Do Delayed Prescriptions Reduce the Use of Antibiotics for the Common Cold?

In April's Journal of Family Pracitce, this paper concludes that "Doctors often misinterpret patient expectations. Improving communications between patient and doctor may be central to reducing patients019 demand for antibiotics. "  I agree.  And I support the authors' efforts to determine if delayed prescriptions ("Take this in 3 days if you don't feel better") but I wonder about the mixed message that this sort of practice sends to the patient.  Since we know that patients can be treated safely with only symptomatic therapy, the delayed antibiotic prescription sends the message that antibiotics may in fact be indicated — even though we have already said that they are not.  Shouldn't we be consistent in our message?   My preference is to have the patient call or return to the office if their symptoms persist.  But since the average cold lasts 6 to 7 days … the patients will still have symptoms after 3 days … will take the antibiotics .. and then will feel better.  Patients (and perhaps even the physicians) will then assume that the temporal relatiohnship of the intervention and the resolution of the symptoms = causality.   But of course (as I discussed in the entry on circumcision a few weeks ago .. ) correlation does not = causality.

American Journal of Respiratory and Critical Care Medicine

Two interesting articles in this month's issue:

Erythromycin Inhibits Rhinovirus Infection in Cultured Human Tracheal Epithelial Cells

and

Intravenous Sildenafil Lowers Pulmonary Vascular Resistance in a Model of Neonatal Pulmonary Hypertension

Of course the latter paper will get more attention … though neither paper is patient oriented, and neither paper would change clinical practice at all.  The paper on erythromycin is a bit troubling to me .. as it is another piece of evidence that the use of antibiotics as anti-inflammatories may increase in the near future.  As UniSci news reports, there is much thought and research going into these ideas.

Benevolence in business?

In a report on the radio this morning, I heard mention of a John Steinbeck quote:

"It has always seemed strange to me," said Doc. "The things we admire in men, kindness and generosity, openness, honesty, understanding and feeling are the concomitants of failure in our system. And those traits we detest, sharpness, greed, acquisitiveness, meanness, egotism and self-interest are the traits of success. And while men admire the quality of the first they love the produce of the second."

Cannery Row by John Steinbeck

It is compelling to me that the features synonymous with success in business are in fact the "negative" traits outlined above, and yet the values we admire in health care (and other professions, in fact) are the "positive" ones.  Indeed, our primary goal in health care is to enhance the quality of the lives of others.   Perhaps this is why "business" skills & personalities in health care sometimes feel & taste like oil in our water.   Yet we can't balance our checkbooks with compassion & generosity.  Finding the balance between good business and simple good-ness is the challenge.  

Those of us bred and motivated by the generosity and benevolence so prevalent in health care will likely revert to these instincts … while those bred and motivated by the power, control, and "success" measures so prevalent in business and government may fall back into the patterns of competition and self-interest.  We both need to understand each other to work productively toward our common goals. 

Ambulatory Morning Report

In this paper, a few internists discover that the spectrum of cases in an ambulatory internal medicine practice is broad.   Let them spend a day in a family physician's office.  

 Today:

  • neonatal jaundice
  • normal pregnancy
  • sarcoid exacerbation
  • new dx – rheumatoid arthritis
  • asthma
  • allergic rhinitis
  • depression
  • knee pain
  • new patient – new dx HSV ("oh I just thought they were cold sores")
  • knee pain, back pain (ACL tear, DJD)
  • MVA – soft tissue injuries
  • depression
  • new patient – teenager (outgrew the pediatrician)
  • 9 month well-baby
  • CHF, HTN
  • HTN, hypercholesterolemia
  • URI
  • Diabetes, HTN
  • 1 year-old: Otitis Media