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.

Monday, March 03, 2008

Expectations

I got a call yesterday from a 40-something guy with a bad cold, asking if I could "call something in." I asked about his symptoms and, hearing nothing alarming, explained that his best plan of action would be to rest and drink plenty of fluids, allowing the illness to run its course. "But can't you call something in?" "Not without a visit," which is my standard rejoinder. I explain that I wouldn't know what to prescribe without an examination. I offered an appointment; he said he'd call back.

About twenty minutes later I got a call from his irate father (not my patient.) The man is sick! He needs medicine! Why won't I call something in for him? Once again I begin to explain the natural history of viral infections ("colds", however bad) and the necessity for an exam before issuing any prescriptions. "Well, my doctor doesn't have any trouble calling things in. You tell them your symptoms and they call something in. Why can't you do that?"

I'd love to say, "Because I'm practicing medicine the right way and your doctor is either too lazy or doesn't care," but remember, we're not supposed to bad-mouth each other. I have no doubt that other offices have come to the conclusion that it's too much effort to spend the time explaining things the way I've just tried to (twice) so they just "call something in;" most likely a prescription version of an OTC medication -- that's recently been shown not to work better than a placebo anyway!

What's the harm, you may be tempted to ask. The harm is to me and my reputation! Now that you've led my patient's family to believe that "calling something in" is acceptable and accepted medical practice, I'm the one stuck with the brunt of their anger just because I'm doing things right. I have no problem standing my ground, but now there's a dissatisfied, angry family bad-mouthing ME everywhere they turn. I resent the way your laziness drags down MY reputation!

I have similar problems when ER docs routinely prescribe antibiotics for bronchitis and otitis media. Hello! Don't you guys read the same evidence we do? Antibiotics in lower respiratory infections don't lessen symptom severity or duration in the absence of pneumonia, and most OMs have been shown to be viral and are most appropriately treated with analgesia for 24-48 hours, reserving antibiotics for persistent fever (hint: persistent > 1 day), vomiting and refractory pain (hint: refractory > 1day.) Or could it be that although you're aces with trauma and really sick people, you suck at dealing with the not-as-sick and just follow the path of least resistance to get them discharged? So what, you say. You're too busy to be bothered trying to explain all that. The problem is that the next time they get bronchitis, they expect antibiotics because "that's what they gave me in the ER." Again, I'm the one who looks stupid for doing it right.

So the next time you're faced with a patient's unreasonable demands and figure there's "no harm" in just "calling something in," recognize that you're managing the patient's expectations as well as their medical condition. And you're doing a shitty job of it.

22 Comments:

At Sun Mar 02, 08:13:00 PM, Blogger CrankyProf said...

It's a shame that you can't call in an ass-kicking for all involved...

 
At Sun Mar 02, 09:18:00 PM, Blogger TBTAM said...

I love it when you rant....

 
At Sun Mar 02, 10:30:00 PM, Anonymous Anonymous said...

Hey, dino. It goes both ways. I've pissed off many a patient in urgent care because I won't give them a Z-pack for their 3 days of runny nose and cough that "still isn't getting better". Of course, all of their primary doctors "always just call in an antibiotic".

Part of it is patients lying. Part is that there just are irresponsible doctors out there--in ERs, urgent cares, and primary care alike--who just take 30 seconds to write a script instead of 3 min. to have the virus/antibiotic/resistance discussion.

 
At Sun Mar 02, 11:36:00 PM, Anonymous Anonymous said...

who just take 30 seconds to write a script instead of 3 min. to have the virus/antibiotic/resistance discussion.

Just a thought from a layperson. Maybe instead of virus/antibiotic/resistance discussion you should have virus/antibiotic/antibiotics side effects discussion. IMHO for most people "this will not help with your cold but may cause kidney damage" (hearing loss, etc. - you can even list the scariest side effects from a couple of popular antibiotics) is more likely to convince someone he/she doesn't need or want antibiotics than any resistance discussion. It is also a whole lot quicker than discussing resistance. I also think you shouldn't entirely blame patients - for years the doctors in the US were overprescribing antibiotics and patients got used to it. If one grew up believing that one should take antibiotics for everything, it's difficult to change one's mind.

I grew up in a communist country with generally bad free medical care plagued by shortages of everything, but our doctors never failed to tell us from the cradle how many side effects antibiotics have and how they should be only taken when absolutely needed. Maybe it was partially caused by shortages, I don't know, but the only time I had antibiotics before I came to the US was when I had a two-sided pneumonia. Sure, I had my share of colds and other minor things. But I was never prescribed antibiotics for that. I think in some cases they underprescribed, but they just didn't have enough antibiotics for all the cases that might need them so they reserved antibiotics for when there was real need.

Far from demanding antibiotics, we grew up being wary of them. I was really surprised when I came to the US at how quickly antibiotics were prescribed in the US. At first I thought the doctors knew better, but after the first one failed to do anything for my bronchitis, I asked doctor about it and he explained about viruses and bacteria. BTW -I did read a book about Ian Fleming and the discovery of pennicilin as a child, just hadn't learned about viruses until later.

At any rate, in my humble opinion the risk of immediate harm to oneself is a whole lot more convincing than the risk of a potential harm to oneself and to others.

 
At Mon Mar 03, 08:09:00 AM, Blogger rlbates said...

Love your post and Anonymous 11:36 comment. Take care. Hang tough.

 
At Mon Mar 03, 08:16:00 AM, Anonymous Anonymous said...

I feel your pain. I was on call over the weekend and was bitched out by a retired doc (not my patient)because I wouldn't meet him in my office at 10 PM, Saturday, or call anything in for his URI symptoms.

 
At Mon Mar 03, 09:35:00 AM, Blogger mark's tails said...

Dino,
I can't remember where I heard or read this but it can take up to 20 years before information such as 'standards of care' become commonly incorporated into medicine.

As a fellow-in-training I would often spend the extra 5 minutes explaining to a patient why Abx were not necessary. Once a patient hung up on me and called back asking to speak to the attending.

The next day the attending told me I was right, but prescribed the Abx anyway. ?!? So what message did that send to the patient then?

As rlbates said "hang tough", there are others out there doing the right thing.

 
At Mon Mar 03, 11:39:00 AM, Anonymous pelican said...

There's no drug in the world that will fix what's wrong with a 40 year old man who has his daddy call to yell at the big mean scary doctor ...

 
At Mon Mar 03, 07:07:00 PM, Anonymous Anonymous said...

Dino
As an ER Doc, i will confess that we do sometimes prescribe antibiotics to otitis media and bronchitis, and other things you roil against. If you haven't sensed it yet, there is a "but"...

In the ER, I am going to get this patient you have counseled, accompanied by his angry father. Already worked up by your compliance with medical standards, and further enraged by a 6 hour wait, the patient will abuse me, my nurses and just about everyone else in earshot with tales of your lineage, your romantic intentions towards your mother, and your sexual orientation in terms of species. Now normally I would tune this out and give the same speech as, you, with a certain satisfaction and glee.

But, alas, times are different now. Your patient is now my customer, and I must worship the twin gods of Customer Satisfaction and Press-Gainey. These are very unforgiving gods, and demand my prostrate prayers lest they smite my group contract by their holy anointed priest from the carpeted section of the hospital; his holiness the Hospital Administrator. After all, his holiness is the only one that can take the scriptures of Press-Gainey and interpret that I am indeed, unworthy as a physician and a human being.

So, rather than offend the gods Customer Satisfaction and Press Gainey, I acquiesce knowing in my heart it is wrong. But it is much simpler than having to justify my disobedience to his holiness in the carpeted section.

All I ask is that you remember us in the temple of medicine known as the ER as the words of you and your brethren "just to go to the ER" slide from your lips. (I know how that call ended). Remember that here in the temple, the standard laws of medicine are changed into something you might not be able to identify.

IglooDoc

 
At Mon Mar 03, 08:48:00 PM, Anonymous Nurse Practitioner said...

It sounds like you need to start sending these patients to the local minute clinic. I guarantee they will not be Rx'd Abx's for 2 days of sx's. They might not be happy but they will be treated appropriately.

 
At Mon Mar 03, 09:01:00 PM, Anonymous Anonymous said...

Aargh. One of these days I'm just going to snap and say "Listen to me, you stupid maroon. You have a cold. It will get better in 14 days if you treat it and in 2 weeks if you don't." And as for sending them to the minute "clinic" I don't jolly well think so. I've seen the handiwork of our local versions and am unimpressed.

 
At Mon Mar 03, 09:01:00 PM, Blogger #1 Dinosaur said...

NP: I'm not sending him anywhere. I offered him an appointment. He doesn't want to be seen; he "has to work."

IglooDoc: Let me see if I've got this straight: You do things you know are wrong because the hospital administrator and Press-Gainey are more important than practicing medicine. How can you look at yourself in the mirror and still call yourself a doctor?

Pelican: Hear, hear!

Anon 11:36: Great idea! I'll have to give that a try.

Mark: Mixed messages indeed! I say refer that attending to CrankyProf for a first-rate ass-kicking.

Cranky, TBTAM, RLBates: thanks for all the love.

 
At Mon Mar 03, 09:10:00 PM, Anonymous Anonymous said...

Yes frustrating. Also frustrating you want to dis the ER docs. We certainly don't have a corner on the market regarding indiscriminate use of antibiotics. Many of the patients I see in the ER are already on amoxacillin or a Z-pack when I see them for their cold, bronchitis, otitis, sinusitis, etc... and are not better a couple of days later. Then I have to explain the whole virus thing.

Or now they have diarrhea and I have to explain (in a very nice way) that their dumb ass doctor gave it to them and stop taking your antibiotic.

 
At Mon Mar 03, 09:53:00 PM, Blogger Femail doc said...

What's got me chuckling is the 40 year old fellow's FATHER calling. Gotta love that. The thought that I might call my children's doctors when they're 40 and I'm 70+ is horrifying.

I tell 'em about my previously well patient who got c diff colitis from a round of antibiotics (not rx'd by me) for bronchitis.

 
At Tue Mar 04, 02:43:00 AM, Anonymous Anonymous said...

Dino
Yes, I call myself a doctor. I also call myself a realist. If you wish to trash me for stating what happens in every ER and every FP/Internist office across the land, then fine. You have leave to do so. I assume you are without sin?
Until you lose your job to satisfaction surveys you cannot possibly judge. And it happens, believe me. And yes, hospital administrators force physicians to do things that are wrong, under the threat of cancelling contracts. So does Medicare, Medicaid, and state regulatory agencies under the guise of EMTALA and HIPPA and P4P.
Look at the Federally mandated ER pneumonia guidelines... antibiotics within 4 hours of arrival. Not examination or diagnosis time. Arrival time. We fall out of that criteria because of the wait to get back from the waiting room. So the hospital presses you to give antibiotics to patients that meet triage criteria... fever, rapid HR, decreased PO2. Whether they have pneumonia or not. The hospital does this because of repercussions from the Feds if they don't get into guidelines. Why not just get an Xray? Because the hospital is understaffed from decreased reimbursement, and there is a stream of sicker patients coming through the door tying up the single Xray tech that is also covering CT and MRI. And, of the two nurses for 15 beds in the ER, one is managing an ICU vent head bleed patient and the other is pushing meds on an acute MI, so more delays.

It does not mean I agree with the care these people mandate. I want to change it. But how can I when my colleagues do not "have my back"?

So, Dino, I admire that you can practice medicine the way it should be. And I am proud that someone in my profession stands up to tell patients they do not need antibiotics, or other unnecessary modalities of treatment. But I ask for your understanding that we all cannot be like you. Sometimes we ER Docs are forced to compromise on the little things like antibiotic prescriptions to angry trouble making patients serve the greater good.

igloodoc

 
At Tue Mar 04, 06:44:00 AM, Blogger #1 Dinosaur said...

IglooDoc: Apologies for the harshness. Of course I understand just how incredibly difficult that rock/hard place nook you're stuck in is. All I would ask is where does it stop?

What if some news organization makes a big stink (pardon pun) about C. diff, with a corresponding government mandate about "decreasing unnecessary antibiotic use"; say to the point where C. diff colitis becomes a "never" event. Then all those URI antibiotic prescriptions aren't so "little" anymore.

And I think it's a shame that your ER colleagues don't have your back. We as physicians need to stand up for the good of our patients, whose idea of "customer service" doesn't always mesh with quality medical care, and protect them from themselves.

Simple? Of course. Easy? No way. See the Tenth Law.

 
At Tue Mar 04, 12:23:00 PM, Anonymous Anonymous said...

Dino
I really did not take offense, because deep down I know you are right. We ERDocs know of the pressures throughout the system. I know you will have to double and triple book, shorten patient interaction time in favor of paperwork, just to maintain or slightly lose income when the medicare cuts hit. You will be forced, at some point, to consider dropping Medicare and lose patients you have throughout your practice. You will have to say to patients "just go to the ER" because you are overwhelmed. You will, like us, be forced to make decisions that do not help patients for the greater good ... so you can stay in business and help the patients you can.

I wonder how it got to be this way, though. Somehow I think we did this to ourselves. We just wanted to see patients, but not deal with the business of medicine. We let MBA's and politicians take over, and get increasingly more powerful. We argued amongst ourselves over this and that, empowering the medically illiterate to start influencing medical decisions. And if the duck-billed platypus is the beaver designed by a government committee, we now work in a duck-billed platypus of a health system.

You are right, tenth law applies.

igloodoc

 
At Tue Mar 04, 04:46:00 PM, Anonymous Anonymous said...

I think this came to a head several years ago with the introduction of the "Z-Pack." So easy, so convenient, doesn't even sound like an antibiotic but rather some mysterious cure-all drug. High volume practices all over town began prescribing these over the phone. Hell, you don't even need to give the pharmacist a dose or directions. Just a name, and "give him a Z-Pack, Refill one time." Easy as that. This has become the standard of care in my community. A very difficult nut to crack!

 
At Wed Mar 05, 05:08:00 PM, Blogger Amanda said...

I agree with the need to be seen in office (heck, I almost have a standing weekly appointment for one of my 4 children or myself- thank goodness we all go to the same family Dr.) I get sinusitis on an almost monthly basis, and I let it go for usually a week, until I simply can't function anymore- my head is congested, my ears throbbing, my throat is raw, my chest hurts when I cough and I have a fever, before I call the office for an appointment. I suppose it's possible that I may have a viral "cold" but if that's the case, why do I get better when treated with antibiotics? And, yes, I've had a CT to check for reasons why I am to prone to sinusitis. I've seen an ENT. I know and use proper hand washing to help prevent getting sick. A virus wouldn't respond to treatment for bacteria, correct? Considering my time is valuable too, is it too much to ask to not have to take 2 hours out of my day to see my doctor for 5 minutes, all to have him do the same thing as last time, and every time? He hands me a script for zithromax (as we have found other antibiotics not as effective- trial and error) and sends me on my way. I have to say as a patient, it is frustrating to be triple booked wait for a minimum of an hour to see my doctor for 5 minutes or less.
There are times for my children I have walked out of there without an abx script, and I believe the virus simply had to run its course. However, it is also as important to help manage their symptoms when over the counter measures have failed- which is why I go.
I'm not an MD, on the other hand, for chronic re-curring conditions, a simple phone call into the office really should suffice.

 
At Wed Mar 05, 05:45:00 PM, Anonymous Anonymous said...

A simple phone call to the office will not suffice because the doctor does not get paid for this service. You would not expect a prescription via a "simple phone call" to the Wal-Mart clinic, the urgent care center, or the ER. Why should you expect your doctor to provide this service gratis? Perhaps you should consider looking for a concierge or retainer practice where you would have already paid for this service through a monthly or yearly fee. At least with a doctor in this type of practice your expectations might be justified.

 
At Wed Mar 05, 06:46:00 PM, Blogger Manda said...

Could you address ear infections sometime? I never take my kids in for colds and I usually wait too long when I should take my kids in to be seen. I understand the abuse of antibiotics yada yada. When is it OK to prescribe antibiotics? Are the doctors we see "doing it wrong" when we're seen and are prescribed an antibiotic for flaming red, bulging, ears or flaming red, pussing and weeping ears? I found out after two years of being prescribed antihistamines for my 5 year old daughter's "excessive fluid pressure behind her ear" that they were doing nothing - if a family practice doctor can't prescribe and diagnose that properly (Singular works, not Zyrtec) how can I trust an antibiotic diatribe?

 
At Wed Mar 05, 07:46:00 PM, Anonymous Anonymous said...

NP you are so full of $hit. Among the worst offenders of the prescribe everybody an antibiotic are minute clinic NP's.

 

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