Sunday, January 2, 2011

The Christmas Rush

The last week of the year is my busiest. Competitors with whom I’m on speaking terms deny this, and I’ve long stopped theorizing why this is so. But calls begin pouring in at Christmas.

His teenage son had a terrible cough and sore throat, explained a caller from the Shangri-La, an upscale beach hotel. Maybe he needed an antibiotic.

The son had the usual virus. The father and mother were unfailingly polite as I delivered my explanation, handed over a bottle of cough medicine, and took my leave, but it was clear they would have been preferred an antibiotic. I urge patients to resist suggesting a treatment to a new doctor. If it’s unnecessary, the doctor may prescribe it anyway to make you happy. If he doesn’t prescribe it, and your thank-you at the end isn’t heartfelt (we are supersensitive to gratitude) he will feel he disappointed you.

Two hours later I drove to another Santa Monica hotel to see another teenager, this one with a sore throat. The father had seen white spots on her tonsils. Laymen believe “white spots on tonsils” is a sign of “strep,” but ordinary viral infections can make tonsils look bad. Some day I’ll write an article on ominous-signs-that-usually-aren’t (white spots on tonsils, cough with green mucus, yellow mucus, thick mucus, no mucus, fever more than … degrees, fever more than … days, green diarrhea, yellow diarrhea, funny smelling diarrhea, funny smelling urine….). Hearing this, patients invariably ask “then how do I know I’m sick?” My answer is: “because you’re sick.” Sickness makes you sick. If you don’t feel very sick, you’re probably not sick. Decide to see a doctor because you feel bad, not because a symptom.

It turned out that I treated her for strep. Good studies reveal that exudates on tonsils plus three other symptoms (fever, swollen neck glands, absence of cough) make the chance for strep fairly likely, and she had all four, so I handed over ten days of penicillin and received everyone’s heartfelt gratitude. Another pearl: if you’re not allergic to penicillin, and a doctor prescribes a different antibiotic for your sore throat (amoxicillin is acceptable), that’s excellent evidence you’re getting a placebo. After 70 years, penicillin is still the treatment of choice for strep; newer antibiotics work as well, but none work better, and all cost far more.

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