"I need antibiotics," Amy informed me. I was a third year resident in Internal Medicine at the time, and Amy had been added on to my once-weekly primary care clinic as an "urgent visit." She was 33-years old, otherwise healthy, and entered the exam room with her mother in tow. "My nose is running, my head hurts, I'm all congested, and it won't go away," she said. From what I could tell in the first thirty seconds, Amy had a cold.
Upper respiratory infections (URIs), otherwise known as the common cold, are caused by viruses for which we have no proven treatment. Whoever discovers a cure for the common cold will win a Nobel Prize. For now, however, we are left with the tincture of time and a $2 billion dollar per year over-the-counter cold remedy industry. Yet when patients see a doctor for a lingering cold, many do not appreciate being told that they simply need to wait.
Unfortunately, treating colds with antibiotics may be ineffective and also harmful. Antibiotic overuse has fostered the emergence of highly resistant organisms such as MRSA and clostridium difficile, pathogens that have caused thousands of fatalities across our nation. Nevertheless, nearly 75 percent of adults with URIs are prescribed antibiotics when they see their physicians. This translates into 41 million unnecessary antibiotic prescriptions per year in the United States at a cost of $700 million per year.
Amy had caught me on the wrong day for unnecessary antibiotics. I had spent the month rotating through the ICU, and that morning, had watched a young woman, Melanie, die of toxic megacolon, a complication of c. difficile colitis. Melanie had recently taken a course of antibiotics for a lingering cough, antibiotics that had likely made her susceptible to this fatal infection. Despite weeks of filling Melanie's blood and belly with our most powerful antibiotics, at 11 a.m., her bowel had burst, and she died.
Two hours later, in the outpatient clinic across the street, I faced Amy. Amy opened her mouth and said, "Ahhhh," before I even had to ask. So I took her temperature, looked in her throat, and listened to her lungs. "Great news," I concluded upon finding her exam completely normal. "You seem to have an upper respiratory infection. You don't even need antibiotics."
Amy did not share my enthusiasm. She was incredulous. "I always get antibiotics when this happens."
Her mother interjected before I could respond. "She can barely sleep. I can't believe that there's nothing you can do for her."
I advised that she get as much rest as possible, and drink lots of fluids. For empathy's sake, I said, "It sounds like a really rotten bug." The only thing worse than no empathy is false empathy. Mother and daughter glared at me.
"Antibiotics treat bacteria," I explained. "An antibiotic will not treat the virus that is causing your cold." The choice of the word, "cold," was an unfortunate one. She started crying and blew her nose, and then opened her Kleenex to show me her snot. "My snot is green," she said.
"Your snot is green," I agreed. And though my medical education had emphasized the importance of body language to demonstrate sensitivity to our patient's needs, head-nodding, eye-contact, and the like, my head froze. Because as tempting as it is to assume discolored snot or phlegm are signs of bacterial infections, the scientific reality is, they're just not.
"If you don't give us an antibiotic, we'll just get it from someone else," her mother said. They left in a huff, and rather than feeling proud that I had made one infinitesimal dent in the beastly mound of antibiotic overuse, I felt sick about the whole interaction. That night I could not sleep, and instead of worrying about my patients dying in the ICU of multi-organ failure, I was plagued by the sense that I had mismanaged a cold.
How do we reconcile the desire to satisfy our patients with the imperative to provide necessary and effective care? The days of paternalistic medicine are long gone. We have entered a new era that emphasizes patient-centeredness, shared-decision making, and patient satisfaction. But in our quest to make our patients happy, has the pendulum swung too far in the other direction? Giving a patient what she wants is not always the same as giving a patient what she needs.
My father, a rheumatologist, likens his role as a physician to a waiter describing the evening's specials. He presents the treatment options in some detail to his patients, and then lets them choose. "Who am I," he said to me when I was a medical student, "to tell someone she would be better off with nausea but improved vision or improved mobility but increased risk of infection. I cannot pretend to know how it feels to be someone else."
There is no question that ideal health care delivery involves a well-informed patient, one who feels empowered to make a decision suited to his unique needs. But there is a fine-line between delivering preference-sensitive care, and care that is delivered simply to meet a preference. As much as we all want to be liked, and as much as we all want to feel heard, a physician's first responsibility is to protect a patient, and society, from harm. Sometimes that means saying no.
The day after I saw Amy I received a clinical message requesting that I call her. I was almost relieved to have an opportunity to give in. I had written an antibiotic prescription before she even picked up the phone.
"I'm glad you called," she said.
"You're still feeling rotten," I said. "I'll fax you in a prescription right now."
"Actually," she said, "I feel much better."
"Didn't you want me to call you?" I asked. "Don't you want an antibiotic?"
"No," she said. "I guess I just wanted to say thanks."
This was not to be the opening scene of a lifelong friendship, but I was not there to be her friend. I was there to be her doctor.