Sunday, March 2, 2014

Feed a Cold and Starve a Fever? Not on my Watch

Physicians and patients collaborate to treat symptoms.   This is not newsworthy and even sounds appropriate.  Isn’t that what doctors are trained to do?   It is but I’m not sure this should be a central focus of our healing mission.  Treating a symptom is not the same as treating a disease. 

For example,  if an individual is having abdominal discomfort, pain medicine should not be the first responder, even if this would bring the patient relief.  Physicians try to understand the cause of the pain which would then guide our therapeutic response. The treatment would differ substantially if the cause of the pain were appendicitis or an ulcer or a kidney stone.

Is Fever the Enemy?

Often symptoms are regarded as diseases themselves that need to be treated.   Over the years, I have been called by nurses hundreds of times to prescribe medicine for patients who were nauseated.  Nurses are exceptional professionals, but they are not physicians.   They are preoccupied with the patients’ comfort and welfare and are vigilant about symptomatic treatment of nausea, diarrhea, headaches, constipation and insomnia.   This is one reason, but not the only reason, that hospitalized patients routinely receive sleeping pills, Imodium, laxatives and acetaminophen.   Most of us at home do not reach for antacids or other symptomatic remedies as often as these elixirs are dispensed in the hospital, where the culture of medicating is more pervasive.  In fact, medical interns and residents often include several ‘standing orders’ for patients they admit to the hospital so that nurses will not have to contact them for advice if these common symptoms develop.  

Standing Orders

If patient develops constipation, then give laxative A.
If patient develops diarrhea from laxative A, then give Metamucil.
If patient develops gas and bloating from Metamucil, then give simethicone.
If simethicone does not relieve gas, then double the dose.
If patient complains that high dose simethicone is causing sleeplessness, then give sleeping pill Y.
If patient complains of lethargy after receiving sleeping pill Y…

Interns who didn’t use standing orders would be guaranteed to receive nurses’ pages around the clock alerting young, tired physicians with scores of symptoms to respond to.  Standing orders were an intern’s insurance policy against paging assault.  This collaboration between interns/residents and nurses is where we physicians first learned to pull the symptomatic trigger so reflexively.   I think even seasoned physicians often casually prescribe anti-nausea medicine rather than aim to understand the cause of the symptom.  It's a tidy response to nurse's concern about a patient, which is often relayed to the doctor after hours on the phone.

In addition, not every symptom should demand an immediate pharmacologic response.   Yet, in the hospital, and often in our offices, this may be our modus operandi.

And finally, are we so sure that symptoms should be squashed?   Why do we treat every fever, for example?   Could it be that fever, diarrhea or vomiting are actually bodily defense mechanisms that are combating disease and illness?  Could it be that an infected person develops a fever in order to make his body less hospitable to germs or to sharpen his immune system?   Are today’s medical professionals really much smarter that millions of years of natural selection?   Let’s dose ourselves with a tincture of humility.  We’re not all that smart.

Even writing about this stuff gets me worked up.  I feel some heartburn developing.   Where are my Tums?


  1. Dr Kirsch, you get a gold star for this one. You said it better than I ever could have.

    I agree totally with the need for humility, and for thinking twice before throwing monkey wrenches into biological systems that we may never completely understand.

  2. Oh my gosh--this drives me crazy. All the parents I see are told by the nurses to alternate acetaminophen and ibuprofen when their kids have a fever. Research shows this is not a good idea for several reasons. How about a little education on fevers? That's what I take the time to do in the office.

    Altho I do prescribe my share of ondansetron for gastroenteritis...get those kids rehydrated.

  3. Education in the office? Humility? Refreshing comments!

  4. At the age of 70+ I was glad to be woken and given sleeping medicine.
    Explaining poor sleep and even restless legs to a doctor is like talking to a wall.
    As well if symptoms are never to be treated by themselves I guarantee you will not be told of them .
    Doctors can be tiresome even if it is for our own good.
    ( and now I am nigh 80 so maybe I know something).