Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Friday, September 08, 2006

Just Drag Me Off to the Tar Pit

It's raining and dreary and miserable. My foot hurts (plantar fasciitis.) My head hurts; I've just taken two tylenol. And people are being really stupid today.

I go around and around and around with a guy who wants an antibiotic. I tell him it won't help because he has a virus. He says, "So you don't know what's wrong with me."
me: Yes I do; it's a virus.
Him: Then why can't you give me something for it?
me: Because it won't help.
Him: Oh, ok. But how about an antibiotic?

Then there's the lady with a TSH of 1.5 on 0.1 of Synthroid for 10 years, but has swollen feet, fatigue, dry skin, a pain under her ribs, and about six other general symptoms. How long has she had these problems? "A while." A week? A month? Since the Carter administration? "Oh, it's been quite a while." Extracting the history, one precious nugget of information at a time, wheedling, cajoling, repeating and re-phrasing every step of the way.

Another lady comes in, talking continuously, telling me about her terrible sinus infection for which she needs Biaxin. Nothing else will do. Just give her some of that Biaxin, please. I don't really need to take her temperature (98.5) or her blood pressure (168/96) or examine her (gorgeous pearly TMs, throat perfect; pinkest, clearest nose I've seen all day; bang on her cheeks with a sledgehammer and she's fine; never even stops talking.) She just needs that Biaxin. Ten minutes of careful explanations about bacteria, viruses, upper respiratory infections, antibiotic resistance -- not to mention side effects, though of course I do -- and she refuses to be swayed. Not only that; she literally won't leave without it. I strike a bargain: three days of Biaxin AND a blood pressure pill, and she has to promise to come back in a month so I can see how she's doing. She thanks me profusely on her way out. I won't see her for a year. I know this because every word of this visit is identical to her last visit -- a year ago. (And my office manager has to explain to her why there's yet another $110 Medicare deductible she has to pay.)

Next there's the 11 year-old girl who had a cold last week. She's fine now, but her dad wants me to "check her out." While there, he mentions a spot on his leg that was there a few months ago. It's gone now, but he wants to know what it was.

And finally there's an older gentleman whose blood pressure was decently controlled on moderate doses of once-daily generic meds. He said he wasn't feeling quite right, so he stopped taking them and switched to something over the counter called "Blood Pressure X". He's not sure what's in it (he forgot to bring in the bottle) and it's kind of expensive, so instead of taking it three times a day he's only taking it twice. But he feels great. Just great! His BP is 190/100, but he feels great. Just an illustration of the Second Law of the Dinosaur: It is impossible to make an asymptomatic patient feel better.


At Sat Sep 09, 06:42:00 PM, Blogger MedStudentGod (MSG) said...

Just wanted to say thank you for trying assiduously to control antibiotic resistance. I hate seeing Abx Rx when the patient has no symptoms other than viral in nature and the doctor just doesn't want to take the time to explain things out.

At Sun Sep 10, 09:16:00 AM, Blogger #1 Dinosaur said...

You'd be surprised how insistent some patients can be, though. More times than you'd imagine, they flat out refuse to accept all the logic/persuasion/education that can possibly be mustered. One strategy is a non-antibiotic prescription if they're only intent on some kind of prescription. Another is a very brief course of something as benign as you can think of; 1-3 days, if you can get away with it. Lots of docs use Zithromax like this, though I try not to.

At Sun Sep 10, 09:20:00 PM, Blogger Big Lebowski Store said...

I cave in on the ABX battle sometimes too. Depends on the kind of day I'm having.


At Mon Sep 11, 03:10:00 AM, Blogger The Tundra PA said...

I am mostly a wall when it comes to antibiotics. Three days of symptoms? Forget it! A week? Forget it! You don't impress me until it's been at least a month, and if you don't have a documented fever, even then I'll talk to you about your chronic nasal congestion. Up here in Alaska, the complaint is "I've got sinus" So I use that language and say "Yeah, but it's a viral sinus!" They usually sigh and shrug. I use a lot of nasal steroids, NSAIDs, decongestants, warm packs to the sinus areas, and stern admonition to drink 2 liters of water daily. Of course, I also have the luxury that ours is the only game in town; they have no where else to go. And all that said, on rare occasions, I cave too. Some patients are more brick than I am.


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