I pulled the chart and read the patient's complaint written in the my nurse's smooth looping cursive hand. "Cold symptoms times 3 days." From the loud sound of the cough and subsequent sniffle coming from behind the door, I knew that needn't have bothered even looking at the compliant.
She was a 42 year-old brown haired schoolteacher. I could tell that when infection was not dishevelling her she was probably fairly attractive, but of course as a doctor I would never notice anything like that.
"Every year, it is the same thing," she said. "Starts off as a cough, then my nose runs with thick yellow stuff. Usually an antibiotic knocks it out."
Of course. Unless the infection is viral, in which case the antibiotic is useless.
"I know my body, and I can only tell you what helps me. What helps me is an antibiotic. Last year I had the same thing, and I let it go too long. It went into my chest and turned into bronchitis."
I initiated my long, pre-recorded argument. There are two kinds of infections, viral and bacterial. Most upper respiratory infections are viral. Antibiotics only work against bacterial infections. Since her symptoms were consistent with viral infection, antibiotics would probably not help her. I could tell from her staid expression she was not going to be receptive to this -- the argument of bacterial resistance is futile.
"I have been sick like this before. I know my body and I know what helps me."
I thought about that a bit. Why is it that so many people are convinced that antibiotics will help a cold? This woman was not dumb. Certainly she has had colds before that resolved without antibiotics. Certainly she has taken antibiotics during a cold and not gotten any better. Yet she, and millions of people around the world insist in believing in this myth.
The way I saw it, there were two things working against me. First, there was the problem of risk versus benefits. Second, there was the Theory of the Fourth Day.
The risk-benefit problem works like this: This woman is sick today. She wants to return to work, to get back on her feet as soon as possible. She has kids, and has a life, and doesn't want to spend that life feeling ill. An antibiotic may or may not help her. But as she knows, and as I the doctor cannot deny, it is unlikely that an antibiotic will hurt her.
Yes, I know the return arguments. Inappropriate antibiotic use leads to increasing bacterial resistance, which increases the danger that bacteria pose to society at large. If we use antibiotics too often, they will no longer work when we most desperately need them. There are also secondary risks, such as the risk of allergic reaction, or side effects such as diarrhea, which can sometimes be serious.
But the truth is, for this woman, at this moment, the chance that she will have a serious complication from an antibiotic is very small. The chance that she will benefit from the antibiotic is also relatively small, maybe 20% or less. Still, from her standpoint, with maybe a 2% complication rate, and a 20% chance that the medication will make a difference, the risk versus benefit analysis favors using the medication. She wants anything that might help her, and, truth be told, an antibiotic might help her. Probably not, but might.
As for the risk to society at large posed by antibiotic resistance, she doesn't want to hear it. I can't entirely blame her. After all, the chance that this one prescription will contribute in any major way to antibiotic resistance is very small. Will I consider the contribution my summer vacation drive will contribute to global warming or world oil prices? No. Should I be surprised if she feels the same about antibiotic use? No.
This is the quandary I find myself in when I try to convince patients to forego antibiotic treatment for colds. Doing so benefits all of society. But does it benefit the patient in any way? Not very much. It takes real altruism to see the value in that argument, and -- how do I delicately put this ? -- we are not in the habit of raising altruists in this country. We focus on personal advancement, personal benefit, personal training, personal fulfillment, personal happiness, personal ethics. The opposite argument for the benefit of the many simply does not ring true.
So why do patients become convinced that antibiotics help them when they have viral infections? This is where the Theory of the Fourth Day comes in. It works like this. Assume that the average viral cold lasts 7 to 10 days. Generally, no one goes to the doctor on day one. Most patients suffer for a while, decide the situation is intolerable, and then go. This usually occurs around day four.
The patient shows up in the doctor's office on day four, the cold in full blossom. The doctor gives the patient a prescription for cough or congestion and an antibiotic. The patient starts taking the antibiotic that day. Even thought the antibiotic does nothing, the decongestant and cough medication helps, and the cold starts to run its course. Two days after the doctor's visit, the cold is 6 days old, and starting to turn the corner.
If the cold lasts seven days, the patient has had complete symptom remission in 3 days after antibiotic initiation. Even if it goes for 10 days, the patient has likely had substantial improvement within a few days of starting antibiotics.
So who convinces patients that antibiotics work for colds? Doctors do, by prescribing them the antibiotics when the cold is already half over. Patients do not have the benefit, when they take antibiotics, of observing their illness course without them, so they have nothing to compare their experience too.
Thus the Theory of the Fourth Day is really a special case example of running an experiment without a control group -- that is, running an experiment without including a group of patients who have gotten no treatment . If you have nothing to compare your results to, you have no proof that you are actually looking at results. Thus patients, even very intelligent patients, can be fooled into thinking that useless medicine that is in fact helping them.
The real danger in the Theory of the Fourth Day is that it convinces patients through experience. If you have a good experience with a medication, you don't forget it. Mere data rarely convinces a person to change his point of view if personal experience says otherwise.
It is a very essential problem with practicing medicine. How does a doctor advance science when science is going up against nothing less than Human Nature?