The patient was not unusual. It was a Wednesday, several years ago in late October. The wet, autumn weather had ushered in a flurry of patients with the same nagging symptoms: sneezing, runny nose, headache, sore throat, sinus pressure… I knew well the constellation of complaints attached to seasonal allergies — I even had them myself. The challenge with this group of sufferers was not, however, management of their symptoms. The challenge was in convincing them that they did not need antibiotics.
“When did this start?” I asked, in my most patient voice, trying hard not to roll my eyes. I knew what was coming, but I asked anyway.
“Well,” the patient said, warming to his subject, “I get these sinus infections every 3–4 months, my nose starts running, sneezing, and itching, and after about a week of that, I get a headache and pressure behind my eyes, then a sore throat with a cough.” He had become more demonstrative and was gesturing with both arms now. “The cough gets worse with lying down and I lose sleep. And that,” he said, finally losing steam, “is why I need antibiotics.”
I looked up from my pad.
“The doc always gives them to me, and after one day it’s all gone. Like magic,” he said.
That’s magic alright, I mused to myself. I wonder if I could sell this guy a magic rock to replace the antibiotics?
“It’s like clockwork,” he continued. “Every three or four months,” he repeated, “I’ve had it this way for years.”
I looked at him. He was 50ish, in fair health with a belly. No concomitant conditions, no medication allergies. His blood pressure was borderline but not worrisome — I would have to choose my battles with this one. “You’ve been getting antibiotics every three to four months for a few years?” I asked for confirmation. “That’s a lot of antibiotics.” In my practice, I’ve always been mindful about overprescribing antibiotics; I know the dangers of antibiotic resistance as much as anyone.
“Oh, my doctor only prescribes once a year, the rest of the infections I treat at Urgent Care,” the patient said. “My doctor is really busy most of the time, so he likes me to see others if I can.”
I was beginning to get a better picture now. “Have you ever seen an ENT specialist for your sinus infections?” I asked him.
“Well,… no,” he said. “The infections aren’t serious enough for a specialist. They always clear up after a day of the antibiotic, usually the Z-Pak or something like it.”
“I see,” I said, tapping my pad with my pencil … and then I launched into my spiel about how drug resistant infections are made, about how many antibiotics Americans are exposed to in their soaps, laundry detergents, eggs, milk, and meat. He nodded along, as if in total agreement.
When I finally began his examination, I noted aloud the findings to keep him abreast of my appraisal: “Bulging TMs, no redness or fluid, that’s a sign of increased pressure, probably from your sinuses, but let’s continue.” A feather light touch to his ethmoid and maxillary sinuses produced dramatic winces of pain from my patient. Again, trying not to roll my eyes, I tipped his nose up and took a good look at his turbinates. “Hmm, pale, congested, and boggy.” I said aloud. My patient nodded triumphantly. The usual culprits were present: clear, post-nasal drip, cobblestone pharynx, enlarged but non-tender lymphadenitis of the neck, voice without hoarseness, and clear lungs. Draping my stethoscope around my neck, I provided my verdict: “Rhino-sinusitis,” I declared. “Likely from seasonal allergies.”
The patient drew himself up angrily.
Here it comes, I thought.
“Clearly you know nothing about infections!” he said loudly. “All of my other providers know an infection when they see one — and without doing all of that rigamarole!” he shouted.
“Rigamarole?” I asked.
“Yes!” he spluttered. “All of that checking my ears, and my throat, listening to my lungs. None of that has anything to do with my sinuses, you’re just trying to pad my bill, I know how you people work!”
I took a long breath, silently counting backward from 10. I explained the particulars that differentiate a sinus infection from seasonal rhinitis, and he agreed with me that his symptoms were more consistent with rhinitis.
“But I looked it up on Google,” he said, holding his ground, “and it said if my face hurts, it’s a sinus infection.” And, he added, “If antibiotics aren’t needed, why do I always get better the next day?”
It wasn’t the first time I’d faced an overzealous patient of Dr. Google’s. There wasn’t time to explain about algorithmic literacy; the skill of framing questions and understanding nuance to get an unbiased answer — and I doubt he would have been receptive to hearing that his beloved Google was only slightly better than a Magic 8 Ball. I decided to try a different approach. What if we worked from the middle out? I wondered. I searched for something we both could agree on: sinus infections were bad.
“Alright Mr. Smith,” I said, “We’re actually agreeing about treating a sinus infection, right?”
He nodded vigorously (something I’m sure he would have had trouble doing if he’d had a real sinus infection).
“What we don’t agree on is that you have a sinus infection.” I said. “Sinus infections are dangerous and should be promptly treated,” I continued. “I agree to treat you with antibiotics if you truly have a sinus infection, OK?”
“Fine,” he agreed. “But how can we tell if there is an infection?”
I raised my finger. ”Now you are thinking like a clinician,” I said sagely. “If only there were a way to definitively identify bacteria in situ … ” I said, dramatically reaching into a drawer and pulling out a culture curette. “Voila!” I said holding it up with a flourish that would have made Vanna White proud.
“I am going to culture your sinuses today,” I said. “It will go to the lab, and they will determine if bacteria are present and what they are.”
Mr. Smith’s face lit up like a sunny day. “Of course!” he said.
I swabbed each of his nostrils, going as deeply into the sinuses as I could, and thought: Some would consider this padding the bill … but he insisted, who am I to argue? I secured and labeled the culture specimen. “Now what to do while we wait for the culture ….” I mused aloud. “I hate to have you so uncomfortable, so how about we come up with a plan while we wait, just in case it’s not an infection?” I outlined a two-week treatment plan with steroid nose spray, antihistamines, NSAIDs, hot drinks with lemon, honey, and ginger for post-nasal drip, rest, increased fluids, and warm compresses for his sinuses.
He looked with satisfaction at the paperwork outlining his treatment plan. I told him I would call him when the culture came back and promised to use an appropriate antibiotic, once the bacteria had been identified. He left the office happy, feeling heard and understood, and I felt the same.
Several days later I called him to tell him his culture was negative for bacteria. He had forgotten I had obtained a culture. He didn’t mind hearing that there was no bacteria, because his symptoms were much better. I set up refills for the steroid nasal spray and told him to fill it in a few months if the sneezing and runny nose started again. I told him if he ever had a fever over 101 degrees, and felt like he had the flu, to come in and see me, but if it was the usual symptoms, to resume the regimen we’d just completed. He enthusiastically agreed. For the next year, I checked in with him as the seasons changed to make sure he had his questions answered and symptoms addressed, and so he knew I was still following him for signs of infection.
The last time we spoke, several years ago at the beginning of spring, he called because he’d recently had an abscessed tooth. He told me the antibiotic prescription had been changed three times because nothing was working; they were thinking of going with IV antibiotics until they found a combination that had done the trick. “You know,” he said, “I remember what you said about antibiotics making trouble down the road, and I told my dentist I’d taken Z-Paks for a few years. He said it may have been what caused the problems.” Mr. Smith also told me that he almost never needs to see the doctor now for his sinus infections, and that he was saving a lot of money to boot!
I realize that in Mr. Smith’s case, I was able to find a middle ground. I also realize that there are some cases in which there is no compromise, no working out from the middle. For safety, sometimes we must insist on immediate and concise medical treatment. But those instances are few and far between. At the end of the day, patients need to feel heard — there’s no possibility of meeting in the middle without that.
How do you compete with (and vanquish) Dr. Google? Share your magic strategies in the comments!
Arlene Dorrough has been a practicing PA for more than 15 years. She is currently working in occupational medicine and urgent care. She is also working as a Medical Examiner for the DOT. Arlene is a 2021–2022 Doximity Op-Med Fellow.
Animation by Diana Connolly