They’ve Taken Away All Our Toys
When I was young, I absolutely loved playing in the family toybox that had passed down from the older sibs. This was a wicker creation of a giant box that was full of all the toys in the house that the younger sibs, myself included, played with. When I felt like playing I started rummaging and it did seem like inevitably the best toys were always on the bottom but there was always something to trigger the imagination and something to do.
This generation does not have a big box of Legos with hundreds of random pieces: they have Lego kits. They do not have a few dolls (a few Barbies that hung out with the velour hair GI Joe dolls). They have American girl set-ups complete with boudoir and trousseau and other French words. I liked having the toybox and I think the biggest reason for it was novelty. Every time I touched a toy it was familiar and yet new at the same time. New is very big with everyone in the world: we like to have new and exciting and options. I was thinking about this when it comes to antibiotic resistance, so I think there definitely will be some words of explanation needed.
When anyone in the ivory towers and regulatory world talks about antibiotic resistance they always blame American primary care physicians – we are the big evil villains cackling away as portrayed in terrible movies. They posit that we are trying our best to wipe out humanity by eliminating decent antibiotics and having to rely on consecutively stronger ones. The truth is (always of course) that people in those ivory towers and in the regulatory world are wrong and have no idea what they are talking about.
Antibiotic resistance is a complicated pathway that starts with antibiotics in our food chain, but it’s also directly related to unregulated antibiotic availability in Third World countries. The truth is that in a Third World country if someone has a sore throat and they are really sick and they don’t feel like they can go to work, and they are worried that if they do not work they will not eat that day and their family may suffer dramatically, so they go to the pharmacy and get it antibiotic. They generally get an antibiotic far more powerful than is needed, particularly for the fact that it is still statistically most likely a cold.
When my patients come to me with a sore throat they are almost invariably much more comfortable financially than those in third world countries. They are not really worried about eating that day, but if they miss enough days, they will be. They also live paycheck to paycheck and they also live with a knowledge that if they do not work eventually they will not eat. So they go to the doctor which costs them more relative time and money than it does the Third World country worker. That Third World country worker can go to the pharmacy which is nearby, get a prescription, start taking the medication and be at work and they will have made a 15 to 20 minute dent into their day. To see me involves driving to see me after getting an appointment and then waiting to see me and then going to the pharmacy and waiting some more, easily a 2 to 3 hour dent in their day.
If I see a patient and tell them they have a virus and that they should go home and take some chicken soup they will drive directly to an acute care clinic down the road and get an antibiotic usually with a steroid shot, a strep test that was negative, a flu test that was negative, and they will then go home with an antibiotic and their steroid and then take the said same chicken soup. But they won’t come back to me, probably not ever. They will badmouth me, they will rate me terribly on yelp or Google reviews.
Sometime in the past I would have been able to sell to that patient on the fact that it’s not critical for them to start the antibiotic and I would be able to help ease their symptoms with a strong decongestant, stronger than they can get over-the-counter, some steroid pills or a shot, or a cough medicine which is much stronger than they can get over-the-counter. Not anymore. All the decent decongestants have been removed from the prescription world because some of those meds were turned into methamphetamines by a few bad people. So gone are the medication’s such as Entex LA or Entex PPE or Entex PSE. Steroids were frowned upon and we were tracked by how many prescriptions or shots we gave, and then cough medicines were our last hope to be able to give a patient something of worth to get them through their cold which would keep them off an antibiotic but would also keep them as our patient. Walmart was the first to claim that pharmacists were being killed for narcotic containing cough medicines and that they were going to stop carrying first promethazine with codeine, a mild narcotic but much loved and beloved by certain club hopping individuals so that it became worth killing over, and then Tussionex, a wonderful cough medicine that patients begged for and that made it of course verboten to use in most instances and uncovered by most insurances, so we are left with a few steroid options and Tessalon pearls to keep people off of antibiotics.
I believe that regulatory physicians should be forced to write a prescription at least once per year, (most don’t), they need to appropriately place the blame (which is a worldwide issue and not just we primary care doctors) and they need to give us back our toy box.
Amen to this Ken, Amen. Old enough to remember when I could write for prescription strength decongestants. Now all I have to offer are OTC meds and Tessalon (which sucks) and then made to feel like a bad doctor if I end up writing for an antibiotic for a URI that’s lasted for 2-3 weeks.
Amen to that – although I do not lament the loss of the ineffective oral phenylephrine
Great article and you are absolutely correct.