Antibiotics

Just Call in My Antibiotics, Doc! I’m sick, I tell you!

Sometimes, patients and I disagree on their treatment. I feel they have a normal, regular viral illness, and they are convinced they have the plague and will die a slow and miserable death in the next hour if I don’t give them that z-pak the last doctor gave them. 

First, I’ll point out that the U.S. has had 11 cases of human plague so far in 2015 (none of which were in Hawaii) and in the previous 10 years, the number of annual cases ranged from 1-17. So, it is fortunately very unlikely you have the plague.  And even less likely that I will be a published author as a result of diagnosing you as such.  

Now, the more pressing issue: why don’t we just give you those antibiotics, you know, just in case?

There are actually several reasons doctors don’t just hand out antibiotics (well, most of us) and it’s not because we’re mean, wielding power over you or just want your copay. We are trying to protect you and your community from the harms that come from the overuse and misuse of antibiotics. 

To understand, it is important to appreciate the difference between bacteria and viruses. Bacteria are microscopic organisms that live in a number of environments, including the human body.  A virus is often considered to be a nonliving infectious agent as it only replicates inside the cells of another living being.  Antibiotics kill bacteria; antibiotics do not affect viruses.  So, those antibiotics will only help if it is a truly bacterial infection. 

Most viral upper respiratory infections will last approximately 7-10 days (not the 2-3 days that everyone thinks), although some people will have symptoms that linger longer or a post viral cough that can last for 6 annoying weeks. Remember that time you got those wonderful antibiotics, that must have cured you?  Did you happen to get those on day #4 or 5?  In other words, maybe about the time you would have started feeling better even without those antibiotics?  Common infections that are usually viral include: colds, flu, bronchitis, pharyngitis (sore throat, with the exception of strep), ear infections, sinusitis, gastroenteritis (stomach “flu”).  So the first reason, we don’t give you antibiotics is, they don’t help. 

 I know your next question: what could be the harm in a few pills for 5-10 days, just so I can feel better, doc?  Actually, there are several potential harms, ranging from self, to community, to worldwide that can result from incorrect use of antibiotics. 

Additional infections: Antibiotics kill all bacteria, not just the ones causing illness (or not causing illness in the case of a virus).  We have bacteria on and in us all the time, helping us maintain our normal life functions, like digestion.  When we take antibiotics, we kill those good bacteria as well as the harmful ones.  That can lead to other issues – including opportunistic infections, ranging from inconvenient like a vaginal yeast infection, to life threatening like C. difficile colitis.  C. difficile is an extremely nasty diarrheal illness that can lead to severe illness, require hospitalization, and in severe cases surgical removal of part of the intestine or a newer treatment option, fecal transplantation. 

Resistance: Bacteria are smart little buggers.  The weakest bacteria will die first, and the stronger ones will not only survive, they will take note of the antibiotic you took and find a way to get around it for next time.  But not just next time for you – they share that information.  So, now we have certain bacteria that are no longer sensitive to antibiotics that used to be lethal to them in the past.  MRSA, methicillin-resistant staph aureus, or just staph, is perhaps the most well-known of these sneaky bacteria.  A 2013 CDC report indicated that 2 million people get a serious infection with a resistant bacterial annually.  As more of these bacteria gain this knowledge, our development of antibiotics will be unable to keep up, and we will be thrust back in medical time to when we had no way to fight bacterial infections at all.

Side effects: Everything has a potential side effect.  Taking a medication and not taking a medication – each has its own risks and its own benefits.  There are risks for interaction with your current medications and disease process, and it’s important to have the opportunity to have these discussions with your provider. 

 

All of these thoughts go through my head when I’m trying to help you feel better. I’m not keeping a secret weapon to magically make you feel better in my pocket just to make you suffer longer.  I’m assessing you, my patient, and doing my best to make sure I’m treating your actual illness as it presents to me right now.  I’m also trying to protect you, your family and your community from future problems that can arise from the use of medications I may give you, including antibiotics.

Family Medicine vs Internal Medicine

Family medicine is the medical specialty that provides continuing, comprehensive health care for the individual and family. It is a specialty in breadth that integrates the biological, clinical and behavioral sciences. The scope of family medicine encompasses all ages, both sexes, each organ system and every disease entity.
AAFP. “Family Medicine, Definition of.” http://www.aafp.org/online/en/home/policy/policies/f/fammeddef.html.

First, let’s start with what it takes to become a doctor. After completing an undergraduate degree (usually 4 years), one must go through the 4 fun years of medical school. While each school operates differently, the fundamentals are the same – learn book stuff, learn clinical stuff, see patients.

After medical school is residency (the first year of which is called internship) and this is where the training starts to really differ. Pediatrics residents focus on babies and children, surgical residents focus on surgery, ophthalmology residents focus on eyes, internal medicine residents focus on adults.

Family medicine residents focus on…everything. Family medicine residents learn adult medicine (including ICU), pediatric medicine, gynecology, obstetrics (although many if not most don’t continue to practice after residency) and psychiatric care. There is time devoted to most specialties (cardiology, dermatology, orthopedics, gastroenterology, etc) and more time is spent in an area of interest to that particular resident.

Internal medicine residents also get time devoted to specialties, but don’t have the pediatric or obstetric training that the family medicine residency requires. Internal medicine offers more options to specialize after residency – cardiology, rheumatology, pulmonology, etc. Family medicine is more limited in this manner – geriatrics, sports medicine, obstetrics.

Both family physicians and internists can provide high quality primary care. Importantly, you want a physician who will look at you as a whole person, not a disease or ailment. Remember, your goal is a long term commitment and working relationship. When you’re seeking a medical spouse, a one night stand just won’t do.

Written by M. Mitchell, M.D.

What is primary care?

Simply put, primary care is your entry into medical care. More importantly, primary care is your long term partner in maintaining your optimal health, for better or for worse, in sickness and in health, from this day forward until death do us part – indeed your medical spouse.

Primary care is care provided by physicians specifically trained for and skilled in comprehensive first contact and continuing care for persons with any undiagnosed sign, symptom, or health concern. Primary care includes health promotion, disease prevention, health maintenance, counseling, patient education, as well as diagnosis and treatment of acute and chronic illnesses.
Primary care physicians devote the majority of their practice to providing primary care services to a defined population of patients. The style of primary care practice is such that the personal primary care physician serves as the entry point for substantially all of the patient’s medical and health care needs – not limited by problem origin, organ system, or diagnosis. Primary care physicians are advocates for the patient in coordinating the use of the entire health care system to benefit the patient.

Source: American Academy of Family Physicians
Primary Care
http://www.aafp.org/about/policies/all/primary-care.html

Primary care physicians (PCPs) are here to help you in many ways. PCPs help you maintain your preventative care so that you can prevent illness or catch it early. PCPs are trained to diagnose – is that cough really something to worry about? PCPs are trained to treat illness, both long term issues like diabetes and acute issues like the flu. PCPs help you navigate the health care system if the medical care you need is beyond primary care capabilities. PCPs coordinate the care you receive from multiple providers if your condition warrants it.

And, if the system works like it should, and you have a primary care provider who knows you and sees you on a regular basis, primary care physicians have many less well-defined job descriptions. Primary care physicians can help you recognize interrelated symptoms that you wouldn’t have felt were connected. PCPs know you, your families, celebrate your successes and mourn your losses. PCPs know your history and health and can recognize more subtle changes than might have otherwise been unapparent.

Finding the right primary care physician can be as difficult as finding the right spouse (why is it so hard to find someone who cooks, cleans, does windows and is independently wealthy?), but equally as important. The right fit could be a life saver.

Written by M. Mitchell, M.D.