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Communicating with patients and families about unnecessary tests and treatments
Resource Stewardship and Communication OSCE Sample Scenario – Unnecessary Antibiotics

Part of the CanMEDS Resource Stewardship Curriculum Toolkit Series

Editors
Geetha Mukerji, MD, MSc, FRCPC
Division of Endocrinology & Metabolism
Women’s College Hospital
Institute of Health Policy, Management and Evaluation
University of Toronto
Toronto, Ontario

Adina Weinerman, MD, FRCPC
Department of General Internal Medicine
Sunnybrook Health Sciences Centre
Toronto, Ontario

Series Editor
Chris Hillis, MD, MSc (QI/PS), FRCPC
Department of Oncology,
McMaster University
Hamilton, ON

Outlined below is a Family Medicine/Emergency Medicine OSCE on resource stewardship and patient communication, focused around antibiotics for an upper respiratory tract infection (URTI). Following the outline of the station is a set of suggestions for ways to modify the station for other specialties based on the Choosing Wisely Canada (CWC) recommendations.

Instructions to Resident

Sarah/Sidney Davis is a 25-year-old patient that you are seeing in the emergency department. They are presenting with a cough, runny nose and a tactile fever (feels warm but temperature not actually measured) for the past two days.

Sarah/Sidney states that they had a similar episode two years ago and they believe the antibiotics prescribed by a walk-in clinic quickly improved their symptoms. Their cough is not productive. They have not coughed up any blood. They do not have any night sweats or weight loss. Their urination and bowel movements are all normal. They have no recent travel history. Sarah/Sidney’s only sick contact is their 2-year-old nephew who had a runny nose on the weekend when they were babysitting for him.

Sarah/Sidney is otherwise healthy and taking no regular medications. They have no significant past medical history or family history. They have no known drug allergies.

On exam, Sarah/Sidney is well appearing. Their temperature is 37.6, with a HR of 68 and a BP of 125/78. On examination of their head and neck you note mild bilateral conjunctivitis, mildly erythematous pharynx with no exudates and some minimal cervical lymphadenopathy. Their ears are normal. Examination of the heart, lungs and abdomen are normal.

Based on the above assessment, you suspect Sarah/Sidney has a viral upper respiratory tract infection (URTI). Since they most likely have a viral URTI, antibiotics are not indicated. Treatment of antibiotics will not hasten the recovery, may cause side effects and may increase antibiotic resistance in the long-term.

Sarah/Sidney is waiting to see you to discuss the management plan for their symptoms. You are aware that antibiotics are not indicated.

Instructions for the Standardized Patient

Overview:

  • Your name is Sarah/Sidney Davis.
  • You are 25 years old.
  • You live at home alone.
  • You have one older sister that lives nearby with her husband and you have one nephew (Michael).
  • Your parents are retired and do not live near you.
  • You are in school working on a master’s degree.
  • On nights and weekends, you work part-time doing clerical work.
  • You presented to your family doctor’s office because you think you need antibiotics for your perceived fever, cough and runny nose that has been going on for two days.

Background medical history:

  • You are in good health.
  • No previous hospitalizations.
  • You do not take any regular medications.
  • You do not have any allergies.
  • You are a runner.
  • You do not smoke or use illicit drugs.
  • You drink alcohol on occasion (e.g. a glass of wine with dinner on some weekends).

Medical history related to current visit:

  • You have had your symptoms for two days.
  • You do not have a thermometer at home, but you feel warm.
  • You have a runny nose and a cough; you are not making any phlegm with your cough and you have never coughed up blood.
  • You have no experienced any other symptoms; your urination and bowel movements have been normal.
  • You have not experienced any weight loss or night sweats.
  • You are not currently sexually active.
  • You have been otherwise very healthy recently.
  • You did get your yearly flu shot.

The purpose of your visit to your family doctor:

  • You have not felt well enough to go to school the last couple of days, but plan on going back as soon as you can; this makes you a little anxious, because you do not want to fall behind, and you think that getting antibiotics will allow you to get back to school faster.
  • Two years ago, you remember having similar symptoms and you went to a walk-in clinic for antibiotics (you do not remember which ones) and started to feel better almost immediately.
  • You think that you should get antibiotics to make you feel better faster and so that whatever you have does not get worse.
  • Your sister had a cough earlier this year and ended up needing IV antibiotics in the hospital because her doctor didn’t give her oral antibiotics; you don’t want the same thing to happen to you.

*In this scenario, the resident should be able to diagnose a viral upper respiratory tract infection (URTI) that does NOT require antibiotics. The resident should communicate a treatment plan to you that does NOT include antibiotics at this time.

*The goal of the scenario is for the resident to appropriately communicate with you why antibiotics are not necessary and treatment for a viral upper respiratory tract infection is limited to treatment of symptoms (such as acetaminophen for fever). You are not aware that antibiotics are not clinically indicated, and feel that your request for antibiotics is reasonable.

The resident’s performance should be assessed based on the resource stewardship conversations rating scale. Your interaction should be guided by how the resident is doing in the scenario.

The resident’s performance should be assessed based on the resource stewardship conversations rating scale. Your interaction should be guided by how the resident is doing in the scenario.

If the resident is not clear in their explanation, does not talk about the risks and benefits, and does not convey why antibiotics are not appropriate, then you can get more anxious and upset in the manner in which you ask for antibiotics.

PROMPTS: Used to standardize the scenario and give all candidates an opportunity to discuss relevant issues.

  • If the resident does not volunteer any downside to taking antibiotics, the following prompt can be used:
    • Is there any downside to taking antibiotics?
  • If the resident does not elicit your concerns about why you are so eager to have antibiotics, you can volunteer these lines:
    • My sister had a cough earlier this year and ended up needing IV antibiotics in the hospital. I don’t want this to happen to me.
  • This can be used as a prompt for all residents, even those that have explained the risks and benefits well:
    • Are you not giving me antibiotics just so that others won’t be infected by these “super bugs” I hear about in the news?

Modifications for different specialties based on Choosing Wisely and Choosing Wisely Canada (CWC) recommendations

This scenario was created to be as general and non-specialty specific as possible. The location of the scenario can be changed to be pre-operative, post-operative, family practice based, etc. The essence of the scenario can relate to all specialties, where a patient is requesting antibiotics that are not necessary to treat their viral infection.

This can also be extrapolated to a scenario about not treating asymptomatic bacteriuria with antibiotics, for which there are several recommendations listed below.

Some specific modifications based on the Choosing Wisely Canada (CWC) recommendations are listed below.

These suggestions may also work for other specialties, and are categorized based on the CWC society lists.

Emergency Medicine

  • “Don’t prescribe antibiotics after incision and drainage of uncomplicated skin abscesses unless extensive cellulitis exists.”
  • Scenario changes to: 35-year-old patient requesting antibiotics for an abscess with incision and draining performed in emergency room.

Family Medicine

  • “Don’t use antibiotics for upper respiratory infections that are likely viral in origin, such as influenza-like illness, or self-limiting, such as sinus infections of less than seven days of duration.”
  • Scenario changes to: Scenario does not change. The location changes to family physician’s office.

Geriatrics

  • “Don’t use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present.”
  • Scenario changes to: 85-year-old patient who is requesting antibiotics (or whose family member is requesting antibiotics on their behalf) because a positive urine culture that was drawn for an unrelated reason shows bacteria even though they are asymptomatic.

Urology

  • “Don’t use antimicrobials to treat asymptomatic bacteriuria in the elderly.”
  • Scenario changes to: 85-year-old patient who is requesting antibiotics (or whose family member is requesting antibiotics on their behalf) because a positive urine culture that was drawn for an unrelated reason shows bacteria even though they are asymptomatic.

References

Contributors and Reviewers

Contributors

Samantha Buttemer, MD, CCFP
Public Health and Preventive Medicine
Queen's University
Kingston, Ontario

Ming-Ka Chan, MD, MHPE, FRCPC
Department of Pediatrics and Child Health
University of Manitoba
Winnipeg, Manitoba

Constance Leblanc, CCFP(EM), MAEd, CCPE
Department of Emergency Medicine
Dalhousie University
Halifax, Nova Scotia

Jennifer Russell, MD, FRCPC
Division of Cardiology within the Department of Paediatrics
Hospital for Sick Children
University of Toronto
Toronto, Ontario

Reviewers

Nancy Fowler, MD, CCFP, FCFP
Academic Family Medicine
The College of Family Physicians of Canada
Ottawa, Ontario

Brian M. Wong, MD, FRCPC
Department of Medicine
Sunnybrook Health Sciences Centre
University of Toronto
Toronto, Ontario

This material may be reproduced in whole or in part for educational, personal or public non-commercial purposes only.
Written permission from the Royal College is required for all other uses.

How to reference this document:
Hillis C, G Mukerji and A Weinerman, editors. 2017. Communicating with patients and families about medically unnecessary tests and treatments. Resource Stewardship and Communication OSCE Sample Scenario – Unnecessary Antibiotics. Part of: The CanMEDS Resource Stewardship Curriculum Toolkit Series. Ottawa: The Royal College of Physicians and Surgeons of Canada.