Care-less Care and Telemedicine

One of my irritations with fast track care, especially Kroger’s Little Clinics, is the overuse of antibiotics. Living in Louisville, where allergies are king, a simple cold often turns into two weeks of miserably clogged sinuses from increased swelling in already perennially irritated mucous membranes.  A few days ago a new version of “careless care” appeared on my radar. Teladoc advertises itself as the first and largest telehealth provider in the US. Some insurance companies and employers pay for their members to utilize the service. This particular patient used it three times in six months, each time receiving and antibiotic for a “sinus” infection, despite the fact that each time she’d only had symptoms for four or five days. She finally came to see me because the medication the teledocs gave never seemed to help. Go figure.

We spent some time talking about the difference between viral infections and bacterial ones, and discussing the problem with bacterial resistance due to the overuse of antibiotics. She promised to see me with her next episode and appeared rueful that she’d not come in sooner with the previous episodes.

The fact that telemedicine can lead to the overuse of antibiotics has been studied[1]. I was unable to find any studies evaluating overprescribing in Urgent Care Centers so I can only relate my own experience. The ERs and the NP staffed Walgreen clinics in my area do a much better job than the Kroger “Little Clinics” where antibiotic prescribing seems to be more ubiquitous than high fructose corn syrup. 

As telemedicine and other forms of convenient care increase, the fragmentation of healthcare does the same. Did I get any patient information from the Teladoc physician? No, of course not. Almost never do I get documents from the Walgreens/Kroger/Walmart nurse practitioner. I can’t fight the convenience and know that as more and more patients have difficulties conveniently getting in to see their primary care doctors, this will only get worse. It is imperative that these groups communicate with patients’ physicians. The question is, do I have an imperative to educate the Board Certified Physician who works for Teladoc? And why do I suspect he/she might not appreciate that? The answer is, I need my healthcare system to allow me to use telemedicine to treat my own patients at their convenience.

1. Ateev Mehrotra, MD; Suzanne Paone, DHA; G. Daniel Martich, MD; Steven M. Albert, PhD; Grant J. Shevchik, MD JAMA Intern Med. 2013;173(1): 72-74.doi:10.1001/2013.jamainternmed.305

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The Thanksgiving Z-pack

Emma & Great Uncle Tim

Thanksgiving this year is likely to become one of my favorite holiday memories. My husband’s niece, her husband, sister and fifteen-month-old daughter visited from Mississippi. We had a nice time showing them our pretty Louisville Zoo where Emma got a new hat to protect her ears. We ate a delicious turkey dinner, checked out some restaurants and explored Christmas lights in the “MegaCavern” which was an old crushed-stone mine now used for rentable storage and zip-lining.

Belle of Louisville in lights.

My daughters stayed up late with their cousins while Tim took to his job as great uncle with enthusiasm.

This year I was on call for our office which is usually quiet but a long weekend can be busier especially since we elected to keep the office closed on Friday. Typically the calls concern respiratory infections and urinary tract issues.

As I explained the normal symptomatology of an upper viral infection (or cold) to the patient on the phone Thanksgiving day, I noticed my husband’s niece listening. When I got off the phone I said, “Everyone thinks a Z-pack is going to make them better. Typically the request for an antibiotic is about halfway through the process and in a few days, they feel better. They assume it’s from the antibiotic but in reality, they were going to get better anyway.” I could see the wheels turning in her head. “My doctor always gives me an antibiotic.” So we talked about the negative aspects of getting an antibiotic every time she has a respiratory infection. The virus won’t respond to it but the bacteria that live in and on her can become resistant to antibiotics. She will be at increased risk of developing MRSA–methicillin resistant staph infection, a skin infection that is difficult to treat. If she does develop a bacterial-caused illness such as a true bacterial sinus infection (usually one-sided sinus pain, purulent nasal drainage AND a fever), a skin infection, urinary tract infection or pneumonia, it may take stronger and more toxic antibiotics to kill the organisms. It is even possible that the infection could be fatal. A good over-view of this topic is here.

She was pleased that the pediatrician had not given her daughter antibiotics, even though Emma has been seen several times for various upper respiratory infections and stomach bugs. She commented that most of her friends’ children were frequently treated with them. Obviously she can’t control what the doctor prescribes for her but maybe next time she will ask, “Is the antibiotic really necessary?” Sometimes that is just the opportunity a provider needs to say “No, it probably isn’t. Let’s just try a little symptomatic relief and lots of fluid and rest!” Maybe another participatory patient was born this holiday.

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