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?

This morning I turned on my computer, fired up the iTunes program, and clciked on the Most Recently Played list. First out was "Wake Up" by Hilary Duff. Well, my young daughter likes to listen to that song.

After that Louis Prima rolled out, then the Subdudes, then Kermit Ruffins, then Louis Armstong. The music rolled on, hour after hour, throughout the morning.

Sweet breezes from home, in rural Mississippi.

He seemed a little uncomfortable.  Not nervous, but he just did not seem to feel quite at home. "No offense," he said, "but I don't like doctors."

"None taken." I meant that sincerely. Some of the best patients are the ones that need me, but not too much.

Sam was one of those, I could tell. Mid-sixties, fit, grandfatherly, only lightly concerned about his health. He had a wife who cared more, though, which is why he was seeing me.

"Yeah, my wife bought this new blood pressure cuff at Wal-mart last week. She tried it out on me, and my pressure was 162 over something. She made me come in."

"Well, I'm glad you did. High blood pressure is a serious thing."

"Not for me. My pressure has been like this for years. Never bothered me."

This was going to be a little harder than I would have liked. I like a patient who does not worry excessively about his medical problems. But if the patient is relaxed to the point of indifference, that is another problem altogether.
"Blood pressure rarely bothers you before you have a heart attack or stroke," I offered. Unfortunately, Sam was old-school, with Southern manners. The problem with old fashioned Southerners is that you can never tell if you are getting through to them. They look at you and smile, and they say "Yes, sir" and "No, sir" right on cue, because their mamas taught them always to be respectful even when they didn't give a hang what they were being told.

Usually the way to get unstuck with fellows like this is to change the subject. I took a little social history.

"Where do you live?"

"Been here in St. Bernard all my life."

"Ever considered moving?"

"No, never. In my profession New Orleans is the place to be. Always has been."

That narrowed his career possibilities down quite a bit. He was too cleancut to be a fisherman or a longshoreman. I guessed he was in the entertainment business.

"I thought you were retired," I said.

"Semi-retired. I am a jazz musician. I have played the trumpet professionally for 36 years."

Now I was interested. I got my first guitar when I was 10 years old. Though I have never been exceptionally good, I can read sheet music and know a E-flat 9 chord when I hear one. And I know enough to know how technically difficult jazz is to play. I'll put Duke Ellington up against a Bach fugue any day of the week. An accomplished jazz musician is a true marvel in the intellectual world.

"So you still play gigs?"

"Oh yeah. A few festivals a year. Not  every week. But every once in a while I get the my old band together and we jam out. It's one of those things you can never put down."

I know the feeling. Lousy though I may be, I have never considered living life without my guitar. Playing is an experience that sticks with you; the pleasure of holding a sacred instrument in your hands, making sounds that are your sole creation, is one of life's great spiritual mysteries.

I could have talked to this cat all day. But I reminded myself of my duty. I am a doctor, and my responsibility was his health. Cue theme music from "Marcus Welby, MD."

We dug back into the blood pressure thing. As I completed my history, then went through the physical exam, a thought rose slowly in my mind. Though I have always stuck with the guitar, my joy with it never developed into a passion. The kind of passion that results in long hours of practice and study, of growth in skill and perfect performance.

What drove Sam to hang with it all these years? To endure the grueling road schedule and poor pay of a jazz trumpeter for all of 36 years? Anyone who could absorb the techniques of Dizzy Gillespie and Miles Davis was smart enough to succeed in something much more boring and financially rewarding. With his mind, he could have even stooped as low as to become a doctor, had he chosen to do so.

I started to ask, but each time I thought to, I was distracted by a medical issue. Duty first. I finished my exam, wrote up a prescription for an antihypertensive, and carefully explained to Sam that he needed to take it without fail. I loved that carefree jazz spirit in him, but hypertension is a problem that answers to method and plain logic, rather than freethinking improvisation.

Sam's keen technical mind must have read mine, though, because he asked my forgotten question for me just as I was ready to head for the door.

"Do you know who taught me how to play the trumpet?"

I told him I had no idea.

He reached into his pocket and pulled out his wallet. After a brief search, he found what he was looking for, and handed me an old photograph.

"This was taken in Chicago," was all he said.

The photo was a little washed out with the years, but I could see several men seated in a booth in a bar. On the left side was a skinny, black-haired man. I looked harder. It was a younger Sam, no question.  A beer bottle stood at Young Sam's right elbow, and to the right of that was a somewhat obese black man, late middle-aged. He looked familiar to me. Then I got it.

"Oh my God," I said, stupefied. "Louis Armstrong."

Yes, it was. I have talked to many people in my day, and heard many a name dropped. Rarely am I impressed. This time I was completely numb.

Turns out in the early 60s Sam was the lead trumpet in Lil Armstrong's jazz band. Lil Hardin Armstong was the second Mrs. Louis Armstrong and a creditable pianist in her own right. Through Lil, Sam got to know Louis. And apparently, Louis taught him a thing or two.

I knew even at that moment that it was unlikely Louis Armstrong had been Sam's teacher for very long. They were probably acquaintances, maybe even friends, and Louis may have coached him a little. But who cares? The man knew and played with the immortal Satchmo!

Louis Armstrong is one of the most towering intellectual figures in American history. Armstrong invented swing. Literally. He is one of the first, if not the very first, recorded jazz artist who consciously accented his notes using the back beat. Most music before Armstrong was written in a four-beat time signature in which the rhythmic emphasis was placed on the first and third beats. As in ONE two THREE four ONE two THREE four. Armstrong started off this way, but thought it would be interesting if he reversed the emphasis, creating a one TWO three FOUR rhythm. This two-four emphasis is called the back beat.

This emphasis on the back beat is the essence of what jazz musicians call swing. Inventing swing for a musician is something like inventing calculus is for a mathematician. It is so essential, so central to modern music that jazz (and rock music) as we know it wouldn't exist if Armstrong hadn't done what he did.

If Sam had told me he knew Shakespeare, and then produced a heretofore unknown 38th play, I would not have been less impressed.

Nor I have never been so jealous of a patient. Perhaps if I had met William Osler, or Jonas Salk, or had dinner with Watson and Crick, I could have had the kind of passion for my own work that Sam undoubtedly had for his. It takes more than just personal inspiration to drive a person to excellence in his profession, but nonetheless to have had the opportunity to learn at the knee of one of the divine in one's own field must be an exceeding and sustaining joy.

No wonder monks carry around the very bones of the sainted.

My all time favorite recording is Louis Armstrong's "West End Blues." (West End is a part of New Orleans. Today it is rubble after Hurricane Katrina, but in Armstrong's day it was a strip of bars and honky-tonks on the outskirts of New Orleans, frequented by gamblers and people of color.) The song opens with a thrilling trumpet solo by Satchmo, unquestionably the most famous blast of notes in jazz history. It progresses to a haphazard, lugubrious chorus that is both lazy, sad, and uplifting at the same time. It lumbers into a passionate, bluesy Armstrong solo that mixes all the jazz, blues, and pain New Orleans ever had to offer,  then ends with the call and response between Armstrong and his remarkable pianist, Earl Hines. There is nothing in music like it.

A guy who knows the guy who recorded that record was once my patient. That alone may be enough to keep me doctoring.

Sam fled to Denver after Katrina, but he and his band were back in New Orleans in April for the French Quarter Festival. The passion and love instilled by a great master burns on after the storm.

Swing on, Sam!

Today I got an idea. August 29 is the one year anniverary of Hurricane Katrina. To commemorate the event, starting August 26 I will post my recollection of what I and my family did each day, as if it were happening in the present. I will continue to do this daily, until September 2 at least, which marks the day the U.S. Army finally came to the city and rescued the people stranded at the Superdome and the Morial Convention Center.

This account will not relate political or historical events necessarily. It will detail on a day by day basis what happened to me and how Katrina affected my life and the people I know.

I am calling this the Katrina Blog Project, and I am hoping I can convince other bloggers and writers from the Gulf South to do the same thing. If a large number of people help me with this, the project will be something of a virtual re-enactment across many blogs of this natural disaster in the words of its victims.

If anyone wants to join me in this I will link to them, so interested readers can surf from blog to blog and learn from personal accounts in a way that no newspaper or book could ever duplicate.

I will publish guidelines to this project in coming weeks. Please post me with your reactions to this idea, and if you want to participate, leave me your blog address so I can link to you.

My first Katrina re-enactment post will be August 26.

There is a truly stunning animated graphic on the web that was recently published by the New Orleans Times-Picayune. It tells the entire sequence of events that occurred during Hurricane Katrina from the beginning, and explains how the flooding happened. I have not seen anything like it before. Very highly recommended.

The take home message is that almost all the levee failures in the New Orleans area were associated with manmade drainage canals and shipping channels such as the MRGO (the Mississippi River Gulf Outlet) and the Intercostal Canal. In particular, it re-inforces my firm belief that my house in Meraux flooded because there were severe design flaws in the manmade MRGO. Amazingly, the Army Corps of Engineers, who designed the MRGO, claims the channel had absolutely nothing to do with the flooding. Watch the graphic and see if you agree.

As for me, the Corp's refusal to admit the harm they have done in creating the MRGO is a flat out insult. I would like to see every one of them go to jail for putting thousands of lives in grave danger because of their gross incompetence.

For a well-deserved mauling of the Army Corps of Engineers, see this article that appeared in Sunday's Washington Post.