Practicing Pharma(cology)

By Carl Nelson

            It seems common practice nowadays when seeing the doctor for a sore throat, to be sent home with a Rx for an antibiotic. This was a definite “No, no.” when I was being taught medicine fifty years ago. We were told that nearly all sore throats are due to a virus, so that an antibiotic is useless therapy. (Actually, worse than useless as it will disrupt the gut biome.) If there was a worry of “strep throat”, the treatment was to take a culture, and then to treat for a positive culture for strep. I don’t believe sore throats have changed much since those days. But then, I received my degree fifty years ago but never practiced.

Nevertheless, I can’t help following the progress of medical practice over the years through accounts of my friends and acquaintances, and through my own medical narrative. “We do not treat until we know what we are treating,” was the general message of my medical school years. (“First do no harm,” is medicine’s Prime Directive. Treatment before clear diagnosis is like a hunter firing off a gun into a shaking bush.) True, out on the wards there was some slop in the application. If there were some malady caused by a very specific agent, then often the specific cure was prescribed – and the cured patient was chalked up as a correct diagnosis. Or, if a diagnosis were a toss-up between two different etiologies (causes), sometimes a therapy would be used to ferret out the answer. Out on the street, as it were, where the suffering is immediate, the rules become more flexible.

Nevertheless, the principles and realities remain the same (no matter the rationalizations).

I was spurred to write this essay on the back of two recent events, which rode in on a sea of like happenings over the years.

It would seem that taking a culture, then testing for sensitivities (if the first antibiotic trial fails) is a thing of the past. For example, I’m growing older and faced with a fairly quickly rising PSA value, my general practitioner referred me to a urologist for follow-up. I was given an MRI scan which revealed a few questionable areas plus a darker area which might indicate a latent infection (which could also be driving up my PSA numbers). In order to distinguish between the two, the urologist tried various antibiotics to see if the numbers would go down. They didn’t. Finally, we decided to do a biopsy of the cancer-questionable areas. I asked him if he could also take a culture specimen of the possible latent infection so that we could see what might grow and what that could be treated with. He said, “Sure,” in the way you might say something to placate a skeptic.

When the results came back, the tissue samples were of a ‘glial’ score right on the line. The cultures grew nothing, he said. But his lack of enthusiasm for taking a culture, makes me wonder if my request is such an outlier nowadays that it wasn’t taken seriously, or that they don’t really know how to handle this sort of specimen work, or if, because of this, the lab did not use the appropriate media for growing the agent most commonly found in prostate infections. That is, was I just “blown off”. I can’t say. But I do have the feeling of being moved relentlessly down a medical services conveyor belt, and wondering at which point I might best jump off – or not.

The second event happened just recently.

The son of an in law has been severely laid up for the past several months with lung problems. He can barely get enough breath to do anything. And he coughs up phlegm, some of it with “little chunks”. In terms of his personal healthcare he’s a total knucklehead. He has a history of asthma, but works without any mask in every sort of dirty environment from chemical tub cleaning, to machine shop work to dirt track racing. He’s an active, very blue-collar sort of guy who can barely get out of bed in the morning to get to work presently. His doctor sent him to a pulmonary doctor who sent him to an allergist, and the allergist sent him home with a “bag of drugs”. She pumps him full of both steroids and antibiotics. Which make him feel and breathe better for a couple weeks, and then he reverts to his initial wretched state. This cycle has been repeated a couple times while he awaits being tested for allergies. Apparently, testing requires a certain state of health?

I know that it is very hard to differentiate between the symptoms of an allergy and those of an infection. However, giving the patient medications for both at the same time would seem to deliver no insight as to which is causing the problem. And steroids mask things. Like inflationary spending or declaring a truce with Hamas, initially the problems will stop.

Moreover, there seems to have been little history taken and measures instituted for determining and alleviating other risks. For example, the patient is quite overweight and snores loudly and wakes drained of energy. His mother uses a CPAP. She talked him into trying it, and it made him feel much better. (Unfortunately, he had the dial turned too high and woke with a sore chest. They’ve adjusted this since.) My wife felt for several years that she was suffering from an allergy with sinus headaches, fatigue, tiredness, sinus congestion – until she found this all went away after using a CPAP herself. Apparently the nasal congestion was caused by trauma to her nasal area due to the breathing difficulties dramatized by her snoring. Certainly, getting my relation’s sleeping problems squared away could clear the waters a bit.

Furthermore, the patient works in very dirty areas without a mask. Some environmental hygiene would certainly be appropriate.

And the patient is also taking drugs for hypertension and other conditions, which might be contraindicated, or exacerbate an allergic condition such as asthma.

The situation is seemingly complex and needs a medical professional who will take the time to carry the investigation to a successful conclusion. What it seems my in-law’s son is getting is a bag full of medicines. The doctor gets a billing. Pharma makes money. And they both have a captured market.

Perhaps after AI has taken most of the jobs away from humans, we will be employed to suffer.

It’s a jungle out there. And in that jungle, doctors nowadays seem to be practicing pharmacology instead of medicine. Taking a thorough history seems a rather archaic practice, also.

In the spirit of Swift, to cut present medical costs it might make sense to simply go to your local pharmacist, describe your symptoms, (or simply ask an acquaintance with like symptoms – or who may know of someone with like symptoms)and buy the drugs (with dosages) the pharmacist sells to those like customers with like symptoms. In this way, we might cut out the MD middleman altogether. (They’re highly trained – and expensive!)

Given the topsy-turvy nature of the world out there, I often wish that I might wake up one day and find that I have been wrong about everything!

But as in the theme song, “It’s a Jungle Out There” to the comedy series “Monk” by Randy Newman repeats:

“You better pay attention

Or this world you love so much might just kill you

I could be wrong now,…  but I don’t think so!

‘Cause it’s a jungle out there

It’s a jungle out there”

If anyone reading this, who is currently working in the medical field, has anything they might like to add to this, I’d certainly be interested in hearing it. “I could be wrong now…”