Antibiotics for your viral cold: Why it’s hard to do the right thing

Antibiotics for your viral cold: Why its hard to do the right thing

Winter is officially here and  we are in the cold and flu season.  This is the time that patients get sick with viral illnesses and primary care doctors get even more frustrated as they try to do the right thing for patients.  What is the right thing?

First of all we want to relieve suffering.  But we also want to do that without causing harm.  We  want to practice the best evidence-based medicine.  And evidence shows us that antibiotics and extra testing does not help the time course of a virus.  In fact, overuse of antibiotics drives drug resistance, increases the overall cost of health care and causes unintended side effects.

I’ve seen comments on the internet that doctors are part of the “business of medicine” and they order tests and use “big pharma” drugs so they can “make money”.  Well, folks, primary care doctors make no money ordering tests or prescribing drugs.

Zero!  In fact, it actually costs us money to do both.  Blood and imaging tests (x-rays) require documentation, follow-up,  time informing patients and can even lead to more testing if something is “borderline”.  We don’t get a dime for this time consuming work that occurs after the patient is long gone from the exam room.

But even with the extra time it takes to order and follow-up on tests and order prescriptions, it takes even more time to explain to a patient why these things are not needed for a viral illness.

Believe me, I get it.  I know how miserable a virus makes you.  I know how nights are worse and how hard it is to sleep with a sore throat or congestion.  I also understand the false hope that taking a pill will make it all better in a day or two.  I know we all want instant cures.   Here is how a typical scenario goes … usually on a weekend phone call:

“Doctor, I really need to be on an antibiotic.  I get sinus infections every year and I’m congested now and last night my throat was burning and I couldn’t swallow and I couldn’t sleep all night long  and I just know this will turn into a sinus infection because I get them every year and I need something called in RIGHT AWAY because I have to go to New York on business on Thursday and I just can’t be sick”.

This phone call will take about 20 minutes because I will get more details and then explain, as kindly as I can,  that this illness will probably last 7-10 days no matter what we do.  I will offer my suggestions for comfort care, rest, pain relief and natural healing methods and the opportunity to re-evaluate if things get worse.

At the end of this phone call, the patient is usually frustrated and may be even angry with me because they really don’t believe what I have said and they really do feel miserable.

This scenario plays out multiple times, day in and day out during the winter season.  Sometimes I just give in and prescribe the antibiotic.  I can only try to do the right thing so long.

Toni Brayer is an internal medicine physician who blogs at EverythingHealth.

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  • doc99

    If you don’t write that Rx, your Healthgrades score suffers.

  • Marcus

    That’s why I stopped caring about patient health a long time ago…I just give the patient what he / she wants. Why should I care if a patient wants to harm themselves with antibiotics? I don’t have enough time to properly educate people…I can move on, the patient thinks I’ve done the right thing, the patient eventually gets better anyway. Everyone comes out smelling like a rose. When later they get IBD because they’ve done this twice a year for 10+ years, they’ll NEVER trace it back to me. I look like the good guy! Watch those satisfaction scores go up!

    I will plainly ask someone, “Will you be disappointed if you don’t leave with antibiotics?” The ones who are more evolved and say “no” or ask to be educated, I’ll spend time with them. I’ll do it *gladly*. But if they expect it, they WILL think you did the wrong thing (“I’m going to go somewhere where someone will DO something”), and if they get a bacterial superinfection…guess where the blame will be?

    Doing what’s best for ignorant patients is just NOT worth it. Taking the time to educate them is also not worth it; most people don’t want to be educated (they feel miserable), and will just find someone else who will give them what they want.

    What I hate is when a patient comes in and has heard from a non-clinician that they might have a “resistant germ”. Once I had a guy who had a sore throat x 2d, heard a co-worker’s relative had strep, demanded abx from urgent care (and got them despite rapid strep and Cx being negative), then came to me when his sore throat wasn’t better (improving @ day 5 but not gone). Mind you, he was already ON abx at the time. He says, “someone told me I could have a resistant germ,” and demanded the “second line treatment” for strep. Would not take no for an answer, would not leave the clinic after I tried to educate / reassure him until I wrote him for yet another abx on top of the one he was taking.

    This is a grown, 40+ year old man. A hypertensive man who would not return for lab review, would not take his BP meds or monitor his BP, would not take his lipid meds (“I’m not a medicine guy”) and would not follow up unless he was in pain.

    I of course documented the harm he was potentially doing to himself and made him “verbalize understanding and agreement” and move on. I have too little time and too many patients to fight the fight.

    • buzzkillersmith

      The guy in paragraph 4: Fire him!! 30 days notice., move on. “Perhaps, sir, you would get along better with a different doctor.” Don’t let the exam room door hit you in the backside!

      Unless you work for corpmed (see my reply to Brayer above), in which case you too are lost and need to find a new job.

    • Beau Ellenbecker

      Its not just doing what’s best for the patient, its whats doing best for everyone. By providing people with obvious viral illness antibiotics you are vastly increasing the likelihood of side effects, antibiotic resistance growth, and reinforcing that behavior.

      Try offering to let them call in if not improving in 36 hours. They save a 2nd copay but still have access to the ABX if they need it. I do this often, find very few patients actually do call and don’t believe I am losing patients because of it.

  • Homeless

    If I want antibiotics, I pay a doctor to prescribe them. If I don’t want antibiotic, I don’t pay a doctor. How is it that doctors don’t benefit from writing prescriptions?

  • PcpMD

    Common problem in primary care, to be sure. I find that the following helps:

    - if its my own patient, and they’ve known me over time, they’re much more receptive to “watchful waiting” and non-antibiotic therapies. It also helps that they know they can get a hold of me easily if things go south (email, phone visit, office visit, whatever works best for them)

    - if they’re miserable, I offer them SOMETHING. Even if its ibuprofen for the killer sinus headache, viscous lidocaine for the painful viral pharyngitis, or a cough med to provide some relief and sleep at night. This both tells them that I’m interested in helping them, and reinforces that I’m not opposed to helpful prescriptions, just non-helpful or harmful ones.

    - For my more trusted patients, I’ll give them a written prescription for antibiotics, and ask them to fold it up and put it in their purse/wallet. I ask them to only fill it if they’re not getting better in ___ days (whatever I think is reasonable). I’ve been surprised at how infrequently they fill it. It seems to provide them with peace of mind, knowing that there’s a backup plan.

    - For prolonged viral URI’s with lots of chest congestion and coughing, I often find that a steroid inhaler provides considerable relief. The down side is that its a ~ $70 hit to the health-care system for each fill.

    These don’t work all of the time, but they do often help. Also, it seems that more patients are getting the message about viral vs bacterial URI’s, and this conversation seems to be getting EASIER each year.

    • buzzkillersmith

      Excellent post. I often do the same stuff. Agree that steroid inhalers for post-bronchitis syndrome do cost a bit, though.

    • Beau Ellenbecker

      I often use oral steroids for bad bronchitis/post viral cough. Do you find the inhaler is better? Evidence seems to be indifferent on the oral but I don’t think their is a good study on the inhaled

  • Rachel Bowman

    You don’t pay doctor for the antibiotics prescription!!! You pay the doctor for his or her years of training, the brain power to KNOW if you need antibiotics or not! Antibiotics can have dangerous side effects, cause allergic reactions, and create resistant bacteria. You should ask doctors how often they take antibiotics… I believe we all practice what we preach when it comes to that one.

  • buzzkillersmith

    I don’t buy it. I takes me a lot less time to explain that the disease is viral. “You don’t need strep test because your throat looks fine.” “No, you don’t have bacterial sinusitis. You have only been sick for a few days. Antibiotics aren’t going to help and might give you diarrhea ( no one likes the big bad D). Call me in a week if you’re not better.” “Great news! You’re going to get better on your own. ” Give a sore throat handout and an ibuprofen/acetaminophen handout. No strep test, no CXR, no antibiotics. On to the next case.
    20 minutes for a phone call about a cold?! Come on. Are you working for corpmed, where pt satisfaction surveys control your life? If so, you are lost. Get another job.

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  • Beau Ellenbecker

    “I’ve seen comments on the internet that doctors are part of the “business of medicine” and they order tests and use “big pharma” drugs so they can “make money”. Well, folks, primary care doctors make no money ordering tests or prescribing drugs.

    Zero! In fact, it actually costs us money to do both.”

    Sorry, but that is just plain wrong. I just moved from a military environment to a civilian one. I am now dealing with the “cost of medicine”. I know many other physicians in my area that order Flu tests left and right despite it not clinically altering their treatment plan. Why? Because insurers pay up to $150 for a combo Flu A/B test. The actual testing material costs about $13. So many of the doctors around me are making an extra $133 for every patient that comes in the Fever and body aches.

    I don’t order them often, but I can see the appeal from my pocket book side.

    Still don’t pass off testing as not being a benefit to some providers. I know numerous providers that bill for all kinds of stuff that they don’t need. EKG’s on every physical, yearly spirometry testing etc…

    • southerndoc1

      As always, the question is why are some insurers so stupid as to pay $150 for a ten dollar test?

  • Harry wingate

    Check out the CDC’s “Get Smart Campaign”. Has a lot of useful info you can share with patient re viral URI’s. I use a “WASP” Rx approach for those who insist.

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