Sunday, December 2, 2012

Primary Care - Trying to Do Right

Winter is officially here and  we are in the cold and flu season.  This is the time that patients get sick with viral illnesses and primary care doctors get even more frustrated as they try to do the right thing for patients.  What is the right thing?

 First of all we want to relieve suffering.  But we also want to do that without causing harm.  We  want to practice the best evidence-based medicine.  And evidence shows us that antibiotics and extra testing does not help the time course of a virus.  In fact, overuse of antibiotics drives drug resistance, increases the overall cost of health care and causes unintended side effects. 

I've seen comments on the internet that doctors are part of the "Business of Medicine" and they order tests and use "big pharma" drugs so they can "make money".  Well, folks, Primary Care Doctors make no money ordering tests or prescribing drugs.

 Zero!  In fact, it actually costs us money to do both.  Blood and imaging tests (X-rays) require documentation, follow-up,  time informing patients and can even lead to more testing if something is "borderline".  We don't get a dime for this time consuming work that occurs after the patient is long gone from the exam room.

But even with the extra time it takes to order and follow-up on tests and order prescriptions, it takes even more time to explain to a patient WHY  these things are not needed for a viral illness.

Believe me, I get it.  I know how miserable a virus makes you.  I know how nights are worse and how hard it is to sleep with a sore throat or congestion.  I also understand the false hope that taking a pill will make it all better in a day or two.  I know we all want instant cures.   Here is how a typical scenario goes...usually on a weekend phone call:

Patient: "Doctor, I really need to be on an antibiotic.  I get sinus infections every year and I'm congested now and last night my throat was burning and I couldn't swallow and I couldn't sleep all night long  and I just know this will turn into a sinus infection because I get them every year and I need something called in RIGHT AWAY because I have to go to New York on business on Thursday and I just CAN'T BE SICK".

This phone call will take about 20 minutes because I will get more details and then explain, as kindly as I can,  that this illness will probably last 7-10 days no matter what we do.  I will offer  my suggestions for comfort care, rest, pain relief and natural healing methods and the opportunity to re-evaluate if things get worse.

At the end of this phone call, the patient is usually frustrated and may be even angry with me because they really don't believe what I have said and they really do feel miserable.

This scenario plays out multiple times, day in and day out during the winter season.  Sometimes I just give in and prescribe the antibiotic.  I can only try to do the right thing so long.


Anonymous said...

Well said. The example you gave is certainly true in my practice and patients believe the antibiotic will make everything better. Ten days. With or without antibiotics.

Steven Reidbord MD said...

Same situation happens often in psychiatry. Patient wants an antidepressant or anti-anxiety medicine. I gently explain that their particular case may be better served by psychotherapy (or exercise, nutrition, mindfulness, etc). They leave dissatisfied, or soon complain of even more misery to convince me how much they need the prescription. Sometimes I cave in, usually I don't.

It's a pity how such struggles create an antagonistic dynamic. Often we become gatekeepers rather than trusted advisors for patients who already have their minds made up.

Michael Kirsch, M.D. said...

Well expressed. Patients that contract C. diff from an antibiotic get sobered up on this issue. These folks can be ambassadors to convince the public not to demand antibiotics for sore throats and other viral infections. Your post is a public service announcement!

MCAT Verbal said...

I think technology has a lot to do with our trend towards immediate medical gratification. For example... Who won the 1996 World Series? iphone it and with 5 seconds you know the answer. Although it may not be logical, I think many patients have similar expectations concerning diagnosis and medical interventions. Give me a pill and 30 minutes from now I will be all better. This is something that needs to be dealt with at all levels of the chain of care.

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Anonymous said...

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