Why I Won't Prescribe You Antibiotics

At least a few times a year I am asked to prescribe antibiotics to people who are not my patients.  From my point of view, there is only one answer that makes sense here – no.   I have the same reaction when patients call me for a refill or advice when I have not seen them in a year or two.  The patient may feel that I will refill their heartburn medicine indefinitely without an office visit, but I won’t.  Once I hit the refill button, I am now totally responsible as the doctor. 

Patient Gets Medication Refill in 14th Century

The Patient’s Perspective

• I’ve been on the same medicine for 10 years and all I need is a refill.  I feel fine.
• I do not want to take time off work for an unnecessary appointment.
• Why should pay a copay when all I need is a refill?  Sounds like a rip off.

The Physician’s Perspective

• No refill until I verify that there are no concerning symptoms. A routine ‘heartburn patient’ may have developed some swallowing difficulties which could signal a serious medical condition.
• Pt may not need the same dosage of the medicine.
• Pt may not need the medicine at all.
• Pt may be on new medications which might impact on the decision to refill the heartburn drug.
• Pt may be overdue for a screening colonoscopy.
• Pt may have general medical issues and needs to be encouraged to follow up with the primary care physician.

It might be tempting for one of our staff to ask me for antibiotics because ‘I have another UTI’.  My secretary might hope that with one phone call, I can save her time and money.  While she may be an able secretary, she may be a lackluster diagnostician.  Many of my own patients come to my office ‘because their diverticulitis is back’.  While their symptoms may remind them of their first episode of ‘diverticulitis’ last year, often the actual medical evidence supporting the original diagnosis is rather thin.  I can’t count how many of these patients have never had diverticulitis. 

Prescribing you medication is a serious responsibility.  It’s not an act that should be casually done with a stroke of a pen, or these days, with a stroke of a key.  Wouldn’t you want all the odds to be in your favor? 

Why Doctors Won't Give Medical Advice

Doctors dispense medical advice.  That’s what we do.  Folks come to our office with various medical issues.  We talk to them.  We poke around some of their body parts.  Then, we exercise our medical judgement.  We might order a CAT scan.  We might prescribe stuff.  We might simply reassure them and send them on their way. This is a typical ‘day in the life’ of a health care provider, formerly known as a doctor. 

From time to time, folks solicit my advice under different circumstances.  Despite my efforts to keep my medical specialty stealth, sometimes the secret seeps out when I am in a social setting.

“Oh, you’re a gastro guy?  Would you mind if I asked you quick question about my husband?  He has a gas problem…”

I get questions like this all the time, and I do my best to respond in way that sounds authoritative, yet dispenses no legitimate medical advice.  Here are some examples of how I might respond to the above inquiry on spousal flatulence.

• “Yeah, if I had a dollar for every time someone asked me about their gas…”
• “Hmmm.  Sounds interesting.  Do you have any corks at home?”
• “Call the gas company.  When we had a gas leak in our house, they simply fixed the pipe with a blowtorch.  Maybe your husband has the same problem.”
• “I would call your husband’s doctor.  I suggest around midnight when you know he’ll be available.  Much better than calling during office hours and dealing with that office rat race.”
• “Are you sure it’s gas?  Have you heard about the light-a-match gas test?”
• “Your say your husband has gas?   You should hear what he told me about you!”

Cows pass methane orally and rectally

The point is that physicians generally defer from giving medical advice to folks who are not our patients.  Even a seemingly innocent query can have serious ramifications.  I would not want to give casual advice to non-patients who have questions about last month’s chest pain or if it’s safe to travel to South America before a cardiac stress test next month. 

This is not just true for doctors.  Try asking a financial planner you meet at a party if you should unload your stocks based on the market’s behavior that day.  Ask an attorney who does not represent you if he thinks you are better off settling your case or proceeding to trial. 

Professionals cannot be flip about rendering advice, particularly to strangers.  Consider this hypothetical.  I’m out to dinner and my friend’s wife, who is not my patient, asks if she should double up on her Nexium because she’s still getting heartburn.  I say yes.  But what she thinks is heartburn is really angina.  My casual remark may make me an accomplice to a catastrophe. 

So, don’t ask me about your husband’s flatulence if he’s not my patient.  Bring him and his gas to my office and we will do our best to deflate the situation.

What Makes a Good Doctor. You Be The Judge

I’ve delved into the issue of medical judgment more than once on this blog.  I have argued that sound judgment is more important than medical knowledge.  If one has a knowledge deficit, assuming he is aware of this, it is easily remedied.  A judgment deficiency, per contra, is more difficult to fix.  Who doesn’t think he has good judgment?

For example, if a physician cannot recall if generalized itchiness can be a sign of serious liver disease, he can look this up.  If, however, a doctor is deciding if surgery for a patient is necessary, and when the operation should occur, this is not as easily determined.  Medical judgment is a murky issue and often creates controversies in patient care.  Competent physicians who are presented with the same set of medical facts may offer divergent recommendations because they judge the situation differently.  Each of their recommendations may be rationale and defensible, which can be bewildering for patients and their families.  This is one of the dangers of seeking a second opinion, as this opinion may be different, but not superior to the first one.  Patients have a bias favoring second opinions as they harbor dissatisfaction, or at least skepticism, with the original medical advice.  

Whose Advice Carries More Weight?

Here are some scenarios which should be governed by medical judgment.

• A 60-year-old woman with severe emphysema uses an oxygen tank.  She has never had a screening colonoscopy.  Professional guidelines suggest that screening begin at age 50.  Does a screening colonoscopy make sense for her considering her impaired health?
• A 40-year-old man has had 1 week of stomach pain.  This started 10 days after he took daily ibuprofen for a sprained knee.  The physician suspects that he might have an ulcer.  Should this patient undergo a scope examination to make a definite diagnosis?  Should the doctor prescribe anti-ulcer medication without determining if an ulcer is present?  Should the ibuprofen be stopped if the patient states he has significant pain if he does not take it? 
• An 80-year-old woman had some recent dizziness and nearly fainted.  The doctor sees her in the office two days later and questions her carefully.  He suspects that the patient was simply dehydrated.  Should the doctor simply reassure the patient or arrange for a neurologic evaluation to make sure that a more serious condition is lurking? 

Of course, you want your doctor to know a lot of stuff.  More importantly, you need a physician who can give you sound and sober advice.  Knowledge and scholarship are important physician attributes, but practicing medicine demands more.  At least, that’s my judgment.  What do you think?

Do You Really Need Plastic Surgery?

We live in an era where plastic surgery is routine.   Indeed, in many parts of the country, plastic surgery is an expected rite of passage.   Years ago, face lifts and ‘tummy tucks’ were done on those in middle age who were trying to experience a surgical time machine.  Now, folks in their 20’s are having all kinds of work done, not to recreate a prior image, but to create a new one.

The traditional scalpel in only one of many tools used to perform body design work.  There is a smorgasbord of injectable fillers that plastic surgeons, dermatologists and other physicians provide to a public who is zealously combating every wrinkle.  Once a person is of the mindset that the only good wrinkle is a dead wrinkle, he will commit yourself to a lifelong odyssey of cosmetic work.  These folks are generally never fully satisfied with how they look.  They are always finding imperfections that they target for correction.
D

I enthusiastically recommend readers to read Nathaniel Hawthorne’s short story, The Birthmark, which speaks so elegantly to this issue, despite that it was published in 1843.

There is an important role for plastic surgery in the medical arena.  These talented professionals perform amazing work in reconstructing folks who have suffered trauma and accidents.  I also recognize that cosmetic surgery provides significant benefits to many patients.  However, it is beyond dispute that our society is preoccupied with physical appearance and is striving for an idealized an unrealistic level of beauty.   Many folks blame Barbie who convinced generations of girls and women that she was the paragon of beauty and attractiveness.   

Ladies, slip into these comfy slippers!

A few days before I penned this post, I read about women who bring designer shoes to podiatrists so they can have surgery that will permit them to wear their choice of stylish footwear.   Indeed, there are foot surgeons who specialize in these procedures.   My reaction?  Outrageous.   We’re not referring here to correcting podiatric deformities.   Can a doctor defend performing surgery on healthy feet so that a pair of shoes, probably not designed for a human, can fit in?  I am sure that there are analogous absurd examples of surgeries and procedures involving other body parts that should embarrass the medical profession.

Patient demand doesn’t justify medical excess.   Physicians need to call out abuses in our own house.  I expect that those practitioners who are bringing disrepute to the profession will claim that they are fulfilling an important medical function.  I say, if the shoe fits…

Physicians and the Art and Power of Observation - Has This Bird Flown?

Medicine is for the birds, or it should be.  Hear me out.

A day before I wrote this, I was on the trail in northwest Ohio, binoculars in hand, trying to tell one warbler from another.  This was the final weekend of The Biggest Week of birding in Magee Marsh on the shore of Lake Erie.  Birders converged here from neighboring states and even from foreign countries to participate in this ornithological adventure.  My companion and I were new to the game.  Indeed, my birdwatching prowess had consisted of being able to successfully identify a blue jay at the feeder on our deck.  I had now entered a different universe.

There were serious birders afoot equipped with photographic and telegraphic equipment that looked like stuff that James Bond might have used.  Birds flitted about that heretofore would have generated no interest on my part.  When a rare warbler was spotted, the excitement raced through the birders like a brushfire, causing a crowd to gather to view the feathered phenom.  And, there were polite disputes among experts who were debating the true identity of the creature before them.  All in all, this was good clean fun.

Birders need knowledge and patience.  In addition, the most accomplished among them must have discerning powers of observation.  Here’s how I spotted a bird.  I simply came upon real birders who were all aiming their scopes and binoculars in one direction, and then tried to spy their target.  The skilled birder, the first on the scene, does not have this advantage.  He carefully scans the trees and foliage trying to find small birds, which are obscured by leaves and branches or camouflaged.  This looks easy, but it isn’t.  Many times, I had trouble finding the bird even when several birders next to me were staring at it.  This didn’t ruffle my feathers as I knew I was a few rungs below the beginner class.

You have to know what to look for, which is the distinguishing skill.  The pro knows the flora and which birds are likely to hang out there.  He sees the subtle moving of a small branch and knows this is not from the wind.  He knows the birds’ voices as individual arias, not as idle whistling.  He tunes out the visual and auditory static.

Easy to Spot 

Not so Easy

The power of observation used to be a honed skill of the medical profession.  Prior to the takeover of the profession by medical technology, physicians could deduce much simply by carefully observing the patient.  While medical educators may state that this skill is still valued, taught and practiced, this quixotic view isn’t part of the reality of medical practice today.  During my days in medical school, I recall learning from experts who could ascertain important medical information by examining a patient’s fingernails.  Palpating the pulse, and appreciating its nuances and subtleties, was an art, and not simply a means of determining the heart rate.  As a medical student, I watched Proctor Harvey, a giant in cardiology, use a stethoscope to hear sounds and make accurate diagnoses that are beyond the skills of nearly all of today’s physicians.   A patient’s speech, gait and skin often held important clinical clues for the physician detective.

I don’t’ think that medical quality is worse today because today’s physicians are not trained to observe.  Instead of observing, we test.   Nearly every heart murmur is subjected to echocardiography, as but one example.  The consequences of overtesting has been overblogged here at MDWhistleblower.  Readers know my serious concerns about overdiagnosis andovertreatment. Technology has both raised and lowered medical quality in this country.

I am wistful when I recall physicians and teachers from two generations ago, who could solve a case with their eyes and ears.  They would have been incredible birdwatchers. 

Colonic Hydrotherapy. Is it Time to Bend Over?

From time to time, patients asks my advice on colonic hydrotherapy, vigorous sessions of enemas that aim to cleanse the body of toxins that are reputed to cause a variety of ailments.   The logic sounds plausible to interested patients.  Over time, toxins accumulate and leech into the body wreaking havoc.  Indeed, using the label ‘toxins’ already suggests that these are noxious agents.  If one accepts this premise, it is entirely logical that cleansing the body of these injurious agents would have a salutary effect.

Not surprisingly, the health benefits of hydrotherapy usually target very stubborn and vague symptoms and conditions that conventional medicine do not treat adequately.  It makes sense that if your own physician is not making sense of your chronic fatigue, for example, that you would entertain other options.  I get this.  Who wouldn’t want to enjoy having more energy, better concentration, an enhanced immune system or delayed aging?  But, in medicine and in life, just because one pathway seems blocked, doesn’t mean that an alternative pathway will be a better avenue. 

Let the Cleansing Begin!

The reason that I do no actively recommend hydrotherapy is because there is absolutely no persuasive and credible medical evidence that it is effective.  While their advertising materials may boast of ‘clinical studies’, there is no firm scientific basis for their claims.  And, these sessions can be costly as patients are often advised that several visits are necessary to address years of toxin build up.

If gastroenterologists did believe that the treatment works, we would be offering it in our ambulatory surgery centers along with our standard endoscopic amusement activities.  (A cynic might suggest here that if medical insurance covered these treatments, then we would!) 

It may very well be that practitioners of this treatment believe in the therapy and genuinely want to provide healing.  And, I have no doubt that many who undergo hydrotherapy feel better.  I’ll never talk a patient out of success from my or anyone’s treatment.  If a hydrotherapy patient were to tell me that his depression has eased, I would express great satisfaction over this.

I admit readily that I, along with every other breathing physician, prescribe treatments and remedies for which no supportive medical evidence exists.   We physicians may sanitize this fact by claiming that our action is an example of ‘the art of medicine’, but we are more likely hoping for the placebo effect.  

Physicians who deviate from evidence-based medicine shouldn’t casually criticize other practitioners who practice off the grid, particularly when patients have great faith in complimentary and integrative medicine.

However, all of us who claim to be healers should aspire for supportive scientific evidence for our recommendations, and we should admit to patients when such evidence is lacking. 

If you opt for periodic colonic cleanses, and you perceive a personal benefit, then be aware that you are engaging in an ‘art’, and not a science.  

Treatment for Diverticulitis Revisited

Is there stuff that you do just because that’s the way you’ve always done it?   I’ll answer for you – yes.

In many circumstances, this makes sense.  For example, I stop my car at red lights just as I have always done.  I recommend that readers do the same as there is an underlying logic for this recommendation.  It is not simply a rote routine that has no rationale.   However, the particular order that we pour ingredients into a pot when making soup, may be more random than rational.   We follow the same order we always have, never pausing to wonder why or if there might be a better way.

And, so it is with many practices and procedures in the medical profession. Let’s return to the medical condition of diverticulitis, which I presented on this blog recently.  Follow the link, if interested.

For the last several decades, this disease has been treated in the same way – with antibiotics.  This means that physicians believe this to be an infectious disease – like strep throat – caused by bacteria.  But, the real reason I think that physicians like me prescribe antibiotics for this condition as because that’s the way we’ve always done it.

Changing established medical practices is like having an ocean liner make a U-turn.  It’s not easy.  For example, when I was a medical student, kids with red ear drums, or otitis, were routinely given antibiotics, assuming that this was a bacterial infection.  But, after a few decades, experts concluded otherwise.

Not Easy to Make a U-Turn

Similarly, I have a strong sense that the established treatment for diverticulitis may be revised.   The classic understanding of this disease was that this was a bacterial infection in the wall of the colon.  The theory was that a tiny puncture would develop in one of the diverticula, which are pouches that are weak points in the colon.  Germs from inside the colon would travel through the puncture site to the outside wall of the colon, which is usually sterile, and an infection would start.  We prescribe antibiotics and the patients generally recover well. 

But, should the antibiotics really get the credit?  What if these patients would have recovered anyway on their own?  I believe many of them would have.   In fact, many patients who have had diverticulitis, often have had episodes that recovered spontaneously without having seen a physician. 

In fact, a prominent gastroenterology professional society recently issued guidelines that expressed that not every case of diverticulitis requires antibiotic treatment.   It may take another 10 years for this recommendation to gain traction. 

I’m not abandoning antibiotics for diverticulitis in my practice yet.  But, I am following the issue closely in the journals.  There needs to be a better reason to do stuff than simple habit and routine – and that includes reading this blog.