When patients demand treatments that won’t work

When my son Ben came down with a  killer sore throat this past summer, he went to his doctor for an antibiotics prescription. He’d suffered this condition in the past, and he knew just what would help ease his painful symptoms. Both he and the doctor agreed this sure sounded like strep, so without even having to wait for the throat swab test results for the group A Streptococcus bacteria that cause strep throat, Ben left the doctor’s office with a prescription for antibiotics in hand.

But were antibiotics the appropriate treatment for Ben’s painful problem? 

The virtually universal recommendation for antibiotic drugs to treat strep throat – or increasingly, sore throats of any cause – is not actually founded on scientific evidence, but rather on a small population of employees at Wyoming’s Warren Air Force Base during the 1940s.

For more than a decade, virulent strains of group A Streptococcus caused unprecedented rates of throat infections among the base trainees, and history’s worst epidemic of rheumatic fever.

Dr. David Newman, in his article called Antibiotics for Strep Do More Harm than Good, picks up on this story:

“Military researchers at the base seized the moment, executing a provocative series of trials that tested the potential of antibiotics to prevent post-streptococcal rheumatic fever. Roughly 2% of the trainees given placebo in their studies developed rheumatic fever, while under 1% of trainees given antibiotics experienced the disease. For every 50-60 trainees treated with antibiotics, the researchers had successfully prevented one case of rheumatic fever. It was a small, but decisive victory. Identifying and treating ‘strep throat’ quickly became a staple of medical education, and little has changed since then.”

Trouble is, since the isolated Warren Air Force Base experience, in large recent studies tracking tens of thousands of strep throats in the general population (many of whom received placebos or no treatment at all) there hasn’t been a case of rheumatic fever reported in a study for nearly 50 years. And when the incidence dropped to less than one per million in 1994, the Centers for Disease Control and Prevention stopped even tracking rheumatic fever entirely.

Dr. George Lundberg, MedPage Today’s Editor-at-Large, also wonders why antibiotics for strep throat became and remain the “standard of practice” to prevent rheumatic fever. Indeed, most major hospital-based medical websites still recommend antibiotic therapy for strep throat infections in order to prevent rheumatic fever.

Dr. Lundberg observes that the length of time a person with sore throat is symptomatic prior to recovery is four to seven days, whether or not strep is found and regardless of whether antibiotics are used. Dr. Lundberg warns:

“One million prescriptions for antibiotics for sore throat may prevent one case of rheumatic fever. But they may cause 2,400 cases of significant allergic reactions up to and including anaphylaxis, 50,000 to 100,000 cases of diarrhea, and some 100,000 cases of skin rash.”

Dr. Ed Pullen of Puyallup, Washington supports this caution when prescribing antibiotics  with the example of another common bacterial infection: acute sinusitis.  He writes:

“There is a lot of evidence suggesting that acute sinusitis of less than 10 days duration usually resolves without antibiotic therapy in about the same number of days and with about the same severity of symptoms as with antibiotic therapy.  The outcome of an episode of acute sinusitis that has not been present long is therefore about the same with or without antibiotic therapy. 

“But antibiotic therapy itself can lead to significant morbidity, both the individual treated and to the larger community.  Complications like antibiotic resistance and C. difficile-related pseudomembranous colitis is becoming more common. With essentially every antibiotic from amoxicillin to Levaquin, side effects are very common. 

“So physicians face the challenge of convincing patients who have been treated for their sinusitis with antibiotics for years and usually get well within days of treatment (as they would usually without treatment) that they are better treated with saline nasal rinse, analgesics and tincture-of-time.

Rampant antibiotic use is very good news for pharmaceutical companies who manufacture and distribute these prescription drugs. Annual sales of antibiotic medications in North America in all settings last year exceeded $11 billion. But we do know that U.S. states with active appropriate antibiotic use campaigns (e.g. Get Smart: Know When Antibiotics Work) do have lower prescribing rates. And here in British Columbia, our Do Bugs Need Drugs? campaign resulted in a reported drop of 18% in the overall number of antibiotics prescribed to children under the age of 14 since the program started in 2005. (See more in this 2010 Do Bugs Need Drugs? Evaluation Summary).

In a New York Times piece called Believing in Treatments That Don’t Work, Tara Parker-Pope listed other examples of ailments for which we patients often expect and demand medical interventions that are not actually evidence-based:

  • Recent press reports detailing the dangers of cough syrup for children have noted that cough syrup doesn’t work. True: no cough remedies have ever been proven better than a placebo, either for adults or children. Yet their use is common.
  • Patients with ear infections are more likely to be harmed by antibiotics than helped. While the pills may cause a small decrease in symptoms (for which ear drops work better), the infections typically recede within days regardless of treatment. Unnecessary antibiotics are still given to more than one in seven North Americans each year for these conditions alone, at a cost of more than $2 billion and tens of thousands of serious adverse medication effects requiring treatment.
  • Back surgeries to relieve pain are, in the majority of cases, no better than non-surgical treatment. Yet doctors perform 600,000 of these surgeries each year, at a cost of over $20 billion.
  • More than a half million North Americans per year undergo arthroscopic surgery to correct osteoarthritis of the knee, at a cost of $3 billion. Despite this, studies show the surgery to be no better than sham knee surgery, in which surgeons “pretend” to do surgery while the patient is under light anesthesia. It is also no better than much cheaper, and much less invasive, physical therapy.

And The Times recently ran this observation from Florida sports medicine orthopedist Dr. James Andrews, who is taking a stand against what he sees as the vast overuse of magnetic resonance imaging (MRI) in his surgical specialty:

“When a healthy runner goes for a jog, she’ll have evidence of ‘abnormal’ fluid noted in her knee capsule on an MRI scan immediately afterward. But there is no injury. And If you want an excuse to operate on a pitcher’s throwing shoulder,  just get an MRI.”

According to a study reported in the journal Pediatrics*, roughly one quarter of pediatrician office visits resulting in antibiotic prescriptions were for acute respiratory tract infections in which antibiotics are not appropriate.

For example, a more recent study in the Journal of the American Medical Association** found no significant difference in patients with acute rhinosinusitis infections treated with antibiotics compared to patients who took a placebo. Researchers reported:

“The benefit was too small to represent any clinically meaningful important change.”

Historically, we know that in the mid-nineteenth century, medical treatment by doctors actually fell out of fashion, explains Dr. Melvin Konner in his book, Becoming a Doctor: A Journey of Initiation in Medical School. The great illumination from this medical revolution was the news that there were many diseases that were essentially self-limited. Dr. Konner writes:

“They would run their predictable course, if left to run that course without meddling, and, once run, they would come to an end and certain patients would recover by themselves.

Typhoid fever, for example, although an extremely dangerous and potentially fatal illness, would last for five or six weeks of fever and debilitation, but at the end about 70% of the patients would get well again.

“Lobar pneumonia would run for 10-14 days and then, in previously healthy patients, the famous “crisis” would take place and the patients would recover overnight.

“Patients with the frightening manifestations of delirium tremens only needed to be confined to a dark room for a few days, and then were ready to come out into the world and drink again. Some were doomed at the outset, of course, but not all. The new lesson was that treating them made the outcome worse rather than better.”

In modern times, the current fashion is trending towards what’s known as evidence-based medicine, what British Columbia physician and author Dr. Kevin Patterson describes as asserting the supremacy of data over authority and tradition:

“You can’t kick over a bedpan without hearing the phrase ‘evidence-based medicine’  rattle out.

“But the problem is that if it makes sense that a treatment will work – or if one stands to make money if a treatment works – then a doctor will, with alarming and disheartening reliability, perceive that it does in fact work.

But in our current chicken-or-egg dilemma, which comes first?

Is it the medical profession’s unquestioning embrace of a particular (and often profitable) treatment option, or is it the consumer’s demand (fueled by consumer education like those “Ask Your Doctor” direct-to-consumer ads sponsored by those who stand to gain financially by these treatment choices?) that also drive these questionable yet widely accepted practices?

What’s your experience been like?  Do all bugs need drugs?

This article was featured as a guest post on The Prepared Patient Forum, November 4, 2011.

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* Adam L. Hersh, Pediatrics Vol. 128 No. 6 December 1, 2011 pp. 1053 -1061 (doi:10.1542/peds. 2011-1337)

** Garbutt JM, et al “Amoxicillin for acute rhinosinusitis: A randomized controlled trial” JAMA 2012; 307(7): 685-692.

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12 thoughts on “When patients demand treatments that won’t work

  1. It is a bit of both. I despair when people come in and the opening line is. “I need an antibiotic for my sore throat.” The other variant is “I need to get rid of my cold quickly.”

    Increasingly, in this situation, I give people a prescription with the advice that they are wasting their money in getting it filled as it will do nothing for them. That way the decision rests with the patient. Viruses which account for 90% of sore throats and upper respiratory tract illnesses do not respond to antibiotics.

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    • Thanks Dr. Joe – but when the patient’s sore throat or cold symptoms eventually improve (which WILL happen, with or without that Rx), doesn’t this just confirm the patient’s belief that it was indeed the drug that cured the illness?
      cheers,
      C

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  2. Oh WOW! I am writing a similar post on my blog and must say I have had a recent, nasty experience with a sore throat patient.

    A few weeks ago, a viral fever was doing the rounds in my locality and a lot of people were catching it. It started off as a sore throat and tailed off after 5-10 days of intense myalgia/malaise/fever.

    One person came to me and was especially insistent when I tried to send him off without a script for antibiotics. However, to placate him, I sent off a battery of tests all of which, expectedly, came back normal, supporting my provisional diagnosis of a viral fever. I saw him on the 3rd day of his illness and he demanded, rather vociferously, a script for antibiotics and I refused, explaining the futility of the same in a viral infection. However, he threw me out, got himself a new physician who was too glad to oblige with a script for a 3rd generation cephalosporin, to be taken for 10 days…

    About 7 days in, he recovered and started abusing me for witholding the “magic” antibiotic that saved his life!

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    • Frustrating and distressing story, Dr. Pranab – especially when you went overboard to provide both lab test results and education to your patient. No wonder so many exasperated docs reach for the prescription pad…

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      • …and we wonder why the rates of antibiotic resistance are ballooning! Ridiculous…

        Anyways, wanted to say that I enjoy reading your blog immensely. And I don’t know if I have said it before, I just LOVE the name of the blog! :-)

        P.S. Please call me Pranab or PC! Dr. Pranab sounds way too formal… especially for someone who has barely been a fully licensed doc for 6 months!

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  3. Okay, PC it is. Where in India are you practising medicine? My son Ben (of the sore throat fame) and daughter-in-law Paula are currently travelling in India for three months (just arrived in Jaipur this week).

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  4. However, if your mother or child were one of those 30% that DID need the antibiotic to recover from typhoid fever, wouldn’t you want the antibiotic? If your 18 m/o daughter has suffered from ear infections her entire life and currently has had one that has lasted 6 weeks and is not improving, and her hearing has been permanantly affected, wouldn’t you want her to have an antibiotic? If your child, after innumerable strep infections, was the one case that developed rheumatic fever – wouldn’t you wish an antibiotic would have been given to prevent it? I would rather suffer a reaction to an antibiotic than do without if it could prevent complications.

    As an RN, I really don’t believe the resistance is from over-prescribing, but from patients NOT COMPLETING the entire course of the antibiotic. I really feel the answer is INDIVIDUALIZED medicine – a decision made by you and your doctor for your particular case alone.

    If the doctor refuses to listen to the patient’s concerns, belittles his concerns, or just has a “no antibiotics unless you are dying” attitude, I don’t blame patients for being upset.

    Likewise, if a patient refuses to listen to results of cultures and insists on an antibiotic for a viral infection – then the doctor has the moral and ethical duty to NOT PRESCRIBE an antibiotic. Many times, the prescription pad is “reached for” simply to get out of that room and on to the next patient. I think there are definate faults on both sides of the prescription pad. Education and listening is important on BOTH sides.

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    • Thanks Cherie for your thoughtful perspective. My concern here is the widespread practice of recommending treatments with little if any science-based evidence to support them. Most patients (not just those high-risk exceptions you list) now expect antibiotics for a common head cold, most ear infections, influenza, most coughs, most sore throats, bronchitis, stomach flu and many other complaints for which an antibiotic Rx is proven to be inappropriate.

      Thanks for bringing up the important point that not completing a course of appropriate antibiotics is also an issue. Mayo Clinic guidelines, for example, include: “If you take an antibiotic for only a few days — instead of the full course — the antibiotic may wipe out some but not all of the bacteria. The surviving bacteria become more resistant and can be spread to others.”

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  5. I have to agree with Cherie. It’s also the track record of the individual patient and knowing what works for you. My tonsils, after a bout of successive infections in my twenties, were declared ‘marginal’ and I was ‘one more infection away from surgery.’ Not a happy prospect.

    Fortunately spring came and the infections ended. For decades now, any throat infection predictably goes straight to my tonsils (quite visible) and then to my ears, accompanied by a low-grade fever, I know that I can either hope it goes away (and sometimes it does, only to return) or get it early with azithromycin, full course. Simple stuff that my brother (a doctor, but not an internist) prescribes for me. I don’t take it for anything else, I get predictable gastro-intestinal difficulties right after, but I am not taking the risk of hearing loss or major tonsil surgery. Plus, I know if I go to an ENT, he’ll prefer something heavier duty– I’m allergic to cephalosporins in any form (worst reaction: a 102 degree fever!) which are often prescribed for this.

    So your son and his doctor may not be ‘off’ in seeing a pattern and going for what works.

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    • Hi Donna and thanks for sharing your story. Ouch! As in Cherie’s case, the concern is not so much antibiotics for severe and dangerous infections, but prescribing them willy-nilly for every case of sore throat as patients have come to routinely expect. I was surprised by Dr. George Lundberg’s stats, for example, that “the length of time a person with sore throat is symptomatic prior to recovery is four to seven days, whether or not strep is found and regardless of whether antibiotics are used.” For the average, rarely experienced case of sore throat, that’s pretty compelling.

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