- A patient walks into my office expecting a prescription
for an antibiotic but I don't write one.
Let's talk about what happens
on this week's Wednesday Checkup.
Bee-whoop!
(smooth jazz music)
Let's set the scene here,
we have a 38 year old female
that comes in with a chief complaint
of upper respiratory symptoms.
It's been going on for a period of two to three days
and her main complaints come from fatigue, sore throat,
dry cough and runny nose.
A little bit of background on the patient,
she has two children, is currently married,
and has a very stressful job.
Probably the most important part of this story
is that she has a vacation coming up in 11 days
and she's worried that this infection
may interfere with those plans.
Normal vital signs, no fever,
pert positives: inflamed nostrils, inflamed throat.
Pert negatives: no exudates on the tonsils
which means those nasty little white
plaques that you sometimes see,
clear lungs, no abdominal pain, no rashes
and very importantly, no swollen lymph nodes.
At this point, I had a very strong suspicion
that my patient has a viral illness.
I didn't even know which viral illness.
But it doesn't make much of a difference
because it doesn't change my management.
Viruses are treated in the same manner.
We give supportive care to the patient,
treat their symptoms, make sure they get enough rest,
hydration, in order for their own bodies
to fight off those infections.
When I told the patient about my diagnosis,
she met it with hesitation and wanted
to know if she was going
to get a prescription for antibiotics.
I explained to her that antibiotics
don't work on viral conditions,
like the one I suspect that she was having.
I had to explain to her that weighing the risks
versus benefits here, I still thought
that not using antibiotics was the right move.
She put her trust in me and told me
that she would call me over the weekend
if any problems were to arise.
Come Sunday, two days later,
the patient calls my office and lets me know
that she's not getting better
and she's wondering if she should
go to a urgent care facility.
I talked to her about her symptoms
it just to me seems like her viral illness
still hasn't improved because she hasn't reached
that day six, day seven where we usually see a turn around.
And I told her that it was in her best interest
to stick with the symptoms management,
treat herself with rest, hydration, with green tea
and honey and stick through it and give
me a call in two days.
Surprise, surprise, patient calls me in two days,
let's me know that she's feeling a lot better
and turned around on day 6 all
her symptoms pretty much resolved.
She did let me know that on Sunday she ended up
going to an urgent care facility
and got a rapid strep test done
which came up negative as we initially thought
so she was very grateful that we didn't unnecessarily
treat her with antibiotics and it was a good result.
And I thought it was important to talk about
this result because it's a very common situation
where doctors either over-prescribe antibiotics
or doctors don't prescribe an antibiotic
and then patients get really upset about it.
So let's talk about that.
The situation of a patient coming
in and requesting antibiotics when their not actually needed
or indicated happens quite often.
And I want to start off telling you why doctors
should not be prescribing antibiotics unnecessarily.
Reason number one: resistance.
Antibiotics work against certain bacteria
that are not resistant to them.
However, when you give patients antibiotics
over and over again you create a type of bacteria
known as a super bug which actually becomes resistant
to that antibiotic and therefore
that antibiotic becomes useless.
And there's only so many antibiotics out there
where we can actually run
out of antibiotics to give a patient
because they have such a multi-drug
resistant bacterial infection.
Second: adverse reactions.
I'm talking about allergic reactions
where the throat closes up, rashes, diarrhea
an infection known as clostridium difficile,
where you kill all the good bacteria in your bowels
so that this bad bacteria grows and festers
and you have the worst bacteria ever.
Three: Antibiotics don't work against viruses
I know many people say "Well as soon as I got the antibiotic
I felt better," you would have felt better
without the antibiotic.
In fact, when we treat a strep throat with antibiotics,
we're not even really treating the strep throat.
It would get better on it's own.
The reason we give antibiotics here
is to prevent the complications of strep throat.
Like rheumatic fever, kidney issues.
Let that sink in for a moment.
And finally fourth: the cost.
Why would you spend money on antibiotics
when you have a virus, they're not even gonna be helping you
and possibly harming you.
The art of medicine is about
balancing the risks versus benefits to be in your favor.
Now let's move on and talk about
what pressures doctors face to prescribe antibiotics
even though they may not be
the appropriate choice of treatment.
First: Patient request.
Like we had in my story, patient comes in
and requests firmly an antibiotic.
You can discuss very clearly with them
why you think an antibiotic isn't the optimal choice.
You can explain the risks, the benefits,
and the patient can still request an antibiotic.
So, you go ahead and write one.
The second connects very closely with the first,
and it's these doctor review sites like
Zocdoc, Yelp and so forth.
Where if a patient doesn't get the treatment
they expected to get,
they can leave a nasty review that can truly hurt
your own business.
Think about it, if I open my own practice,
and I'm trying to establish myself and have a good name
and give quality service,
and not give unnecessary antibiotics,
but a patient really wanted them,
they leave me a bad review,
that can really hurt my business.
Three is something you may not have heard of,
it's CYA medicine, Cover Your "Butt" medicine.
Essentially what doctors are doing, is that
they're afraid that if you don't prescribe antibiotics
for a patient, and they actually do
have a bacterial infection, they get worse,
they may be held liable through a lawsuit,
and that's scary stuff for a doctor.
You don't wanna be sued by a patient,
especially in the age we live in
where it seems everybody's just suing everybody
all the time.
Fourth is patient satisfaction.
If a patient pays to go to the doctor's visit
and leaves with no prescription,
and instead leaves with advice
to drink green tea, honey and hydrate,
they feel like they didn't get a lot out of the visit
and can leave very unhappy.
But we have to remember, the reason we pay
for a doctor's visit is not to buy a prescription,
it's to consult a doctor on their medical opinion
as to what's going on with you
and what is the best treatment option
to solve that problem.
Please don't think I'm anti antibiotics.
Antibiotics are a life saving drug, and when appropriate
is so important to give.
In fact, if someone has a viral infection,
they become more susceptible to getting
a bacterial infection on top of it.
So that if you initially have symptoms
of a viral illness that suddenly get worse,
you may need antibiotics.
I'm definitely for antibiotics,
but I'm for responsible use of antibiotics.
We covered antibiotics and I told you my story,
but I also happened to go to my P.O. box today
and picked up some packages (shaking box)
Pennsylvania
Oh my god why is everyone sending these shirts?
It's a Newfoundland with a little heartbeat.
Bear, what do you think about this shirt?
(laughing) What do you think?
California, San Diego.
Oh my (laughing) god.
Chest compressions! Chest compressions!
Cynthia, thank you so much for this shirt.
"If you don't start making merch soon I swear to god."
I'm sorry!
I'm working with the trademark attorney,
there's so much nonsense when it comes
to making your own merch.
I'm a doctor, I have no idea what I'm doing,
but I promise there's gonna be merch soon.
Japan!
(surprised) Ooh! A little Japanese Kit-Kat action.
Kit-Kat Easter eggs, white chocolate Kit-Kats.
Thank you my Japanese friend.
This is from Denmark, look at this.
Look at these candies.
Look at these candies!
This is what's leading the obesity epidemic
but I'm gonna love it.
Thank you so much.
"Safe guard your families health
with a mild laxative.
Healthaway products from 195-"
(gasp) Is this like, this looks genuine.
This is like an artifact.
Carol, this is amazing!
I'm gonna save this, I don't even wanna show you guys
what this is.
This is weird health products from the 50's.
This one's from Jamaica.
Ooh! "Our Daily Bread"
because everybody needs a carb.
Bear, bomb check?
Good.
"First aid kit, do not open unless emergency"
That's so sweet.
You guys need to watch my video that I did with my nephew
Ari where we did a Disgusting Science Experiments,
so click here for that bad boy.
And as always, stay happy and healthy.
(laugh)