Ah-CHOO!
At the family practice where I work, my preceptor books patients every 15 minutes with a few last-minute emergencies squeezed in. I, on the other hand, see patients every half hour to allow for the fact that I'm still learning. Not to mention the fact that I'm still sneaking out of the examining room to look up drug dosages, fumbling though the sample closet for ages to find what I want and occasionally waiting for my preceptor to finish with his patient to confirm my treatment plan with him. So I take longer.
All in all, I'm seeing about 12 patients a day. Par for the course, according to my impromptu discussions with fellow residents during our academic half days. Out of those 12, at least 2-3 are coming in with a cold. Every single day.
Why on earth would anyone see their family doctor for a cold? I really don't get it. You have a stuffy nose, a cough and you generally feel like crap. And it's been going on for three days. What on earth do you think that seeing your family doctor is going to do? If there was a magic pill that cured the common cold, don't you think you would have heard about it by now?
So now I have a "spiel"-- I explain all the things that I can rule out based on the physical exam. No swollen tonsils with white crud on them? Not strep throat. Ears look fine? No ear infection. Lungs sound clear? Not a pneumonia. Then I go on to tell them that since there is nothing going on that we can treat with antibiotics, they just have to let the virus run its course. Usually people are okay with that, and if they seem to want more I'll perscribe a cough suppressant with slightly more codeine in it then you can get over the counter. Or a swish-and-spit mouthwash that is only slightly better than placebo at helping a sore throat. But it makes people happy.
My preceptor, after 10 years as a family physician, is slightly more accomodating. If people honestly think they need an antibiotic, he'll occasionally give it to them even if it goes against evidence-based medicine. I can understand the urge to keep your patients happy, but I also don't think that patients should dictate their own treatment. It may sound paternalistic of me, but that's why we train for so damn many years... so that we have to knowledge and the tools to make treatment decisions for them. Otherwise, ALL drugs would be available over the counter. My preceptor good-naturedly refers to me as The Antibiotic Nazi. At least, I'm hoping it's good natured.
But back to the point. Why do people come in with a cold? Do they honestly think it's something worse? Even if everyone in their family has a cold, they've had a cold in the past and there's nothing new and interesting about this particular bug? I can understand in the case of a child, because parents always err on the side of caution when a kid has a sniffle. And kids are much more likely to have strep throat or ear infections. But when a healthy 35-year-old comes into the office with a two day history of stuffy nose, cough and fatigue, I have to be honest and say that I'm rolling my eyes in my head...
Sigh. But that's what a family doc is there for, right?
Labels: family medicine
posted by Couz at 6:52 PM
14 Comments:
Interesting point of view and quite timely as I am suffering from one hell of a cold .. any suggestions? ha-ha.
The only reason (as a healthy 32 year old) I would ever see a Dr. for a cold is when I am threatened with formal discipline if I don't bring a sick note in following a sick day, especially annoying when my regular Dr. is not available and I has to pay for said note!
12:06 AM
It's even more amazing when they come in to the ER at 3AM and wait 2 hours to be seen and have to pay more for the service. And they are that much more irritated when they don't get a "definitive" treatment.
rolling the eyes indeed.
5:29 PM
I went into see mine today, as my right ear was really hurting (history of ear infections), and I've got a surgery scheduled for March 1st. Normally, I never take antibiotics if I can avoid it, don't even let the kids take them if I can avoid it, but this ear pain is something else.
So, yep, I have an ear infection but no strep (had it twice last year, but this one didn't feel like it). So, yep, I'm on an antibiotic and decongestant (can't take codeine at all, and many decongestants don't work on me).
I hear ya on the rolling eye thing, though. My hubby was doing to me all weekend.
6:04 PM
Good for you for sticking to your guns on your "antibiotic nazism". Giving out antibiotics when they are not needed is just ridiculus. It just gives to the antibiotic resistant bugs more of a chance.
Its really too bad that, legally, you docs cant just give out placebos in situations like these. The doc's happy because it gets the patient out the door without resorting to giving unneeded antibiotics, and the patients are happy because they feel like they have been treated, its a win win.
9:36 PM
i think there could be a couple reasons why people show up wanting their "colds" checked out. First one is alot of people are living paycheck to paycheck, and they cant afford to get 'really' sick and miss much work. (not everyone has paid days off for sickness)..2nd reason, with all the hoopla about the bird flu, lyme disease, and numerous other serious health concerns that can begin with 'flu like' symptoms, many people have become paranoid..
8:32 PM
I respect a dr who's careful handing out antibiotics. I like that my pediatrician is that kind of dr. It annoys me to no end that my sister will e-mail her pediatrician when her kids are sick, asking for an antibiotic, and he gives it to her. I think it's irresponsible of him.
2:23 AM
Oh look, one more reason I could never be a doctor. I'm assuming "screw off, don't be such a baby, you've got a cold you loser" isn't appropriate?
4:18 PM
hey there Antibiotic Nazi,
It's cold-season and it's nice to hear that there's at least one doc out there that will only write a rxn when it's needed not when it's wanted. I think that your patients will understand that you are looking out for their best interests by NOT giving them drugs that they don't need. I can't tell you how many times i've switched docs b/c I felt that all they want to do is write a rxn and send you on your way.
Great Job!!
cheers
mel
4:27 PM
I wonder the same thing nine times a night in the Emergency Room. For God's sake we've all had low grade fevers runny nose and sore throat and none of us have ever died from it. It's a natural consequence of medical care being highly subsidized and thus devalued. Maddening.
9:56 PM
Well, you kinda answered your own question.
As long as you keep giving people with colds fancy mouth washes and cough syrup with codeine they are gonna keep coming back.
Prescribing these products that are basically no better for their cold than what they could grab by themselves merely validates their suspicions that they have something "worse" than the common cold. Or, something that is "treatable".
Then, they tell their friends about the cough medicine, and the friend goes to her doctor and the myth that when one has a cold for more than a couple days they should see a family doctor keeps perpetuating.
Stop prescribing crap they don't need just so they leave with a smile.
p.s. love your blog!
12:42 AM
You know I used to get pissed a lot at people that would show up in the ER for colds, minor symptoms etc.
But I realized that people who haven't been trained in the medical field generally don't have any ability to discrinate harmless from harmful. Which I guess is not really their fault. I think most people with a cold think that's all they have but there is a little part of their minds that wonders if it could be something else. Mono, strep etc. That uncertainty brings them in. Some people are just looking for reassurance that it's not something ominous. I think there should be some sort of self screening before you see the doctor but it's not hard and fast. Like me, I'm sure you've seen very subtle presentations of sepsis, meningitis. If these people didn't notice something slightly off and waited to show up the outcome might be different, (thank God he/ she self screened). On the other side of the spectrum, I've also seen people who didn't want to bother the doctor and showed up with frank peritonitis thinking it's just a bad gas (Why the fuck did he self screen).
As you point out there are also a lot of people that come in demanding shit like antibiotics, CT scans. They think it's a burger king. your way right away. I hate that suff.
You bring up good points and I've had this debate with a lot of people. Good luck with everything.
Ram
10:07 AM
Thanks, this is one of the many entries I really enjoyed reading in your blog!
I added you to my links. I hope you don't mind.
3:04 PM
You keep being an Antibiotic Nazi -
it will be MDs like you that keep the number of resistant organisms to a minimum.
Another thing is that perhaps they could call and have a doctor call them back, sort of a telephone triage thing? Spend 5 minutes on a call, ask the right questions and see if you can cover the problem over the phone with reassurance, always letting them know they can call back if they get worse.
3:03 AM
I absolutely match with your post.
11:25 AM
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