Joe was an average guy
When Joe visited Maggie Mae, he felt that he should bring an engagement ring. He didn't
want his daughters to see it so he took it out of its box and wraped in up tight in some foil to
protect it and put it in his pocket.
Later on, he had a dream in which he saw Maggie Mae rummaging through his suitcase
looking for a ring. Would she actually do such a thing? Some dreams reveal truth and some
are pure fantasy. Who is to know?
Joe was told by a waitress to be careful how he threw his money around. He left big tips which
was fine if you are the waitress concerned, but he ran into a waitress who wanted his money
and seduced him in order to get his money. He took the children and ran.
She knew that he could see through walls and yet she still rummaged through his suitcase to
look for the engagement ring. Why would she want to leave such a poor impression of herself
with him? He couldn't understand how her mind worked in this instance.
On another occasion, she lied to him complete with all of the body language of a lie. Why
would someone tell a lie and signal it so clearly? It is like announcing to the world, "I am a liar
and proud of it." Her mother was into bold faced lies. Again, you could tell she was lying.
People were simply too polite to tell her to her face that they knew she was lying. Not sure of
the motivation that either one of them had. When one lies, it is like telling the listener that they
are too stupid to notice the lie.
Maggie Mae was a family physicians and like most family docs, she over-prescribed antibiotics.
The resultant domination of drug resistant bacteria in the patients obviously left them more
susecptable to problems for up to one year. Joe thought that it would be difficult for him to live
with a "Quaker" who practiced germ warfare.
medical examiner
The Pink-Bubble-Gum- Flavored Dilemma
Why doctors give out antibiotics you don't need.
By Zachary Meisel
Posted Wednesday, May 21, 2008, at 3:21 PM ET
While working a busy night shift in the ER recently, I evaluated a 13-month-old girl. On her
chart, the triage nurse had written: "Infant with fever and runny nose. Mother here for
antibiotics." The baby was fussy but probably more tired than uncomfortable. Between her
squirms, she cooed and smiled at me. Her anxious and upset mother, however, was in far
worse shape, repeatedly sticking a rubber bulb syringe up her infant's nostrils in a futile
attempt to suck out an endless stream of snot. The mom was also really mad: She had been
waiting for more than three hours for a doctor to see her daughter. Now she wanted
antibiotics: specifically, a prescription for bubble-gum-flavored amoxicillin.
By my assessment, the child was not acutely ill: She'd had a low-grade fever for two days, her
mother! said, and a mild cough, but she had clear lungs and appeared well-hydrated. Her
eardrum may have had some fluid behind it but wasn't red or bulging. Just as the baby was
trying to put my stethoscope in her mouth, paramedics pushed through the ambulance doors
with a patient who was having an acute stroke. I had to decide right then if I was going to give
this mother the antibiotics she wanted, even though I thought her daughter probably didn't
need them.
The profligate prescription of antibiotics—for children and adults with upper respiratory
infections, sinus infections, and even middle-ear infections—is a problem because most of
these illnesses are caused by viruses, not bacteria, which are what conventional antibiotics
attack. Of more concern is the direct connection between antibiotic use and the emergence of
drug-resistant "superbugs": As the medicine eliminates germs that are sensitive to it, drug-
resistant mutant strains prosper. The result is a major publi! c-health problem. Antibiotic-
resistant infections such as methicillin-resistant Staphylococcus aureus may cause more
deaths in the United States than AIDS does.
In the doctor's office or the ER, it's hard to tell the difference between bacterial and viral
infections, and so doctors are tempted to prescribe antibiotics whenever they're unsure.
That's especially true when doctors think that patients expect to take the medicine home,
according to a recent study. Investigators interviewed patients with respiratory infections who
went to the ER in 10 hospitals affiliated with medical schools, asking whether the patients
expected to receive antibiotics and about whether they were satisfied with the care they
received when they were discharged. The researchers also asked physicians why they
prescri! bed antibiotics. The main conclusion was that doctors were significantly more likely to
prescribe if they believed that patients expected them to—but did a lousy job predicting which
patients those actually were. And the patients most satisfied with their care were the ones who
left the ER with a better understanding of their condition, antibiotics or no antibiotics. The take-
home message for doctors like me: Spend an extra five minutes talking to your patients about
their medical problems, and you can send them away happy and without unnecessary
medicine.
So once doctors absorb the result of this study and similar investigations, will they write fewer
prescriptions? I bet not. To give out fewer antibiotics, the doctors will have to believe that their
patients won't benefit from them. If you look closely at the ER study, 73 percent of the patients
who received antibiotics for acute bronchitis had illnesses that were either deemed by their
doctors to have likely been! caused by a bacteria or to have origins that were in that gray toss-
u p area between a bacteria and a virus. If the doctors were right, and these were bacterial
infections, they would, in fact, warrant antibiotics. Also, in many of these cases, the doctors
gave other persuasive reasons for choosing antibiotics, including "ill appearance of the
patient" and "concern about follow-up."
In my ER world, these factors, if intangible, are understood to be really important in helping us
decide how to treat patients. The real dilemma of antibiotic prescriptions is that the most
serious consequence for writing them unnecessarily is not a risk to the individual patient but
the emergence of the superbugs that pose a risk to public health in general.
Nowhere is this tension between individual care and public health greater than in the ER.
Office-based cultures for bacterial infections, which take days to turn around, are not feasible
in what we call "th! e trenches." And because follow-up can never be assured, it's hard to
follow recommendations such as those of the American Academy of Pediatrics, which
advocates "watch and wait" for 48 to 72 hours for children with middle-ear infections rather
than an immediate dose of antibiotics. If we overprescribe antibiotics in the ER, that's because
in the trenches the care of one patient often trumps the care of the public. Maybe that's
myopic, but there you have it. And it is why efforts to reduce antibiotic use by giving out more
information about resistant infections or teaching doctors how to manage patient expectations
may ultimately fall flat.
In the end, I did not prescribe antibiotics for the 13-month-old baby. Instead, I took the time to
explain thoroughly why I didn't think she needed them (while my colleague took care of the
stroke patient). But no matter what that study says, that mother l! eft in a huff— highly
dissatisfied, I can assure you. I'm not sure w hat I'll do the next time I see a similar case.
Perhaps I will refuse to write the prescription again, notching another victory for public health.
But, for all I know, something intangible will be different: Perhaps the kid just won't look right,
or maybe the mother or father will seem too disorganized to be relied on to return if the kid
worsens. And that may persuade me to send them home with a bottle of pink-bubble-gum-
flavored amoxicillin. It's likely that the fussy kid and his parents won't sleep any better that
night. But I will.
http://www.slate.com/id/2191908/
Next
When Joe visited Maggie Mae, he felt that he should bring an engagement ring. He didn't
want his daughters to see it so he took it out of its box and wraped in up tight in some foil to
protect it and put it in his pocket.
Later on, he had a dream in which he saw Maggie Mae rummaging through his suitcase
looking for a ring. Would she actually do such a thing? Some dreams reveal truth and some
are pure fantasy. Who is to know?
Joe was told by a waitress to be careful how he threw his money around. He left big tips which
was fine if you are the waitress concerned, but he ran into a waitress who wanted his money
and seduced him in order to get his money. He took the children and ran.
She knew that he could see through walls and yet she still rummaged through his suitcase to
look for the engagement ring. Why would she want to leave such a poor impression of herself
with him? He couldn't understand how her mind worked in this instance.
On another occasion, she lied to him complete with all of the body language of a lie. Why
would someone tell a lie and signal it so clearly? It is like announcing to the world, "I am a liar
and proud of it." Her mother was into bold faced lies. Again, you could tell she was lying.
People were simply too polite to tell her to her face that they knew she was lying. Not sure of
the motivation that either one of them had. When one lies, it is like telling the listener that they
are too stupid to notice the lie.
Maggie Mae was a family physicians and like most family docs, she over-prescribed antibiotics.
The resultant domination of drug resistant bacteria in the patients obviously left them more
susecptable to problems for up to one year. Joe thought that it would be difficult for him to live
with a "Quaker" who practiced germ warfare.
medical examiner
The Pink-Bubble-Gum- Flavored Dilemma
Why doctors give out antibiotics you don't need.
By Zachary Meisel
Posted Wednesday, May 21, 2008, at 3:21 PM ET
While working a busy night shift in the ER recently, I evaluated a 13-month-old girl. On her
chart, the triage nurse had written: "Infant with fever and runny nose. Mother here for
antibiotics." The baby was fussy but probably more tired than uncomfortable. Between her
squirms, she cooed and smiled at me. Her anxious and upset mother, however, was in far
worse shape, repeatedly sticking a rubber bulb syringe up her infant's nostrils in a futile
attempt to suck out an endless stream of snot. The mom was also really mad: She had been
waiting for more than three hours for a doctor to see her daughter. Now she wanted
antibiotics: specifically, a prescription for bubble-gum-flavored amoxicillin.
By my assessment, the child was not acutely ill: She'd had a low-grade fever for two days, her
mother! said, and a mild cough, but she had clear lungs and appeared well-hydrated. Her
eardrum may have had some fluid behind it but wasn't red or bulging. Just as the baby was
trying to put my stethoscope in her mouth, paramedics pushed through the ambulance doors
with a patient who was having an acute stroke. I had to decide right then if I was going to give
this mother the antibiotics she wanted, even though I thought her daughter probably didn't
need them.
The profligate prescription of antibiotics—for children and adults with upper respiratory
infections, sinus infections, and even middle-ear infections—is a problem because most of
these illnesses are caused by viruses, not bacteria, which are what conventional antibiotics
attack. Of more concern is the direct connection between antibiotic use and the emergence of
drug-resistant "superbugs": As the medicine eliminates germs that are sensitive to it, drug-
resistant mutant strains prosper. The result is a major publi! c-health problem. Antibiotic-
resistant infections such as methicillin-resistant Staphylococcus aureus may cause more
deaths in the United States than AIDS does.
In the doctor's office or the ER, it's hard to tell the difference between bacterial and viral
infections, and so doctors are tempted to prescribe antibiotics whenever they're unsure.
That's especially true when doctors think that patients expect to take the medicine home,
according to a recent study. Investigators interviewed patients with respiratory infections who
went to the ER in 10 hospitals affiliated with medical schools, asking whether the patients
expected to receive antibiotics and about whether they were satisfied with the care they
received when they were discharged. The researchers also asked physicians why they
prescri! bed antibiotics. The main conclusion was that doctors were significantly more likely to
prescribe if they believed that patients expected them to—but did a lousy job predicting which
patients those actually were. And the patients most satisfied with their care were the ones who
left the ER with a better understanding of their condition, antibiotics or no antibiotics. The take-
home message for doctors like me: Spend an extra five minutes talking to your patients about
their medical problems, and you can send them away happy and without unnecessary
medicine.
So once doctors absorb the result of this study and similar investigations, will they write fewer
prescriptions? I bet not. To give out fewer antibiotics, the doctors will have to believe that their
patients won't benefit from them. If you look closely at the ER study, 73 percent of the patients
who received antibiotics for acute bronchitis had illnesses that were either deemed by their
doctors to have likely been! caused by a bacteria or to have origins that were in that gray toss-
u p area between a bacteria and a virus. If the doctors were right, and these were bacterial
infections, they would, in fact, warrant antibiotics. Also, in many of these cases, the doctors
gave other persuasive reasons for choosing antibiotics, including "ill appearance of the
patient" and "concern about follow-up."
In my ER world, these factors, if intangible, are understood to be really important in helping us
decide how to treat patients. The real dilemma of antibiotic prescriptions is that the most
serious consequence for writing them unnecessarily is not a risk to the individual patient but
the emergence of the superbugs that pose a risk to public health in general.
Nowhere is this tension between individual care and public health greater than in the ER.
Office-based cultures for bacterial infections, which take days to turn around, are not feasible
in what we call "th! e trenches." And because follow-up can never be assured, it's hard to
follow recommendations such as those of the American Academy of Pediatrics, which
advocates "watch and wait" for 48 to 72 hours for children with middle-ear infections rather
than an immediate dose of antibiotics. If we overprescribe antibiotics in the ER, that's because
in the trenches the care of one patient often trumps the care of the public. Maybe that's
myopic, but there you have it. And it is why efforts to reduce antibiotic use by giving out more
information about resistant infections or teaching doctors how to manage patient expectations
may ultimately fall flat.
In the end, I did not prescribe antibiotics for the 13-month-old baby. Instead, I took the time to
explain thoroughly why I didn't think she needed them (while my colleague took care of the
stroke patient). But no matter what that study says, that mother l! eft in a huff— highly
dissatisfied, I can assure you. I'm not sure w hat I'll do the next time I see a similar case.
Perhaps I will refuse to write the prescription again, notching another victory for public health.
But, for all I know, something intangible will be different: Perhaps the kid just won't look right,
or maybe the mother or father will seem too disorganized to be relied on to return if the kid
worsens. And that may persuade me to send them home with a bottle of pink-bubble-gum-
flavored amoxicillin. It's likely that the fussy kid and his parents won't sleep any better that
night. But I will.
http://www.slate.com/id/2191908/
Next
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