I’ve written before on the increasing danger of bacteria that are resistant to multiple antibiotics.  This resistance is a side effect of the use, and frequent misuse, of the many antibiotics physicians have at our disposal.  I’ve also written about the pressure that physicians sometimes face from patients to prescribe unnecessary antibiotics.

Last week Slate published an article by Dr. Zachary Meisel, an emergency department physician who recounts facing a very common dilemma.  He took care of an infant with a cold whose mom clearly expected a prescription for antibiotics.  Knowing that antibiotics won’t help the baby, but not wanting to dissatisfy the mom, what was he to do?  (Why an infant with a cold would be in an emergency room rather than in her pediatrician’s office is a vast subject for a different post.)

Dr. Meisel cites a recent study that examined patient expectations for antibiotics and their satisfaction with the care they received.  The study concluded

“Patient satisfaction was not related to receipt of antibiotics but was related to the belief they had a better understanding of their illness.”

So for most patients, education about the disease is more valuable than a prescription.  This is an important lesson for us doctors to learn.  A prescription may take only 30 seconds to write, but ten minutes of teaching is better for the patient and for society.  This is another example of an instance in medicine in which efficiency and quality diverge, and doing the right thing takes some time.

So what did Dr. Meisel do?  To find out, I urge you to read the Slate article.

(Thanks to Luetrell T. for pointing me to the Slate article.)

Learn more:

Slate article:  The Pink-Bubble-Gum- Flavored Dilemma – Why doctors give out antibiotics you don’t need

My post about the pressure to prescribe unnecessary antibiotics: Acute Bronchitis

My post about resistant bacterial infections: Serious MRSA Infections More Common

Annals of Emergency Medicine Study: Antibiotic Use for Emergency Department Patients With Upper Respiratory Infections: Prescribing Practices, Patient Expectations, and Patient Satisfaction

“But he can’t be a man ’cause he doesn’t smoke
The same cigarettes as me.”
– Rolling Stones, (I Can’t Get No) Satisfaction

An article in this week’s New England Journal of Medicine illuminates the social dynamics of smoking and quitting, and generated a lot of attention in the media.  The study followed twelve thousand people, many of whom were initially smokers, from 1971 until 2003.  The large group was all connected in one large social network, meaning all of them were connected to each other through friendship and marriage.

The study followed this large group for 32 years and studied the social patterns of those who quit smoking.  The results showed that smokers very frequently quit in social groups, not alone.  So when one smoker quit, it was very likely that much of the social network directly connected to her quit as well.  This suggests that quitting smoking is much more of a group behavior than an individual decision.

Interestingly, as time went on, those who remained smokers became increasingly marginalized in the social network, as those with the most social connections became the least likely to smoke.  So it appears that the social status associated with smoking a generation ago has reversed.  It’s finally cool to quit.

Learn more:

New York Times article:  Study Finds Big Social Factor in Quitting Smoking

New England Journal of Medicine Article:  The Collective Dynamics of Smoking in a Large Social Network

New England Journal of Medicine Editorial:  Stranded in the Periphery — The Increasing Marginalization of Smokers

A fascinating animation of the data in the study

Osteoporosis, which means very low bone density, is a major risk factor for fractures.  Fractures can be catastrophic for older people, and effective medicines exist to treat osteoporosis and prevent fractures, so detecting osteoporosis before a fracture happens is very important in older patients.  Since osteoporosis is very common in postmenopausal women, screening them for osteoporosis is a well-established part of preventive care.

Though men are less likely then women to have osteoporosis, a fracture in an older man is just as potentially catastrophic.  Until now, no clear guidelines have been available to guide physicians about whether or when to screen men for osteoporosis.  Frequently, therefore, osteoporosis has been diagnosed in men after the first fracture.

This week, the Annals of Internal Medicine published a review of the medical literature about screening men for osteoporosis, and on the basis of this review, the American College of Physicians issued a clinical practice guideline for screening men for osteoporosis.  Their recommendations are:

• Clinicians should periodically perform individualized assessment of risk factors for osteoporosis in older men.
  Risk factors for osteoporosis are
  • age (>70 years)
  • low body weight (body mass index <20 to 25)
  • weight loss
  • physical inactivity
  • corticosteroid use
  • androgen deprivation therapy
  • previous fragility fracture
• Clinicians should obtain dual-energy x-ray absorptiometry (DEXA bone density scans) for men who are at increased risk for osteoporosis and are candidates for drug therapy.

Though much is still not clarified, like the number of risk factors that should prompt screening or the frequency with which screening should occur, this is a valuable start.  So if you’re an older skinny sedentary guy (or if you love one) ask your doctor about getting a test for osteoporosis.

Learn more:

The American College of Physicians clinical practice guideline:  Screening for Osteoporosis in Men

Doctors are trained to try to figure out what’s wrong and fix it.  We’re trained to make a plan and execute it, to do something.  But that impulse to order the next test, prescribe the next therapy or do the next procedure can harm our patients if it’s done without consideration of the patient’s goals.  That’s particularly true with older frail patients whose quality of life is decreasing.  In our reflexive rush from symptom to test result to treatment, we may never stop to think that the treatment may cause as much harm as good, and that the benefit we hope for is unrealistic.

This week the NY Times had an important article about a geriatric program that educates patients and their families and puts their goals first.  The program is called “slow medicine” because at each step there is time for questions, answers and deliberation.  With this perspective a futile hospitalization may be avoided, a surgery that is unlikely to impact the patient’s overall course may be refused, a loved one’s wishes about her last days may be honored.

If you are caring for a loved one who is in the last chapters of his life, I urge you to read the article.

Doctors need to relearn that life-saving is only temporary and that comfort is sometimes the best treatment we can offer.  Families and patients need to learn to ask difficult questions and to find doctors who will answer them.

(Thanks to Dr. Mark Urman and to Andrea G. for bringing the article to my attention.)

Learn More:

New York Times article:  For the Elderly, Being Heard about Life’s End

Tangential Miscellany:

Happy Mother’s Day to all the moms out there!  Thank you for the years of sacrifice, work and worry.

I almost never write about children’s health.  I’m not a pediatrician, and most of what I know about kids’ health I learned as a dad, not in training.  This topic, however, is important enough to concern all of us.

Measles is a very contagious viral illness that causes high fever, a rash, cough and a runny nose.  Complications can include pneumonia, brain inflammation and death.  In 1958 there were 763,094 cases of measles reported in the US.  The measles vaccine was introduced in 1963, and widespread vaccination has nearly eliminated measles in the US, with fewer than 150 cases annually since 1997.  In 2000 endemic US transmission (contagion from patient to patient in epidemics) was declared eliminated.

This year 64 cases of measles have been reported in the US so far, making it the largest number of cases since 2001.  Twelve cases were in California.  No deaths have been reported.

All but one of the patients were unvaccinated or had unknown vaccination status.  The one vaccinated patient with measles reminds us that the vaccine is very effective, but not perfect.  Being vaccinated is not a guarantee of immunity, and part of the protection that each child has is the crowd of vaccinated children around her.  Some of the 64 children with measles this year were too young to have been vaccinated, but 14 of them had claimed exemptions from the vaccination because of religious or personal beliefs.

On almost all issues of controversy I side with patient autonomy and individual liberty.  I certainly would not advocate overriding the parents’ right to refuse vaccinations on behalf of their children.  But I would assert that these parents are reckless, and I don’t want their children in the same school cafeteria, playground, or pediatrician waiting room as my kids.

Learn more:

New York Times article: Measles in U.S. at Highest Level Since 2001

Centers for Disease Control and Prevention feature:  Measles Update: Outbreaks Continue in US

Morbidity and Mortality Weekly Report early release: Measles – United States, January 1 – April 25, 2008