Explainer

Re: I am considering going back to the white coat ...

TheRanger — Fri, 26 Jun 2009 01:44:06 GMT

I didn't think you would want to address the PharmFree project which is a med school student initiative to reduce the pharamaceutical company influences over doctors including some of the things I previously listed.

http://www.pharmfree.org/

Nor have you addressed why pharmaceutical companies push their package deal for restricted formularies which means an insurance company must only allow the patients/subscribers to use a particular pharmaceutical companies products even if their is another product which is safer, more effective and cheaper but may be the only major product of another pharmaceutical company. This practice is often disguised because if another multi-product pharamaceutical company offers products which do not compete with the first company they can still be used in the restricted formulary. It may also be disguised by partial packages where a major exclusive drug is paired in the formulary with a high profit drug that is similar to drugs from other pharmaceutical companies.

A restricted formulary is jargon for an insurance company only covering certain approved drugs. Remember, you can always "get" any drug your doctor prescribes. The issue is whether your insurance company will pay for it or you will pay the entire price. This is the moral high road of insurance companies who will tell you that you are never "denied" a drug; they just won't pay for it.

Re: I am considering going back to the white coat ...

janneys2005 — Thu, 25 Jun 2009 04:32:24 GMT

Frankly, Ranger, I have addressed everything you just threw at me already. Which leads me to believe you either can't comprehend what I have said, or you aren't trying. Either way, it would be a waste of my time to continue trying to educate you on this matter. Have a nice life.

Re: I am considering going back to the white coat ...

TheRanger — Wed, 24 Jun 2009 13:51:48 GMT

Maybe you can explain what the PharmFree project is if there is no doctor/pharmaceutical company link.

Re: I am considering going back to the white coat ...

TheRanger — Wed, 24 Jun 2009 13:32:00 GMT

The thread here is nosocomial disease not antibiotic resistance. You can get antibiotic resistance at home when you take what the doctor prescribed. While that is not good, you are at least not getting an additional surprise package from the hospital.

Every patient brings in a resident population of bacteria some of which may have plasmids which can cause antibiotic resistance as you state. However, what needs to be controlled in hospitals is the source of multi-resistance plasmids which can transmit resistance to pathogens acquired in a hospital as well. You make it sound like resistance is only a random occurence. If that were true there would be no "house" pathogens for a hospital. That is just not true. Unless there was some form of transmission of plasmid or pathogen, there would be no particular bacteria in a hospital. That is the issue; not the mode of any antibiotic resistance. The patient does not care whether the nosocomial disease is antibiotic resistant when they contract it or not. Non-resistant bacteria cause damage too especially in hospital patients.

Then the bacteria are not harmless are they? Solution! Load the patient up with commensals. Nice try. Ever hear of opportunistic organisms like Psuedomonas. Thoses are normally part of

The US is rated something 37th in the world for health care. One of the reasons is the arrogant faith in antibiotics rather than stringent infection control. We are behind such technological advanced countries like Greece, Colombia, Chile, Cyprus, Costa Rica, and Singapore.

We have a choice; improve transmission control or play the new antibiotic game which has a diminishing return on it and high costs.

Re: I am considering going back to the white coat ...

TheRanger — Tue, 23 Jun 2009 22:30:43 GMT

Have doctors prescribed antibiotics for colds?

"All antibiotics work against a set population of bacteria."

Help us out here and tell us what the acronyms MRSA and VRE stand for.

"If a patient has a bad infection, and the doc suspects it could be, say, VRE, he hits them with a combination of drugs that would LIKELY be efficacious. When the sensitivities come in, he adjusts if necessary. "

Now you have hit the oxymoron of medicine; act now to stop a severe infection or wait for the lab results to know what it is and what antibiotic will work. If there is really such a need then the doctor acts and also gets the labs. However, what antibiotic does the doctor choose? Here is the another dilemma. If the doctor always uses the latest super antibiotic for a less than serious infection, then the sooner that antibiotic will not be effective. The hot field in pharmaceutical antibiotics is designer antibiotics based on molecular modeling.

"Antibiotic use promotes development of antibiotic-resistant bacteria. Every time a person takes antibiotics, sensitive bacteria are killed, but resistant germs may be left to grow and multiply. Repeated and improper uses of antibiotics are primary causes of the increase in drug-resistant bacteria.

While antibiotics should be used to treat bacterial infections, they are not effective against viral infections like the common cold, most sore throats, and the flu. Widespread use of antibiotics promotes the spread of antibiotic resistance. Smart use of antibiotics is the key to controlling the spread of resistance."

http://www.cdc.gov/drugresistance/community/anitbiotic-resistance-faqs.htm#4

http://www.cdc.gov/drugresistance/diseases.htm

Also explain restricted formularies at both the insurance company level and the hospital level. Hint: use the term package deal.

Re: I am considering going back to the white coat ...

dapperdan32 — Tue, 23 Jun 2009 18:22:11 GMT

janneys2005- thank you for trying , but "Ranger" appears to be a troll

Re: I am considering going back to the white coat ...

janneys2005 — Mon, 22 Jun 2009 23:40:49 GMT

Are you serious? Do you not know how antibiotics work or something? For being a microbiologist, you sure don't grasp how doctors use your field at all. I'm pretty sure this explanation is a waste of time, but I've got nothing to do right now so I'll go ahead anyway:

There's more to doctoring than reading C&S reports and prescribing what they say. You know how they say medicine is an art? It's because doctors already have a pretty good idea what's causing an infection before the culture is even sent. They look at the symptoms and they get a picture, plus they have a vast knowledge of what the most likely pathogen is in any age group with any particular condition. They have a good idea what the culture is going to be when they send it, but they send it anyway just to be thorough.

Sensitivities, similarly, are helpful but not necessary. All antibiotics work against a set population of bacteria. If a doctor has an idea what you're infected with, then he has an idea what to treat you with, too. They don't need you to run a lab test to tell them that this gram positive is sensitive to penicillin, for example. They already know that. The only thing sensitivities are useful for is determining if the strain is resistant to most drugs.

If a patient has a bad infection, and the doc suspects it could be, say, VRE, he hits them with a combination of drugs that would LIKELY be efficacious. When the sensitivities come in, he adjusts if necessary.

You act like treating infections is a shot in the dark, but it is definitely not. The doctor has a lot more information than just your culture before the culture is even sent. So stop pretending docs are just fools throwing drugs around and that they couldn't possibly know as much about bacteria as you.

As far as drug companies, they prefer to heavily market drugs that patients will ask for and need every day, like heart meds and anti-depressives. When was the last time you saw a commercial for antibiotics?

Re: I am considering going back to the white coat ...

TheRanger — Mon, 22 Jun 2009 22:29:59 GMT

How can you possibly know efficacy without culturing? You are essentially playing the odds that this infection is the same as the last one.

Tell me drug companies don't sponsor conferences in resorts again. I love fairy tales.

Re: I am considering going back to the white coat ...

janneys2005 — Mon, 22 Jun 2009 20:56:13 GMT

Seriously, Ranger, your lack of understanding of what doctors actually do every day is really hurting your credibility. I second what Bondsman said. In many hospital scenarios, when you are presented with an infection, you assume worst case scenario and prescribe broad spectrum coverage in hopes that something will knock back the infection. When the results come in, you can adjust then, but waiting would be deadly. Doctors run culture and sensitivity EVERY DAY so I don't know where you get the claim that doctors don't care about this. Antibiotic resistance is unfortunate, but not using antibiotics and letting patients die in some effort to preserve antibiotic efficacy is worse! What are you saving it for if you're not willing to use it on sick people?!

Also, having normal ranges IS important because there are slight differences between labs in how values are reported, i.e. a 12 in one lab could actually be a 13 in another. The problem was so bad with PT values, they had to invent the INR!!! And, like Bondsman said, you could waste your time reading through every value and double checking it against what you know (yes, doctors do know what a normal Hct is...), or you could have it highlighted and then go straight to the results that are abnormal. It saves time and reduces error. Is that a bad thing?? Even the best doc could miss a line of text or accidentally trace over to the value above or below the one of interest. It happens. Would you prefer doctors make stupid errors so you can point at them and call them idiots? I am sure patients would rather have these safety margins in place.

Also, doctors choose antibiotics based on the efficacy versus a certain infection, NOT on whether a drug rep told them about it. That would be completely pointless. A lot of antibiotics are generic anyway. Plus, if one could get away with it, a good doc would choose the cheapest drug that still works and doesn't have too many side effects. No one wants to run infusions at $1000 a day if they can help it. I know an Infectious Disease doc, and his antibiotic choice is as follows: efficacy>tolerability>cost. Notice "drug reps" didn't make the list.

Re: I am considering going back to the white coat ...

Bondsman — Mon, 22 Jun 2009 19:50:16 GMT

TheRanger:

If you call a pest control company to your house on a complaint, they cannot do anything unless they identify the specific pest that is present and then treat it only with something that has been found and approved as effective for that pest.

A doctor on the other hand does not have identify what is infecting you or even if it is a bacterial infection and not something else like an allergy. Instead they prescribe the antibiotic recommended by the last pharmaceutical company salesmen who invited the doctor to a "conference" in the Bahamas or where ever. Most doctors only run cultures to determine if it is even bacterial and not viral if the current favorite antibiotic and its backup fail to work . Even then they don't run sensitivities and MIC's. This is why there is MRSA and other resistant bacterial strains.

OOS means out of specification btw. However think about what you are saying when a doctor orders a test and needs help to tell him what they mean. It is not about who is best but what the doctor understands. Many times medications change what the in specification values are. When that happens an in spec value may actually be out of spec for the patient if they are taking certain meds. Think of flying on an airplane where the pilot needs to whip out the manual in order to fly the plane.

Ranger,

Case 1: Someone comes in to the hospital and they are frankly septic. They are *dying* right before your eyes, you draw some blood and the lab says there are gram negative rods in there, or gram positive cocci, whatever. Do you:

1. hit that with the best drugs you can at that time or

2. wait for the culture and sensitivity report to come back in 2-3 days to tailor the most appropriate antibiotic to the job?

If you chose option 2 - your patient is dead. Pretty much without question.

Case 2. Someone comes in with their 6th UTI in the year. They've already been instructed on hygeine, sent to urology, etc., you just need to treat the UTI, symptoms are mild. Do you:

1. Act like Ranger's hypothetical doc and hit it with cefkillitall or

2. get a u/a and c&s and give whatever it's NOT resistant to?

In this case, probably option 2.

The point being doctors use sensitivities *every day* to tailor their therapy, BUT there are ALSO times NOT to, such as when the delay in treatment caused by waiting would be detrimental to the patient. Your doctor knows when it's appropriate to do one or the other, that's their job.

And on the OOS, say your normal hemoglobin should (in your area) be between 12 and 15. A value comes back as 6. You don't need that highlighted because you *don't know* what it means!!! You have it highlighted to *bring it to your attention*. If you are ordering a test you'd d@mn well know what the results of it mean. To imply your doctor doesn't is.... amazing - and not in a good way.

Re: I am considering going back to the white coat ...

accio — Mon, 22 Jun 2009 18:47:24 GMT

MrRanger - obviously regardless of how educated you are, you cannot practise medicine because you are unable to communicate. Just keep loading the microbiology reports into the computer because until you learn the behavioural skills taught to pre-schoolers, you will not be able to actually work with physicians.

Re: I am considering going back to the white coat ...

TheRanger — Mon, 22 Jun 2009 18:45:31 GMT

If you call a pest control company to your house on a complaint, they cannot do anything unless they identify the specific pest that is present and then treat it only with something that has been found and approved as effective for that pest.

A doctor on the other hand does not have identify what is infecting you or even if it is a bacterial infection and not something else like an allergy. Instead they prescribe the antibiotic recommended by the last pharmaceutical company salesmen who invited the doctor to a "conference" in the Bahamas or where ever. Most doctors only run cultures to determine if it is even bacterial and not viral if the current favorite antibiotic and its backup fail to work . Even then they don't run sensitivities and MIC's. This is why there is MRSA and other resistant bacterial strains.

OOS means out of specification btw. However think about what you are saying when a doctor orders a test and needs help to tell him what they mean. It is not about who is best but what the doctor understands. Many times medications change what the in specification values are. When that happens an in spec value may actually be out of spec for the patient if they are taking certain meds. Think of flying on an airplane where the pilot needs to whip out the manual in order to fly the plane.

Re: I am considering going back to the white coat ...

Bondsman — Sun, 21 Jun 2009 23:50:53 GMT

TheRanger:

You are right about psittacosis. However, yes many doctors are idiots when it comes to infectious diseases. Most wouldn't know a MIC from a gene probe. That is why lab reports always highlight oos values.

Here's your problem! You are probably correct that most would NOT know a gene probe from an MIC. So what? In the clinical practice of medicine, what difference would that knowledge make in their day to day decision making?

In the second part you are wrong in saying that doctors are idiots when it comes to infectious diseases, dealing with them IS their job -- and apparently by your posts, NOT yours. They are in fact good at doing so.

It's a crackup that you think it's BAD for lab reports to highlight non-normal values! I assume that's what you mean by OOS. Uh, wouldn't placing attention on potentially life-threatening information be a GOOD thing? What do you want, NOT highlighting them to see what doctor is the "real man" and which one kills their patient by missing it? See, the difference between medicine and lab work is that medicine isn't a game you can repeat if you get it wrong. Someone gets *hurt* or *dies* if you do. A good doctor is an highly educated *tradesman*, really, and does the right thing, hopefully by the right thought process. A good doctor is NOT someone who can recite the formal definition of the chi square test or transfer cultures from one vial to another without contaminating them. There are other people that do that.

Re: I am considering going back to the white coat ...

janneys2005 — Sun, 21 Jun 2009 22:31:41 GMT

I actually typed that with paragraphs but it didn't post that way. Sorry about the block text...

Re: I am considering going back to the white coat ...

janneys2005 — Sun, 21 Jun 2009 22:30:10 GMT

Yes, I understand that antibiotic resistance profiles vary among hospitals, but that is because it is dependent upon antibiotic use trends within hospitals. I.e., hospitals create their own populations of resistant bacteria. Resistance can arise de novo via mutation, or it can be transferred, as you probably well know. Resistance in an E. coli UTI patient, for example, does not mean that a patient picked up a novel E. coli strain within the hospital. It means the patient's E. coli picked up a resistance plasmid, which can be carried across both pathogenic AND non-pathogenic bacteria AND between species. The key here (so I will repeat it) is that even the surface bacteria harbor these resistance plasmids, and can transfer that resistance to the pathogens. I will reword this one more time for clarity. We are not just talking pathogens being spread person to person. We are talking harmless bacteria acting as a reservoir of resistance that provides the plasmids that make other bacteria deadly once antibiotics wipe out commensals that keep them in check. Since bacteria are fairly ubiquitous, even the best sanitation would be unable to prevent such spread. Unless you were able to absolutely sterilize every surface, object, and person. I am just saying the dynamics here are subtle. It is not necessarily as simple as saying Doctor X's white coat passed a unique strain of E. coli to Patient Y, ergo white coats are bad. It is not as simple as saying pathogens are in place X, Y, and Z, and all we have to do is sterilize between visits; no, it is the POTENTIAL for pathogenicity that is worrisome and it is ubiquitous. Even if a doctor never entered a patient's room, there is a good chance the patient will still develop a colony of resistant bacteria simply by being in the room. (Whether or not they become symptomatic depends on their immune status/drug use, etc.) The key to reduce transfer is to reduce this reservoir population that carries resistance plasmids - absolutely sterilizing rooms as best as possible between patients is the best place to start, in my opinion.