Easy or Hard?

Let's play "easy or hard." What would you do?
1. Mom brings in a 2-year old girl. The girl has been having a green runny nose for three days. She has been running a low grade fever (under 100). She is eating (though not as much as usual), sleeping, and still playing. She also attends daycare. Physical exam reveals mild nasal congestion; lungs are clear, eardrums look normal. Do you:
a) (Easy) prescribe amoxicillin for "sinusitis" so she can go back to day care and prevent mom from calling you in 3 days to say, "she's still not better!"
b) (Hard) let mom know that green rhinorrhea does not necessarily mean a bacterial infection, particularly in an upper respiratory infection of a few days with no other significant symptoms (e.g., fever, lethargy, findings on physical exam); explain that antibiotics are not indicated, discuss the role of over-the-counter remedies, encourage fluids, rest, nasal saline drops, and a humidifier or vaporizer; and ask that the mom call back in a few days if symptoms have not improved or if she is worsening.

2. Dad brings in a 6-year old boy. The boy was reportedly diagnosed with asthma by another pediatrician 4 years ago. He takes albuterol in a nebulizer when he gets sick. His "breathing attacks" consist of a junky rattle in his chest with coughing. He has no problems with breathing or coughing when he is not sick. He is now out of albuterol and wants a refill. On exam, his lungs are clear. Do you:
a) (Easy) write the refill and send them on their way
b) (Hard) explain that his current condition sounds more like a simple cold than an asthma attack; advise the father to use a humidifier at nighttime, watch the child's breathing for signs of retractions or respiratory distress; educate about the side effects of albuterol; and hold the refill unless symptoms change or progress
c) (Very Hard) same as "b" but also perform pulmonary function tests in your office to more definitively evaluate the symptoms; go over the results with dad and explain what it means and why

I could go on, but you get the idea. The Hard choices are good medicine; they bring the patient into the care, produce better outcomes, educate for the future, and are supported by clinical data and experience. But the Hard choices take time. They rarely, if ever, lead to better reimbursement (in fact, according to proper CPT coding, the simple act of writing a prescription can potentially increase the "complexity" of the visit and lead to mo' money; therefore, the education costs me both time and money!). Some patients don't want the education; they just want the prescription (this is called "convenience," and it's why CVS is betting that people will prefer to go to a nurse practitioner in a minute clinic instead of their regular doctor; it's not the best care, but that's irrelevant...)

It's been said that our current system therefore rewards mediocrity. Pay-for-performace (P4P) clearly isn't the answer, if only because "performance" means different things...and to a payor, it usually means "saving money." "Quality" is much more difficult to define, or at least measure.

I've heard that we should let the free market decide. Lawyers are free to charge whatever they want. The best lawyers charge the most. Can't afford it? Don't like it? Fine, see a cheaper lawyer. You'll get adequate representation. Which is fine for drawing up a will or contesting a small claim. Is that acceptable for multi-million dollar liability lawsuits? How about first-degree murder cases? Without giving an answer to that question, let's extend it to medicine. Yes, I know, concierge care is already a small example of this taking place. Does this mean that the poor are effectively excluded from the best care? Is that fair? Is that just? Is that simply the consequence of a capitalistic health care system?

Easy and hard, indeed. No answers here, not yet. Perhaps the lack of standardized incentives is actually an advantage: let everyone determine for themselves what they really do want. You want a quick scrip and no fuss? Find a doctor like that, or go to a minute clinic. You want 24-7 concierge care and 2-hour visits? Fine, just pony up. You want a doctor that takes time to listen, offers quality care, matches your personality? Listen through the grapevine and see who your friends and neighbors recommend. Don't like Doctor A? Go see Doctor B, maybe she's better. Everyone gets paid, everyone gets what they want--or at least compromises to get "good enough". So maybe the status quo is the best idea after all.

Resistance: Fall of Man

Right after the stomach bug made its way through the household (as described in The Circle of Bleccccccch), my wife came down with lower abdominal pain, suspicious for a UTI.

(It's okay, I've received the necessary clearance to discuss this with you.)

So I brought home a urine dipstick from the office, confirmed (+) leukocytes, and wrote her a prescription for ciprofloxacin for 3 days.

Five days later, she was having back pain. Seems like the UTI bug fought the cipro and won, and was now moving on to the kidneys.

I consulted my Sanford Guide, wrote a new prescription for bigger, badder Levaquin x 7d, and soon enough, we were good again.

Last night, as the Levaquin started clearing her system, the back pain returned.

We called her OB-GYN, who recommended a repeat urinalysis, this time with culture, as well as a renal ultrasound.

(I suppose we could talk about the ethics of treating family members, but I think my treatment to this point was very standard-of-care. One of the unwritten perks of marrying a primary care physician is easy access to treatment and prescriptions, at least for (apparently) straightforward issues.)

The renal ultrasound was normal. (Levaquin: $25. Renal ultrasound: $694. Peace of mind: priceless.)

Meanwhile, the OB-GYN heard from her partner, who had been talking with a local urologist, who described the exact same thing in 3 other patients recently. UTIs that failed to respond to cipro, followed by Levaquin, finally cured with Augmentin.

The Sanford Guide notes "increasing resistance of E. coli to both TMP-SMX [aka Bactrim] & FQs [fluoroquinolones such as cipro and Levaquin] a concern." We should know in a couple of days exactly what the bug is, and its antibiotic sensitivities, but we are seeing the evolution of antibiotic resistance in almost real-time. The standard, first-line antibiotics are no longer working, and we have to resort to stronger and/or more unusual treatments.

In a similar manner, skin infections such as boils and abscesses used to be treated with Augmentin or first-generation cephalosporins such as Keflex or Duricef. The bug that commonly causes these infections is known as staphylococcus aureus, or staph aureus, or staph. Within the past 3-4 years a particularly hardy variety of staph has emerged, known as MRSA (methicillin-resistant staph aureus). It laughs at Augmentin. It eats Keflex for breakfast. Pediatricians are now being advised to use Bactrim as the new first-line therapy against MRSA, and there are only about 3 or 4 other antibiotics total that have any effect. In some parts of the country, about 20% of the staph is now MRSA. In other places, it is 50%.

I don't get a bacterial culture of every skin infection that I see. However, I can say this: in my area of South Mississippi, over the past two years, every single abscess culture has been MRSA. 100%. Without exception.

And people wonder why I am stingy with my antibiotics.