A real doctor will first do no harm

I’m really miserable and need that 5 day antibiotic to get better faster.

Ninety eight percent of the time it is a viral infection and will resolve without antibiotics.

But I can’t breathe and I can’t sleep.

You can use salt water rinses and decongestant nose spray.

But my face feels like there is a blown up balloon inside.

Try applying a warm towel to your face.

And I’m feverish and having sweats at night.

Your temp is 99.2. You can use ibuprofen or acetominophen.

But my snot is green.

That’s not unusual with viral upper respiratory infections.

And my teeth are starting to hurt and my ears are popping.

Let me know if that is not resolving in a week or so.

But I’m starting to cough.

Your lungs are clear so breathe steam, push fluids and prop up with an extra pillow.

But sometimes I cough to the point of gagging.

You can consider using this strong cough suppressant prescription.

But I always end up needing antibiotics.

There’s plenty of evidence they can do more harm than good.  They really aren’t indicated at this point in your illness.

But I always get better faster with antibiotics.

Studies show that two weeks later there is no difference in symptoms between those treated with antibiotics and those who did self-care only.

But I have a really hard week coming up and I won’t be able to rest.

This may be your body’s way of saying that you need to evaluate your priorities.

But I just waited an hour to see you.

I really am sorry about the wait; there are a lot of sick people with this viral thing going around.

But I paid $20 co-pay today for this visit.

We’re appreciative of you paying promptly on the day of service.

But I can go down the street to the walk in clinic and for $95 they will write me an antibiotic prescription without making me feel guilty for asking.

I wouldn’t recommend taking unnecessary medication that can lead to bacterial resistance, side effects and allergic reactions. I think you can be spared the expense, inconvenience and potential risk of taking something you don’t really need.

So that’s it?  Salt water rinses and wait it out?  That’s all you can offer?

Let me know if your symptoms are unresolved in the next week or so.

So you spent all that time in school just to tell people they don’t need medicine?

I believe I help people heal themselves and educate them about when they do need medicine.

I’m going to go find a real doctor.

A real doctor will first do no harm.  I wish you the best.

Emily Gibson is a family physician who blogs at Barnstorming.

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  • http://www.howtobesick.com Toni Bernhard

    Thanks for this post. As I write about in my book, “How to Be Sick,” I have a hard-to-diagnose and treat chronic illness. I’ve seen many specialists but now work mostly with my GP. He is open to treatment ideas that I bring him but his rule is: “Do no harm.” He’s willing to experiment…but not if it could do me harm. Sometimes I’ve felt frustrated by his cautious approach but, after ten years, I’ve come to realize that he’s right. He’s always acted in my best interests, and I feel fortunate and blessed that he’s stuck with me all these years even though he can’t “fix” me.

  • http://pulse.yahoo.com/_T6Q3QYSV23W2ENKYMVRBKITJHY Bobbi

    I am so thankful that I was blessed with finding a physician many years ago who had the “If it aint broke, don’t fix it” mentality. Old “Doc Hudgins” taught me that our bodies have an amazing capacity to heal themselves. His favorite “prescriptions” were push fluids and get plenty of rest. I was given further instrucitons to call with changes of s/s.  I can only think of one time that he prescribed antibiotics for myself, husband or children. My mother-in-law is currently suffering the effects of ill prescribed antibiotics that almost killed her. I loved the advice of reexamining priorities in the article. Our bodies can do amazing things if we just let them.  My advice to anone who has an attending that wants to push antibiotics at the drop of a hat is to run, do not walk to the nearest exit.

  • Chris Niemann

    Good advice, this reminds me of the episode of House where he got candy out of the vending machine and gave it to the patient who was insisting on taking medication.

  • http://www.facebook.com/profile.php?id=100000977601479 Melissa Gastorf

    Have you been listening in my exam rooms?  I have had that conversation more times than I care to count.  My favorite is the follow up.  

    I went to the urgent care and they gave me an antibiotic, and I am all better now.  

    OK

    Don’t you have anything to say

    Glad your better.  What can I do for you today

    Don’t you care?  

    Yes, I said that I did, now what are you here for today?

    My sinuses are still killing me, I think I need another course of antibiotics.

    Well let me take a look, but you didn’t get better from the first set, chances are you have a virus.

    So and so down the street gave me antibiotics, don’t you think you should?  I paid my co-pay

  • http://twitter.com/#!/CloseCall_MD Close Call

    “I feel it moving into my chest.”

    Barf.

  • Tracey

    My daughter had a fever for days, horrible hacking cough that was keeping us all up at night. I had reported to the doctor that up until the morning we saw him she had 102-103 fever. He printed up 3 pages of what to do to help alleviate the cough and told me that she would be fine in a few days.  2 days later when we got in to see her regular pediatrician and her fever was back up to 103 with the cough she ordered a chest x-ray and discovered that she had pneumonia.  My husband is now on his 4 round of antibiotics in 2 months plus Prednisone because the first time he complained of a sinus infection the doctor told him it would  clear on its own.  Sometimes as patients we really do know if we are sick or not.

    • Anonymous

      The high fever with cough is not routine viral sinusitis.  It meets criteria for further evaluation (blood count, xray) to determine if antibiotics are indicated.  So this scenario certainly is not pertinent to your daughter’s situation.  Now the four rounds of antibiotics and steroids for sinusitis is a very sad situation indeed.

      Emily Gibson (author of original post)

      • Tracey

        That was exactly my point in response to your story.  More testing was indicated but we were lumped into the “viral” category and given reading material and sent on our way.  There was a viral infection going around at the same time, which I had, but she clearly had something different. We were lumped into the category of overreactive parents who take their kid in for every little sniffle and sneeze which is just not true.  If the doctor had spent the time looking at her and listening to what we were describing he might have ordered some more tests instead of telling me to use a humidifier and elevate her head; which by the way I said numerous times that we had been doing for over a week.  As patients we do sometimes feel like the doctors have contempt for us non-doctors and even some of the replies to this post have echoed that sentiment. We are looking for your knowlege and experience but also want to know that we are heard.

  • Anonymous

    What a smarmy, judgemental doctor!   There is no mention of the last time this particular patient had an antibiotic and occasional antibiotic use is not harmful.  The doctor has made a judgement without asking any questions.  The doctor has assumed the “important events” of the patient’s coming week are arbitrary.  It may be a student facing final exams, a patient facing a vital job interview in this economic crisis, a daughter’s wedding – This doctor asked no questions at all and in not listening to the patient, but in using a “one size fits all” knee jerk response and dismissing the patient’s concerns out of hand, has caused harm to the patient whether offering an antibiotic or not.  Not clever and not good medicine.  Not cute at all. 

    • Anonymous

      You’re missing the point.  It doesn’t matter what he has going on in his life — the illness is viral.  Period.  You CAN’T fix a viral infection with a Z-pak.   Just because it’s his daughter’s wedding doesn’t make this a viral illness.  Doctors shouldn’t give antibiotics for viral infections.

    • Anonymous

      Eleanor, I did expect some reaction like yours from patients on this one.  There is a frequent expectation that for a patient a clinical encounter is like a fast food order and that if the clinician doesn’t deliver the desired treatment in a timely way, with a smile, that we have failed the customer. 

      I’m the smarmy judgmental doctor who wrote this and in my real practice, I do ask what kind of “hard week” the patient is facing but it won’t change whether or not an antibiotic is prescribed in this particular scenario.  It usually results in a discussion about how to reorder priorities, listen to what your body needs, and finding ways to minimize symptoms to be able to tolerate the activities that can’t be rescheduled.

      And just so you know, I’ve very recently been ill wishing for that miracle cure for a viral infection that will take time and self care to resolve, and without antibiotics it took two weeks to get over the “green stuff”, painful facial pressure, low grade fevers and gagging cough from the post nasal drainage.  I resisted the very strong temptation to find an urgent care (my “hard week” was indeed stressful, delivering our youngest child to her first year of college 3000 miles away from home and we were on the road and attending orientation activities while I was sick) because I knew antibiotics would not make a difference. 

      So in this case it was “Physician, heal thyself” –I’ve had to listen to my own smarmy advice and lived to tell about it…

    • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

      “Beverly Hillbillies”

      Mister Drysdale invested in Granny Clampett’s cure for the common cold.

      In the end, he found her elixr cured the cold. Guaranteed.

      Just take her potion, and in a week, you’ll be better.

      That was over 40 years ago. We’ve known this for a while.

    • Terry M

      “occasional antibiotic use is not harmful.”

      Sorry, but you lost all credibility with this statement.  This common misconception is exactly why posts such as Dr. Gibson’s are necessary.

  • http://profiles.google.com/petermbenglish Peter English

    “What a smarmy, judgemental doctor!”, writes Eleanorofcastile.

    That’s exactly the sort of response that explains why doctors prescribe medicines that “probably won’t do any harm”, in general don’t, but which do in some cases, and by driving up antibiotic resistance.

    I entirely agree with the post (except the bit about breathing steam – I know the author means “water vapour”, and most patients would interpret them correctly – but pedants would insist that steam is at 100 degrees celsius and would scald badly).

  • http://www.facebook.com/victor.raggio Víctor Raggious

    very  nice. 

  • Anonymous

    Really?

    I’m a frequent patient who reads this blog to see what is going on with doctors, and all I find is that they hate their patients.  Of course you know about more cold remedies than the average patient.  You’re a trained physician and they’re not.  That’s no reason to exhibit this kind of contempt.  

    • http://twitter.com/#!/CloseCall_MD Close Call

      Most doctors don’t hate or have contempt for their patients.  (Why would anyone willingly give up their 20′s and go 150k in debt to work with people they hate?)  It’s more frustration.  The author’s beef is with the continued insistence of a patient who feels they absolutely NEED an antibiotic.  Demanding the doctor to treat them for something the doctor feels they don’t have…  well, when the doctor gives in to that… that’s bad medicine. 

      As a patient, whenever you find yourself having a conversation like the one Dr. Gibson’s describes with your own doctor, you should think to yourself, “Jeez, I have a GOOD doctor.”  Why?  Because they actually give a crap to spend the time with you to explain why you don’t need antibiotics.  They give you a time frame as to when to return.  They explain the risks of taking antibiotics.  They give you alternatives to feel better.  AND  they are polite when you bring up the incredibly rude, “Well, I already paid my co-pay” bit. 

      Above is the PERFECT example of what EVERY doctor or PA or NP should be saying to you with 3 days of greenish cough, low grade temps and a normal exam.  

      Not Avelox!

      Sorry about all the caps in this post.  This old Texas doc gets excited whenever he’s about to end his post with moxifloxacin. 

    • Anonymous

      I’m certainly sad to hear this sample encounter appears to you to portray a contemptuous hatred for the patient.  Nothing can be further from the truth.  I honor and respect my patients enough to listen to them (something that I didn’t illustrate in this brief blog post written to make a point about unnecessary antibiotic prescribing), tell them the truth as I know and understand it, and be available to them 24/7 if the treatment plan is not working and things are getting worse.   I certainly don’t give my personal cell phone number to people for whom I hold contempt, and every one of my patients has my cell phone number and email address in their wallet.

  • Terry M

    Great blog post.

  • http://drinkingfromthefirehose.wordpress.com/ Thirsty Scholar

    I have heard the “but you’re not doing anything for me” complaint/question far too often. My response is always to re-emphasize two things:

    First, it’s good that the patient came in to the office since they were concerned about their health, and that we take that concern seriously. The patient shouldn’t feel guilty about asking for drugs, or a test, or anything else. However …

    Second, I *DID* just do something: I evaluated you, considered a few evidence-based strategies, considered your particular case, thought about the questions you raised and then made my best recommendation. That thought process (not just signing a script) is exactly what you pay me for*. Sometimes spelling out everything that just went on in your head helps the patient appreciate (but probably not understand) your thinking and can sometimes be reassuring.

    *=No one pays me. I’m a medical student. I actually pay to work … but still …

  • James deMaine

    Part of the problem is that expectations of the patient have been set by previous doctor visits and that “denial” of the antibiotic looks like a negative power play.  Over time in primary care, patients and doctors tend to match up with their style of care.  I had lots of patients breathe a sigh of relief when I didn’t recommend antibiotics in that they wanted to try something more natural.  Perhaps a teaching pamphlet on line or in the waiting room about the doctor’s philosophy about antibiotics would help (this is a big issue in pediatrics and primary care).

    Unfortunately, I did run into one patient who simply demanded an antibiotic.  After a long back and forth discussion, I told him that in my opinion that it wouldn’t help and could cause harm.  He then yelled, “I didn’t come for your opinion, I came for service!”

    Needless to say, a complaint about my care was submitted and the patient went off to another doctor.

  • Anonymous

    I’ve been hospitalized 4 times with sepsis because of doctors who immediately lumped me into “antibiotic seeking patient” categories and dismissed me.  You could at least run a CBC/diff and get a basic idea of viral vs bacterial.  Every time my segs have been over 92% (yes, patients do sometimes actually know things as much of a shock as that may be).  Had someone listened to me for 15 seconds and ordered a simple, cheap, routine test it probably wouldn’t have been a problem as they all would have been dealt with much earlier and only required PO antibiotics.

    Do no harm doesn’t mean to make snap judgments and withhold antibiotics as your post makes it sound; it means to make the right decision for every patient that walks through the door, as I’m sure you MEANT it to say.

    • Anonymous

      Of course relevant history of severe illness is pertinent in a situation like yours.  Does everyone with viral-type symptoms need a CBC to look for a left shift?  Absolutely not, but someone with sepsis history might.  This is where evidence-based clinical guidelines need to be left at the door.

      No clinician of quality ignores the history a patient brings to the encounter. 

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    Reading through the various opinions is very distressing as a clinician. In my practice we take a thorough history and know our patients well. We try to treat appropriately based on what we are told and elicit during the history and what we find during the exam. We repeatedly read in our journals and are taught at conferences that the majority of upper respiratory infections are viral not bacterial and do not respond to antibiotics. We are continually warned about emerging bacterial resistance to overuse and mis- use of antibiotics and emergence of aggressive forms of antibiotic related colitis non responsive to conventional therapy. I use antibiotics in those with COPD or some measure of immune system compromise. It is usually a point of contention because even with a detailed explanation, handouts of educational material from the Center for Disease Control and NIH patients want what they want. I try to point out what situations would change my approach and try to leave the communication channels wide open by phone, cell phone, email etc. That must be the reason why I frequently receive a call the next day that the patient is not better yet. That calls for listening to the symptoms and complaints again, supporting the treatment regimen with facts and encouragement to the patient, being empathetic and sympathetic. I have read much on sinus infections despite thirty three years of practice and have seen twice in the past year a patient who I treated and my wife ( who has her own personal physician) go from having a viral upper respiratory infection into a prolonged infection requiring three weeks of antibiotics, decongestants, and steroids. It happens and there is no proof or evidence that starting an antibiotic on day one would have prevented these complications. Most of the physicians I know went into medicine to help people through prevention , education and treatment. We try to be perfect in our diagnosis and treatment but it is not yet an exact science. Despite what some on this board think, we hurt too when our patients are not getting better or develop   a complication. It calls for a re-evaluation of the facts each time to re-assess decision making but does not justify giving an antibiotic when it is not needed and risking ill effects of those medications. Respecting the human bodies ability to heal and first do no harm work for me.

  • Lynda Stidham

    Very well written, Dr Gibson. I have had some or all of that conversation hundreds of times in my 23 years of being a primary care pediatrician.  We must first do no harm, second provide reassurance, education and explanation, and third tell the patient what signs or symptoms neccesitate a phone call.  In pediatrics the vast majority of respiratory infections are viral and we must discern which kids might have a bacterial infection. Even bacterial infections do not require antibacterial treatment, as we have learned with acute otitis media (AOM).  70-80% of cases of AOM resolve without antibacterial treatment. The immune system really can do its job.

    Antibiotics are NOT harmless.  Inappropriate use leads to resistant super-germs, “allergic rashes” that are probably viral but lead to a lifetime label of antibiotic allergy, diarrhea (including C. diff)….

    Physicians must not become spineless when confronted by a demanding patient.  We must do the right thing even if it is tough.  If patients leave the practice then so be it. And how tragic is it that urgent care centers (and many ERs too) have become antibiotic vending machines—even with a negative rapid Strep test, even with a negative CXR.  Patients leave “happy” because they “left with something” but they don’t realize that they received poor care.

    What happened to the “common cold?”  Does anyone realize what the common cold experience is like? You feel crummy for 5-7 days. You cannot breathe through your nose. It’s tough to sleep.  It’s tough to work. But a cold is a viral sinusitis. (For several yrs now I explain that a cold is a viral sinusitis and will last upwards of 10-14 d. A bacterial sinusitis is a cold/cough that won’t go away.)  Antibiotics are NOT helpful or needed for a cold.

    European docs have been telling us for 25 yrs or so that we American docs use too many antibiotics. In Europe most cases of AOM + even bacterial sinusitis are not treated with antibiotics. And most kids get better!

    TY to all that have submitted their thoughts.  It’s interesting to see the range of comments.

  • Joe Kosterich

    Great post. The automatic assumption by some people is that they need an antibiotic. Being a doctor is not the same as being a salesperson who just fills orders.Hence refusing “orders” is good medical practice albeit not always easy.