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From conversations with medical professionals: Antibiotic “misuse” is one of the most frustrating things in the field. They’re taught about antibiotic resistance in school, but then contribute to the problem by overprescribing it. The y describe the circumstances that patients (and parents) just want “a pill” to solve “a problem”, and that while the doctors know that it’s a viral infection, they still prescribe the antibiotics to placate the patient/parent. Further compounding the problem.

They’d be better just prescribing placebos or “drink some ginger garlic tea and rest”

9 comments

I do not understand why there is a huge gap between scientific knowledge and physicians.

I had a problem with an allergic reaction to an antibiotic. This resulted in me actually paying attention to drug labels, side effects and what a drug is being prescribed for. It has quite literally ruined my trust in doctors.

Last year I had stomach pain, I thought it was appendix. So, I went to an urgent care because my physician could not see me. They had access to my medical records. Quickly, I receive a diagnosis of "Diverticulitis". 2 minutes later I'm given a prescription for Cipro, which I'm deadly allergic to. New guidelines suggest not using antibiotics in uncomplicated diverticulitis. I didn't take the meds, and I'm pretty sure I just pulled an abdomen muscle as it healed over the next few weeks.

I have many stories from sports injuries and doctors offering steroid injections as first line treatment, which is no longer recommended.

NSAIDs are also not recommended for tendon injuries and it is the first thing the doctor will offer.

I don't get it. The information is easily available. Saying I read a study or a updated recommendation gets most doctors visibly upset. Not sure if it is the long working hours and trying to move as many patients as possible or just lack of giving a fuck.

Warning: anecdotal evidence from a limited perspective.

I did a biochem undergrad and was surrounded by premed students. Every single one of them was a North Face-wearing, click-y, "there to get the grade" student. They didn't display the same kind of awe for the amazing biological processes we were learning about, and they certainly didn't put in any legwork into undergrad research projects. They weren't nerds. They wanted a job with prestige and money. Several of them were bullies that talked bad about us and were not fun to be around.

I spent my time thinking about human regenerative cloning, transfecting biochemical synthesis pathways into things, the metabolome, connectome, etc. They used flash cards and socialized and would quickly change the subject when talking about biology topics. The material didn't matter one bit to them.

Complex things were gamed even more. They spent their time memorizing o-chem reactions rather than following the electrons.

My experience led me to believe that there are doctors that are only after the title and wage. They're not domain material geeks like us. I just question how many are actually like that, because my school was loaded to the brim with these people.

That's funny because something similar happened to a friend of mine. He was the only biochemist in a class that was mandatory for med students. It was about drugs and their (side) effects. The professor was so happy that there was at least one student in the room who could answer his (mostly rhetoric) "why" questions, while the other students were just memorizing.

"like us". It seems like the developer field has its share of Brogrammers and other non-traditionally nerdy types. Speaking as a super-nerdy science geek, it's probably not all bad that the field has widened - along with the bro's you get more women, non-compsci, and people-of-color entering the field, if some of the gate-keeping is relaxed.

There are MD/PhD doctors out there at the cutting edge, but most docs are more like PC repair techs - swap things out until the problem goes away, have a basic understanding of the underlying tech. You don't have to be a chip designer to swap a motherboard, or follow the electrons to prescribe some meds :-)

  > My experience led me to believe that there are doctors that are only after the
  > title and wage. They're not domain material geeks like us. I just question how
  > many are actually like that, because my school was loaded to the brim with these people.

There's a quick way to tell if a field is staffed _mostly_ by enthusiasts or mostly by money. Does the field have an active after-work topic community?

There exist active lawyer forums, and the things they discuss might as well be philosophy for the depth of analysis they invest. Software forums by the ton. Nurses seem to have active forums, though I haven't really looked at them. Vehicle mechanics, musicians, agriculture, teachers, pilots, scientists, authors, truck drivers, engineers, even construction. I could go on.

Which major top-dollar professions do not seem to be represented? Doctors, office administration, bankers. These are professions that seem to have very few enthusiasts working in the field. I'm sure they exist, but they are rare.

I should go tell my physician how much I appreciate her. I have a good one.

Exactly what I also wrote. The only people who are really good at any complex topic are huge geeks with some level of obsession for it. I've met plenty of programmers, mathematicians and even some finance people (those people work in trading) who are like that, but never a doctor.

I've met internists who are like this. Encyclopedic knowledge of their field, excited about theory, obviously spending a lot more time on literature than they're strictly required to. It kind of makes sense that the "true nerds" would end up in these jobs, because specialized internists spend tons of extra time in training but make less money than "procedural" specialties (surgeons, mostly).

The best family doctors I've met aren't mega-nerds but at least seem to genuinely care about helping people.

How many of them made it? Of the people I knew in college that wanted to go to medical school afterwords, like 1/8 of them actually got in.

(I went to a good school, these were intelligent people)

Ditto. While I'm sure they get patients who read random stuff on the internet, its frustrating that I can often get better information searching the internet with a basic understanding of how to determine the validity and how damn often thats better than my doctors recommendation and understanding and how often it changes the treatment path that would have been taken.

You absolutely need to be your own advocate because most doctors just follow a playbook and/or don't have time to think deeply on your issue, and/or don't spend time keeping their knowledge up to date.

To add another anecdote from the perspective of living in two countries - the recommendations we get from doctors in each country are often polar opposites of each other. Drugs available over the counter in one country are outlawed in the other, and vice versa. Information from a trustworthy source in one language is called pseudoscience in the other, and vice versa. Meanwhile, the health outcomes do not seem to be significantly different in either place. I am less and less convinced by anything my doctor says, in any language.

At the population level, outcomes are driven mostly by public health measures (clean water, food safety, vaccination) and cultural factors (obesity, substance abuse). Individual healthcare interventions barely move the needle.

I don't have the citation handy but the Institute of Medicine researched this and found it takes about 17 years in average to get all physicians to adopt new clinical practice guidelines. For physicians with a wide scope of practice it's just tough to keep up with all the chances. There might be some opportunities to use technology in clinical decision support systems that warn about potentially inappropriate treatments, but those have to be handled carefully so as to not slow down patient care unnecessarily.

Possible explanation: People who become physicians do so for wrong reasons. Medicine is highly paid, high status field and thus attracts people who are reasonably smart and just want to have a good life, but are, in the end, not very internally motivated to keep studying their field. Better system would select for people who are more geeky and like to read the new antibiotic studies for fun, much like many developers do stuff like write their own compilers and file systems for fun.

Have you ever talked to real physicians? Except for a few small specialties the pay isn't that great once you factor in educational expenses, unpaid overtime, and liability insurance. Very few are really in it primarily for the money.

We already have a shortage of primary care physicians. Imposing additional selection criteria based on some arbitrary, subjective measure of geekiness would be completely stupid and counterproductive.

Expected lifetime earnings for a typical doctor are ~$7M compared to ~$1.4M for the median person. The pay might not be "that great" by your standards but it's still 4x more than the typical person earns, even taking into account ~$500k of education costs. A typical lawyer makes only ~$5M and has similarly expensive education and a demanding work schedule.

Software engineers only started earning that kind of money in the last decade or so. When today's new doctors were starting off on their education path ten years ago, doctors probably still earned twice as much as even top software engineers.

Medicine is also prestigious in a way that few other careers are. People take notice when you say you're a doctor, and a lot of people enjoy that feeling. A huge number of parents pressure their kids into pursuing medicine, having your kid become a doctor is a surefire way to win the status game among your friends.

I personally know quite a few doctors. I'd say for most of them that desire to help people and desire for personal status were both motivating factors in their career choice.

But they don't know this before starting, which makes things worse. People are even less motivated after they discover this, especially if they started this career for the money.

I know people who got into the medical field because the like "Grey's Anatomy". Incompetence and lack of internal motivation is everywhere. I think most people are just not good at their job.

Urgent care doctors in particular are basically glorified pharmacists. I will never go to an urgent care unless I know what it is and how to fix it, and I just need their signature.

If you need real help, go to an emergency room or wait for a specialist.

It isn’t so much a knowledge gap as misalignment between patient and doctor interest: there is pretty much zero incentive for doctors to follow a non pharmacological path, limited incentive for them to follow a more difficult pharmacological path, and low to no cost to them for following that easiest pharmacological path.

Doctors are highly trained technicians who are well rewarded for processing patients quickly and are well protected (insured) against the inevitable occasional error, assuming such thing can be a) detected and b) proved.

We are better protected from our lawyers and bankers than we are from our doctors.

It really astonished me how doctors still continue to suggest NSAIDs and RICE for muscle or tendon injuries. I would understand if doctors didn’t adopt best practice for uncommon ailments, but muscle / tendon issues are so common…

It's about money and they just want to get rid of you, because they are understaffed, overworked and not happy people.

> I do not understand why there is a huge gap between scientific knowledge and physicians.

Why do you assume physicians are making their treatment decision based on gaps in their scientific knowledge or incompetence?

I am not a physician, but a major factor you are completely ignoring is liability. By prescribing/treating aggressively they know they are guaranteeing negative side effects that may be unnecessary. But they need to weigh that against chance of a terrible outcome for the patient & potentially loosing their livelihood.

I don't think you read the complete post.

Let's take fluoroquinolones for example. It is an extremely dangerous antibiotic, no longer recommended as a first line treatment for simple infection. Yet, patients are being prescribed it for SUSPECTED unconfirmed infections. This screams either incompetent physician or lack of familiarity with current scientific knowledge/new guidelines.

> Let's take fluoroquinolones for example. It is an extremely dangerous antibiotic, no longer recommended as a first line treatment for simple infection. Yet, patients are being prescribed it for SUSPECTED unconfirmed infections. This screams either incompetent physician or lack of familiarity with current scientific knowledge/new guidelines.

Which is the same example you gave in your first post...

> Yet, patients are being prescribed it for SUSPECTED unconfirmed infections.

AFAIK bacterial infections are in-practice often only suspected not confirmed before prescribing anti-biotics so why emphasize this?

Like I said I think you are ignoring other incentives (Malpractice Risk, Bias for action etc.) at play that cause a Physician to look at the same situation and come to a more aggressive treatment plan than your armchair diagnosis.

>AFAIK bacterial infections are in-practice often only suspected not confirmed before prescribing anti-biotics so why emphasize this?

It does happen but is a HUGE problem in medicine. This doesn't mean this is the CORRECT procedure and exactly what I am talking about. Infection should be confirmed and correct antibiotic used. Plus, not all infections require antibiotics.

>Like I said I think you are ignoring other incentives (Malpractice Risk, Bias for action etc.) at play that cause a Physician to look at the same situation and come to a more aggressive treatment plan than your armchair diagnosis.

By not following guidelines and prescribing wrong medication or when medication does not help a specific problem the physician is a lot more likely to be sued if patient suffers from side effects.

This is a huge problem, and something really ought to be done about it. I'm not sure what that would look like from a top-down, structural or regulatory perspective (loosen regulations and make it easier to become a doctor so that we have more doctors with more time?), but I have some bottom-up, individual-level ideas that I described in a comment on another post[1]:

---

> We briefly discussed my anxiety, but his immediate solution was the anti-anxiety drug. I made it clear that I was worried about the procedure and wanted to know more details about it. He didn’t want to explain the procedure beyond “we’ll inject medication that will help preserve your vision”, and he avoided answering repeated questions. Maybe he tried to shield me from the details and not confirm my worst fears.

Based on stories I've heard from emotionally immature doctor friends and my own experience being a little more confrontational with my doctors, he most likely didn't know the answers to your questions and was too proud to say, "I don't know."

It seems many forget that, at the end of the day, doctors are people, too, with just as many flaws and emotions as the rest of us. It's unfortunate that this affects quality of care, but it's a fact of life in every industry.

The best thing you can do for yourself in such a situation is to prepare yourself before appointments and remember the humanity of doctors during appointments. If your doctor is being dodgy about answering questions, let them know that it's okay if they don't know and that you won't think anything less of them for it. If it's an urgent matter, suggest looking it up together so that your doctor can provide context for whatever research you manage to find.

A doctor is like a contractor you've hired to inspect and maintain your body. As with any contractor, if you want them to do a good job, you have to work with them, as a team.

---

And, as a child comment pointed out, if you really don't like your contractor, you can always fire them and find a new one, and in fact, you should. Don't reward people for bad behavior, vote with your wallet, etc. etc.

[0] https://news.ycombinator.com/item?id=29109114

I don't buy that the primary issue is with human antibiotic use.

Doctors have become increasingly stingy with antibiotics, sometimes at the expense of human well-being -- meanwhile 80% of antibiotics are used in livestock production.

We could reduce the need for antibiotics in livestock if we treated animals better. Giving animals a bit of breathing room and fresh air would reduce the need to jack them up on antibiotics from day one.

Reducing use in humans seems like banning straws to take on plastic waste -- a feel good policy that won't actually fix much.

I have to wonder, though, if it's human prescribed antibiotics that source these super-bugs.

It's pretty common practice in the cattle industry, for example, to just pump cows with antibiotics because studies have shown cows constantly on antibiotics grow fatter than cows not on antibiotics. (Likely, because they don't ever really get sick). [1]

That makes me wonder how many of our super bugs have origins in the livestock industries where common practice is literally a recipe to bread superbugs.

[1] https://www.cidrap.umn.edu/news-perspective/2020/06/report-s...

It's been funny working at the intersection of human and animal health. The medical types all want to blame agriculture. The agriculture types all respond that they're not using major frontline human antibiotics (outside some stuff for companion animals).

It's sort of a complex mix - there's a lot of bulk use in agriculture, but the drug-microorganism pairings in human medicine are somewhat more acute.

This is one of the contentious points in trade between the USA and the EU: The EU does not allow preventive antibiotic use, but the USA does. Same for growth hormones. As a result, USA meat can not be imported in the EU. USA claims this is foul play, protectionism, against WTO rules.

Now the EU does allow curative antibiotic usage on animals, so I wonder if this is actually such a big difference. If a vet prescribes antibiotics for the slightest reason, there might not be much changed in reality.

This is certainly a problem when banning antibiotics for growth promotion, but allowing the prophylactic use of antibiotics.

Any animal in the type of farm looking for growth promotion is at risk for a bacterial infection basically all the time.

Isn’t this paper actually debunking that argument (That overuse of antibiotics has increased antibiotic resistance)? The paper says that resistance didn’t diminish when antibiotic use was decreased. It seems that our common understanding of how resistance develops was incorrect, at least partially.

If there is selective pressure to increase resistance, resistance increases over time.

If there is not selective pressure to increase resistance... nothing. There is no pressure to change anything relating to resistance. It could increase. It could decrease. It could stay the same. There is no reason to expect anything in particular about it.

Of course, but the US fee-for-service model is aligned elsewhere. I think a lot of them think that as long as they are not prescribing a z-pack every month, it won't be that big of a deal. Also, customer acquisition is hard. Patients will just find another primary or go to an urgent care and get the meds there. For primary care, being seen as "not helpful" won't just lose one patient, but a whole household of them. As you quote above, people want a quick fix. The person consuming 3000 calories of carbs per day wants a magic pill to fix their type 2 diabetes without them having to make any changes. I don't envy them.

SGLT2 inhibitors pretty much are magic pills for type 2 diabetes.

https://www.fda.gov/drugs/postmarket-drug-safety-information...

But of course it's better to prevent the condition in the first place.

Wait until people find out the side effects, then you'll get another thread exactly like this one but about SGLT2 inhibitors instead of antibiotics

Another very promising treatment for type 2 is DMR. We need to do a lot more research on the duodenum as it is clear it is a major linchpin in type 2.

[https://gut.bmj.com/content/69/2/295]

Autophagy is the real silver bullet for T2DM treatment but you won't get that from a pill especially if you continue to ingest sugar.

There was talk to the placebos on SBM at one point, the gist of it being that it would be far worse for them to do so for a few reasons. It erodes trust is the big point. But, I assume, there would be issues with informed consent too. How does one prescribe a placebo where the user can lookup the drug by name online.

Not a medical professional, but I think the issue comes down to doctors saying no as a group and being ok if they shop another doctor. If enough do that, the issue goes away.

It seems odd to me that doctors are even allowed to prescribe antibiotics when they know they aren't necessary. Why shouldn't that be grounds for disciplinary action?

That's one of the interesting experiences when moving to Sweden. One is highly unlikely to be prescribed antibiotics here, and one gets prescribed very "old" antibiotics, that my partner who was trained in France said are hardly used anymore in France due to resistances. When she started working as a GP here she found out that it's very hard for doctors to prescribe antibiotics, i.e. the conditions under which doctors are allowed to prescribe them are very strict.

There's a lot of things that are frustrating about the medical system here, but the restrictions on antibiotics is one of the very good things.

Sounds sensible, but I imagine it won't do much good if it's just Sweden doing it.

You're right it won't do much good, but it is nice to see a country take a principled stand and actually practice what they preach and be the change they want to see.

Why prescribe it if we know it is viral? First, the doctor should determine whether or not it is viral or bacterial. If it turns out that it is viral, then DO NOT PRESCRIBE ANTIBIOTICS. Is it because of placebo? Because if so, the costs are too high. Tell them to take zinc or whatever for a week.

Well, that’s not covered by my health plan!