Be Careful What You Ask For

“Could you come and give me some penicillin?”

Uh oh.  

The guest had a sore throat. He was fifty years-old. The only throat infection that antibiotics cure is strep, largely a disease of children and adolescents. Strep in a fifty year-old is so rare that I’ve never seen a case.

Doctors who prescribe unnecessary antibiotics claim that patients “demand” them. In fact, after I’ve seen these patients, ninety percent are perfectly happy with good medical care. About ten percent seem puzzled but remember their manners. Only a tiny minority give me a hard time.

But a tiny minority of a minority does not equal zero. Over thirty years, plenty of patients have lost their temper or (in the case of women) burst into tears. While not as mortifying as being sued for malpractice, it’s in the ballpark.

Unlike doctors in an office, I have the advantage of a phone conversation before seeing the patient. If a guest hints that he requires an antibiotic, I discuss his symptoms, suggest that antibiotics might or might not work, and try to gauge the likelihood that he won’t take no for an answer.

In this case, the guest seemed particularly assertive. I didn’t want to take the risk, so I referred him to a local walk-in clinic where he’ll probably get his penicillin.

Turning Bad News Into Good

A glum eleven year-old sat on the bed. His glum parents and two glum adolescents sat nearby. The eleven year-old had developed a sore throat, casting a pall over their vacation. They hoped I would make it go away.

Doctors love making things go away, and this would happen if the child had strep, the only throat infection (diphtheria aside) that medical science can cure.

Parents assume that a child with pus-covered tonsils has strep, but many viruses do this. Researchers have determined that a doctor can diagnose strep by observing four signs.  (1) pus-covered tonsils, (2) swollen neck glands, (3) fever, and (4) absence of cough. Since it’s strictly a throat infection, other respiratory symptoms such as cough or congestion make strep unlikely.

This patient had zero out of four. His throat and neck glands were normal; he had no fever; he was coughing.

Working hard to turn this into good news, I explained that the child had an ordinary virus. He would feel under the weather for a few days before getting better. I handed over some remedies, assuring them that these would help. Staying in bed wasn’t necessary. They should try to enjoy themselves.

When the father politely asked if something might speed things along, I explained why it wouldn’t. Never forgetting their manners, the parents expressed gratitude. I left them my cell phone number and urged them to phone if any problem developed. 

We parted on good terms, but I could sense their disappointment. No matter what the doctor said, everyone knows that sick children must rest. So they would wait.  

The Free Market Strikes Again!

I spend less than $1,000 a year for supplies, so giving them out gratis is no sacrifice. Two or three times a year, I place an order at a pharmaceutical web site. It’s easy, but sometimes I get a jolt.  

I hand out doxycycline, an old antibiotic and the recommended treatment for the most common pneumonia and the most common sexually transmitted disease. In 2012 I paid $50 for a bottle of five hundred. That’s twenty-five treatments which works out to $2.00 for each. When I ran low in 2014 I decided to reorder. Checking the web revealed that five hundred seemed to cost $1,655. That couldn’t be right, so I looked around, but it wasn’t a typo. So I ordered azithromycin, effective and about $4.00 per treatment.

This happens regularly. Remember penicillin? You may think it’s obsolete, but it remains a superb antibiotic and the best treatment for common infections from strep throat to syphilis. Twenty years ago it was as cheap as aspirin. I could buy a thousand for $30. Now the price is $130 and rising.

Here’s what happens. As a drug gets older and older, it gets cheaper and cheaper. But doctors like newer drugs. Everyone (you included) believes they are immune to advertising, but you’re not, and doctors are no different.

It’s a good rule that any drug in an ad is wildly expensive and not superior. Look at the ad: if it doesn’t say the drug is the best, it isn’t. A few years ago Avelox or Levoquin would cure your pneumonia as well as doxycycline at forty times the cost. Doxycycline at $1655 a bottle still costs less but not by as much.

As doctors incline toward a new drug, they prescribe the older one less. Pharmacies buy less. Pharmaceutical companies stop making it. Eventually the remaining companies notice the absence of competition, and the free market works its magic.   

Good Doctors Do It

“I’m coughing my head off. My head is plugged. I have a fever. I’m on vacation, and I need something.”

I’ve seen over 4,000 guests with respiratory infections. To the average hotel doctor, this is an easy visit. He arrives, performs the traditional exam, prescribes the traditional antibiotic, and accepts his fee and the guest’s thanks. What’s not to like?

That the antibiotic is unnecessary doesn’t bother the doctor, but it would bother me. Despite my colleagues’ insistence that patients demand an antibiotic, most of mine don’t. A small minority appear disappointed when I don’t prescribe one, and a tiny number make it painfully clear that I’ve missed the boat.

For decades, solemn editorials in medical journals have urged us to stop prescribing useless antibiotics, warning that they’re poisoning the environment, producing nasty, drug-resistant germs that are already killing thousands. 

Despite this, giving antibiotics for viral respiratory infections remains almost universal. Almost every doctor whose prescribing habits I know – admittedly a limited sample – does it. None believe they help. All tell me that patients expect them.

“I don’t want an antibiotic if I don’t need it,” patients often tell me. “But how do I know?”

“You don’t, but bacterial respiratory infections are rare in healthy people.”

“What if it’s bronchitis? I get that a lot.”

“Antibiotics don’t help bronchitis.”

“That’s what my doctor gives me. Are implying he’s incompetent?”

“No. Prescribing unnecessary antibiotics is so common that one could call it the standard of practice – meaning competent doctors do it.”

Isn't Science Wonderful - Continued

As I wrote last time, doctors treat strep throat with an antibiotic. Does it work?

That seems a no-brainer because antibiotics definitely kill strep bacteria. But the answer turns out to be….maybe. In scientific studies, giving antibiotics to patients with strep throat is not dramatically effective. Some doctors suspect they don’t work. This contrasts vividly with treating strep infections in other areas such as the skin where it’s often obviously lifesaving.

“Wait a minute!!” assert experts including my professors in medical school. It’s true that strep throat goes away in three to five days even if not treated, but doctors must treat in order to prevent rheumatic fever, a disease that can produce devastating heart disease. Scientists don’t understand why, but a small percentage of strep victims go on to develop rheumatic fever. Antibiotics lower the risk.

Are they right? Again science delivers the answer: maybe. Evidence for preventing rheumatic fever in America comes from a study conducted sixty-five years ago when rheumatic fever was common. It’s rare now. I’ve never seen a case. Everyone agrees it wasn’t a terrific study.

Some doctors believe that rheumatic fever is so rare in the US that giving an antibiotic is more likely to cause harm (yes, antibiotics can cause harm) than benefit.

While it’s fun to make controversial statements in this blog, with patients I stick to the standard of practice. This means I sometimes give treatments whose scientific basis is weak. If you prefer therapy that’s guaranteed, you must stop seeing scientific practitioners like me and seek out alternative or complementary healers. Google “alternative medicine.”  You’ll notice that their treatments always work.

Isn't Science Wonderful!

“He has pus on his tonsils, so it’s probably strep,” said a guest, calling about her teenage son. I hear this phrase regularly. It causes me some stress because I know that later I might find myself delivering a why-antibiotics-won’t-help explanation to a sullen audience. 

One popular (i.e. wrong) medical belief is that pus on tonsils is a sign of strep throat. In fact, this is true only about ten percent of the time. Viral infections produce identical exudates.

Arriving in the room, I discovered that the boy had pus on his tonsils but also a fever, swollen, painful glands in his neck, and no cough. Good scientific studies show that the presence of these four signs: pus on tonsils, fever, swollen neck glands, and NO cough raise the odds of strep to over fifty percent, so prescribing an antibiotic is appropriate. I prescribed an antibiotic. The family made it clear they were in the presence of a doctor who knew his business.

Isn’t science wonderful? It is. But it’s wonderful in ways that are often not satisfying. More in my next post.

Three More Great Sins of the Medical Profession

 4. Doctors order too many tests and prescribe too many drugs.

Correct. We love tests, but so you. Most patients with a painful injury assume they need an X-ray, but they don’t.  Those with a high fever (“flu”), sore throat (“tonsillitis”), cough (“bronchitis”), or stuffiness (“sinus infection”) assume they need an antibiotic, but they usually don’t. Doctors hate to disappoint patients, so they lean over backwards to “do” something like order a test or prescribe.

 5. Doctors order too few tests and prescribe too few drugs.

We can’t win.  Some clinic directors and insurance plans restrict the tests and drugs we can order. This infuriates doctors as well as patients, but the sad fact is that experts set up guidelines to discourage useless tests and wrong or unnecessarily expensive drugs. They sometimes work.

6.  Doctors ignore alternative and folk medical practices.

I notice enthusiasts treat folk medicine with respect, but no one advocates folk dentistry...  It turns out that many alternative practices work but less dramatically than advocates claim.  Acupuncture definitely relieves pain. Unfortunately, its action is unpredictable and not always complete. Despite vivid reports, Chinese surgeons rarely use it for anesthesia. Chiropractic manipulation relieves some backaches for a limited time.

The Same Thing

“My wife had strep last week. Now I have the same thing.”

I receive one “same thing” phone call per week. Naturally, guests hope I’ll agree.

This is not the traditional warning against self-diagnosis, because the guests are usually right. If necessary, I’m happy to phone a pharmacy with the appropriate prescription.

Everyone with an upset stomach suspects food poisoning. If your dinner companions are also sick, it’s a possibility, but if you’re the only one, you probably suffer the common stomach virus which makes you miserable for a day or two. Most guests with vomiting or diarrhea don’t want to travel to a pharmacy. For those willing, I sometimes provide symptomatic remedies. Sadly, in the US no common intestinal infection is curable with antibiotics.

Other illnesses are tricky, but a young woman who’s had several bladder infections knows when she has another. This is perhaps the only infection where it’s acceptable to prescribe an antibiotic over the phone.

Inevitably, respiratory infections produce the most “same thing” calls. These are stressful calls because many guests proceed to tell me what they need, and they’re wrong.

As I repeat with boring regularity, many doctors, perhaps a majority, prescribe useless antibiotics for viral respiratory infections. That includes yours. That doesn’t mean you have a bad doctor; prescribing useless antibiotics is so common that competent doctors do it.

When, after hearing the symptoms, I explain that this doesn’t describe anything that antibiotics cure, guests assume there will be no antibiotic unless I make a housecall and collect a fat fee. In fact, I do everything possible to avoid a housecall because not giving an antibiotic guarantees an unhappy patient. If I yield to his entreaties, I hate myself.

I Don't Like Coughing

“I’ve been hacking up stuff for a couple days, and it’s turning green.”

“It sounds like the virus that’s going around,” I said. “It’ll last three or four or five or six more days. Medical science doesn’t do anything dramatic.”

“At home I’d tough it out. But I have meetings all week, and I need something to knock it out. When can you get here?”

If you read this blog you know my heart sinks when I hear “I need something to knock it out….” It guarantees an unsatisfying visit. Either the guest will feel resentful if he doesn’t get an antibiotic, or I’ll give an antibiotic (if it seems like he’ll blow his top, and sometimes I’m too slow), and I’ll leave hating myself.

Now, readers, you’re probably thinking: “Yes, isn’t it disgraceful that doctors give useless antibiotics so often that patients expect them. But sometimes you need an antibiotic. How can you tell?...”  The answer is so surprising that you and your doctor may not believe it. In an otherwise healthy person (infants and the elderly excepted) the only common disease with a cough that antibiotics cure is pneumonia. Everything else is a virus. ..in my opinion (my lawyer insisted I add that).

A Stressful Life

I’m running low on ondansetron, the best antinausea pill.

Unfortunately, I’m not low on many other supplies. I buy through an internet pharmaceutical company that charges a fat handling fee for orders under $200. Eight bottles of ondansetron, 240 pills, will cost $25. I could use more tongue depressors, but 500 at $5.24 is not much help. I dispense large quantities of  cough medicine and lidocaine gargle for sore throats, but those cost only a few dollars a piece. My bottle of 500 Amoxicillin capsules ($28) is half empty; stocking up would help but medicines have expiration dates, so one must be careful.

A few years ago, after thirty years of use, my blood pressure cuff broke, but I had a spare. Should I buy another? Will I be practicing when I’m 108?....

One of my boasts is that, unlike other hotel doctors, the fee I announce is the fee I collect. I don’t charge extra for anything. It turns out that pills, injectables, and supplies for common ailments are so cheap that I struggle to assemble an order exceeding $200. Life is tough.

The Superiority of American Medicine

Patriots boast that American medicine is the best in the world. My view is more nuanced, but let me take their point of view. You’ll be amazed at the dumb things foreign doctors do!

They don’t give antibiotics for ear infections! 

If a child suffers a painful ear infection, the doctor prescribes an antibiotic. In many European countries, doctors give medicines for pain and fever but no antibiotic. If you’re wondering what happens to these poor European children, the answer is: they get better. Even in America, many experts believe that antibiotics don’t work for ear infections. It will take a lot more than expert opinion to persuade American doctors to avoid antibiotics in ear infections. American doctors love antibiotics as much as American patients.

They don’t care for hysterectomies!

Many women develop lumpy growths on the uterus called fibroids which may cause pain and irregular menstrual bleeding. A gynecologist can cure this by removing the uterus. It’s the second most common operation American women undergo (after caesarians; America leads the world in both).

The French have the odd idea the world would be a better place if there were more Frenchmen, so French doctors don’t sterilize women if they can avoid it. Mostly, they perform an operation that cuts off the fibroids but leaves the uterus intact. The surgery is more complicated and takes longer than a simple hysterectomy. American gynecologists could do the same, but they don’t, and they rarely discuss it with patients because they know American women aren’t interested.

They don’t try to cure every patient.

American doctors order more tests and prescribe more antibiotics, chemotherapy, and other powerful drugs than foreign doctors. They also perform far more surgery. These extras don’t necessarily cure. Sometimes they make patients sicker, but the important thing is that we’re doing something. American like aggressive doctors.

Foreign doctors spend a great deal of time making patients feel better – for example by ordering physical therapy (massage, exercise, heat, baths). American doctors prescribe physical therapy to speed recovery after surgery or injuries. European doctors prescribe it after childbirth and for migraines, irritable bowels, arthritis, fatigue, depression – dozens of problems.

European doctors actually send patients to health spas for baths, massage, etc., and health insurance pays for it! If you believe this is a waste of money, American doctors agree. Patients may feel better after a spa treatment, they explain, but it’s psychosomatic (in other words, if someone feels better -- but it’s only psychosomatic -- that’s not good).

Drugs are Cheap

A least they’re cheap for common problems your doctor encounters in the office which are the same as I see in hotels. Here are examples from my favorite internet supplier as of 2018.

Some drugs cost almost nothing, less than a penny a pill. A thousand hydrochlorothiazide (the most popular diuretic and blood pressure pill) costs $6.34. Valium 5mg is over a penny: $12.20 for a thousand. I can buy a thousand Benadryl, an antihistamine, for $11.28.

An excellent prescription pain remedy, Tramadol, costs $1.69 for a hundred; $15.11 for a thousand.

Long ago states began requiring doctors to file a report each time they hand out narcotic pain pills, so I gave it up. Despite the impressive street price of the most popular drug of abuse, Oxycontin, a bottle of a hundred costs $8.77.

Cortisone cream: $0.99 per tube.

Antibiotic eye drops for conjunctivitis: $2.25

Antibiotic ear drops for swimmer’s ear used to be about twice as expensive, but they’ve shot up to over $20. Luckily, it’s considered OK to use antibiotic eye drops for ear infections, so that’s what I do. 

The three day Bactrim antibiotic treatment for urinary infection (six tablets) is about 35 cents. A hundred costs $5.40.

Ten day treatment for strep throat, twenty amoxicillin 500mg: $1.30.

Ten day treatment for pneumonia, twenty doxycycline, is about $1.70.

A big attraction of injections is that a doctor can charge for them. If he writes a prescription, the pharmacy gets the money. Don’t assume common injectables are expensive. To begin, a disposable syringe costs twenty cents.

For allergies and itching, a vial containing thirty doses of injectable cortisone (Decadron 4mg) costs $11.06. That’s about 40 cents a shot.

For pain, a shot of morphine costs about $2.30 if the doctor buys single-dose vials, but that’s an expensive form. Multiple dose vials cost less than half as much per dose if he or she can find them.

Within the past five years, ondansetron has replaced Compazine and Phenergan as the leading treatment of vomiting. One shot costs 15 cents. A vial of ten doses is $1.54

Plain old Valium injectable has skyrocketed. This happens when some companies stop making a drug and the others realize they have little competition. Five years ago I paid $5.04 for a vial of ten shots; it’s now $51.00.

Something to Knock It Out, Part 1

An FBI agent was suffering a bad cough. He informed me that this happened every year, and his doctor knocked it out with an antibiotic.

My philosophy on prescribing a useless antibiotic is that I don’t unless the patient threatens to make a scene.

This FBI man seemed out of an old movie: dressed in suit and tie, composed and unemotional. He made eye contact, listened intently, answered succinctly, submitted to my exam, and did not interrupt as I spoke.

I explained that he had a virus that was incurable but would go away in a few days. As I delivered advice and handed over cough medicine and tablets for his fever, I could see him absorbing the news that I wasn’t prescribing the antibiotic.

He was not a person to quarrel with a figure of authority. He said nothing, but I could sense his inner turmoil….

Deciding the ice was getting very thin, I added: “You said your doctor gives you an antibiotic. This illness doesn’t require one, but I’ll write a prescription in case you want to call him and discuss it.”

He accepted it without comment. He also handed back the medical form that I had asked him to sign. In the hall, glancing at the paper, I saw that he had covered it with obscenities.

Things Patients Tell Us That Are Almost Never True, Part 1

“I need something stronger….”

It’s common sense that if a drug isn’t working, the doctor should prescribe a better drug. In fact, the usual reason a drug doesn’t work is that you have a problem a drug won’t solve. Mostly, when hotel guests make this statement, they’re taking an antibiotic for their bronchitis. A week or two has passed, and they’re still coughing. I have to explain that these illnesses last a week or two no matter what medicine you take. Similarly most “pinkeye” doesn’t respond to drops, and doctors still debate whether antibiotics help middle ear infections.     

“I’m allergic to….”

As I wrote on March 23, almost everyone who believes they’re allergic is wrong. Another large group claims that they’re allergic to a drug that upsets their stomach. In fact, this is not an allergy – meaning that it’s never fatal. This is important because you should never take a drug to which you are (genuinely) allergic. If a drug upsets your stomach but an alternative is more expensive or less effective, you might choose to feel sick for a while.