Antibiotics and medical economics

In going through my daily readings this morning I came upon a couple of articles that show how medicine and economics sometimes combine to produce a less than optimal outcome. The first article was in Healthday entitled Steer Clear of Antibiotics for Colds; the second from WebMD entitled Drug-Resistant Staph May Get Nastier.

The first article is basically a reminder that colds (and flus, for that matter) are viral infections that don’t respond to antibiotic treatment. The second discusses a dangerous type of drug-resistant staphylococcal infection that is spreading in epidemic proportions. What do these two articles have in common?

The real take-home message from both is that antibiotics are over prescribed and that the more antibiotics are prescribed unnecessarily (and necessarily, too) the greater the likelihood that resistant strains of bacteria will select out and emerge in numbers that threaten us all. We’re in an escalating race already, with new antibiotics being developed all the time to counteract the bacteria that have become resistant to the old antibiotics. Soon, the bacteria will become resistant to the new antibiotic and the cycle repeats. In the old days, penicillin treated almost everything; now it treats almost nothing.

How does this cycle intersect with medical economics?

Simple.

A medical practice is a business just like any other. And for any business to remain successful (unless it’s the only game in town) that business has to keep its customers happy.

Despite the white coats, the stethoscopes, otoscopes, scalpels, and all the other medical equipment they ply (not to mention the God like attitude), doctors are in business to make money. They have house payments, car payments, kids that need braces, money for vacations, vet bills, and all the other expenses that non-doctors have. Crass though it sounds, they are all concerned about the bottom lines of their practices. Since patients are the lifeblood of a medical practice, no doctor wants to lose patients. The best way not to lose patients is to keep them happy, which doctors do by treating them successfully. Conversely, the way doctors lose patients is by not making them well.

When a patient comes into a doctor’s office with a bad cold, the doctor has a couple of options. He (I’m going to use ‘he’ because, well, because I’m a he and I could easily be talking about myself here. I hate the cumbersome construction of he or she. I live with an extremely competent ‘she’ physician to whom I daily turn for all kinds of medical advice, so I can be exempted from accusations of sexism.) can counsel the patient on the fact that the infection is viral and that rest, fluids, Tylenol, etc. are the treatments of choice. Or he could say something along the lines of, ‘Well, looks like you’ve got a little infection going on. It’s probably just a cold, but I’m going to put you on an antibiotic just in case.’

The first scenario I described is the correct way to treat the patient, but often ends up costing the doctor the patient. As a result, the second script is the one most often followed because it keeps the patient happy. Let me explain.

Going to the doctor costs money. No one likes to spend money and get nothing in return. If, during a heat wave, you’ve called the air conditioner guy to look at your air conditioner that isn’t working well and he comes out, checks it with all his paraphernalia, then tells you, “Yeah, it’s working fine, it just can’t keep up with this heat. That’ll be $75 please. You feel ripped off. You don’t want to be told it’s working okay; you want it to cool your bloody house. It’s the same with doctors. People pay money to doctors to get them well, not to be told to rest and increase their fluids–even though that is the proper treatment for a cold.

When MD and I ran a huge primary care medical practice in Arkansas, the number one complaint about some of the doctors who worked with us was: he (or she) didn’t do anything. From the patient’s perspective, he (or she) came into the clinic to purchase wellness–instead, these people got told to go home, rest, drink a lot of fluid, and take Tylenol, which they had probably been doing in the first place.

These dissatisfied patients would often go to another doctor a day or two later who would give them a prescription for an antibiotic.. The patient would take the antibiotic and get well almost immediately. And never go back to the first doctor. It doesn’t take many of these experiences to ensure that doctors hand out antibiotic prescriptions right and left, even though they know they don’t do any good.

Why did the patients get well when they started taking the antibiotics if antibiotics don’t work for colds? Because these patients were almost over their colds when they started taking the antibiotics. Their own immune systems had defeated the viral infection just about the same time they started taking the drug. (Usually a cold or other viral upper respiratory infection runs its course in 5 to 10 days. Most people wait a few days before going to the doctor in the first place. If the doctor tells them to rest and drink fluids, it takes them a couple of more days to get an appointment with someone else. So, by the time the second doctor visit comes around, the virus is almost beaten down.) One of the hallmarks of a viral infection is that when the immune system finally knocks it out, recovery is almost immediate. So, if someone starts taking a drug right before this immediate improvement takes place, it’s difficult to convince that person that the drug didn’t really do it.

Sometimes a viral infection beats down the immune system a little, allowing an actual bacterial infection to set up shop. At that point, antibiotics are required to knock out the infection. Many doctors, myself included, use that excuse to give antibiotics on the first appointment.

The absolute best way to treat a cold or other viral upper respiratory infection is to rest, drink fluids, take Tylenol for the discomfort. If the problem doesn’t get better in a few days, see a physician. If the doc tells you it’s just a virus, go home and continue you rest and fluid regimen. If you’re not better in a few days, or if you start coughing up yellowish sputum or blowing nasty yellowish, green snot out of your nose, it’s likely that you may have developed a bacterial infection. Go back to your same doc or call the office. You’ll probably get a prescription for an antibiotic then.

Help your doctor practice good medicine and prevent the spread of drug-resistant bacteria.

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9 thoughts on “Antibiotics and medical economics

  1. There could be other options here: for example, a placebo prescription for those who are prescription reliant. (After all, isn’t the antibiotic a placebo when used this way for colds?) And what about vitamin C – or other immune support?

    However, is it really a prescription that patients want, or is it some sympathetic listening (even 2 minutes of undivided attention could be meaningful) – something doctors who immediately reach for their prescription pads don’t give.

    I would be interested to know what percentage of patients would be satisfied with practical medical advice together with encouragement to undertake self-care – as compared to being given a prescription. Even being given permission to rest in the face of job deadlines and hectic family demands. After all – if a doctor says you must rest it does something vital … it removes the guilt factor.

    Hi Sheilah–

    I thought exactly as you do when I first got out of my medical training. (in fact, virtually every new doctor feels the same way) I thought patients wanted to be talked to, to be reassured, and that they would understand. It took a while for the reality of the situation to set in. Patients want to get well. They want medicine–that’s why they go to the doctor. That’s why I switched from primary care to nutritional medicine. I wanted to feel like I was actually doing something for people besides giving them the drug du jour.

    Best–

    MRE

  2. This may be a little picky, but I would never used an antibiotic on a COD, but I might use one on a COLD. Nuff said, except I’ll take that proofreaders job.

    Hi Mark–

    MD just read the blog and pointed the same thing out to me. It’s true. I would never use an antibiotic on a Cod, even if I knew what kind to use.

    It’s all changed now. Thanks for the heads up.

    MRE

  3. What do you think about the use of antibacterial soaps and the like? I used to avoid them, but diabetes caused me to get very prone to skin infections and so I have resorted to antibacterial body washes. (Hopefully that susceptibility will go away now that I have my blood glucose thoroughly normalized, which, by the way, I’ve managed in the last week or so with the guidance of Protein Power — in 30 or more readings I haven’t seen one over 115 mg/dL, so thank you VERY MUCH for that!)

    Hi Francis–

    I’m happy to hear that your blood sugars are doing so well. Keep after it.

    I think that antibacterial soaps are a problem. Many people who don’t need them use them adding to the antibiotic runoff, which, in time, can breed bacterial resistance. My recommendation is that for people like you, who needed such soaps at one point, to use them. All others who don’t need them, should avoid them.

    Best–

    MRE

  4. At long last, I can finally add a valuable(?) comment.

    Baytril, NuFlor, or Azactam, using an intra muscular or intraperitoneal injection can be used on a Cod. Needle size (22-24 gauge) depends on the size of the fish and the type of antibiotic used. Aeromonas and Pseudomonas bacteria are the most common offenders, and cause ulcer disease in the fish. But unfortunately, resistance is becoming a big problem. Many strains of Aeromonas bacteria are resistant to tetracycline, and now some are becoming resistant to Azactam and Baytril.

    Hi Karen–

    See, even Cod that are over antibioticed (is that a word?) are adding to the problem.

    Cheers–

    MRE

  5. When I read in the various low carb forums about people’s benefits from going low carb, often they will say that they have NOT been sick, or only once or twice sick, since they started low carbing. I thought that was strange but I did some looking and found an article that talked about the suppression of some part (don’t remember which) of the immune system immediately after a rise in blood glucose from a high carb meal.

    Being a “Senior citizen” I cannot say for sure, but I don’t think I have been sick more than once in the past four years that I have been following PPLP. And that was after I had driven two days (1000 miles) to visit my son. My “lunch” when traveling back then was still a large blueberry malt. Often I would have two during the day, so I was getting a big slug of sugar from each. And probably was exposed to some “bug” during the trip since I got sick soon after arriving at my son’s.

    I just went out and back and did it malt free! 🙂
    Prevention is the best thing, by far!! Thanks!

    Hi Larry–

    Thanks for the comment. It’s a common one from folks who adopt a serious low-carb lifestyle.

    Cheers–

    MRE

  6. I can’t imagine someone seeing a doctor for a cold (though I know it happens). I just stay home and rest. If it doesn’t get better, THEN I will see a doctor. I’ve only been on antibiotics once in my life, and that was for a nasty gum infection that hadn’t responding to two attempts at “root planing.”

    The antibiotics, incidentally, killed EVERYTHING, good and bad, and I developed a yeast infection when it killed the good bacteria.

    Hi Victoria–

    That’s one of the problems with antibiotics: they kill both the bad and the good.

    MRE

  7. Conversely, my son’s very poor fiancee went to the doctor with what seemed to be classic strep. They sent her to a ear/nose/throat doctor who ordered a strep test. It was positive and they gave her a prescription. Because she had “insurance” she couldn’t get sliding scale prices, but it happened over the year change so deductibles for 2 years meant she had to pay the whole thing herself. Total–around $400!! She’s a waitress at a chain restaurant! Perhaps in this one case they could have given her the antibiotic first to see if it helped? I’m not in favor of unneeded antibiotics, but in this case it would have saved her a lot of money.

    Hi Lynn–

    I can’t believe that the first doctor didn’t do the strep test and treat. Strep is one of the bacteria that still respond to plain old penicillin, so it’s really easy to treat. I’ve checked for and treated countless cases of strep and never sent a patient to an ENT specialist for a sore throat. Seems a bizarre way to operate for a primary care doctor. The charges for the first doctor should have been about $15 for the strep test plus an office visit. $400 for an uncomplicated case of strep throat is an outrage.

    Sorry you’re son’s fiancee had such a bad experience at the hands of the medical profession.

    MRE

  8. Had to laugh as your post so perfectly illustrates why the following conversation pops up every year or so in our household:

    Hubby: I’ve got a cold. I’m going to make an appointment to see my doctor.

    Me: Why? She can’t do any thing for you when it’s a cold. It’s a virus, after all. Just stay home and rest.

    Hubby: When I was growing up, Mom used to take me to our kindly old family doctor and he’d give me a penicillin shot. I always felt much better after that blah blah blah.

    Me: Penicillin is an antibiotic, it won’t do squat for a virus. Your kindly old family doctor was a quack if he was giving you a shot of it for a cold.

    Hubby: All I know is that I felt a lot better after I got it.

    Me (muttering as I throw up hands and walk away): He could have been slipping you salt water for all you knew and you’d have felt just as good.

    I didn’t fare much better growing up, only in my case, my mom was having my dad pick up penicillin without a prescription at the pharmacy across the line in Mexico and doling it out to us kids at the first sign of a sneeze. That nonsense ended for me when I developed an allergy to it.

    Hi Esther–

    The scenario you describe is all too common. The only real reason for going to the doctor with a cold and sore throat is to be checked for strep because untreated strep can lead to some some serious long term consequences. If the strep screen is negative, then ride it out. If positive, take the antibiotics UNTIL THEY ARE GONE. And don’t let anyone–doctor or otherwise–tell you that they can diagnose strep by just looking. I’ve read far too many papers on this one to believe that. Viral sore throats can look just as nasty as strep and strep positive sore throats can just be a little red. It must be checked with a strep screen to really know.

    Best–

    MRE

  9. You point about sore throats is well-taken, they are the one thing I don’t fool around with. Fortunately hubby only gets a mild one that lasts less than a day when he’s first coming down with a cold. I used to get horrible ones when I had a bad run of sinus infections, the doctor would alway swab because my throat looked so bad. It never was positive, though. Funnily enough, those infections coincided with an abcessed tooth that I had. When I had a root canal done, they went away. A year later, I started to get them again and wouldn’t you know it, that root canal was going bad. I had a pretty severe abcess in it and my jaw was actually swollen just like those old time drawings of people with toothaches. The pain was unbelievable. They wanted to re-do the root canal but by then I’d had enough and told the dentist to just pull it. Haven’t had a sinus infection since. I tell you one thing, though. I really, really wish that I had been following a LC diet back then because I’m sure that I would have never gotten that bad molar in the first place if I had. That was the first and last real dental problem that I’ve ever had and I’m hoping that my current diet keeps it that way. Given the checkups that I get these days, I think I’m on the right track.