Feb 19 2008
You’re a patient. That cold just isn’t getting better and you have purulent drainage from your nose, and your face hurts and your teeth hurt. You probably have sinusitis, right? You go to a doctor to get an antibiotic.
You’re a doctor. Deep down, you know there’s a good chance the patient has a self-resolving condition. You’d rather not do x-rays on every patient who presents with these symptoms, because x-rays are expensive, expose the patient to harmful radiation, and they are not always accurate. You could puncture the sinuses and take a sample for bacteriological culture, but that’s expensive, painful, and the patient would NOT appreciate it. The patient may not really need treatment, but you want very much to do something to help. If you can find a reason to give the patient an antibiotic, you can feel that you have done something worthwhile. Antibiotics don’t work for a viral infection, but you rationalize that you’re not 100% sure it’s not bacterial, and that sometimes a bacterial infection develops superimposed on a viral infection and mild bacterial infections can develop into severe ones with complications, and maybe you could ward that off. You convince yourself that it really would be prudent to prescribe an antibiotic. Both you and your patient are happy. The patient gets better. You remember this pleasant experience and are reinforced to do the same next time.
Maybe that’s not such a good idea.
A recent study in JAMA showed that antibiotics were not superior to placebo for treating bacterial sinusitis diagnosed by the clinical criteria used by many primary care physicians. There is a growing concern that we have been overtreating sinus infections. Recent research has also shown that we were overtreating ear infections in children, that many of them resolve just as fast without treatment. That doesn’t mean antibiotics should never be used for ear infections. There are now guidelines for using age and clinical presentation to determine which children to treat and which ones can be safely observed without antibiotics. Most of these observed ear infections will resolve but some will eventually require antibiotics too. The situation with sinusitis is similar: most patients may not need antibiotics, and we’re trying to thrash out better criteria for identifying those who will.
Critics point to this kind of thing as a defect of conventional medicine. We use treatments that are not based on good evidence. We do things for years and then find out we were wrong. New studies are constantly contradicting older studies. We keep changing our minds.
In fact, this kind of thing illustrates the value of scientific medicine. Science never claims to have absolute truth. It is willing to change its practices as the evidence changes. More importantly, evidence-based doctors are willing to stop doing things that the evidence says don’t work. No amount of influence from “Big Pharma” will perpetuate the use of drugs for sinus infections if the evidence shows they are unnecessary. No amount of irrational belief will trump the evidence. No doctor can get away with saying, “In my experience, …” when good evidence contradicts that experience.
Remember when annual chest x-rays and urinalyses were part of the recommended annual physical? No more. And it would be easy to make a long list of similar relinquishments.
Contrast that with “alternative” medical systems like homeopathy or chiropractic. They don’t change very much, and they almost never give anything up. I searched the literature and consulted professors of chiropractic in an attempt to find anything that chiropractors have uniformly stopped doing, and I was only able to find one thing that fit the bill. I don’t think any chiropractor is still using Palmer’s “nerve tracing” technique where he claimed to be able to feel nerves unknown to anatomists.
Limiting antibiotic use to strict evidence-based guidelines has several benefits: it reduces medical expenses, it minimizes unnecessary side effects, and it reduces the risk that the bacteria will develop resistance to the antibiotic.
So we’re going to bite the bullet, follow the science, and learn to be much more selective about using antibiotics. Now, the only problem with being scientific is that the patients are not going to be happy. They’re used to going to the doctor to get a “cure.” They’re used to seeing their sinusitis symptoms resolve after getting antibiotics, and they will be unwilling to forgo treatment long enough to find out if their symptoms resolve just as fast without antibiotics. They want their doctor to “do something.” And when he doesn’t, they may be attracted to alternative providers and quacks who will always “do something” and get the inevitable placebo effect.
The frustration science-based doctors feel was illustrated by a tongue-in-cheek quiz in the February 2008 issue of the medical humor magazine Placebo Journal:
You diagnose a young child with acute otitis media. Which are the most common reactions by the mother when you recommend observation for the treatment instead of antibiotics?
B. Disbelief. Then anger.
C. Disbelief. Then anger. Then appreciation for the honesty and information after which she leaves the office to go to the ER for antibiotics.
D. None of the above as you stopped this bullsh#t approach to treatment years ago because you saw you were losing too many patients.
And in the general course of human perversity, some patients will inevitably go to the other extreme and cite these studies to refuse treatment for cases where antibiotics really are indicated.
The sound bite may be that “antibiotics don’t work for sinusitis,” but the real story is a bit more complex. The challenge is twofold: getting doctors to apply the best evidence appropriately, and getting patients to understand why they may not be getting that magic pill they have learned to expect.
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