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Loading ...Seven patients were in the waiting room before I arrived at the office this morning. It is “sick season.” There is definitely a high and low tide when it comes to patient volume in our office, and the tide is on the rise. It hasn’t nearly reached peak – which happens in the first three months of the year – but the numbers are definitely up. Viruses pay no attention to the state of the economy.
The main complaint today was cough, congestion, sore throat, and runny nose. I had the same thing on Monday. My wife is suffering from it right now. It is the crud; a bug; a viral upper respiratory infection. Another name for it: job security.
Most of the time people come into the office with a URI, they come in to “make sure it is not something more serious.” They have sinus pressure and wonder if it is sinusitis. They have a loose cough and wonder if it is bronchitis or pneumonia. They have a sore throat and wonder if it is strep. It is OK with me that they come in for this – as long as they are not expecting me to do anything about it if it is just a URI. The problem comes up when they expect more when it is not appropriate.
Being a doctor puts you in a bind sometimes. On one hand, you are doing medicine – following guidelines, using your clinical knowledge to treat or prevent disease. On the other hand, you are making a living; and your job is to “keep the customer satisfied.” When you are taught at an academic institution, you can stick to the rules and not really care about the patients’ impression. It does you no harm financially if they leave. In private practice, however, you want to be a popular doctor. There is a degree to which a doctor has to sell him/herself to the patient.
Sometimes it is easy to make your patient happy; you treat an ear infection, remove a splinter, or manage a chronic disease. You do things for the patient and they benefit. Other times, however, what is good medicine and good business are at odds. Perhaps the biggest offender in this area is the viral upper respiratory infection. What do you do for a URI? Nothing. The body’s immune system fights off the infection and the patient essentially “cures themself.” So when people come into the office, paying to see you and get your advice, you are put into a dilemma: do you do nothing (which is the right thing to do) or find something to do? I have heard it many times that a patient comes in with a URI and the physician does nothing, and the patient feels like they have wasted their money. “He told me there was nothing to do.” “He didn’t do anything for me.”
To make matters worse, there is the lingering idea that antibiotics are the holy grail of medications. Doctors did overuse these medications – probably in part that they felt it did no harm to give them for a virus – and it meant you were doing something. Plus, nearly every time you gave someone an antibiotic for a virus, the patient got better. Patients put that together, and so the myth of antibiotics was born.
The myth of antibiotics states:
- Bacterial infections require antibiotics
- Green snot means there is bacteria
- Fever implies there is bacteria
- Bringing up phlegm with a cough means it is bacterial bronchitis
- Pink eye is best treated with an antibiotic
- Bronchitis, sinus, and ear infections require antibiotics to get better
- It is better to “catch something early” with an antibiotic than to wait until it is needed
- If a person is given an antibiotic and gets better, then the antibiotic made them better
- It is better to over-use an antibiotic than under-use it
Tip: Don’t do this.
Both doctors and patients are subject to this myth, but the patient’s belief in it is often the tipping point – especially in the private practice setting. Why? It gives the doctor something to do for the patient who is paying for the visit, and patients won’t feel like the doctor does anything unless the antibiotic is given. So you hear things like this:
- “I have been sick for two days with a sore throat, but now my sinuses are killing me.”
- “I had a head cold for a few days, but now it has gone down into my chest.”
- “My child was sick for a few days – I thought it was a virus – but then she started running a fever.”
- “The last time I had this, I got bronchitis. I wanted to catch it before it got that bad.”
It has gotten easier in the past ten years – especially with the publicity given to resistant bacteria. More people seem to be happy with waiting it out without an antibiotic. But often the urge to do still is strong. This is the main reason that I have prescribed cough/cold medications. These medications don’t do anything that OTC meds can do, but they make it seem like you are doing something.
Parents also felt the need to do something when their child got sick – and so cough/cold medications were given. Did it help? They got pulled off of the shelves because there was no evidence that they did. So now what do you do when your child gets sick? You wait. You don’t do anything.
I doubt there will ever be an end to this need to do. I see people with a cough that has gone on for over a week and sometimes treat with an antibiotic. Some studies have justified this decision – as adult cases of pertussis (whooping cough) have risen and are a fairly common cause of chronic cough. But the bottom line is that people come to their doctor for two main reasons: to rule out bad stuff (things we have to do something to prevent harm), and to have the doctor do something to make them feel better.
Is it worth it to pay to see a doctor who says ther is nothing to do?
The answer to that question goes far deeper than what is taught in medical school.
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{ 23 comments }
WHen I feel awful, I don’t always know that what I have is a virus. I’m a singer, and my throat is my career, so sometimes I go to my doctor to make sure that what I have will get better by itself, and that there’s nothing I can do (aside from rest, liquids, and perhaps Vitamin C or Cold-Eeze), to get better faster, so I can get back to doing my job. If I have a URI, or if I have anything else, I’m not looking for medication unless it’s actually going to help, and I hate to have an antibiotic prescribed because a doctor thinks I want one, or for “prevention”. I”m willing to save them for when it’s really necessary. Tell me I have a virus, that there’s nothing to be done for it, since we don’t have cures for viruses yet, and that, after much suffering, I will get better by myself, and I’ll be okay with that. I’ll go home and complain about my misery to all my friends, but I won’t blame my doctor.
Don’t forget to place employers and their rules as culprits in this drama. If you decide to take sick time off for an URI (that is if you have sick time available) you frequently need to have a doctor’s note to get paid for it. So in you come!
Telling a patient “there’s nothing we can do” can easily be perceived as “I, the doctor, am not going to help you.”
Surely there’s something you can offer, even if it’s just to suggest an OTC remedy that would help the patient with their symptoms. People also can find it reassuring if they know it’s OK to call the doctor in a week or so if their symptoms haven’t resolved.
One local clinic I know hands out packages of cocoa, tea, chicken broth and Kleenex, so people who come in with URI symptoms don’t leave empty-handed.
It’s all in how you spin it.
Sandy: I was a voice Major in college – I know what you mean. Hot tea with lemon and honey was a mainstay.
John: Schools are even worse than employers. The “No child left behind” law made it even worse, because schools won’t accept parent notes any more.
Zee: Agree that delivery is important. I like the idea of handing things out. Still, people come in with expectations sometimes that are frustrating
For some reason, my brain keeps drawing a correlation between this post, and WhiteCoat’s post here: http://whitecoatrants.wordpress.com/2008/11/17/help/ regarding the lady who kept calling for help.
I guess it’s because the lady is calling for help she doesn’t need (much like your patients asking for or expecting meds they don’t need), but I know there’s more to it and my brain just won’t process it today…..I’m also suffering from congestion, cough, sore throat, so maybe that’s it.
Ah…this explains the overly eager med student who kept offering my husband cough medicine — which I was sure we’d been told wasn’t actually effective, weren’t we? — earlier this week.
And, yep, he went only because work requires both a doctor’s note (*and* using two days of annual leave) before you can take sick leave.
Zee already said what I was going to, kind of.
A doctor friend of mine told me that when she was in med school, she was told never to let the patient leave the office empty-handed. If she didn’t give them a prescription, then the patient left with a brochure or a piece of paper with some OTC meds listed.
Maybe this would work with your patients. How about a patient handout with suggestions for easing URI symptoms? (My favorite for scratchy/sore throat is hot lemonade. And Popsicles. And I avoid milk products to keep the mucus thinned out.)
Also sympathy, liberally dispensed, is helpful. I remember once commiserating with a physician client about her cold and offering some words of sympathy, and came away surprised (and kind of amused) at how eagerly she accepted them. But I guess she had been listening to patient complaints all day and was ready for some compassion herself.
We all need a little kindness and understanding.
Rob, tell me that mouth pipette-like, snot-suction device is a joke…
I mean, obviously it’s funny.. but is it a real product?
Fizz: It is how we always inflated our children. Don’t you know about child inflation?
It is real.
http://www.amazon.com/Nosefrida-USA-LLC-Nasal-Aspirator/dp/B000OS8BP4
Good God, that thing is REAL? Didn’t anyone think to put a trap on it, to catch the snot and keep it from going into the suctioner’s mouth? Like a DeLee?
http://www.midwiferymercantile.com/images/delee%20suction%201.jpg
I almost gagged reading the Amazon reviews of the thing.
My childhood family doc believed in not sending anyone away empty handed. He also believed that people subscribed to the theory that if it hurts that means it’s working. So he gave Vitamin B injections for patients with viral URIs. They got a shot (strong medicine to their minds) that wouldn’t hurt and might help by boosting their energy. So they went away happy.
As an added plus, everyone knew that they were getting a shot if they came in. That did keep some people from coming in unnecessarily. And kids learned some stoicism – most would insist that they were well enough for school. And thus a generation of non-complainers was born.. hallelujah!
I have seen a trend toward patients being more informed about viruses within the last few years. I am an optomist.
I think patients want sympathy and the doctor’s reassurance that it is NOT a secondary bacterial infection. I also think a handout with homeopathic and over-the-counter remedies would be a good idea to make the client feel taken care of. One technique I have found to alleviate the pain of clogged sinuses is the use of a neti pot. Sore throat suffering is relieved by use of Chloraseptic or the generic equivalent. Zicam throat spray and nasal spray work wonders at alleviating symptoms and seeming to make the cold end sooner. You don’t agree with those I have listed? GREAT! Write YOUR recommendations for your patients and you have a winner of a handout.
One reason I sometimes see a doctor about an URI is that my friends keep pressuring me to do so. I am perfectly happy to have my doctor offer sympathy and send me on my way if it’s viral (which I already know it is). I am just getting over a URI and as usual I hear the same two things from friends:
1. go to your doctor NOW and
2. it is YOUR fault you are sick
Many of my friends think that sick people CAUSE their own illness due to working too hard, not washing hands enough, not having a positive enough attitude, not eating properly, not taking the right combo of vitamins, not exercising or sleeping enough, etc. Therefore another good thing to say to this stereotypical patient is “It is NOT your fault! I am seeing a lot of this right now”
Being the stoic person that I am, I generally don’t see my PMD unless the symptoms persist after taking the OTC stuff for several days, & with no signs of it getting better. Even at that, if it’s a nasty URI my Doc just prescribes expectorant capsules (the name escapes me), which have worked well in the past. I empathize with your frustration though. People tend to panic & it’s good to have a Doc that can offer reassurance, even if there’s no prescription to go with it. I imagine you have a few that insist on antibiotics, regardless.
Please keep in mind that some patients may feel really stupid if they go to the doctor and there is nothing “wrong.” I know I sometimes feel ashamed for wasting the doctor’s time. So please validate are feelings that a bad cold can seem like the end of the world.
I know I always freak out because of my Asthma. I have had many of a cold turn into a bad bad asthma attack. So some of us may be steriod seekers.
FYI – I have included just a few quick notes and suggested some tools (family practice friendly guidelines and NON-Antibiotic prescribing PADS) that might help Physicians, Patients and eventually society (through lowered antibiotic resistance rates).
1) In the early 1990’s a program began to curtail the over use of antibiotics and limit the spread of antibacterial resistant organisms. It was known as the PAACT program (Partners for Appropriate Anti-infective Community Therapy) and started in Port Perry, Ontario, CANADA (where we certainly see our share of colds and viral infections) under the leadership of a local family Physician Dr. John Stewart and research pharmacists Laurie Dunn and John Pilla.
2) The educational program used specially designed and user-friendly guidelines and a special prescription pads that DID NOT prescribe ANTIBIOTICS, but advice. ( see the website http://www.mumshealth.com for these and WALL POSTERS for Physician offices).
3) This program was replicated in many jurisdictions including Michigan, USA. The program was evaluated and published in peer-reviewed journals. The results showed a significant drop in the use of antibiotics.
We continue to promote and encourage others to get involved as we and many others no the importance of this issue.
If you need more information – see the website or would like to start a program feel free to e-mail us at paact@mumshealth.org.
Cheers and best wishes, John
Just a follow-up on my previous e-mail.
Our e-mail is
paact@mumshealth.com
NOT
paact@mumshealth.org
It’s so hard to know what to do. We had a very nasty virus running around that started out with body aches and a high fever (104 in ear), that my 3 yo caught. I was totally OK with not having an antibiotic, grabbing a doctor’s note and waiting it out. In less than 48 hours it turned into a double ear infection, tonsillitis, and sinusitis with the same fever. We then went home with an antibiotic that turned into two courses to get rid of the sinus infection. My daughter caught the same virus – I told the doctor what my son went through – and we left with a prescription – just in case. Of course I filled it and then gave it to her when it seemed to turn bad as his had. She was only sick three days, he was sick fourteen. Do viruses turn bad like that often? Or is it just that kind of year? Last year we struggled with Strep as did most of our small town.
John: Thanks for the resources. I have seen some of that stuff. To be truthful, this post was simply me venting about the dilemma I face every day and the pressure itself. I rarely prescribe unnecessary medications, even with demanding patients. I have found ways to explain and to try to help them feel better. I just wanted to give the emotion that doctors feel – that is one of the main purposes of this blog. It is not the whole picture.
Amanda: Nothing is worse than normal. I don’t mind people coming in for things that end up being viral. I would rather have people come in for milder stuff than to stay home for more serious stuff. As a mother you need to be cautious and listen to your intuition – it is often right.
But there is no way of knowing if your daughter really needed the medication. Your doctor did what many of us do. We care about our patients and understand the difficult situation they are in. It is our job to make them happy as well as to keep them healthy.
Then there is the placebo effect:
Placebo is a latin word which means, ‘I will please’
A patient who presents with symptoms that are not in correlation with their concerns may be candidates for a placebo from their healthcare provider. The patient may accept and ingest the placebo, and through the power of suggestion along with the subjec-expantacy effect, the patient may have their symptoms altered or eliminated due to the patient’s beliefs and expectations.
Everyone wins, and the health care provider ‘pleases’ the patient.
Dan Abshear
I got so frustrated this past spring when, for the first time, I spent a large amount of time in a private practitioner’s office. Good lord, the amount of unnecessary medicine he would give out! I was shocked! Appalled! And then I realized the truth you mentioned: to be a good businessperson, you have to keep your customers happy. And sometimes that is at odds with what your medical training would have you do. I’m still uncomfortable with it, not sure how I’m going to handle it, kind of happy I have all of residency to keep trying to figure it out.
And tomorrow, the tables will be turned: I am bringing my cat into the vet, because she has some goopy eye discharge. A virus, I’m sure; not even conjunctivitis. But she’s a cat, and I may be 5 months from my M.D. but maybe, just MAYBE there’s something I don’t know about cats and colds, so off to the vet we go. I’m already gearing myself up for, “It’s a virus, there’s nothing to do for it.” It’s still going to suck, I know.
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