“I think I have bronchitis.  I probably need some antibiotics.”

All primary care doctors hear that phrase very frequently.  A patient develops a productive cough that lasts for several days, malaise, and slightly elevated temperature.  Then the patient sees her physician with a clear and predetermined expectation of the correct treatment — antibiotics.  Knowing that antibiotics are not indicated for acute bronchitis, the physician is then forced to balance practicing appropriate evidence-based medicine with satisfying the patient’s expectations.  To some extent, this dilemma of physicians is self-inflicted.  A generation ago, antibiotics were routinely prescribed for acute bronchitis, and an entire group of patients have therefore grown up misinformed by previous physician practice.  The myth that green phlegm necessitates antibiotics also became well-entrenched at that time, leading patients to think that they are being prudent by only demanding antibiotics when their phlegm becomes colored.

Many unseen problems arise when patient expectations deviate from good medical practice.  Unnecessary antibiotic use leads to increasing bacterial resistance, which is now a serious global problem.  Antibiotics can also sometimes cause serious side effects.  But perhaps the most subtle problem is that taking unnecessary antibiotics strengthens the patient’s perception that this is the correct treatment.  The patient would have recovered at the same time regardless of whether any medication was prescribed, but when recovery follows an antibiotic course, the belief that one caused the other becomes unshakable.

I’m certainly not advocating a return to the bad-old-days when physician authority and paternalism ruled supreme and patient preferences were disregarded.  I’m just suggesting that the best care is delivered when the doctor listens carefully and the patient has an open mind.

To that end, here’s a wonderful (and short) review of acute bronchitis written for patients.

Tangential Miscellany:

Two bad trends in our society, our increasing litigiousness and our increasing faith in the potency of vitamins, collide to produce this ridiculous story.

This is another example of a tiny number of irresponsible people imposing a lot of inconvenience on millions of others.  The Associated Press reports in this Forbes article that four East Coast supermarket chains will only sell products containing dextromethorphan (DXM) to customers over 18 years of age.  DXM is a cough suppressant and is very common in over-the-counter cough remedies.  I recommend it all the time.  Why the new restriction?  Apparently some teenagers have been taking DXM in extreme doses in attempts to get high, and five teenagers died in cases that may have been associated with DXM abuse.

This may not have merited my notice if it didn’t follow on the heels of another major cold medicine hassle.  Recently stores and pharmacies have made it necessary to show identification to buy pseudoephedrine, a very commonly used over-the-counter nasal decongestant (the ingredient in Sudafed).  The quantity of pseudoephedrine that can be bought at one time has also been severely limited.  You can imagine what an annoyance this is if you have a few young children at home who always have colds (and infect their parents).  Some winters my family goes through Sudafed by the bucketful, but now we can only buy it by the thimble.  Why would any organization stand between a cold sufferer and his nasal decongestant?  Because some people use pseudoephedrine in drug labs to make methamphetamine (crystal meth).  So because pseudoephedrine might be used to make an illegal drug, your nose has to run a little longer before you get relief. Has anyone done a study to check if this restriction has made crystal meth more difficult to obtain?  I doubt it.  But once in place restrictions like these are never lifted, even if they are totally ineffective.

So I beg all the irresponsible recreational drug using teenagers out there:  Before the next drug fad spreads, please let me know so I can stock up on whatever otherwise-harmless medicine you’re about to yank out of our hands.  Thank you.