I don’t know about you, but I’m tired of being talked at about antibiotic stewardship. We all realize it’s a problem. And though it’s common practice to blame urgent care providers for the situation, we aren’t uniquely culpable for antibiotic overuse.

To anyone paying attention, it’s clear that antibiotic overprescribing in urgent care remains as rampant as crime in Gotham City. And the topic has become exhausting for UC providers, not because we believe it to be unimportant, but because we are spoken to about antibiotic stewardship like we are Bruce Wayne when, in reality, we’re much closer to Batman. Allow me to elaborate.

Batman, Bruce Wayne’s secret alter ego, is concerned more than anyone for the safety of the people of Gotham City. He works tirelessly, generally to the detriment of his own well-being, to subdue the pervasive criminal elements threatening his fellow citizens. He does this because of an abiding sense of duty to protect them, despite being shown far more disdain than appreciation for his efforts.

When by day embodying the persona of the seemingly aloof billionaire Bruce Wayne, he places his ego aside and humbly conceals his heroic identity. Consequently, Mr. Wayne endures the ire of the citizenry as he seemingly sits back idly and allows Gotham to remain in a state of chaos. Meanwhile, he suits up each night and steadfastly fights epidemic violence to protect the thankless many whose safety he regards as his personal responsibility.

We care for our patients in the same way and likewise unfairly face the brunt of the blame for the disastrous situation of antibiotic overprescribing we are facing. In all my years as an urgent care doctor and director, I can count on one hand the number of providers I’ve seen prescribing antimicrobials with wonton disregard for their lack of clinical indication. Instead, I see providers who show up daily, taking the Hippocratic Oath to heart, and try to do right by their patients. But like Gotham, our clinics are often in chaos. There’s always more work to be done than humanly possible, so we do the best we can. And like Batman, we always have to pick our battles.

One of the greatest sources of burden for Batman, however, is not the physical threat of his enemies, which is significant, but rather the moral injury of being held out as the scapegoat for the problems facing Gotham instead of the well-intentioned vigilante he is. The simplicity of having a single target of blame is tempting, but dangerous. Administrators, policy researchers, and others who might speak on antibiotic stewardship without serving in the trenches risk invoking the same moral injury when they point the finger at UC clinicians as being solely responsible for antibiotic prescribing practices.

This is an important phenomenon to be sensitive to as the pandemic and corresponding “great resignation” unfold and we face frequent staffing shortages. Working in UC is already a tough job. And the truth is there are always going to be some patients who vehemently demand a non-indicated antibiotic regardless of how adeptly we communicate and attempt to educate or how much extra time we spend with them. However, a visit that results in a questionable prescription for azithromycin after a week of cough and runny nose doesn’t mean that the clinician didn’t put forth a valiant effort towards a different outcome. Quite the opposite actually. Most often, the provider did the best they could within the confines of the time and energy they could devote to that patient in the moment.

Nobody is more aware of the issue of unnecessary antibiotic prescribing than the UC clinicians who face the unreasonable demands for these antibiotics from countless patients every shift. What is defeating, though, is to be held repeatedly and singly responsible for its existence simply because we are the ones writing the prescriptions at the point-of-care. Provider-blaming thinly disguised as “education” is an unfortunately common and ineffective technique aimed at solving this issue. The allure of this strategy lies in its simplicity. However, antibiotic overprescribing, like crime in Gotham is a complex, systemic problem that will require solutions at every level to solve.

Motivating clinicians, whether it be with a carrot or, more commonly and misguidedly, with a stick, will not solve this crisis. Batman’s quest for peace and justice in Gotham was facilitated not by those who sought to tell him how to do his job but rather by those like his butler Alfred and Commissioner Gordon, who supported him and worked to remove the barriers to his mission. Similarly, UC providers already are fighting hard to protect our patients and do the right thing. Success in achieving our shared mission of better antibiotic stewardship doesn’t lie in finding innovative ways to motivate us or inform us of the problem. Rather, it lies in support from administration and systematic efforts to educate and redirect antibiotic-seeking patients.

This support and empowerment may come in many forms. Clinics can create policies clearly outlining to patients when antibiotics will not be prescribed, dismiss patient surveys when disgruntlement is based on not getting an antibiotic, and reduce expectations for the rate at which providers need to see patients so they can spend more time with each (which, in fact, is a more reliable predictor of satisfaction than antibiotic prescribing). The form of “support,” that has the lowest probable return on investment, however, is lecturing at providers or forcing them to complete yet another LMS module on stewardship. Moreover, such a strategy is more likely to be counterproductive by furthering burnout, learned helplessness, and disillusionment.

The more fruitful strategy involves nurturing UC providers, who generally hold themselves to high standards of performance. This form of nurture and professional development can come in many forms like mentorship programs, recognition for any and all achievements in performance metrics, and allowing discretion over provider’s choices for CME. In such an environment, I’ve found clinicians routinely will strive to improve their practice without need for much nudging whatsoever.

One compelling facet of the character of Batman is his unflinching endurance through perpetual martyrdom. But while he may offer a compelling role model (and metaphor), he’s only a comic book character. My fellow UC clinicians, while certainly heroic “Bat-people” on many levels, are only human and have a limited tolerance for moral injury before breaking. Frontline providers require real support in this mission rather than lip-service about “prioritizing antibiotic stewardship” if we are going to collectively protect the usually well-meaning, but occasionally misinformed, people of Gotham.

Antibiotic Prescribing in “Gotham City”
Joshua Russell, MD

Joshua Russell, MD, MSc, FAAEM, FACEP

Quality and Provider Education, Legacy - GoHealth Urgent Care, is affiliated with the University of Chicago Medical Center in Vancouver, WA, and is Editor-in-Chief of JUCM.
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