing</h2> National programs and interventions can help GPs use antibiotics more wisely One successful way they do this is by <a href="https://pubmed.ncbi.nlm.nih.gov/34356788/">giving GPs feedback</a> about how they prescribe antibiotics. This works better when it’s provided by organisations that GPs trust, it happens more than once and clear goals are set for improvement. The NPS (formerly National Prescribing Service) MedicineWise program, for example, had been giving feedback to GPs on how their antibiotic prescriptions compared to others. This reduced the number of antibiotics prescribed. However, <a href="https://australianprescriber.tg.org.au/articles/the-end-of-nps-medicinewise.html">NPS no longer exists</a>. In 2017, the Australian health department did something similar by sending <a href="https://behaviouraleconomics.pmc.gov.au/projects/nudge-vs-superbugs-behavioural-economics-trial-reduce-overprescribing-antibiotics">feedback letters</a>, randomly using different formats, to the GPs who prescribed the most antibiotics, showing them how they were prescribing compared to others. The most effective letter, which used pictures to show this comparison, reduced the number of antibiotics GPs prescribed by <a href="https://behaviouraleconomics.pmc.gov.au/sites/default/files/projects/nudge-vs-superbugs-12-months-on-report.pdf">9% in a year</a>. <h2>Clearer rules and regulations</h2> Rules and regulations are crucial in the fight against antibiotic resistance. Before April 2020, many GPs’ computer systems made it easy to get multiple repeat prescriptions for the same condition, which could encourage their overuse. However, in April 2020, the Pharmaceutical Benefits Scheme (PBS) <a href="https://www.pbs.gov.au/pbs/industry/listing/elements/pbac-meetings/psd/2019-08/antibiotic-repeats-on-the-pharmaceutical-benefits-scheme">changed the rules</a> to ensure GPs had to think more carefully about whether patients actually needed repeat antibiotics. This meant the amount of medicine prescribed better matched the days it was needed for. Other regulations or policy targets could include: <ul> <li> ensuring all GPs have access to antibiotic prescribing guidelines, such as <a href="https://www.tg.org.au/">Therapeutic Guidelines</a>, which is well accepted and widely available in Australia </li> <li> ensuring GPs are only prescribing antibiotics when needed. Many of the conditions antibiotics are currently prescribed for (such as sore throat, cough and middle ear infections) are self-limiting, meaning they will get better without antibiotics </li> <li> encouraging GP working with antibiotics manufacturers to align pack sizes to the recommended treatment duration. The recommended first-line treatments for uncomplicated urinary tract infections in non-pregnant women, for example, are either three days of trimethoprim 300 mg per night or five days of nitrofurantoin 100 mg every six hours. However, the packs contain enough for seven days. This can mean patients take it for longer or use leftovers later. </li> </ul> <h2>Australia lags behind Sweden</h2> Australia has some good strategies for antibiotic prescribing, but we have not had a sustained long-term plan to ensure wise use. Although Australian GPs have been doing well in <a href="https://www.safetyandquality.gov.au/our-work/antimicrobial-resistance/antimicrobial-use-and-resistance-australia-surveillance-system/aura-2021">reducing antibiotic prescribing</a> since 2015, <a href="https://pubmed.ncbi.nlm.nih.gov/35098269/">more</a> could be done. In the 1990s, Sweden’s antibiotic use was similar to Australia’s, but is now less than half. For more than two decades, Sweden has had a national strategy that reduces antibiotic use by about <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5677604/">7% annually</a>. It is vital Australia invests in a similar long-term national strategy – to have a centrally funded program, but with regional groups working on the implementation. This could be funded directly by the Commonwealth Department of Health and Ageing, or with earmarked funds via another body such as the Australian Centre for Disease Control. In the meantime, individual GPs can do their part to prescribe antibiotics better, and patients can join the national effort to combat antibiotic resistance by asking their GP: “what would happen if I don’t take an antibiotic?”. <a href="https://theconversation.com/profiles/mina-bakhit-826292">Mina Bakhit</a>, Assistant Professor of Public Health, <a href="https://theconversation.com/institutions/bond-university-863">Bond University</a> and <a href="https://theconversation.com/profiles/paul-glasziou-13533">Paul Glasziou</a>, Professor of Medicine, <a href="https://theconversation.com/institutions/bond-university-863">Bond University</a> Image credits: Getty Images This article is republished from <a href="https://theconversation.com">The Conversation</a> under a Creative Commons license. Read the <a href="https://theconversation.com/no-antibiotics-arent-always-needed-heres-how-gps-can-avoid-overprescribing-213981">original article</a>.

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I think I have the flu. Should I ask my GP for antivirals?

<a href="https://theconversation.com/profiles/lara-herrero-1166059">Lara Herrero</a>, <a href="https://theconversation.com/institutions/griffith-university-828">Griffith University</a>; <a href="https://theconversation.com/profiles/wesley-freppel-1408971">Wesley Freppel</a>, <a href="https://theconversation.com/institutions/griffith-university-828">Griffith University</a>, and <a href="https://theconversation.com/profiles/yong-qian-koo-1457640">Yong Qian Koo</a>, <a href="https://theconversation.com/institutions/griffith-university-828">Griffith University</a> If you test positive for COVID and you’re eligible for antivirals, you’ll likely ask your GP for a script to protect you from severe disease. <a href="https://healthdispatch.com.au/news/immunisation-coalition-urging-people-with-flu-like-symptoms-to-g">Antivirals</a> are also available to fight influenza viruses, via a doctor’s prescription. But they have a mixed history, with their benefits at times <a href="https://theconversation.com/controversies-in-medicine-the-rise-and-fall-of-the-challenge-to-tamiflu-38287">overstated</a>. It can be difficult to get an appointment to see your GP. So when should you make the effort to see a GP for a prescription for influenza antivirals? And how effective are they? <h2>What exactly is influenza?</h2> The flu is primarily a viral infection of the respiratory system that can spread through sneezing, coughing, or touching contaminated objects then touching your nose or mouth. Common symptoms include headache, sore throat, fever, runny or blocked nose and body aches that last a week or more. Influenza is actually a group of viruses, divided into several <a href="https://www.cdc.gov/flu/about/viruses/types.htm#:%7E:text=There%20are%20four%20types%20of,global%20epidemics%20of%20flu%20disease,%20https://www.cdc.gov/flu/professionals/acip/background-epidemiology.htm">sub-groups</a>. Flu A and B are the <a href="https://www.health.gov.au/resources/collections/aisr?language=en,%20https://www.health.gov.au/resources/collections/australian-influenza-surveillance-reports-2023?language=en">most common groups</a> that circulate in humans. <h2>What are flu antivirals?</h2> Influenza antivirals, target specific parts of the viral life cycle, which prevents the virus replicating and spreading. Most flu antivirals <a href="https://www.nejm.org/doi/full/10.1056/NEJMra050740">target</a> neuraminidase, an important enzyme the virus uses to release itself from cells. On the other hand, COVID antivirals work by inhibiting other parts of the viral life cycle involved in the <a href="https://www.tga.gov.au/news/media-releases/tga-provisionally-approves-two-oral-covid-19-treatments-molnupiravir-lagevrio-and-nirmatrelvir-ritonavir-paxlovid">virus replicating itself</a>. Three influenza antivirals are <a href="https://australianprescriber.tg.org.au/articles/influenza-overview-on-prevention-and-therapy.html#r20">used in Australia</a>. Relenza (zanamivir) is an inhaled powder and Tamiflu (oseltamivir) is a capsule; both are five-day treatments. Rapivab (peramivir) is a single injection. These antivirals may also come with <a href="https://www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm">side effects</a>, such as a headache, vomiting, cough, or <a href="https://www.immunisationcoalition.org.au/resources/antiviral-treatments-for-influenza/">fever</a>. Tamiflu and Relenza generally cost A$40-50 in Australia, plus the cost of the consultation fee with your doctor, if applicable. <h2>How effective are antivirals for the flu?</h2> Antivirals have the greatest effect if started 24-72 hours after symptoms. This is to prevent the virus from reaching <a href="https://www.mdpi.com/1660-4601/19/5/3018">high levels in the body</a>. Among healthy adults, if Relenza or Tamiflu are started within 48 hours from your first symptoms, they can <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD008965.pub4/full">reduce the duration</a> of symptoms such as cough, blocked nose, sore throat, fatigue, headache, muscle pain and fever by just under a day. For people who have developed severe flu symptoms or who have existing health conditions such as heart disease or chronic obstructive pulmonary disease (COPD), antivirals that start later (but still before day five of symptoms) can still reduce the <a href="https://academic.oup.com/cid/article/52/4/457/378776?login=true">severity of infection</a> and reduce the <a href="https://thorax.bmj.com/content/thoraxjnl/65/6/510.full.pdf?frbrVersion=3">chance of</a> <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/215903">hospitalisation</a> and <a href="https://academic.oup.com/jac/article/72/11/2990/4091484?login=false">death</a>. In a study from the 2009 swine flu (H1N1) pandemic in the United States, treatment with antivirals (Tamiflu and Relenza) <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3358088/">reduced</a> the chance of needing to be hospitalised. Around 60% of hospitalisations prevented were among 18-64 years olds, around 20% in children 0-17 years, and 20% in adults aged over 65. The research is less clear about whether antivirals prevent the development of flu complications such as secondary bacterial pneumonia. They might, but so far the data aren’t clear. <h2>Are flu antivirals becoming less effective?</h2> Antiviral resistance to Tamiflu has been <a href="https://link.springer.com/article/10.1007/s10096-020-03840-9">reported</a> around the world, mostly in <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7223162/">immunocompromised people</a>, as they <a href="https://link.springer.com/article/10.1007/s10096-020-03840-9">have</a> a weakened immune system that allows higher viral loads and prolonged viral shedding. The impact of the antiviral resistance is unclear but there is evidence indicating resistant strains can uphold their ability to replicate effectively and spread. So far it’s not clear if these stains cause more severe disease. However, government agencies and surveillance programs are constantly monitoring the spread of antiviral resistance. Currently there is <a href="https://www.cdc.gov/flu/treatment/antiviralresistance.htm">minimal concern</a> for strains that are resistant to Tamiflu or Relenza. <h2>Antivirals can also prevent the flu if you’ve been exposed</h2> Tamiflu and Relenza can also be used to <a href="https://onlinelibrary.wiley.com/doi/10.1111/irv.12046">prevent flu infections</a>, if we’re exposed to the virus or come into contact with infected people. Some studies suggest Tamiflu and Relenza can <a href="https://www.bmj.com/content/326/7401/1235.long">reduce the chance of developing symptomatic influenza</a> by 70-90%. Many health agencies around the world <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8165743/">recommend</a> “prophylactic” treatment for high-risk patients in hospitals or age care setting when people have been in contact with others infected with influenza. <h2>So who should talk to their GP about a prescription?</h2> <a href="https://www.health.nsw.gov.au/Infectious/factsheets/Pages/racf-antiviral-treatments-and-prophylaxis.aspx#:%7E:text=The%20Australian%20Therapeutic%20Guidelines*%20recommends,of%20severe%20disease%20from%20influenza.&text=people%20with%20chronic%20conditions%20including,heart%20disease">Australian guidelines recommend</a> doctors offer antivirals to people with influenza who have severe disease or complications. Doctors can also consider treatment for people at higher risk of developing severe disease from influenza. This includes: <ul> <li>adults aged 65 years or older</li> <li>pregnant women</li> <li>people with certain chronic conditions (heart disease, Down syndrome, obesity, chronic respiratory conditions, severe neurological conditions)</li> <li>people with compromised immunity</li> <li>Aboriginal and Torres Strait Islander people</li> <li>children aged five years or younger</li> <li>residents of long-term residential facilities</li> <li>homeless people.</li> </ul> Doctors can prescribe antivirals for the prevention of influenza <a href="https://australianprescriber.tg.org.au/articles/influenza-overview-on-prevention-and-therapy.html#r20">in</a> vulnerable people who have been exposed to the virus. Antiviral treatment also can be <a href="https://www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm#:%7E:text=Antiviral%20treatment%20also%20can%20be,48%20hours%20of%20illness%20onset">considered</a> for otherwise healthy symptomatic patients who have confirmed or suspected influenza, if they can start treatment within 48 hours of developing symptoms. In some instances a doctors can make a clinical diagnosis of influenza based on the symptoms and known close flu positive contacts of the patient. However, it is preferred to have flu diagnosed by one of the approved diagnostic tests, such as a <a href="https://24-7medcare.com.au/influenza/australian-gp-influenza-2023-guide/">rapid antigen test</a> (RAT) or the more accurate <a href="https://www.health.nsw.gov.au/Infectious/factsheets/Pages/influenza_factsheet.aspx">PCR test</a>, similar to what is perfomed for COVID. There are also now combo tests that can <a href="https://www.tga.gov.au/news/media-releases/first-combination-covid-19-and-influenza-self-tests-approved-australia">distinguish between SARS-CoV-2 and influenza virus</a>. Remember, the flu can cause <a href="https://www.abc.net.au/news/2023-07-23/flu-season-hitting-children-hard-antivirals-may-help/102633722">severe illness or death</a>, particularly among people from the high-risk groups. So if you think you might have the flu, wear a mask and stay away to avoid spreading the virus to others. <img style="border: none !important; box-shadow: none !important; margin: 0 !important; max-height: 1px !important; max-width: 1px !important; min-height: 1px !important; min-width: 1px !important; opacity: 0 !important; outline: none !important; padding: 0 !important;" src="https://counter.theconversation.com/content/210457/count.gif?distributor=republish-lightbox-basic" alt="The Conversation" width="1" height="1" /> <a href="https://theconversation.com/profiles/lara-herrero-1166059">Lara Herrero</a>, Research Leader in Virology and Infectious Disease, <a href="https://theconversation.com/institutions/griffith-university-828">Griffith University</a>; <a href="https://theconversation.com/profiles/wesley-freppel-1408971">Wesley Freppel</a>, Research Fellow, Institute for Glycomics, <a href="https://theconversation.com/institutions/griffith-university-828">Griffith University</a>, and <a href="https://theconversation.com/profiles/yong-qian-koo-1457640">Yong Qian Koo</a>, , <a href="https://theconversation.com/institutions/griffith-university-828">Griffith University</a> Image credits: Shutterstock This article is republished from <a href="https://theconversation.com">The Conversation</a> under a Creative Commons license. Read the <a href="https://theconversation.com/i-think-i-have-the-flu-should-i-ask-my-gp-for-antivirals-210457">original article</a>.

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Should GPs bring up a patient’s weight in consultations about other matters? We asked 5 experts

<a href="https://theconversation.com/au/team#fron-jackson-webb">Fron Jackson-Webb</a>, <a href="http://www.theconversation.com/">The Conversation</a> Australian of the Year and body positivity advocate Taryn Brumfitt has <a href="https://www.smh.com.au/healthcare/doctors-should-avoid-discussing-patient-s-weight-australian-of-the-year-says-20230707-p5dmhv.html">called for</a> doctors to avoid discussing a patient’s weight when they seek care for unrelated matters. A 15-minute consultation isn’t long enough to provide support to change behaviours, Brumfitt says, and GPs don’t have enough training and expertise to have these complex discussions. “Many people in larger bodies tell us they have gone to the doctor with something like a sore knee, and come out with a ‘prescription’ for a very restrictive diet, and no ongoing support,” Brumfitt <a href="https://www.smh.com.au/healthcare/doctors-should-avoid-discussing-patient-s-weight-australian-of-the-year-says-20230707-p5dmhv.html">told the Nine newspapers</a>. By raising the issue of weight, Brumfitt says, GPs also risk turning patients off seeking care for other health concerns. So should GPs bring up a patient’s weight in consultations about other matters? We asked 5 experts. Brett Montgomery - GP academic Yes, sometimes – but with great care. I agree that weight stigma is damaging, and insensitively raising weight in consultations can <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0251566" target="_blank" rel="noopener">hurt people's feelings and create barriers</a>to other aspects of health care. I also agree people can sometimes be “overweight” yet <a href="https://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0287218" target="_blank" rel="noopener">quite healthy</a>, and that common measures and categories of weight are <a href="https://theconversation.com/bmi-alone-will-no-longer-be-treated-as-the-go-to-measure-for-weight-management-an-obesity-medicine-physician-explains-the-seismic-shift-taking-place-208174">questionable</a>. On the other hand, I know obesity <a href="https://www.racgp.org.au/FSDEDEV/media/documents/RACGP/Position%20statements/Obesity-prevention-and-management.pdf" target="_blank" rel="noopener">is associated with</a> heart disease, joint problems, diabetes and cancers. GPs should be ready to help people with their weight when they want help. <a href="https://www.bmj.com/content/377/bmj-2021-069719.full?ijkey=FnARkmvxLOMFvlb&keytype=ref">Our assistance somewhat effective</a>, though sadly dietary efforts often have minimal effect on weight in the long term. Meanwhile, treatments causing larger weight changes (<a href="https://insightplus.mja.com.au/2021/10/bariatric-surgery-public-system-access-still-terrible/">surgery</a> and <a href="https://www.nature.com/articles/s41366-022-01176-2">some medicines</a> are often financially inaccessible. I feel safe discussing weight when my patient raises the issue. Fearing hurting people, I often avoid raising it myself. I focus instead on health rather than weight, discussing physical activity and healthy diet – these are good things for people of any size. Emma Beckett - Nutrition scientist No. It’s not likely to succeed. Large systematic reviews bringing together multiple studies of multiple weight-loss diets show weight loss is not generally maintained long term (<a href="https://pubmed.ncbi.nlm.nih.gov/32238384/">12 months</a> to <a href="https://www.nature.com/articles/0802982">four years</a>). The idea that weight is about willpower is outdated. The current body of evidence <a href="https://theconversation.com/whats-the-weight-set-point-and-why-does-it-make-it-so-hard-to-keep-weight-off-195724">suggests</a> we each have a weight set point that our body defends. This is determined by genetics and environment more so than education. There may be associations between weight and health outcomes, but losing weight <a href="https://theconversation.com/just-because-youre-thin-doesnt-mean-youre-healthy-101185">does not necessarily equate</a> with improving health. Fat stigma and fatphobia are <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2866597/">harmful too</a> and can <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4381543/">compromise access to health care</a>. Instead, consider asking a better question. Healthy eating reduces disease risk <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3935663/">regardless of weight</a>. So maybe ask how many vegetables are your patients eating. Would they like to see a dietitian to discuss strategies for a better-quality diet? Liz Sturgiss - GP/researcher No. A <a href="https://pubmed.ncbi.nlm.nih.gov/33211585/">US study</a> estimates it would take a family doctor 131% of their work hours to implement all preventive health-care recommendations. It's impossible to address every recommendation for preventative care at every consultation. One of the key skills of a GP is balancing the patient and doctor agenda. <a href="https://www.obesityevidencehub.org.au/collections/treatment/weight-bias-and-stigma-in-health-care">Weight stigma</a> can deter people from seeking health care, so raising weight when a patient doesn't have it on their agenda can be harmful. A strong <a href="https://academic.oup.com/fampra/article/38/5/644/6244494?login=false">therapeutic relationship</a> is critical for safe and effective health care to address weight. Weight is always on my agenda when there is unexpected weight loss. If a patient has rapid weight loss, I am concerned about an undetected <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7283307/">cancer</a> or infection. Additionally, I am increasingly seeing patients who are unable to afford food, who often have <a href="https://www.aihw.gov.au/reports/dental-oral-health/oral-health-and-dental-care-in-australia/contents/introduction">poor oral health</a>, who lose weight due to <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/1747-0080.12580">poverty</a>. Weight loss for the wrong reasons is also a very concerning part of general practice. Nick Fuller - Obesity researcher Yes. GPs should play a role in the early detection of weight issues and direct patients to evidence-based care to slow this progression. <a href="https://pubmed.ncbi.nlm.nih.gov/31032548/">Research</a> shows many people with obesity are motivated to lose weight (48%). <a href="https://pubmed.ncbi.nlm.nih.gov/31032548/">Most</a> want their clinician to initiate a conversation about weight management and treatment options. However, this conversation <a href="https://pubmed.ncbi.nlm.nih.gov/32385580/">rarely occurs</a>, resulting in <a href="https://pubmed.ncbi.nlm.nih.gov/33621413/">significant delays to treatment</a>. Starting the conversation presents challenges. Although obesity is a complex disease related to multiple factors, it's still <a href="https://pubmed.ncbi.nlm.nih.gov/25752756/">highly stigmatised</a>in our society and even in the <a href="https://pubmed.ncbi.nlm.nih.gov/23144885/">clinical setting</a>. Sensitivity is required and the wording the clinician uses is important to make the patient feel safe and avoid placing blame on them. Patients often <a href="https://pubmed.ncbi.nlm.nih.gov/20823355/">prefer terms</a> such as “weight” and “BMI” (body mass index) over “fatness,” “size” or “obesity”, <a href="https://pubmed.ncbi.nlm.nih.gov/27354290/">particularly women</a>. Measuring weight, height and waist circumference should be <a href="https://pubmed.ncbi.nlm.nih.gov/33621413/">considered routine in primary care</a>. But this needs to be done without judgement, and in collaboration with the patient. Helen Truby - Nutrition scientist Yes. A high body weight contributes to many chronic conditions that negatively impact the <a href="https://www.aihw.gov.au/australias-health/summaries">quality of life and mental health</a> of millions of Australians. Not all GPs feel confident having weight conversations, given the sensitive nature of weight and its stigma. GPs' words matter – they are a <a href="https://doi.org/10.1111/nbu.12320">trusted source</a> of health information. It’s critical GPs gain the skills to know when and how to have <a href="https://doi.org/10.1186/s12875-019-1026-4">positive weight conversations</a>. GPs need to offer supportive and affordable solutions. But effective specialist weight management programs are few and far between. More equitable access to programs is essential so GPs have referral pathways after conversations about weight. GPs' time is valuable. Activating this critical workforce is essential to meet the <a href="https://www.health.gov.au/resources/publications/national-obesity-strategy-2022-2032?language=en">National Obesity Strategy.</a> <a href="https://theconversation.com/au/team#fron-jackson-webb">Fron Jackson-Webb</a>, Deputy Editor and Senior Health Editor, <a href="http://www.theconversation.com/">The Conversation</a> Image credits: Getty Images This article is republished from <a href="https://theconversation.com">The Conversation</a> under a Creative Commons license. Read the <a href="https://theconversation.com/should-gps-bring-up-a-patients-weight-in-consultations-about-other-matters-we-asked-5-experts-209681">original article</a>.

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Gastro or endometriosis? How your GP discusses uncertainty can harm your health

You wake with stomach pain that worsens during the day and decide to see your doctor. You describe your symptoms and your doctor examines you. Then the doctor says, “From what I hear, I think you could just have a stomach bug. Rest and come back in three days.” This might be a less definitive answer than you’re after. But doctors can’t always be sure of a diagnosis straight away. As <a href="https://link.springer.com/article/10.1007/s11606-022-07768-y">my review</a> shows, doctors use various ways of communicating such uncertainty. Sometimes there is a mismatch between what doctors say when they’re uncertain and how patients interpret what they say, which can have harmful consequences. <h2>Why does uncertainty matter?</h2> Doctors <a href="https://link.springer.com/article/10.1007/s11606-017-4164-1">cannot always explain</a> what your health problem is or what caused it. Such diagnostic uncertainty is a normal and <a href="https://doi.org/10.1001/jama.2022.2141">ever-present part</a> of the processes leading to a diagnosis. For instance, doctors often have to rule out other possible diagnoses before settling on one that’s most likely. While doctors ultimately get the diagnosis right <a href="http://dx.doi.org/10.1136/bmjqs-2012-001615">in 85-90%</a> of cases, diagnostic uncertainty can lead to diagnostic delays and is a huge contributor to harmful or even deadly misdiagnoses. Every year, <a href="https://www.mja.com.au/system/files/issues/213_07/mja250771.pdf">an estimated</a> 21,000 people are seriously harmed and 2,000-4,000 people die in Australia because their diagnosis was delayed, missed or wrong. That could be because the wrong treatment was provided and caused harm, or the right treatment was not started or given after the condition had already considerably progressed. More than <a href="https://www.mja.com.au/system/files/issues/213_07/mja250771.pdf">80% of diagnostic errors</a> could have been prevented. Three medical conditions – infections, cancer and major vascular events (such as strokes or heart attacks) – are the so-called “<a href="https://doi.org/10.1515/dx-2019-0019">Big Three</a>” and cause devastating harm if misdiagnosed. In my review, the top three symptoms – fever, chest pain and abdominal pain – were most often linked to diagnostic uncertainty. In other words, most of us will have had at least one of these very common symptoms and thus been at risk of uncertainty and misdiagnosis. Some groups are less likely to be diagnosed correctly or without inappropriate delay than others, leading to <a href="https://doi.org/10.1001/jama.2022.7252">diagnostic inequities</a>. This may be the case for <a href="https://www.liebertpub.com/doi/10.1089/whr.2022.0052">women</a>, and other groups marginalised because of their <a href="https://onlinelibrary.wiley.com/doi/10.1111/acem.14142">race or ethnicity</a>, <a href="https://doi.org/10.1016/j.socscimed.2020.113609">sexual orientation or gender identity</a>, or <a href="https://doi.org/10.1001/jama.2022.7252">language proficiency</a>. <h2>How often do you hear ‘I don’t know’?</h2> My research showed doctors often make diagnostic uncertainty clear to patients by using explicit phrases such as: “I don’t know.” But doctors can also keep quiet about any uncertainty or signal they’re uncertain in more subtle ways. When doctors believe patients prefer clear answers, they may only share the most likely diagnosis. They say: “It’s a stomach bug” but leave out, “it could also be constipation, appendicitis or endometriosis”. Patients leave thinking the doctor is confident about the (potentially correct or incorrect) diagnosis, and remain uninformed about possible other causes. This can be especially frustrating for patients with chronic symptoms, where such knowledge gaps can lead to lengthy diagnostic delays, as reported for <a href="https://doi.org/10.1016/j.ajog.2018.12.039">endometriosis</a>. Subtle ways of communicating uncertainty include hedging with certain words (could, maybe) or using introductory phrases (my guess, I think). Other implicit ways are consulting a colleague or the Internet, or making follow-up appointments. If patients hear “I think this could be a stomach bug” they may think there’s some uncertainty. But when they hear “come back in three days” the uncertainty may not be so obvious. Sharing uncertainty implicitly (rather than more directly), can leave patients unaware of new symptoms signalling a dangerous change in their condition. <h2>What can you do about it?</h2> 1. Ask about uncertainty Ask your doctor to share any <a href="http://dx.doi.org/10.1515/dx-2021-0086">uncertainty and other diagnostic reasoning</a>. Ask about alternative diagnoses they’re considering. If you’re armed with such knowledge, you can better engage in your care, for example asking for a review when your symptoms worsen. 2. Manage expectations together Making a diagnosis can be an evolving process rather than a single event. So ask your doctor to outline the diagnostic process to help manage any <a href="http://dx.doi.org/10.1136/ebm.14.3.66">mismatched expectations</a> about how long it might take, or what might be involved, to reach a diagnosis. Some conditions need time for symptoms to evolve, or further tests to exclude or confirm. 3. Book a long appointment When we feel sick, we might get anxious or find we experience heightened levels of fear and other emotions. When we hear our doctor isn’t certain about what’s causing our symptoms, we may get even more anxious or fearful. In these cases, it can take time to discuss uncertainty and to learn about our options. So book a long appointment to give your doctor enough time to explain and for you to ask questions. If you feel you’d like some support, you can ask a close friend or family member to attend the appointment with you and to take notes for you. Image credits: Getty Images This article originally appeared on <a href="https://theconversation.com/gastro-or-endometriosis-how-your-gp-discusses-uncertainty-can-harm-your-health-196943" target="_blank" rel="noopener">The Conversation</a>.

Caring

Why has my cold dragged on so long, and how do I know when it’s morphed into something more serious?

Common colds are caused by viruses. There are no effective cures, and antibiotics do not work on viruses, so treatment is targeted at managing the symptoms until your immune system has cleared the cold. So why might someone go to a doctor at all for a cold? Well, occasionally a cold might turn into something more serious requiring assessment and specific treatment, and a GP visit could be warranted. Or you may just want reassurance and advice. <h2>Don’t rush to the GP for something totally normal</h2> Problems arise when there too many unwarranted visits to GPs for cold symptoms. Studies have shown <a href="https://www.annfammed.org/content/11/1/5" target="_blank" rel="noopener">antibiotics</a> are <a href="https://onlinelibrary.wiley.com/doi/abs/10.5694/mja16.01042" target="_blank" rel="noopener">still prescribed widely</a> for viral colds, even though they don’t help, and this contributes to antibiotic resistance. It hastens the arrival of an era when many antibiotics simply don’t work at all. On average, children have <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7152362/" target="_blank" rel="noopener">four to six colds</a> per year, while in adults the average is <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7152362/" target="_blank" rel="noopener">two to three</a>. Some people are more <a href="https://www.sciencedirect.com/science/article/abs/pii/S1530156705601189?via%3Dihub" target="_blank" rel="noopener">prone</a> to colds, but we don’t know exactly why. The usual cold persists about one week, although 25% last two weeks. In one <a href="https://journals.asm.org/doi/10.1128/jcm.35.11.2864-2868.1997" target="_blank" rel="noopener">study</a> with 346 adults, the infection lasted 9.5 to 11 days. Cold symptoms may last longer in younger children. One <a href="https://publications.aap.org/pediatrics/article-abstract/87/2/129/56810/Upper-Respiratory-Tract-Infections-in-Young?redirectedFrom=fulltext" target="_blank" rel="noopener">study</a> showed an average duration of colds ranged from 6.6 to 9 days. But symptoms lasted more than 15 days in 6.5% of 1-3 year old children in home care, and 13.1% of 2-3 year old children in day care. A cough tends to last longer than other symptoms, and often beyond the actual viral infection. The average <a href="https://www.annfammed.org/content/11/1/5" target="_blank" rel="noopener">duration</a> of a cough is about 17.8 days. <h2>Discoloured sputum, cough or snot</h2> Discoloured mucus in snot or cough is a common trigger for requesting antibiotics from a GP. But as we know, antibiotics are useless against a virus. They only work against bacterial infection. In fact, thick or coloured nasal mucus secretion is common following colds. Only a tiny proportion <a href="https://europepmc.org/article/pmc/pmc7151789" target="_blank" rel="noopener">involve</a> bacterial infection. When it happens, this is termed <a href="https://www.nps.org.au/australian-prescriber/articles/treating-acute-sinusitis-3" target="_blank" rel="noopener">acute rhinosinusitis</a>. But antibiotics are not recommended unless it lasts more than ten to 14 days and there are <a href="https://europepmc.org/article/pmc/pmc7151789" target="_blank" rel="noopener">signs</a> of bacterial sinusitis infection, such as: <ul> <li>symptoms worsening after improvement in the original cold</li> <li>return of fever and</li> <li>strong facial pain.</li> </ul> A prolonged cough after colds is usually caused by an irritated throat or the clearing of sticky mucus coming down from the nose. The cough may sound moist (so wrongly called “chesty”) due to the phlegm, but only small amounts of phlegm are coughed up. Yellow or green coloured mucus is often interpreted as a <a href="http://theconversation.com/health-check-what-you-need-to-know-about-mucus-and-phlegm-33192" target="_blank" rel="noopener">sign</a> of bacterial infection. But yellow or green sputum alone <a href="https://www.tandfonline.com/doi/full/10.1080/02813430902759663" target="_blank" rel="noopener">does not</a> mean you have a serious bacterial infection. One study found being prescribed antibiotics under these circumstances <a href="https://erj.ersjournals.com/content/38/1/119" target="_blank" rel="noopener">failed</a> to shorten recovery time. Nasal saline sprays and washes can be used to rinse out the nose and sinuses and possibly <a href="https://dtb.bmj.com/content/57/4/56" target="_blank" rel="noopener">shorten</a> rhinosinusitis and cough after colds. <h2>Could it just be hayfever, or another underlying issue?</h2> Hayfever or allergic rhinitis is a common cause for prolonged symptoms after a cold, especially cough and nasal congestion and maybe also sneezing. The damage in the upper airways following a viral infection may allow airborne allergens to trigger hayfever. Self-medicating with antihistamines, nasal saline spray or intranasal steroids is worthwhile if <a href="https://theconversation.com/health-check-why-do-i-have-a-cough-and-what-can-i-do-about-it-119172" target="_blank" rel="noopener">allergic rhinitis</a> is suspected. There may be other reasons for persistence of cough, such as exacerbation of underlying asthma or chronic lung disease. If so, this may require a visit to your GP. <h2>What about bronchitis or pneumonia?</h2> Many people worry about developing a chest infection after a cold. Acute bronchitis is a self-limiting infectious disease characterised by acute cough with or without sputum but without <a href="https://www.nhs.uk/conditions/pneumonia/" target="_blank" rel="noopener">signs of pneumonia</a> (such as high temperatures and feeling breathless). Most acute bronchitis cases are caused by viruses. Antibiotics are often prescribed, but produce <a href="https://www.tandfonline.com/doi/full/10.1080/14787210.2016.1193435" target="_blank" rel="noopener">no significant clinical improvement</a> compared with placebo, so are not recommended. Pneumonia is a potentially serious secondary disease that <a href="https://pubmed.ncbi.nlm.nih.gov/28159155/" target="_blank" rel="noopener">may follow</a> an episode of flu in a small number of cases, but is <a href="https://www.ncbi.nlm.nih.gov/books/NBK532961/" target="_blank" rel="noopener">relatively rare</a> following a cold. Symptoms and signs of pneumonia feature heavily in the list of warning signs that signal the need for a medical assessment. <h2>When should I seek medical help for a cough or a cold?</h2> Contact a GP if you experience: <ul> <li>shortness of breath or trouble breathing</li> <li>feeling faint or dizzy</li> <li>chest pain</li> <li>dehydration</li> <li>fever or cough symptoms that improve but then return or worsen</li> <li>worsening of chronic medical conditions such as asthma.</li> </ul> This is not a complete list, but may guide you on what to expect and what to watch out for. You might also contact your GP (perhaps for a telehealth consult) if you are finding your symptoms very unpleasant, or are concerned your condition is more serious or prolonged than expected. You might just need reassurance and education about self care options. This article originally appeared on <a href="https://theconversation.com/why-has-my-cold-dragged-on-so-long-and-how-do-i-know-when-its-morphed-into-something-more-serious-190429" target="_blank" rel="noopener">The Conversation</a>. Image: Shutterstock

Body

22-year-old dies of cervical cancer after GPs turned her away 15 times

A 22-year-old woman died of cervical cancer after GPs turned her away 15 times and told her not to worry about the “Jade Goody effect”. Emma Swain pleaded with her GP for a smear test as she was experiencing symptoms, but was told she was too young by medical professionals. Instead, doctors had placed the blame on her contraceptive pill for her symptoms and told her what happened to Jade Goody was unlikely to happen to her. In 2009, TV personality Jade Goody died from cervical cancer at the age of 27. Emma first approached her doctor about a smear test in May 2013 after experiencing back pain and bleeding after sex. But her request was refused because the cervical screening is only offered to women over the age of 25. Her GP has since admitted that if the 22-year-old had been given the smear test, she may still be alive. Devastated at the loss of his daughter, Darren Swain <a rel="noopener" href="https://www.mirror.co.uk/news/uk-news/woman-22-cervical-cancer-told-23084319" target="_blank">told the Mirror</a>: “To have watched one of your children go through that and to know it could have been prevented is incredibly hard to accept. “We trusted these people – the professionals – to know what they were doing. I’ll never forgive them.” Darren, 51, said: “Basically, he told her she was worrying over nothing. He couldn’t have been more wrong. It cost Emma her life.” Over the course of four months, Emma contacted her doctor 14 times but was advised to swap her brand of contraceptive pill. She changed her pill five times during those four months. Unfortunately, Emma was diagnosed with cervical cancer in December of that year and died the following year in 2014. Emma’s family has since been fighting a six-year legal battle, one that they have recently won. Her family has been awarded compensation for her death. In a letter to the dad-of-three, Dr Stephen Golding, Dr Hendrik Parmentier and practice nurse Maureen Dillon from The Haling Park Partnership in Croydon, South London, apologised for what happened to Emma. They wrote: “We admit that if the care and treatment provided to your daughter had been of a reasonable standard, on the balance of probabilities, she would have survived.” A spokesperson for the surgery told the Mirror: “Since Emma’s death, the practice has reviewed its processes to ensure lessons have been learned.”

Caring

Warning about using antibiotics this winter

We always feel like we’re taking the right step towards health when we return from the pharmacist with a handful of antibiotics, but new research seems to suggest if you’ve got a cough, cold or sore throat you might be better off with a natural remedy. <a href="https://www.sciencedaily.com/releases/2016/07/160704223418.htm" target="_blank">A study</a>, conducted by King’s College London, has found reducing the amount of antibiotics prescribed to patients by GP practices for common respiratory tract infections does not lead to an increase in serious complications like meningitis. The study, funded by the NIHR, analysed patient records from over 600 UK general practices, taking into account four million individual cases over the course of 10 years. The study found no higher rates of serious bacterial complications present in patients who visited practices that were less likely to prescribe antibiotics as treatment. This research comes amid heighted concerns in the medical community that an overreliance on antibiotics could <a href="/news/news/2016/06/australia-overuse-of-antibiotics-is-increasing-superbug-threat/">increase the threat of superbugs</a>. The study’s lead author, Professor Martin Gulliford, argued most respiratory tract infections are caused by viruses and will generally take care of themselves without treatment, but added antibiotics can still be used in the event of complications. Professor Gulliford said, “As a practicing GP, I see very few complications from patients who have upper respiratory tract infections and who decide to opt for a non-antibiotic approach to treating their infections. Patients are recognising that most upper respiratory infections are viral and virus infections do not respond to antibiotics. “ “Our paper should reassure GPs and patients that rare bacterial complications of respiratory infections are indeed rare. Fortunately, if there are any signs of a complication, the GP can quickly step in and offer an appropriate antibiotic.” What’s your take on the research? Do you think we as a society are becoming over reliant on prescription antibiotics for common ailments? Share your thoughts in the comments. Related links: <a href="/health/body/2016/06/does-cold-weather-cause-the-flu/">Does cold weather actually cause the flu?</a> <a href="/health/body/2016/06/herbal-remedies-to-beat-insomnia/">3 herbal remedies to beat insomnia</a> <a href="http://www.oversixty.co.nz/health/hearing/2016/05/how-to-protect-your-ears-from-the-cold/">How to protect your ears from the cold</a>

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No, antibiotics aren’t always needed. Here’s how GPs can avoid overprescribing

I think I have the flu. Should I ask my GP for antivirals?

Should GPs bring up a patient’s weight in consultations about other matters? We asked 5 experts

Gastro or endometriosis? How your GP discusses uncertainty can harm your health

Why has my cold dragged on so long, and how do I know when it’s morphed into something more serious?

22-year-old dies of cervical cancer after GPs turned her away 15 times

Warning about using antibiotics this winter

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Catalogues

Travel

Health

Lifestyle

Finance

Entertainment

Property

Information

Keep up to date

Search

No, antibiotics aren’t always needed. Here’s how GPs can avoid overprescribing

I think I have the flu. Should I ask my GP for antivirals?

Should GPs bring up a patient’s weight in consultations about other matters? We asked 5 experts

Gastro or endometriosis? How your GP discusses uncertainty can harm your health

Why has my cold dragged on so long, and how do I know when it’s morphed into something more serious?

22-year-old dies of cervical cancer after GPs turned her away 15 times

Warning about using antibiotics this winter

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