Criticizing your customers and your colleagues is a sound business practice that will help you position your industry in the best possible light. Sound like a wise public relations strategy? Of course not. Yet, as the cloistered and collegial world of medicine is exposed to greater outside scrutiny, this is just the tactic physicians appear to be embracing.
Public finger-pointing between physicians and other parties in health care is perhaps most visible when it comes to payment mechanisms, but it's evident elsewhere. Medical societies, for instance, have tapped some of the brightest scientific minds to establish best practices — which are summarily ignored. Managed care organizations' attempts to encourage physicians to follow sound clinical guidelines invite doctors' suspicion and derision.
When this defensive posturing is played out publicly, it fosters distrust of the health care system. It also creates an image problem for physicians that ultimately will diminish the profession's influence in health care.
In other words, physicians' own media relations strategy — whether it involves managed care or otherwise — needs work.
Antibiotic resistance is an excellent case study. A review of hundreds of articles printed during the past two years in 31 regional and national newspapers, to examine how physicians have responded to this issue, found one clear trend: Physicians blame and criticize two groups that they can ill afford to alienate — their patients and their fellow doctors.
While the subject of antibiotic resistance is narrow, it is increasingly important. Further, poor media relations skills on any given subject may be indicative of how physicians are likely to position themselves in the news media when it comes to other sensitive issues as well.
Antibiotic resistance, of course, affects more than just individuals; it has global implications that worsen by the day. Consider that 2 million pounds of antibiotics were produced in 1954; today, it's more than 50 million a year. Bacteria resistant to methicillin, the next-to-last line of defense against resistant bacteria (before vancomycin), killed 1,409 people in New York City in 1995 — 200 more than the number murdered in the city the same year.
Patient misuse of antibiotics, primarily where patients don't take the full course of medication, is an important factor contributing to the spread of antibiotic resistance. So is overprescription. Antibiotics often are prescribed, studies have found, for viruses — against which they have no effect. In a common scenario, a parent takes a sick child to a physician. The doctor determines that the child's illness is due to a viral, not a bacterial, infection. Because there is no treatment for the viral infection, the doctor tells the parent to let the virus run its course and perhaps to try some over-the-counter pain medication. But the parent feels entitled to get something out of the office visit; being told to let the virus run its course isn't satisfactory. The parent insists on a prescription for an antibiotic and may even threaten to find a physician who will write a prescription. Feeling pressured, the physician may write an unnecessary prescription for an antibiotic, even though it will have no positive effect on the child's illness.
These issues, patient misuse and doctor over-prescription, are why physicians blame their patients and fellow doctors through the news media for contributing to antibiotic resistance, and they are legitimate contributing factors. But does that mean that physicians should lash out at these two groups through the media?
Some of the physicians quoted in articles about antibiotic resistance in the past two years positioned themselves in a sympathetic light. They acknowledged that they feel compelled to act in the best interests of their patients — even if it's not what the patient wants or expects — without stating that they actually contribute to the problem. They often portrayed themselves as victims of patient demands. Several did acknowledge, however, that they possessed some control over overprescribing by ensuring that patients are properly educated about antibiotic use. Physician statements sometimes indicated that doctors recognized their roles and responsibilities when prescribing antibiotics. More often, though, physicians tended to blame either their patients for "forcing" them to write unnecessary prescriptions, or their colleagues for improper prescribing. These statements were probably not intended to be indicative of industry or organizational policy.
When physicians incriminate their fellow doctors, the media are probably only too happy to quote them. It is important to understand that when speaking to reporters, sources are at the mercy of the reporters' selection of statements, and that those statements may or may not be applied in the context intended. Sometimes the physicians don't even supply the context.
The bluntness with which these physicians made disparaging remarks — tactful or not, accurate or not — varied considerably. Fairly typical statements pointed to overuse in general, without specifically saying who was to blame. Those who did point subtly to prescribing habits as a contributing factor conceded inappropriate professional judgment, but sounded factual and passed no personal judgment on their colleagues.
Although more than 250 articles were reviewed, the majority didn't contain statements from physicians addressing the causes or significance of the issue. Those that did, though, weren't exactly complimentary of the medical profession. So just what have physicians been saying in print about why antibiotic resistance continues to spread?
"Time is a big issue. If you don't prescribe, you have to spend time explaining what to watch for, when to recontact the doctor and what over-the-counter items can help." (Steven Lowenstein, medical director, Colorado Department of Public Health, in the Denver Post.)
"On the other side are the doctors who prescribe antibiotics to patients who don't need them." (Steve Ostroff, Centers for Disease Control, in the Chicago Tribune.)
"The odds are twice as high for people in rural areas to receive antibiotics for ... viral illness than for those in urban areas. They seem to prescribe antibiotics more often." (Ralph Gonzales, University of Colorado assistant professor of medicine, in the Denver Post.)
"Too many doctors keep doling out too many antibiotics for ear infections, fevers and other problems, even though many such cases are viral and likely to disappear on their own in a few days." (Stan Block, pediatrician, in the Chicago Tribune).
Statements such as these may be accurate, but from a positioning standpoint, the physicians focus too much attention on their own profession, rather than use the opportunity to deflect some finger-pointing. Herein is the first public relations lesson for physicians: There are different "truths" with respect to any subject and any argument. While public relations practitioners are interested in being truthful, they are also interested in accurately portraying their organization as positively as possible.
"The majority of infectious-disease specialists are pretty good, but I have one colleague who uses vancomycin very irresponsibly. I stopped working with him over it. A lot of people use vancomycin because they don't know anything better." (A physician who asked not to be identified, in the Washington Post.)
This kind of statement has the potential to damage physicians' collective reputation, because it makes other doctors sound incompetent. Singling out any group within the profession, such as infectious-disease specialists, not only damages the reputation of physicians in general, but can also lead to harmful infighting and more internal finger-pointing.
"The well-off folks in the suburbs have more access to physicians, and they have certain expectations. They may pressure doctors for an antibiotic so they can get their children back in day care, or so they can feel they're doing something." (Benjamin Schwartz, epidemiologist, National Center for Infectious Diseases, in the Wall Street Journal.)
"Doctors believe they have to send patients away with a prescription, or [patients] don't feel like they got their money's worth. All of us are taught to say no, but we get a lot of pressure from patients. Whether right or wrong, doctors prescribe medicine over the phone because it's just the nature of the beast." (Thomas Moore, senior fellow, Center for Health Policy Research, George Washington University Medical Center, in USA Today.)
While patients pressure their doctors, physicians still have to acknowledge that they're the ones with the prescription pads. Otherwise they appear irresponsible and controlled by untrained lay people.
"We're asked, 'Do something about my child not sleeping nights. Do something about the pressure in his ears. Do something about his runny nose.'" (Ken Chan, ENT, in the Denver Post.)
One path physicians certainly do not want to go down is sounding whiny, as this doctor does. Few people will feel sorry for members of a wealthy profession who seek pity for having to do their job.
"One [problem] is in hospitals. We want to try to reduce antibiotic use there in the first place by preventing infections ... [Medical personnel] don't have time to wash their hands [because they] are shunted from one ward to another," (David Reeves, medical microbiologist, in the Toronto Guardian.)
Hospitals contribute to antibiotic resistance "because they don't follow good infection-control strategies. The hospital is not a very safe place. Five percent of the patients who come to the hospital get a hospital-acquired infection." (David Henderson, deputy director for clinical care, National Institutes of Health, in the St. Louis Post-Dispatch.)
If hospitals and clinics contribute to the problem of antibiotic resistance, physicians do, too, in the public's eye, because they are inextricably tied to hospitals and clinics. Physicians should focus their public criticism elsewhere while addressing their concerns about hospitals and clinics internally. Though these statements may be true from a medical standpoint, from a positioning standpoint they bite the hand that feeds them. Like patients, hospitals and clinics are a group that doctors can ill afford to alienate. Just as physicians depend on patients for their business, they depend on hospitals and clinics, to differing degrees, to provide access to those patients.
Not all the doctors are getting it wrong. Many of the statements reported in the mainstream news media were harmless. A few even had it right.
"The power to prescribe is also the power to say no, the power to withhold. It isn't easy, finding the balance between necessary authority and reasonable open-mindedness. You can't devote yourself to guarding the pharmacy door, but neither can you allow a patient's requests to determine your professional judgment." (Perri Klass, a Boston pediatrician, in the Washington Post.)
"We're the ones with the training, and we're the ones who are supposed to give advice. I wouldn't let a patient force me to write a prescription for a controlled substance if he didn't need it. I wouldn't do it for an antibiotic, either." (Rhonda Kendrick, family physician, University of Illinois at Chicago, in USA Today.)
Overall though, most physicians' media relations strategy appears unwise, judging from the articles. More likely, it reflects the absence of a strategy. Physicians need direction from public relations representatives to fashion a consistent message they want to communicate through the media, whether the subject is antibiotic resistance, managed care, or any sensitive topic. Alienating those they intend to serve can only be damaging.
In the case of antibiotic resistance, a more effective media relations strategy might be to remind the public tactfully that there are many factors. One of the most overlooked causes is that pharmaceutical manufacturers essentially stopped their research and development in antibiotics in the 1980s, because they felt stronger antibiotics would not be needed. The proliferation of antibiotic-resistant strains has exposed this as a tactical error, and medicine has played catch-up ever since.
Portraying yourself and those you work with in a positive light, while describing potential avenues for improvement, is always a more effective public relations strategy than placing blame. There's a difference between making disparaging statements and offering legitimate warnings. Physicians may do well to seek media relations guidance from their professional societies or, if possible, the organizations in which they work, to hone their message, improve their image, and thus, guard their stature in health care.