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17 Jun 2019

Transcript:   AMA Ethics and Medico-Legal Committee Chair, Dr Chris Moy, ABC Radio Perth, Breakfast with Russell Woolf and Nadia Mitsopoulos, Monday, 17 June 2019

Subject:   Antibiotic resistance


RUSSELL WOOLF:             This is a story that we can all relate to, really. I'd be surprised if you haven't had a course of antibiotics at some point in your life, but I wonder, when you go to your doctor to get those antibiotics, do they offer you a repeat? And if they do, do you ever get it filled? 1-300-222-720 if you would like to call up. 1-300-222-720, we're keen to hear what your experiences have been. I guess it would save you from having to go back to the doctor, right? To get another prescription. But how do you know if you need another course of antibiotics or not?

NADIA MITSOPOULOS:   And it is possible to have too much of a good thing. The overuse of antibiotics is leading to the rise of dangerous superbugs that have become resistant to traditional drugs. So should doctors be able to offer repeats at all, or is it time to keep a tighter rein on where these drugs are going, and who's taking them? That's what the Federal Health Department is consulting on at the moment. And I wonder what Dr Chris Moy thinks. He is a GP, and he's also Chair of the AMA's Ethics and Medico-Legal Committee. Good morning to you.

CHRIS MOY:                       Morning.

NADIA MITSOPOULOS:   Why would a doctor - first of all - offer a patient a repeat on their antibiotics?

CHRIS MOY:                       Look, at the moment, you know, one would hope that the main decision is what the condition is. So, in general, there are clear recommendations for how long you should treat things. And it depends on partly the condition that's in front of you, and also the recommendations for it, but also the severity of the condition as well. So that's what would happen.

The issue is that at the moment, when somebody comes in and we need to assess somebody, and I think the first problem is not the repeat - it's actually whether the antibiotics should be prescribed at all - and that's another big question, I think that's a far bigger question than the repeats. But once the prescription is written, most of the computers for example, that we use on our desks that you see tend to have a default number of prescriptions. So, they'll have - for example - say it's once a day, there were seven days plus one repeat so that'll be 14 days. And it tends to be defaulted and it may sometimes be- it's quite easy just to add the repeat, and then the patient walks out with 14 days when they may only need seven for most situations.

NADIA MITSOPOULOS:   So, you're saying because that's the default position that that comes up automatically.

CHRIS MOY:                       Yes. In general.

RUSSELL WOOLF:             I seem to recall, Dr Moy, that my doctor in the past has given me antibiotics for however long, however many days, it might be six days, with no repeat, like with very specific instructions – “this is a short term course, you need to take it every day, and you need to take it right up until the sixth day, but then you don't need to take it beyond that”.

CHRIS MOY:           And that's the way it should be done, really, when prescribing medications. You should be, number one, only taking it when it’s required, and again I say I think there's a far bigger question in that we are overusing antibiotics upfront. I don't think it's just the repeats, but the actual prescription is the far bigger issue, I think. But, also, the length of time is also a problem. And obviously you're seeing a fantastic doctor who's giving you absolutely the advice that should happen without sometimes taking the easy option. Having said that-

RUSSELL WOOLF:            [Speaks over] Can I say because he also does most of the times tell me, I'm giving you a repeat. I'm saying on a rare occasion that often enough he says this is one course, one time only. But almost every other time I get a repeat.

CHRIS MOY:                       Yeah. Look, there are other tough situations, for example, where you do need the repeat as well, because there are situations where things need to be treated on average - say for 10 days for example - and the current script only has seven. They don't always match up with the conditions, that's actually part of the problem. There's actually a certain number in the pack and there's a certain number that the condition is required for. So, we have got this combination of - in terms of the repeats - the combination of the very easy to just add the repeat kind of a default situation.

I think there is actually - and I'll put it out there for your listeners as well - I think there is a bit of that mentality, well it's- you know, if you don't get the repeat, then the doctor's just doing it to bring you back. And I think there is a little- there is sometimes, and I've felt it myself, pressure to actually provide the repeat because a patient's gone: “well, I'm much better with that repeat and I would like you to provide it”. So there's sometimes pressure as well. I think we as doctors and the community need to work together to actually get the right advice, make a decision, and try to get out of that sort of thinking, and to try and just give the right amount for treatment.

NADIA MITSOPOULOS:   So on that point then, because as a patient and as a doctor, obviously you would be thinking: “oh I'm going to have to- if this doesn't work I'm going to have to come back and spend another $50, make another appointment which I might not get to straight away, so let's just play it safe, give me the repeat and then I'll decide if I need it or not”. Because would patients ask for a repeat?

CHRIS MOY:                       Yeah. Quite often they would. I'll give an example which is probably a really common example - somebody who has a severe chest infection. Now number one, for most chest infections, most people don't need antibiotics, but there are certain people that would need those antibiotics and then they would be given antibiotics. Now for those situations, the majority of people, even after the antibiotics have finished, they may still have symptoms such as a cough. In fact, the cough may actually become more fruity and may bring up more phlegm, because they're actually getting better at that point because everything's loosened up. But the problem is that there's a perception by the individual - the patient - who feels that they're not getting better. And because of previous experiences like that, they'll say: “look I really need that repeat”.

And so I think it's a much more important thing for you and your doctor, and you to ask the questions, the patient, for the doctor to be able to be given a space to explain it properly about what is the recommendation and what is best for you, but also to balance this issue about trying to minimise the use of antibiotics so we don't end up with this massive long-term Armageddon-ish type problem which may occur in the future where we may not have antibiotics to provide.

RUSSELL WOOLF:             You're listening to ABC Radio Perth and WA. Nadia Mitsopoulos and Russell Woolf with you, and we're talking to Dr Chris Moy, who is Chair of the AMA's Ethics and Medico-Legal Committee. We're really keen to hear what your experience has been with this issue of getting scripts from your doctor, and are you getting repeats too often? Are you happy with the process? If you want to call and be a part, we'd love to hear from you. Be a part of the program, 1-300-222-720.

We speak to a lot of GPs, Dr Moy, and they're under increasing time pressure to perform more and more and more. We're asking them to be the gatekeepers to so many things that perhaps 30 years ago they were not. A part of me can then understand why they might want to write a repeat out just in case you need it, so that you don't need to make a separate appointment, because surely by doing that you'll be blocking somebody that maybe needs quicker access to their GP from being able to get it.

CHRIS MOY:                       Look, that's a legitimate argument which is put for making it easy to provide those repeats. But, at the moment, as you know, the current debate is the fact that there is this overuse of antibiotics, and that the use of too many repeats is actually going to create a far bigger problem where it's increasing the resistance out there. So, despite the fact that it appears there’s lots of different antibiotics out there, it is actually quite a limited number of groups of antibiotics which, unfortunately, bugs are incredibly quick at actually developing resistance to, particularly if medications are overused. Because they mutate, and they evolve really quickly, and that's the problem. They're getting so good at getting resistant to the antibiotics we're giving them.

In fact, there is actually a worldwide problem now where pharmaceutical companies, I think, are quite reluctant to try and produce new antibiotics because as soon as they develop one, as soon as we start putting it out there to some degree, you know, we grab it straightaway because it's the one that'll work because no bugs are resistant to it, but then the bugs to become resistant to it very quickly.

NADIA MITSOPOULOS:   Dr Chris Moy, how would you and other doctors feel then, do you think, if the power for you to offer repeats was limited or even eliminated? Which is what something the Federal Department of Health is certainly consulting on at the moment.

CHRIS MOY:                       Look, there is a debate about this because I think it is, you know, I think you've brought up issues about the practical problems that have been brought up, the difficulty sometimes getting back to see the doctor, and also sometimes it is absolutely appropriate to have a longer course. There are situations where the recommendations are longer than the actual first prescription, for example.

The issue is about getting the right balance, and maybe making the right sort of checks and balances before you provide that first repeat, to make it so that there's actually some thought involved before that repeat is actually prescribed, and so we start to value it a bit more. Because, at the moment, to be frank, in society I think we've kind of been living on easy street with this and we kind of- we've been living like millionaires with antibiotics, and I'm afraid we're not in that situation anymore.

We are creating a crisis at the moment, and it's trying to get that right balance where it's practical enough so we don't get in that situation where, you know, like somebody who needs it can't get it. But also that there's some thought involved for both the doctor - but also the patient as well - so they start to value the antibiotics as well, so that we actually as a community start to value this incredible resource which was created, you know, more than a century ago which really we need to preserve. Otherwise, we're going to actually make it very dangerous for our children.

NADIA MITSOPOULOS:   And just quickly then. Dr Chris Moy, that's up to doctors who should then be really firm with patients. If patients go: “look, I've got this, I need antibiotics”, they've got to say: “no, you don't, trust me on this one, you don't”, because there are a lot of patients who are going: “no, but trust me, it's what I need”. I mean, this is the argument they have to have.

CHRIS MOY:                       And this is the point about, really, the two sides of the story. It's about patients - as patients, when they walk into the room, to be prepared to actually listen to their doctors and actually take the advice that they’re given, without sort of feeling as if they know everything, or feeling as though they actually, you know, just want the repeat for convenience’s sake. And doctors also to be applying that same level of thought to preserve and apply stewardship to something which is an incredible resource for us in the health system.

RUSSELL WOOLF:             Dr Chris Moy, we really appreciate you spending the time with us today from the AMA's Ethics and Medico-Legal Committee, which he chairs.


17 June 2019

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Published: 17 Jun 2019