The Theory of the Fourth Day

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?

Comments

[difficult patient]

If anitbiotics are not appropriate, then don't prescribe them. I have a question, though. If her condition worsens, and you find that it is bacterial, will you charge her for the return visit if she doesn't improve? Those copays can really add up . . .

[Michael Hebert]

D.P.:
I try not to prescribe if they are not appropriate. But doctors are under a lot of pressure from patients to do otherwise. I have, on occasion, lost patients to other doctors over this issue, and in the greater scheme of things the temptation is very great. Why lose a good patient over a matter like this?

I am not defending it, I am just pointing out the forces in play.

As to your second question, if there is doubt I will instruct the patient to call my office in a week if he or she has not gotten better. If there is no improvement, I am willing to call something in.

Unfortunately, if a patient comes in, it is difficult not to charge them. You have to document the visit, pull the chart, make room in the schedule. And believe it or not, many insurance carriers (especially Medicare) require that you charge for every visit. Most patients have trouble believing it, but Medicare law specifically prohibits giving free visits. It is considered fraud. Many HMOs go along with that rule.

[scan man]

"Mere data rarely convinces a person to change his point of view if personal experience says otherwise." Deserves a place in the Quotations page!

[Moof]

I'm with Scan Man on that quote!

Actually, I had a hard time not laughing my way through the whole post. I hear that sort of thing all the time from people I run into ...

Last winter, one very angry lady told me that a physician who was replacing hers (her usual fellow was on vacation) wouldn't give her anything for her cold; she was absolutely certain that it was going to settle into her chest, and that she'd end up in the hospital ... because "That's what ALWAYS happens when they don't give me antibiotics." Well, I noted that she never did get the antibiotics, and she ended up being just fine. I still expect to hear the same story the next time it happens, though.

Personally, I would be embarrassed to bother a physician for something like a cold ...

Great post! I'd like to send a whole slew of people here to read it! >;o)

[Judy]

I've learned to wait until day 7 as long as my blood sugar is normal. OTOH, I've occasionally gotten a lecture about waiting so long when the infection was clearly bacterial. Hard to tell from here unless my blood sugar goes through the roof - which it doesn't always, even with a bacterial infection. Saves on co-pays, though.

[Pk]

For me, because of taking a strong regimine of immunosuppression drugs ... if I get even a cold, I'm to go into the doctor.

I do not, however, insist on antibiotics because I have cough, sore throat or other such things. I do let the doctor decide when it is appropriate. (There are times that the doctor takes my opinion into account, which, I'm usually on the negative side of use of antibiotics, though ... please, no ... :D)


I really do wish that people would get it ... maybe if they would ... those with immunosuppressed systems ..for what ever reason ...wouldn't have to be so overcautious and worry about drug resistant infections being spread around society.

[Michael Hebert]

Moof, Judy: Thanks for the comments. There is nothing wrong with seeing a doctor for a cold as long as you are willing to accept what he or she says. If the doctor says no, you don't need antibiotics, it is important to see that as a professional opinion and not as a value judgment.

Pk: I left this out of my post, but another problem is the perception that one antibiotic is "stronger" than another. This is false. If a bacterial strain is susceptible to an antibiotic then that antibiotic is strong enough. Even doctors buy into this nonsense: I find docs who write for expensive, broad-spectrum antibiotics like Levaquin or Augmentin like water because they think the old stuff won't work. Then patients turn up in the hospital with urinary tract infections resistant to Levaquin because they have taken it so many times.

[Brian Levine]

Not all patients are as enthused about antibiotics. My children's pediatric practice routinely prescribes antibiotics for bronchitis. Adds $40 and another hour out of my workday to deal with the perscription.

I imagine that the cycle of seeing 4 to 5 kids an hour, listen, examine, prescribe, next patient, shortcuts any other diagnostic procedures. With brochitis, do you caution about building fires in fireplaces or camping out with fire rings? Both are common with kids where I live.

My son sleeps in the living room at his mother's house and she was fond of having a fire at night. I realized this wasn't helping after two weeks. He had bronchitis for a month.

[Amka]

When I was a young mother dealing with chronic ear infections in my children, I told my mom that I thought they should just put antibiotics OTC and sell otoscopes so we parents could do it on our own. I was tired of going to the doctor. We are intelligent, after all, and can figure it out. My mom, being a little older, reminded me that not everyone would use them appropriately. I grumbled about that. But then, the more I heard people talk about their colds and aches, the more I realized how true that was.

So true about inappropriate OTC use, that I've now swung to the other side and thought that some medications shouldn't even be OTC.

Do you want me to scare you all a bit regarding this? There are countries where antibiotics are, in fact, OTC. My MIL from Russia could go get just about any drug she wanted without visiting a doctor.

http://www.tufts.edu/med/apua/Chapters/Russia.html

If not taking the full course is a problem here, how much of a problem is it there?

Antibiotic resistant bugs will more likely originate in places like this rather than America.

Another problem are the low dose antibiotics given to feed cattle throughout their lives, regardless of infection.

[Michael Hebert]

Amka:
I was aware that antibiotics are OTC in other places. That and the use of antibiotics in farm animals is a serious international health problem. Much more important than the Avian flu. Possibly more important than global warming.

I wonder if anything will be done about it. Probably not, and if not, the Age of Antibiotics will pass in time and humanity will be back to the situation in 1900.

One sign of the apocalyse: people will cancel plastic surgeries as stories spread about patients getting almost untreatable superbug infections from facelifts.

[Babs]

How do we as patients know if it is viral or bacterial? I once heard it was the color of the phlegm although I don't remember what color was what. Is this right?

[L C Broyles]

There is a vein of thought that superbugs aren't super at all. That, in fact, other bacteria (commonly found in the environment) can destroy the superbugs, which would mean they are weak. I am a nurse. Several of my spinal cord injury cases go into the hospital (for subjective complaints or wounds, etc), are diagnosed with infections and they are immediately started on these broad antibiotics before any infection is even cultured, and in the absence of clinical signs or symptoms. I blame the doctors for prescribing something that is not indicated. Lose a patient over it. Be honest. Their best interest is your duty.

[Michael Hebert]

Babs: Viral respiratory infections tend to run their courses in about a week. There is no fever, no nausea or vomiting, just nasal congestion. Conventional wisdom says viral nasal discharge is clear and not very thick, but this is not always the case. Generally, I consider antibiotics when the patient has a fever, if the infection has not improved in a week, or if the patient has pain above or below the eyes (suggestive of bacterial sinus absecess).

LCB: There are some people who think that the mutations that make bacteria antibiotic resistant may weaken their viability in nature. Whether this will affect disease in humans in the long term is not clear. I, like you, know of doctors who just put all hospital admits on antibiotics. Unfortunately, insurance companies encourage the practice: they are more likely to reimburse an admission if the patient is on antibiotics, because this suggests the patient has a serious medical condition.

[The Laundress]

Whoa,

all too often, when coworkers get sick, I hear this:

"Doctors never prescribe medicine anymore! I know my own body, if I don't get antibiotics, this sinus infection will get worse and worse".

Hear this maybe every other week?

Probably growing a big patient backlash about this plus not forking over the drugs for pediatric ear infections!

[OrthoDoc]

That was a good post, Dr. Herbert.

Rational use of antibiotics is becoming rare today. I try my best to resist the temptation of prescribing an antibiotic for everything. We have a similiar problem in prescribing antibiotics potoperatively. Most of the consultants put patients on a week long course, but there are two of them who restrict to at the most three or two post-op doses for regular cases. My point is that in the midst of all irrational behaviour there are docs who resist all temptation!

[Janae]

Excellent post!

I prefer a conservative approach and have told my pediatrician that. I have no problem going back in a few days later if things have gotten worse. I prefer to be safe and see how my children's immune systems handle it. As a consequence my 6 yo son has had antibiotics maybe 5 times; 6 times for my 2.5 yo daughter since had a period of frequent ear infections.

I'm very open about my feelings about antibiotics with family. Subsequently, 3 of my sisters take a conservative approach as well. Now, if only I could get my mom to stop recommended the ED for treatment when a trip to the dr's would be just fine.

[Kim]

Wow, I must have had really healthy kids because I vaguely remember antibiotics about 6 times over three kids and one of those was for pneumonia.

I also had a pediatrician who didn't dish 'em out willy nilly and this was back in the 1980s. Then again,as a nurse, I knew most things were viral.
Even when my son had febrile seizures, we just treated the fever unless an actual source for the infection was found.

Now for me, I thought Motrin was the nectar of the Gods. I'd ask my doc for a prescription just in case and when it went "OTC" I did a happy dance!
That would knock a fever faster than you could say "acetaminophen".

.

[Cathy]

I also worry about overuse of levaquin. I have a good friend who has a history of several admissions from pneumonia. It's been atleast 4 years since she has had pneumonia. She has non-stop refills for Levaquin. Not only are they VERY expensive for just a few pills, but, she takes them every time she has even one symptom of cold or sore throat or even being hoarse for a day. She has been doing this for 4 years. But, she also takes her temperature NON-STOP, all day long. She has more thermometers then what wal-mart has. One above her sun-visor, in the glovebox,in her purse and 2 or 3 at home. She takes her temp while driving down the street. She also now uses a pulse-ox non-stop. It is nothing to be in the car with her and she is taking her temp and has her finger stuck in the pulse-ox machine. If her temp is 98.7 she will take a levaquin.

[Michael Hebert]

Levaquin is the most abused antibiotic on the planet. I hesitate to use it in my own practice because so many patients have had it that I about resistance.

I admit a lot of patients to the hospital from nursing homes, and I never put a nursing home patient on Levaquin, because so many of them have resistant bacteria. I once treated a nursing home patient with a urinary tract infection that was sensitive to every antibiotic tested EXCEPT levaquin. She was admitted through the ER, and what do you think the ER doc started her on? Levaquin!

Everyone thinks Levaquin is the golden bullet and some doctors use it for absolutely everything. And of course the company that makes Levaquin has no incentive to teach people otherwise. So, in a few years, the drug will be used to death and the manufacturer, having squeezed every penny out of its patent, will move on to something else.

[Flea]

We don't stand a chance against mother nature. The theory of the 4th day is a terrific back-door method of getting mother nature to work her magic while we resist the temptation to prescribe.

best,

Flea