Posted by: notdeaddinosaur | March 3, 2008

Expectations

I got a call yesterday from a 40-something guy with a bad cold, asking if I could “call something in.” I asked about his symptoms and, hearing nothing alarming, explained that his best plan of action would be to rest and drink plenty of fluids, allowing the illness to run its course. “But can’t you call something in?” “Not without a visit,” which is my standard rejoinder. I explain that I wouldn’t know what to prescribe without an examination. I offered an appointment; he said he’d call back.

About twenty minutes later I got a call from his irate father (not my patient.) The man is sick! He needs medicine! Why won’t I call something in for him? Once again I begin to explain the natural history of viral infections (“colds”, however bad) and the necessity for an exam before issuing any prescriptions. “Well, my doctor doesn’t have any trouble calling things in. You tell them your symptoms and they call something in. Why can’t you do that?”

I’d love to say, “Because I’m practicing medicine the right way and your doctor is either too lazy or doesn’t care,” but remember, we’re not supposed to bad-mouth each other. I have no doubt that other offices have come to the conclusion that it’s too much effort to spend the time explaining things the way I’ve just tried to (twice) so they just “call something in;” most likely a prescription version of an OTC medication — that’s recently been shown not to work better than a placebo anyway!

What’s the harm, you may be tempted to ask. The harm is to me and my reputation! Now that you’ve led my patient’s family to believe that “calling something in” is acceptable and accepted medical practice, I’m the one stuck with the brunt of their anger just because I’m doing things right. I have no problem standing my ground, but now there’s a dissatisfied, angry family bad-mouthing ME everywhere they turn. I resent the way your laziness drags down MY reputation!

I have similar problems when ER docs routinely prescribe antibiotics for bronchitis and otitis media. Hello! Don’t you guys read the same evidence we do? Antibiotics in lower respiratory infections don’t lessen symptom severity or duration in the absence of pneumonia, and most OMs have been shown to be viral and are most appropriately treated with analgesia for 24-48 hours, reserving antibiotics for persistent fever (hint: persistent > 1 day), vomiting and refractory pain (hint: refractory > 1day.) Or could it be that although you’re aces with trauma and really sick people, you suck at dealing with the not-as-sick and just follow the path of least resistance to get them discharged? So what, you say. You’re too busy to be bothered trying to explain all that. The problem is that the next time they get bronchitis, they expect antibiotics because “that’s what they gave me in the ER.” Again, I’m the one who looks stupid for doing it right.

So the next time you’re faced with a patient’s unreasonable demands and figure there’s “no harm” in just “calling something in,” recognize that you’re managing the patient’s expectations as well as their medical condition. And you’re doing a shitty job of it.

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