The Protocols of Penicillin

April 2nd, 2010  |  by  |  Published in Uncategorized  |  8 Comments

SickKid270-thumb-270x270JP has strep throat–fun, fun, fun. Nothing beats a miserably sick child with a high temperature for bringing out certain primal parental reflexes.

This played out with me when I took him to the pediatrician. We just changed doctors recently because the docs at our previous practice never seemed to be able to get their act together. Any appointment short of a verifiable emergency meant being consigned to an hour or more in waiting room hell.

The new folks are a fast-growing medical practice in New York that has only recently begun expanding into my part of Brooklyn. The offices definitely give me pause. Shopfronts dressed up like a cross between a health clinic and hair salon; call me old fashioned, but I think I prefer my doctor to have bad taste in interior design.

Anyway, before I went in for the appointment, I called my uncle, an ear, nose and throat specialist. He told me that if JP had strep the doctor was going to recommend amoxicillin, and that I should refuse it and ask for a stronger antibiotic, whose name now escapes me.  JP was then for strep (he puked after they jabbed the sample stick down his throat; fun!), and it came back positive.

Now, I should point out that the doctor, as it turned out, was on vacation. I was seeing the nurse practitioner (not that there’s anything wrong with that). She recommended amoxicillin, I said no, and…she looked dumbfounded. It simply never occurred to her that I might have a medical plan already in place.

“But amoxicillin is our first protocol medicine,” she said.

“That’s nice,” I replied, and parroting my uncle, added, “but it’s over-prescribed and not particularly effective. I want this” and asked for the other drug (whose name escapes me; downfall of writing at work and not home).

She seemed stumped and left the office for a few moments to poke around on her computer. When she returned, she said that against her better judgment she would offer me a different drug–still first protocol but not the one I asked for. Or, if I didn’t like that, I could ask my uncle to phone in the prescription.

Now, I’m going to keep my choice of drug to myself. That’s between me and JP. What I would like to point out is the nurse practitioner’s reliance both on rigidly defined protocols for treatment and her use of the computer to tell her what the options were.

Does this strike anyone as poor medical care? Shouldn’t the nurse at least pretend that she’s making up her mind based on experience, training, and a bit of black magic?

At work after the appointment, I was scolded by one of my coworkers. There were, he said, real public health policy issues involved in those protocols, and I was undermining the broader efficacy of the drugs by trying to insist on a non-first-protocol treatment. My desire to benefit myself at the expense of greater society was a prime example, he said, of the “tragedy of the commons,” which I learned was a societal danger caused “not by malicious outside forces but by the apparently appropriate and innocent behaviors of many individuals acting alone.”

In short, I was lousing up society by insisting on specific health care for my child rather than a cookie-cutter simulacrum. My response? (and I would like to hear from people who either agree or disagree)

Fuck the commons.


Responses

  1. Ellen M says:

    April 2nd, 2010at 9:38 am(#)

    I have to say, I’m with your co-worker. What I probably would have done in your place, if I were convinced that my uncle were right — he probably was, but how many strep cases does an ENT see? he sees the hard stuff — I’d ask to talk to a doctor, assuming there was one in the building. NPs are great for a lot of things, but they don’t have the training and experience of an MD, so it does sound like she was out of her depth. But for my money you either trust your medical practitioner, or you get another one.

  2. nmw says:

    April 2nd, 2010at 9:55 am(#)

    Let me put your co-workers point slightly differently. The over use of antibiotics and the use of stronger than needed antibiotics contributes to the evolution of drug-resistant bacteria. Those drug resistant bacteria could well be what infects your son next time around. It’s not just about the nebulous commons. It’s about the long term vs short term consequences of the action for you and yours.

    I actually think you should care about the commons. But even if you don’t there are reasons to not push for the strongest antibiotics possible.

  3. Dad is in the House says:

    April 2nd, 2010at 1:03 pm(#)

    Gosh, I have my beefs with the medical system right now but I have to say the amoxicillin should work. (My particular problem at the moment is I can’t get my child to get any in her.) Sounds like your uncle wants to feel superior to the chumps at the local pediatricians office. Bless their hearts, doctors loooooove to compete with their co-tradesmen/women and make their patients pawns in their little ego trips. To my mind, the protocol is certainly a good starting place. If there are problems later, then I wouldn’t hesitate to push for a stronger drug.

  4. jennifer says:

    April 2nd, 2010at 2:39 pm(#)

    Regarding your feeling that the nurse, in following a treatment protocol, was practicing “poor medical care”: There’s no question that when choosing an intervention, the clinician should always consider the *individual*, just as much as the ailment/diagnosis itself. But a key reason that evidence-based disease treatment guidelines and protocols exist in health care is because it reduces variation in utilization, which often reduces health care costs, without adversely affecting (or even improving) patient outcomes and quality of care. This is largely Atul Gawande’s point in his 2007 New Yorker article called “The Checklist”, which was the basis of his recent book.

    http://www.kevinmd.com/blog/2010/02/atul-gawande-checklist-manifesto-reviewed.html/comment-page-1

    Again, no question that clinicians must always treat the individual. But when there is nothing to indicate that the individual warrants a non-standard treatment (e.g., penicillin allergy), the clinician is generally practicing good medicine if s/he follows the treatment standard.

  5. Richard Nash says:

    April 5th, 2010at 4:40 pm(#)

    Not only do I agree with Fucking the commons, I go out of my way to do so. You are paying for a product, why should you not elevate and or educate yourself if you can? If you go and purchase a car or food or any other product, you get what you want, why are the rules different here? I’m sure that the germans have a word that combines mediocrity and hypocrisy but I for now don’t.
    We don’t vaccinate or use antibiotics unless it’s a matter of life and death anyways. So outside of the modern marvels of the ER and diagnostics/lab work within the conventional medical model, they can at a minimum “Eat Cake”. I won’t play ball just because a bunch of humps put forth a premise that is not empirical in the first place.
    And for all those above: The standard protocol is the largest and most expensive scam ever perpetuated on the american public. Over 100k people are killed just from their meds or combination of meds every yr. How is that for your standard of care? How about raising the bar a little bit?

  6. deaddrift says:

    April 5th, 2010at 11:17 pm(#)

    If you have a child, and your response is ‘fuck the commons,’ you are not thinking clearly. The commons is where your child will spend the entirety of his or her life.

    I recommend a little self-education in game theory, which reveals that in many (if not most) cases, parties that cooperate do better than parties that selfishly compete.

  7. jennifer says:

    April 6th, 2010at 11:23 am(#)

    Richard,

    One key reason for deadly medication errors and medication interactions is the very way the U.S.’s health care is financed and delivered. In 2001, the Institute of Medicine of the Nat’l Academy of Sciences published a report called “Crossing The Quality Chasm: A New Health System For The 21st Century” that identified as the root cause of many types of medical errors the fact that in the U.S., there are few rewards for low-tech interventions and coordination of patient care. Here is a quote from the 8-page report brief (pdf located at http://www.nap.edu/html/quality_chasm/reportbrief.pdf, if you are interested):

    “The public’s health care needs have changed as well. Americans are living longer, due at least in part to advances in medical science and technology, and with this aging population comes an increase in the incidence and prevalence of chronic conditions. Such conditions, including heart disease, diabetes, and asthma, are now the leading cause of illness, disability, and death. But today’s health system remains overly devoted to dealing with acute, episodic care needs. There is a dearth of clinical programs with the multidisciplinary infrastructure required to provide the full complement of services needed by people with common chronic conditions.

    “The health care delivery system also is poorly organized to meet the challenges at hand. The delivery of care often is overly complex and uncoordinated, requiring steps and patient ‘handoffs’ that slow down care and decrease rather than improve safety. These cumbersome processes waste resources; leave unaccountable voids in coverage; lead to loss of information; and fail to build on the strengths of all health professionals involved to ensure that care is appropriate, timely, and safe. Organizational problems are particularly apparent regarding chronic conditions. The fact that more than 40 percent of people with chronic conditions have more than one such condition argues strongly for more sophisticated mechanisms to coordinate care. Yet health care organizations, hospitals, and physician groups typically operate as separate ‘silos,’ acting without the benefit of complete information about the patient’s condition, medical history, services provided in other settings, or medications provided by other clinicians.”

    [While I have not reviewed the entire IOM report in a while, I’m willing to bet that it cites a number of empirical studies to back up its claims?]

    I am sure there is evidence that the power of the PHRMA lobby, along with flaws in the FDA’s testing protocols, have also contributed to drugs being released on the market too soon, resulting in bad things happening to patients who take them. I am no supporter of PHRMA and I think the FDA’s testing protocols are flawed. I do not support the tendency nowadays to overmedicate or turn to the prescription pad, and the alarming frequency at which patients go into a doctor’s office asking to be prescribed a branded drug by name (as a result of marketing campaigns). And “best practices” and “standard protocols” must change as more is learned, more effective interventions are developed and evaluated, more data are collected – otherwise, we might still be employing leeches to cure blood ailments or performing lobotomies on anxious women. I just don’t think that the mere *existence* of prescription drug treatment protocols are the root cause of adverse medication interactions. If I’ve misinterpreted your comment, feel free to clarify?

  8. Dr. Kate says:

    January 13th, 2011at 3:30 pm(#)

    Just in case anyone else links to this old discussion through another article, I’d like to quote the 2009 Red Book. The Red Book is the definitive reference from the AAP on pediatric infectious disease.

    “Although penicillin V is the drug of choice for treatment of GAS pharyngitis++, ampicillin or amoxicillin equally are effective. A clinical isolate of GAS resistant to penicillin *never has been documented.*” (emphasis mine)
    ++ GAS = group A strep, aka strep throat

    Your uncle was flat wrong, and the nurse practitioner was right. Your son’s case of strep sounds pretty cookie cutter (age, symptoms, etc) so it was totally appropriate to treat him by the protocol. The only variant was a mininformed parent. My guess is that as an ENT, your uncle sees the one out of 100 patients with weird bacterial infections or co-infections of multiple bacteria that need stronger antibiotics. He then generalized based on his almost but not-quite relevant experience to your son’s routine case of childhood strep throat. It’s not about “fuck the commons” — your son was probably treated with either a suboptimal antibiotic or one with a higher risk of side effects than necessary.

    And no, the NP shouldn’t pretend to base her decisions on “experience, training, and a bit of black magic”. You want that, go to a shaman. You want someone who makes their decisions based on current information, then go to a medical practice where the practitioners know the limits of their knowledge and look up information when they need to. In 6 years I’ve never encountered a parent who refused amoxicillin for strep throat unless it was due to allergy, and as a pediatrician from one of the top medical schools in the country I’d need to go look that up.

    From a pedatrician who doesn’t tell my kids’ pediatrician how to do his job

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