Reprinted from the Annals – on patients and customer (dis)service:

Humming a little tune as I rounded the corner and headed down the homestretch of my afternoon in the office, I plucked a chart from the wall outside of room 14. Carol Todd, a woman of 48, had come to see me about “cellulitis of the scalp.” My nurse had scrawled a question mark after her history, and then an exclamation point. I shot a quizzical look into the nurses’ pod at her. She rolled her eyes at me and mouthed the words, “You’ll see.” I knocked on the door and entered the examination room.

Mrs. Todd, a short, stout woman, pursed her bright red lips into a scowl as she saw me. I introduced myself, welcoming her to our clinic. She brushed me off with a dismissive wave of her hand. “Are you really old enough to be a doctor? You look just like a kid.” I started to answer something about medical school, residency, years of experience, but she just shrugged at my response and snapped, “I’m in a hurry, doctor, so if you wouldn’t mind I’d like to get to my problem. I spent 30 minutes in your waiting room surrounded by coughing people, and I’m in no mood for small talk.” I sat back in my chair and asked her to describe her symptoms. “I don’t have symptoms, I have cellulitis. Didn’t the nurse tell you? It should be right there in the chart. I made her write it down.” Her finger jabbed impatiently at the chart I held in my hand. I swallowed down a little smile as it threatened to spread across my lips and instead asked her to tell me about her “cellulitis.” I made a mental note to ask her about her medications—would they include haloperidol or fluphenazine?

“Well, I started having a headache yesterday, and now there are bumps on my head. Here, you feel them,” she demanded. I wheeled myself warily forward and dutifully palpated her scalp. Nothing. “Do you feel them?” she asked impatiently. “Here, you’re feeling in the wrong place. Feel there.” She grabbed my hand, clamping it down over a stretch of perfectly flat scalp. “Now do you feel it?”

Again, I detected nothing but normal scalp. I nodded sagely anyway. “Yes…I think I feel them now. I see what you are talking about,” I said.

I asked her some questions about her history. She had no fevers, scratches, or unusual exposures. There was no history of hiking or tick bites, and she was feeling generally well. Her scalp wasn’t warm or tender. I couldn’t find a shred of evidence to convince me that she had an infection, or any other disease state for that matter. She took no psychotropic medications. I tried my best diplomatic voice, the one I usually reserve for fights with family members. “What would you like to do about it, Mrs. Todd?” I asked evenly.

She raised her eyebrows, which were penciled in high arches on her forehead. “What do you mean?” she asked incredulously. “You’re the doctor. I’m paying you. I want you to tell me what to do about it!”

I started in on my viral illness speech, and then told her about how unnecessary I thought antibiotics were. I explained in depth about the lymphatic system and allowed that she could have been feeling enlarged lymph nodes in her scalp. “Maybe you have an upper respiratory virus, or a sinus infection that is just beginning. Maybe this is the first sign. You must come right back in if you are feeling sick.”

I listened attentively as she told me of her history of other infections for another 10 minutes. But things went from bad to worse. She persisted: “The last time they gave me Z-something, that five-day thing. It worked fine. Maybe you should give me that.”

I shook my head no and replied, “I don’t think that would be the right thing in your case, Mrs. Todd.”

“You mean you’re not going to give me an antibiotic?” she asked. “I wasted all that time for nothing.”

I nodded apologetically. “I’m really sorry for all of your inconvenience. I hope you understand that I just want to do what I think is best for your condition,” I added as she readied herself to leave.

That was not the last I heard from Mrs. Todd. Two weeks later, I found a small yellow envelope in my mail cubby. It was stamped “Confidential,” never a good sign. It came from the customer service office, a new department in our hospital system. An official-looking form explained that a patient had complained about my care. A photocopy of the complaint was included. Mrs. Todd had written about her wait and my failure to diagnose her cellulitis. Undeterred by my explanations that afternoon, she had gone to the emergency department, waited again, paid again, and eventually emerged with a diagnosis of cellulitis and her prescription for azithromycin. She held me responsible for both of the waits. “Please refund my charge for the office visit and my charges from the ER,” she wrote. “I should have been diagnosed correctly by Dr. Glazer in the first place.” She enclosed both bills, the totals circled and underlined with copious red ink. An accompanying hospital-generated form letter urged me to contact our customer service representative immediately.

I called from my clinic that day. The representative listened impatiently to my description of the encounter. “Yes, doctor, I am a nurse myself. I have read your note. You wrote that there was no evidence to support a diagnosis of infection. That’s all very good. But now we’ll have to waive the cost of her care.” She paused and then went on, “What would make all of our lives simpler is if you would just do what the patient wants. Is it really such a big deal to give her an antibiotic? The ER doctor did, and she was happy with him.”

I replied by asking pointedly, “Don’t we have a problem with antibiotic resistance here at our hospital?”

She countered with, “What’s that got to do with anything? She will get the antibiotics anyway, and you might as well not make her unhappy about doing it.”

Three days later I again paused to read a chart outside an examination room door. “Cough, sore throat for 5 days. Diagnosed with bronchitis,” the nurse’s narrative read. “Started on [clarithromycin] 3 days ago. No better. Wants something stronger.” I sighed, my mind’s eye conjuring Mrs. Todd’s loopy handwriting on her letter of complaint and the hospital bills with their accusatory slashes of red ink. Then, cowed by the imperatives of customer service, I reached into my pocket for my prescription pad.

The Annals follows with a commentary from an academic physician slamming the young doctor:

But the vignette nicely presents a serious problem: Do we have an ethical/professional commitment to treat all patients in a cost-effective and high-quality fashion, no matter what their desires? The increasingly prevalent rhetoric of patient as customer or consumer, which is driven by those who wish to bring more market incentives to health care, brings with it the notion of the customer always being right. More informed, more aggressive patients can and do assert their customer rights to the kind of care they want. Should doctors cede their authority to the patient in low-stakes situations, such as antibiotic-seeking behavior?
The answer is no, resoundingly no. Providing patients with more information so that they can make better health care decisions is the right thing to do. But prescribing unnecessary antibiotics clearly puts the patient at risk for side effects with no offsetting medical benefit—so in the case described here, quality suffered.

So easy to be preachy in his academic bunker at the Brigham, shielded from the real-world. “Antibiotic-seeking” behavior is a common occurrence in HMO primary care – especially in the world of high-deductible insurance. Sometimes a simple antibiotic prescription may outweigh the risk of a complaint – or lawsuit.

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  • Anonymous

    We should be able to prescribe a “placebo” medication that has a co-pay and is picked up at the pharmacy.

  • Kara

    My comment is thus:

    In 1999 I became very ill suddenly and I insisted on antibiotics because I would get better and relapse when they stopped. I literally begged for them.

    I was labeled hysterical for “seeking” antibiotics. They were more than willing to give me Prozac.

    A PHD & MD researcher (microbiologist) discovered I was infected with Borrelia burgdorferi. And guess what?? Antibiotics cured me.

    We have gone so far with anti- antibiotics that as medical people we are discouraged from even giving them when appropriate!

    (although cellulite of the scalp would not be appropriate).

    And yes..10 years from now, I may be resistant to an infection. And it may kill me. But I would rather not wait in a wheelchair for that to happen.

    I thank G-d every day for antibiotics. And I am thankful for the researcher who actually believed me.

  • Anonymous

    Ya just can’t win.:(

    From the standpoint of a layperson, though, I think the writer would have made a stronger case if he had been less disparaging about the patient. I mean, the eye-rolling started before he even walked into the exam room. Pre-judge much? I’m not sure what the comments about the patient’s stoutness and her red lipstick and penciled-in eyebrows were meant to add – was it relevant or was it meant to reinforce some kind of stereotype about the Middle-Aged Female Patient from Hell? And the comment (inaccurate, as it turned out) about antipsychotic meds was, well, a wee bit nasty.

    I feel for you guys, I really do. You have my utmost respect for what you deal with every day, all day long. But you’d be surprised at how disrespect or frustration, such as that experienced in the episode above, can be subtly telegraphed to the patient… and all too often the encounter goes rapidly downhill, with neither party really listening to what the other is saying.

  • Kara Tyson

    As my old professor from India used to say, “it is a hard thing”. (he said that about a lot of things).

    Medicine is rarely cut and dry. It is not easy to determine if something is not there vs. something that you miss (or just do not have knowledge of).

    It is easy to be caught up in antibiotic resistance and at the same time not see the bigger picture. Risk vs. benefit. Sometimes the risk is worth it. Sometimes it isnt.

    The question really is, who decides if the risk is worth it. The patient, the Dr., or the ‘all knowing, all wise’ CDC/FDA/DEA.

  • Anonymous

    Good Job, Kara. It’s comments like yours that make ID Docs quit and have allowed the microbials to win the war. I usually give people like you a couple of days of Penicillin or Bactrim just to shut you up and get you out of my ER, but then you come back with your daughter, son, uncle, even Poodle when they catch the same cold.

  • james hubbard MD

    my 2 cents worth; probably not realistic, but here goes: 1) we physicians are not health care professionals but disease managers, strictly speaking. our job is to accurately identify or diagnose medical problems and then apply proven, or at least reasonable therapeutics to that problem. 2) when patients come to us with a complaint, the patient’s job is, with our assistance, to point out signs and symptoms. our job is to then develop a strategy to arrive at the most accurate diagnosis, then treat accordingly. the patient gets to choose a) who to present to; and b) whether to apply, agree with, or follow the reccommended plan. period. otherwise, why not just hand out medical menus at the door.

  • Anonymous

    Isn’t the solution simply to tax antibiotics at a high enough rate so that people who use them bear more of their externalities (i.e., the cost in terms of increased resistance in the population)? The tax revenue could go to research on better, newer antibiotics.

  • Kara

    Good job anonymous. More taxes. We can tax fast food, tax those that dont exercise, tax those that drink, ect. ect.

    As to the original story..I assure you, if that had been a male patient there would have been NO assumption of mental illness. That same Dr. would have sent the patient to an expert on cellulitis of the head.

    And its comments like yours that encourage Dr.’s to not listen to patients, not do their own research and believe everything that comes out of a textbook and the CDC.

    and ID’s dont make the sun set and rise.

  • Anonymous

    Let’s just make all antibiotics over the counter and be available to the population and let’s make all controlled drugs also over the counter. This will relieve the congestion in the ER’s. Let those people who want to fix themselves, diagnose and treat themselves. That’s one way to get rid of those people from the face of the earth.

  • Anonymous

    I think the problem is that most American patients don’t realize that antibiotics have side effects and that in rare cases these side effects may be more serious than the illness they have.

    I grew up in another country (yes, the health system there had problems, but this is beside the point) and I’ve always been told that while antibiotics are necessary in some cases they all come with side effects – be it hearing problems or kidney damage or whatever and should be avoided unless absolutely necessary. About the only time I was prescribed antibiotics during the first 19 years of my life was when I was 15 and had pretty bad pneumonia. Maybe shortage of some drugs had something to do with it, but I think the main point was right.

    Antibiotic resistance sounds to many laypeople like triple integrals to sombody who can barely do arithmetic. But “this is not likely to cure your cold, but in rare cases it may damage your hearing” sounds much more convincing. I doubt it very much that the woman described in the post would be likely to insist on the particular antibiotic if the doctor were to recite every single potential side effect listed on the label. Even if the chance of a particular side effect is small.

  • Anonymous

    That’s the point. If the patient did not have cellulitis, why prescibe an antibiotic….period.

    “That same Dr. would have sent the patient to an expert on cellulitis of the head.”

    What type of doctor would that be? An MD who specilaizes in infectious agents/diseases is an “Infectious Disease” doctor. That stated a simple cellulitis should be the realm of a FP or internist.

  • Anonymous

    That “cellulitis” may actually be a fungal infection and if this lady takes an antibiotic, the fungus will just love it. Oh, I’ll just give her what she wants. Let her suffer.

  • Anonymous

    “Good Job, Kara. It’s comments like yours that make ID Docs quit and have allowed the microbials to win the war. I usually give people like you A COUPLE OF DAYS [emphasis mine] of Penicillin or Bactrim just to shut you up and get you out of my ER….” So saith Anon 718.

    Uh, is that a full course of penicillin or bactrim? If not, aren’t you causing the problem you complain about — antibiotic resistance?

    Gee the practice of medicine would be so great if we could just get rid of the patients.

    Hang in there, Kara.

  • Anonymous

    to anon 519 — then if you think it’s fungal, why wouldn’t you tell the patient so instead of assuming she’s nuts?

  • Anonymous

    Actually a couple (three days) of bactrim would be completely appropriate in a simple UTI in women. The point is we should only give antibiotics when appropriate, and not at only the patient request. When is the last time you saw an antibiotic acquired C. diff that required a colectomy? Hasn’t been more than a couple of months for me. But hey do what the patient asks right Kara. Give those antibiotics out like M&M’s.

  • Pat O’Connor

    Dr. Kevin

    I am an 53 year old individual was born with a condition called primary lymphedema (Milroy’s Syndrome)and am a ten year survivor of two B-cell lymphomas.

    As a result of the lymphedema, I have endured massive cellulitis infections since 1960.

    I could tell your stories from hell about doctors who don’t know or care about what they are doing…and I could write volumes about brillant and compassionate medical professional for whom I have the absolute utmost admiration and respect.

    Doctors are like normal people…some good…some bad.

    The flip side of the coin, the patients are likewise. I sponsor a global website on lymphedema, ten online medical support groups in three countries and maintain ten medically related blogs.

    I deal with and correspond with doctors and patients everyday. There are two patients that literally drive me up the wall.

    First, are the ones who only was to wallow in self pity, complain moan and gripe…but who steadfastly refuse to do anything to help themselves or to follow the treatment regime outlined by their doctor.

    Secondly, are the ones who “think” they know everything and then proceed to tell the doctor everything about how to treat them.
    They are also the ones who often go off on dangerous tangents, believe everything they hear, try “folk” medicines and usually wind up in a serious situation because of their ignorance and arrogance.

    Cellulitis is an easy enough infection to diagnose from the physical signs present. The specific causative bacterium may not be able to be diagnosed without cultures. But the infection itself is quite obvious.

    As a person who has lived off antibiotics, I presently am down to a very limited selected to now choose from. Bacterial resistance is a very real threat and one I have faced.

    In this particular situation, I must agree with you, Dr. Kevin and as a patient I applaud your actions.

    Frorm my (humble) perspective you took the appropriate action and I also feel it was a shame on the hospital that they did not give you the backing and support you deserved from this unexcusably hostile patient.

    Also, excellent coment from Dr. Hubbard.

    Regards,

    Pat O’Connor
    Lymphedema People
    http://www.lymphedemapeople.com
    Cellulitis
    http://cellulitisinfections.blogspot.com/

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