It all started with my sending a tweet.
Actually, that's not quite true. The way it really started was with my frail elderly patient calling me in mid-January, to tell me he thought he had a UTI. But that part of the story is not new and novel; I've often had patients contact me with similar concerns.
I did what I usually do: ordered a UA and UCx. (I know, in theory better to check a UA, and if it looks suspicious, send for UCx. In practice, that's logistically difficult if you don't have the patient in clinic and aren't able to dip the urine right then and there.)
The trouble was, the patient had called me on a Friday morning. "Bummer," I thought, "I'll probably get the UA on Saturday but the culture might not be back until Monday."
Sure enough, on Saturday I checked my fax queue and there was a preliminary report: lots of white cells and nitrite in the urine.
High-risk elderly patient with symptoms. He needed empiric treatment started before the urine culture results would be available.
Being the clinical decision-support junkie that I am, I decided to take a quick peek at empiric treatment recommendations on UpToDate.com, where I confirmed that the recommended treatment is TMP-SMX. Unless, that is, there is local resistance >20%.
Or I could prescribe a fluoroquinolone. But, notes UpToDate, "increased resistance is mitigating the usefulness of the fluoroquinolone class."
Hm. I found myself noticing that choices do, in fact, induce decision-fatigue. (No wonder so many docs just prescribe whatever they're used to prescribing.)
Clearly, the task at hand -- selecting a suitable antibiotic for empiric treatment of UTI -- would be much easier if I knew what the local resistance antibiotic resistance patterns have been recently.
So, I decided to call the lab itself, Quest Diagnostics, thinking that maybe they'd be able to tell me about local resistance patterns.
The staff answering Quest's results line seemed quite perplexed by my inquiry. They transferred me to the microbiology lab in San Jose, where they were equally perplexed. Sorry doctor, your culture results won't be available for 1-2 days. And *then* we can tell you what the resistance pattern is for YOUR submitted sample.
I kept telling them I'm not asking about my sample, I'm asking about recent resistance on all urine samples from community patients.
I kept being told that resistance results will soon be available for MY sample.
Finally they transferred me to a supervisor, who told me that she sees what I'm getting at, and no, they don't provide this information.
"But you must be culturing 1000 urines per week," I pointed out. "You must have a sense of how much resistance there is to certain drugs."
She laughed. "We run more like 10,000 urines." But, she went on, this didn't mean they had general antibiotic resistance data to share with doctors. Instead, she recommended I try the public health office. I didn't bother to point out that they wouldn't be open on a Saturday.
I hung up, picked an antibiotic to prescribe, and sent my request to the patient's pharmacy
And then I sent out a tweet, commenting that although Quest does all these cultures, somehow the resistance data isn't available to community docs like me.
A tweet heard across the country
To my surprise, my tweet was noticed by another doc, @HenryWeiMD, who addressed a follow-up tweet directly to @QuestDx -- something I hadn't thought to do -- urging Quest to help @GeriTechBlog.
A few hours later, I received an email from Henry, addressed to me and someone at Quest, in which Henry introduced me to a contact at Quest and pointed out that if this kind of antibiotic resistance data isn't yet being made available to community doctors, then it really should be as this would be a "HUGE low-lying apple/big win for public health."
It turns out that Henry was a Presidential Innovation Fellow, though he'd been very much acting in a personal capacity when he followed up on my tweet. His tweet had prompted someone from Quest to send him a message offering assistance.
A week later, I was notified that my issue had been referred to Quest executives, who would be following up with me.
And then a few weeks later, I finally received a phone call from a very nice Quest VP.
"You're the first to have asked"
Yep, that's what he told me. Which I find a little hard to believe, but it's certainly possible that this is the first time that such a request has made it up the command chain. (Seems unlikely that the local microbiology supervisor would be forwarding inquiries such as mine.)
But here is what is really really exciting: now that I've asked -- and miraculously been heard -- Quest is willing to work on producing local antibiograms for community clinicians!
Now, it's not available yet. We'll have to be a little patient and let them figure out how to do it. It's one thing to have the raw data, and another to collect it, organize it, and present it to a clinical audience. But if all goes well, eventually community docs will be able to access local antibiotic resistance data from Quest.
Woo-hoo! Smarter antibiotics prescribing, here we come!
Will docs actually use this info? Who knows, it'll probably depend on how easy it is to access. For instance, if local antibiograms end up printed at the end of every abnormal UA report, I'd expect many doctors to incorporate this into their prescribing decision. However, if one has to call Quest or look it up online, then the information will likely be used less often. Still, better to have such info online rather than not at all.
In the meantime, as someone with a background in quality improvement, I'm intrigued by the twist that social media brings into all of this. In the past, we practicing doctors have not had easy ways to make ourselves heard and noticed. Now we can tweet and blog, although if you're a small fry like me it's also helpful to get a boost from someone with a little more clout and connections. (Thanks Henry!)
So what conclusions have I drawn from this so far?
- Clinicians should be vocal about specific things we need in order to practice according to guidelines.
- Social media can connect you to allies and like-minded others.
- It helps to know people who know people.
Summing it up
By commenting on a sensible clinical issue -- my needing local antibiograms for better empiric UTI treatment -- via Twitter, and getting echoed by another doctor with more visibility and connections, I found my request being considered by a senior executive at Quest Diagnostics.
I'm left concluding that we clinicians should be vocal and specific in pointing out things we need in order to practice care according to guidelines or best practices. Social media offers some good opportunities to do this.
I'm also very grateful to the leadership at Quest Diagnostics for engaging with this issue. If they can start providing clinicians with local antibiotic resistance data, they'll be doing patients and providers a really good, useful service.