Public awareness of antibiotic resistance has grown.
Around 80 per cent of those surveyed in the Norwegian Citizen Panel say they are worried that antibiotics will stop working.
Still, antibiotic use in Norway has increased by 19 per cent since 2021, following years of decline.
More pressure leads to more prescriptions
General practitioner (GP) and communicator Kaveh Rashidi believes that the work situation for doctors plays a key role.
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Kaveh Rashidi finds it difficult to say no when the patient insists on a quick cure to recover a few days sooner.(Photo: Siw Ellen Jakobsen)
At an event about antibiotic resistance during Arendalsuka, the largest political gathering held in Norway every August, he described how pressure and time constraints shape daily practice.
GPs account for most of the antibiotic prescriptions in Norway. Many experience pressure from patients.
"The more pressure we are under, the less energy we have to resist patient demands," says Rashidi.
Patients simply go to another doctor
A central part of a GP's role is gatekeeping: to limit sick leave, referrals, addictive medicines, and antibiotics.
"What we’re evaluated on often conflicts with that role. We’re expected to see 20 patients a day to prevent long waiting times and comply with GP regulations," says Rashidi.
He finds it difficult to say no when the patient insists on a quick cure to recover a few days sooner.
"If we say no, they just go to another doctor," he says.
More profitable to say yes
Researchers Arnstein Mykletun and Kristian Østby at the Norwegian Institute of Public Health presented an ongoing study during Arendalsuka.
They examined GPs' prescribing of addictive medications, antibiotics, and sick leave using registry data and interviews.
Their findings confirm Rashidi's experience: Under today's financing model, it pays more to write a prescription than to spend time finding other solutions. GPs receive a base payment per patient and additional fees per consultation and procedure. More consultations and procedures mean more income.
The researchers believe that with such limited time per patient, it's easier to say 'yes' than 'no.'
This undermines both the gatekeeping role and national guidelines on antibiotic use.
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Big differences between doctors
The differences between GPs are significant.
Doctors earning NOK 2,000 (USD 196) per hour in fees prescribe, on average, 41 more antibiotic courses anually per 1,000 patients than those earning NOK 1,000 (USD 98). That equals about 20 per cent of total prescriptions.
The higher the income, the more antibiotics are prescribed to patients.
The main reason is that doctors who earn the most have more and shorter consultations.
14 per cent more antibiotics
Most GPs in Norway are self-employed.
Only about 20 per cent are municipal employees on fixed salaries. They do not have the same incentives to work quickly.
Researchers found that patients of self-employed GPs receive 14 per cent more antibiotics than those of salaried GPs.
Requires integrity
Rashidi believes the solution lies at the system level, not with the individual doctor.
"When everything revolves around quantity and getting as many patients in and out as possible, it takes a great deal of integrity and work ethic to maintain quality," he says.
He points out that quality often depends on time, and calls for incentives that go beyond simply rewarding speed.
Rashidi also calls for more public education.
"When patients understand antibiotic resistance, the conversation becomes easier. But sometimes the gap is so wide that you eventually give up," he says.
Dark clouds on the horizon
For the time being, Norway has little antibiotic resistance compared to many other European countries.
But the trend worries experts.
Resistant bacteria are becoming more common.
"At some point, we will lose control, just as has happened in many European countries. If we wait until that happens, regaining control will be far harder," Kristian Tonby, head of the Norwegian Society of Infectious Diseases, told Science Norway during Arendalsuka.
