Friday, July 12, 2013

The Primrose Path

I had heard the phrase "Primrose Path" many times but had not realized it comes straight from The Bard....Hamlet no less.

Whiles, like a puff'd and reckless libertine, 

Himself the primrose path of dalliance treads, 

The phrase implies a tendency to take the easy, pleasant path when there are more rigorous, stone strewn alternatives.  It is likely related to the concept of being led "down the garden path", although that one has some additional implications of willful deception.

I see the medical system go down the wrong path from time to time.  Physicians today are smart.  They have at their keyboards the accumulated wisdom of practitioners from time immemorial.  They have diagnostic technology that is Star Trek level stuff compared to my training back in the early 1980s.

And I still see clinicians, good ones, get fooled.

There are many contributing factors, but one of the biggest ones is the lure of "the primrose path".  We, both the physician and the patient, want the diagnosis to be neat, clean, something we can fix.  We want easy.

This tendency may be more pronounced in an Emergency Room setting.  We have significant time pressures - time spent unraveling a complex story in room 4 is accompanied by a steady drip of blood in room 9.  We have patients and families who are in fact im-patient and who quite often arrive with a fixed notion of what is wrong.  And despite the vaunted wonders of Electronic Medical Records we usually do not have the ability to review in detail previous clinical data.  So often the patient is from out of town. Or is from a health system that guards their data jealously.  The other day my passwords for our major outpatient health system just quit working.  Naturally there had been another system "upgrade".

And of course some patients have no coordinated health care, they just wander from ER to ER.  For these nomads the ambulance is more of a taxi service.

The end result of incomplete information often is a diagnosis of some kind of bacterial infection and the prescribing of an antibiotic.

"The doctor said I had just a touch of pneumonia."

"It was early Lyme disease, that makes the fourth time I have had it."

"I had another kidney infection."  This last one is usually based on a mildly abnormal urine sample....the culture often comes back negative in a few days time.

If antibiotics were innocuous we would put them into the water supply.  They are not.  But worse than allergic reactions and more immediate than the issue of increasing antibiotic resistance, is the problem of missed diagnoses.  My list of things that do not turn out to be a simple UTI, or an enigmatic tick borne illness, or "a touch of pneumonia" grows ever longer.

Heart attacks.  Endocarditis with sepsis.  Allergic reactions.  Cancers of the lung, kidney or bladder.  Leukemia.  If we start lumping in the folks who were felt to just be "a little dehydrated" from a stomach bug and just in need of a bag of IV fluid I could add several more serious diagnoses.

Patients want that simple answer and that antibiotic prescription.  Not infrequently they demand it.  They are rightly worried about how much ER care costs and want to be out the door with as few tests as possible.  And they are fairly often correct in their self does not pay to become a medical Luddite and assume that nothing will be treatable with antibiotics, although some days it does feel that way.

Come closer for a moment, and I shall whisper something interesting in your ear...

Almost everyone who walks out of the ER with an antibiotic prescription feels better.

Of course they do, the placebo effect is still alive and well.  And it gets a big help from the fact that several of the commonly used antibiotics have moderate anti-inflammatory properties.  Sure, a person with a mild asthma flare due to a cold really ought to be on a short course of the anti-inflammatory steroid, prednisone.  But that azithromycin or doxycycline for "almost pneumonia" is like being on Prednisone Junior and may well get you by.  Heck, I am old enough to remember that we once used tetracyclines to treat the joint inflammation of rheumatoid arthritis!

Remember that most people do get over most illnesses.

Of course a trivial antibiotic prescription does not do much for that lung cancer, or that viral myocarditis, or the septic embolus that is causing that pale, visibly shaking patient to have a painful, white as the sheet leg.

So what can we do?

Not much I fear.  I am seeing a trend in recent years.  As primary care clinics are getting reimbursement bonuses for chronic disease management we are seeing them devote more and more of their resources to, no surprise, chronic disease management.  For diagnosing something new the two pathways appear to be specialist referral or off the the ER.  And the former route is so much paperwork and bother.

If I only handled emergencies, or to stretch it a bit include as well the urgent things that should be seen when the clinics can't, I would have a lot more resources to deploy.  That abdominal pain that has been going on for months and has baffled several previous doctors is probably not going to be figured out in the ER tonight.  Another batch of antibiotics for a soft diagnosis of diverticulitis may not be the answer.

But no matter what the demands of the shift turn out to be, physicians need to still think.  Sometimes think really hard, considering and reconsidering a wide range of diagnoses.  Pull up that clinic file if you can.  Call that specialist to pick their brains a bit.  There are some superb clinical data bases such as UptoDate, they are your friends.

And you have to sell the patients on this approach.  You need to explain why you are repeating some tests and not others.  I always try and look wise and full of gravitas while telling them that my job in the ER is to never miss a serious problem and that takes some effort.

Most ER stuff is actually very straightforward.  Put in those stitches.  Remove that fish hook.  Stabilize a patient and call the helicopter.  But some of it is very difficult indeed.

Doctors, don't take the easy path for convenience.

Patients, same advice.

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