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?
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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