We all have been sick and wish for a magic cure. Sometimes it seems we find the right fix, but it was just coincidental. I see many people who want antibiotics to fix a viral illness because “it always works” but I want to try to show why this isn’t usually the case. Using antibiotics for most colds and coughs isn’t necessary and can lead to problems.
My urgent care experience
This blog is generally about pediatric health, but sometimes the principles are similar in adult medicine, so I’m sharing a personal story.
I was visiting my parents out of town and came down with fever, chills, and a sore throat. Due to the fatigue and shaking chills, I wasn’t sure if I’d be able to drive the 4 hour trip home the following day. I decided to go to a walk in clinic to see if there was a treatment to help get me on my feet again.
Although it’s less common for adults to get Strep throat, I wanted to have my throat swabbed because I had been exposed to just about everything at work.
If it was just a viral illness, fine. I’d tough through it with fluids and a fever reducer for the body-shaking uncomfortable chills.
But a child had gagged and coughed in my face earlier that week when I was doing a throat swab – and he had Strep. If I had Strep (as I hoped), then an antibiotic would treat the cause and I’d be back in shape in no time.
I could technically call out an antibiotic for myself, but I didn’t want to do that. That is poor care and I would never recommend treating anyone with a prescription without a proper evaluation.
I followed my own advice and went to a walk in clinic since I was out of town. If I was at home, I would have gone to my primary care physician because I believe in the medical home.
The provider walked into the exam room looking at the nurse’s notes saying it sounded like I had a sinus infection. (I use the term provider because I don’t recall if he was a physician, NP, or PA.)
What?
He hadn’t even examined me or gotten any history from me other than answers to the cursory questions the nurse asked. Not to mention that my symptoms had just started within the past 24 hours and didn’t include any form of nasal congestion or drainage.
I’m a physician and know that sinusitis must have persistent symptoms for much longer than 24 hours. But I kept that thought to myself for the moment.
He did a quick exam and started writing a script to treat my sudden onset of fever without cough/congestion.
He literally started writing the script as he was telling me, once again, that I had a sinus infection.
Now I couldn’t stay quiet any longer.
I said I really just wanted a throat swab to see if it was Strep. I didn’t want an antibiotic if it wasn’t Strep throat.
He argued for a bit about the validity of rapid Strep testing.
I argued that I did not meet the criteria for a sinus infection and that the rapid strep tests are indeed fairly reliable (not perfect).
As a pediatrician I won that argument easily. In the end I was swabbed.
The test was negative. I most likely didn’t have Strep throat after all.
He still gave me a prescription for a commonly used antibiotic called a Z-pack, which I threw away.
Did I get better?
I felt better the next day, so if I had just taken the z-pack, I would have thought it worked.
Ironically, the Z-pack is not a very good antibiotic against Strep, the one reason I would have taken an antibiotic. Resistance rates are high in my area, so unless a person has other antibiotic allergies (which I do not) I would not choose it for Strep throat.
But my body fought off an unnamed virus all by itself. That’s what our immune system does. Pretty cool, right?
No. Not cool.
Well, yes… it is cool that we can get better with the help of our immune system and no antibiotics. But not cool that a less knowledgeable person would have taken the prescription without question.
Unfortunately, I think many people trust the medical care provider, even when he or she is wrong. Even smart people don’t know how to diagnose and treat illnesses unless they’re experienced in healthcare, so anyone could be fooled. Especially since we’re vulnerable when we’re sick. Even more so when our kids are sick. We want to do anything to help them.
False security in an unnecessary treatment.
Many parents come into my clinic wanting an antibiotic for their child because the child has the same symptoms as they have and they’ve been diagnosed with a sinus infection, bronchitis, or whatever. They’re on an antibiotic and are getting better, so they presume their child needs the same.
Most of the time they both likely have a viral illness, and the natural progression is to get better without antibiotics, but it’s hard to get buy in to that when a parent’s worried about a child. Even harder when the parent is certain that their antibiotic is fixing their viral illness.
Confirmation bias.
Confirmation bias is the tendency to process information by looking for, or interpreting, information that is consistent with one’s existing beliefs.
A false belief is reinforced when we think we get better due to an antibiotic. It doesn’t prove that the antibiotic worked, but our minds perceive it as such.
We want to believe something works, and when it appears to work, it affirms our false belief.
The wrong treatment plan.
In my example, not only did I not have a sinus infection, but if I did have a false negative Strep test and actually needed an antibiotic for Strep, the Z-pack wasn’t a good choice.
False negative tests mean that there is a disease, but the test failed to show it. False negative tests are the reason I usually do a back up throat culture if I really think it is Strep throat and not a virus.
If the wrong treatment is given, not only do you fail to treat the real cause, but you also take the risks associated with the treatment for no reason.
Doesn’t the doctor (or NP or PA) know the antibiotic won’t work?
Yes, they know (or should know) how antibiotics work and when they’re indicated. But unfortunately, there are other factors at work when quick fixes are chosen.
Top 3 reasons that lead to patients getting unnecessary prescriptions:
1. Time
One problem is that it’s much easier to give a prescription rather than taking time trying to teach why a prescription isn’t needed.
The faster they see a patient, the more patients they can see and the shorter the waiting time is, which makes people happy.
I see many unhappy parents who follow up with me because their child is still sick and the “last doctor” did nothing. I have previously blogged about the Evolution of Illness so will not go into it in depth here.
2. Experience
Sometimes it’s hard for physicians, NPs, and PAs to not try something to make a sick person better. After all, that’s why we do what we do, right? We want to help. We’ve all heard of patients who get progressively ill because an infection wasn’t treated quickly and we don’t want to “miss” something.
While missing a significant illness can happen, it’s not common. Common is common. Most upper respiratory tract infections are viral. It’s knowing how to recognize worrisome symptoms that comes from experience.
Physicians (MD, DO)
Physicians spend years of not only classroom training, but also clinical training to learn to recognize warning signs of illness. Even a brand new physician has at least 2 clinical years during the total 4 years of medical school. Then they spend at least 3 years of residency seeing patients in a supervised capacity before they can work independently. That’s at least 5 years of 60-80 hour work weeks.
The physicians in my office, including myself – now 18 years in practice – still ask for help if we feel it could be beneficial. Sometimes a second set of eyes or putting our heads together helps to put things into a clearer picture.
Trust that if we say it’s a virus, it’s a virus. We know that bodies can still be significantly sick if it’s Just A Virus, but most of the time you can manage symptoms at home. Listen to what we say are warning signs that indicate your child should be reassessed. Bring your child back if symptoms worsen or continue longer than typical. Symptoms can worsen, but taking an antibiotic does not prevent that progression in most cases.
Be sure to question if you do not understand or agree with an assessment or treatment plan, as I did in my example above. It is essential to have this type of communication for the best care.
Nurse Practitioners (NPs) and Physician Assistants (PAs)
I love the NPs in my office. They do a fantastic job and make patient access easier. They see a lot of sick kids and do a great job treating when needed and giving “just” advice when that is what is needed. (That’s usually harder, trust me.)
They are always able ask questions if they don’t know what to do or for a physician to see a patient if a parent wants a second opinion.
I do not want this to become an argument if NPs and PAs are good. They are needed in our healthcare system to help patients get seen in a timely fashion. I welcome and appreciate them as part of the healthcare team.
But I do want to acknowledge that the training and background can vary widely, and I think it’s important to know the experience of your provider. It is not as regulated to become an NP or PA as it is to become a physician.
Many NPs have years of work experience before returning to school to get their advanced degree. But newer online programs do not require much clinical experience. At all.
If they then begin working independently without much supervision, they learn as they go and may or may not learn well. I’m not saying they’re not smart, but I also know how lost I felt those first months as a new physician after many supervised hours, and I know they have a small fraction of those supervised hours. I can’t imagine doing that as a new grad!
This is why I think that all new practitioners should work with others who have more experience, so they can learn from the experience of others. I worry when inexperienced people work alone in clinics, with no one to bounce questions off of.
Learn more about the training of healthcare providers in What kind of doctor is your doctor?
Patient experience and the 6th sense as a parent
Experience as a parent (and patient) matters too.
We can’t see what your child experienced last night if we’re seeing them in the morning and symptoms changed. Many symptoms are worse overnight, which makes it difficult to assess during the day. Of course if symptoms are urgent at night, go to a 24 hour facility that can adequately evaluate the situation.
If you are able to wait until regular business hours, you must describe it so we can understand it.
If you feel uncomfortable with the treatment plan, talk to the provider. List your concerns and let them address them. That’s not the same thing as demanding a prescription or further testing. It means asking for more information about why they feel the current plan is the correct one.
3. Surveys
Many hospitals, clinics and insurance companies are surveying patients to see if “good care” was provided. These surveys are used to place providers on insurance contracts and decide payment and salaries.
People are happier and think care is better if something was done. A lab, x-ray, or prescription (whether needed or not) is “something” people can identify.
People do not feel that information about viral illnesses and what treatments can be done at home is as worthwhile as a tangible treatment, even if it’s the correct treatment. They see the prescription as making the cost and time taken for the office visit “worth it” even if it is bad care. Leaving empty handed (but with proper treatment) doesn’t satisfy.
And the surveys reflect that.
Sadly, the pressure felt by physicians and other medical providers to perform well on surveys has been shown to have many negative side effects. Healthcare costs rise from unnecessary tests and treatments. Side effects of unnecessary treatments occur. Hospitalization rates and death are even higher with high patient satisfaction scores.
Don’t look for a quick fix. Look for the right fix.
Antibiotics certainly have their place. They are very beneficial when used properly. For a fun read about being responsible with antibiotics, visit RESPECT ANTIBIOTICS: USE THEM JUDICIOUSLY TO ENSURE WE CAN STILL WAGE THE WAR AGAINST BACTERIA from Dr. Michelle Ramírez.
If we use antibiotics inappropriately, they cause more problems.
