Guest posting from Dr Catherine Berry,  Infectious Diseases Staff Specialist and Antimicrobial Stewardship lead for Hunter New England Health.

I’m still recovering from a week of ID on call. It’s intense and we provide service for a huge area of NSW. It’s interesting and challenging trying to see the problem through the referrer’s eyes. Some of the questions are simple and we are sharing some cognitive load – sometimes the referrer is the first to see a once-in-a-career diagnosis. Scrolling through X, (Twitter), I saw this feed. (H/T to the fabulous @mededtwagteam)

Suddenly I was that intern again trying to get a medical review. I remember clearly the terror of not being able to communicate how worried I was and being dismissed over the phone. Practice, training in ISBAR and graded communication has helped me get better but paradoxically, over time, I’m now more the receiver than initiator of consults.

I try and remember however how hard it is to pick up the phone.

As Alex Broom found out when he asked a range of junior doctors a few years back, this hasn’t changed: initiating an antibiotic with a vague indication may be preferable to disturbing an expert. Infection control: why doctors over-prescribe antibiotics (theconversation.com)

The other side is the authority the specialist can feel they need to impart with the challenges of verbal communication despite not having the patient in front of them.

Now when I tour facilities and am curious about prescriber antibiotic choices, I’m frequently told that it was the consulted specialty team’s choice and they want to follow that plan. I see patients on very broad-spectrum IV antibiotics days after they are better. It made me reflect again how we give and receive advice especially over the phone.

It struck me about some key points we think through when we give antibiotic advice:

• Getting an idea of the problem – is it diagnostic or therapeutic? Is it even an infection?
• Who is the host – is this simple or complex – do guidelines apply or are we already on 2^nd or 3^rd line therapy?
• Where is the patient and is it the right place?
• An agreed working diagnosis is essential – and what else do we need to exclude?
• What’s the right management?
  • A- antimicrobial selection (agent, route, dose, comorbidités, allergies)
  • I – indication
  • M – microbiology
  • E – evaluate empirical therapy in 48-72 hrs
  • D – duration – set a review date
• In particular, outlining both the scenario of when things are going well and things are going slowly and what to anticipate.
• Finally when to call back?

I think this last point is the most important.

For my GP colleagues – us tertiary specialists are so impressed by your expertise. But we don’t always know your facility or resources. We might not know that you have 24 hour on-calls with limited support or that your ED only has an I-STAT machine and the blood courier only comes once a day.

It might help to ask us questions like:

• So if this patient isn’t neutropenic, can we de-escalate antibiotics for community acquired pneumonia? Or would you like us to call you with an update?
• Is it fine to treat this infection per Therapeutic Guidelines?
• I can see this patient isn’t due to see you for a while, will you help make an earlier appointment or should I get them to call the rooms?

But most of all if something isn’t clear, in particular with antibiotic plans – do call us 😊