Letters to the Editor

To the Editor

In his article, “GPs’ reason for ‘non-pharmacological’ prescribing of antibiotics” [1], P. Petursson describes the phenomenon whereby we often in general practice prescribe antibiotics without a microbial indication. With his interview method, he is able to give a clear and, in my opinion, true view of our everyday work. He draws attention to the problems associated with an excessive use of antibiotics, but also proves to have a good understanding of the situation of GPs and concludes that “non-pharmacological prescribing can be both rational and legitimate”.

I agree with his description and in part also with his conclusion. However, I do believe that his analysis is flawed, which is illustrated in the abstract in which he says that the GP must become “better equipped to resist patient pressure”. Even though he emphasizes that it is scientifically justifiable to rely on elements other than the evidence-based biomedical ones, he is still not able to tear himself away from the guilty conscience of GPs in this regard. Here, the excuse is pressure from the patient. However, we have to acknowledge these other elements, and be proud of them, even though they lead to treatment that is non-pharmacological. Otherwise, our profession will never become scientific.

The general practice consultation is a dialogue, which must result in something useful for the patient. In a good dialogue, one party is not under pressure from the other party. The GP is not under pressure from the patient to do something which he or she actually believes to be wrong. Instead, the GP will try to understand the patient's reasons for requesting a specific treatment. The basis of the consultation is the patient's description of the problem, which the GP combines with his or her own assessment of the problem to form a basis for decision (and treatment), which the patient can use and the GP believes to be medically acceptable. The patient's reasons for requesting pharmacological treatment may be so important that they overshadow the GP's reasons for non-pharmacological treatment.

When Petursson finds that “Fear of conflict and discomfort due to conflict appear to be common among GPs who will make great efforts to maintain peace with patients”, it is not only due to the GP's fear of conflict but means that the conflict is symptomatic of the fact that it has not been possible to find a common basis for decisions, which means that there is a risk that we will come to a decision which the patient has not taken part in and thus is of no use to him or her.

The author states that “Decisions that appear to be irrational or non-medical from a biomedical viewpoint may indeed be rational and medical in the process of winning trust and confidence”. I believe that he should have said “…be rational as a result of the dialogue”. This means that in the dialogue the patient may give reasons that, in a given situation, justify a departure from strictly biomedical elements in order to find a solution which is useful to the patient.