Forget the reassurance, people want Cipro

Street Smarts. By Scott Gottlieb, MD, amednews contributor. Nov. 12, 2001.

STREET SMARTS

A column looking at the corporate side of health care

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A woman who writes for one of the weekly news magazines based in New York complained of a really bad cough. She had chest pain and felt short of breath and eventually developed a low-grade fever.

Concerned she may have anthrax, she went to the emergency department. The doctor on call examined her and told her not to worry, it was just a virus. No ciprofloxacin, no chest x-ray, no anthrax test.

The physician's reassuring words weren't enough. The woman wasn't satisfied until she saw an infectious disease specialist a few days later.

She remembered that article she wrote about the Middle East. She went over the mail she had received the last month. And she wanted the blood test and the prophylactic fluoroquinolone until the results were back.

Evidenced-based medicine is not cutting it here. On the cusp of a health scare, people are leaning hard on doctors to provide treatments and tests.

The fact that this attack has been targeted at professionals with the biggest megaphones has increased the heat on us.

Officials at the Centers for Disease Control and Prevention, in particular, have been roundly criticized in the media for spreading reassuring words before all the medical facts were in.

That postal workers took the official advice and died has not been lost on the media.

Officials were confused and harassed and did the best they knew under the most difficult circumstances. These are good people working hard in a strange new world.

In the final analysis, we might find that we were all duped by the terrorists. We were put on the trail of the low-grade, clumpy anthrax that was sent to New York only to be off-guard when the high-grade, finely milled stuff turned up in Washington, D.C.

But health officials were also failed by the rules that guide us as physicians. In the words of USA Today's editorial board, "Public health officials have consistently approached the evidence with the precision befitting scientific research or an easily treatable disease outbreak."

As Deputy Surgeon General Ken Moritsugu, MD, MPH, said at a news conference in explaining the slow response, "We're taking it one step at a time ... tracing it back very systematically, following the science."

In some ways, it's the difference between listening to the epidemiologists who say you'll only need 150 smallpox vaccines to quell any outbreak, or the politicians, who say go out and buy 300,000 so every American knows there's a vaccine with his name on it.

Heading off a terrorist attack is not a scientific process, and public fear won't be persuaded by evidence-based medicine. It might just be that doctors have more than a medical role in a time of crisis, but a political role to demonstrate that all the care will be available all the time on a moment's notice.

Does that mean giving the worried well a starter dose of Cipro? Or testing the worried sick for anthrax? As Jerome Groopman, MD, wrote in the Wall Street Journal, "the potential for inappropriate use and toxic side-effects [of antibiotics] must be weighed against the allaying of fear that comes from knowing that the family medicine chest holds a potentially lifesaving drug."

New York published an article, "Doctor Love," proclaiming that single doctors are New York City's "most datable" professional again. "It's definitely the direct contact to the Cipro. ... It's nice to be around someone who knows his spores, is equipped to administer a nasal swab, and has no problems pronouncing the word cutaneous."

One gets the sense that the editors were only half-kidding.

Dr. Gottlieb is a resident in internal medicine at Mount Sinai in New York and a former analyst for the Wall Street firm Alex. Brown & Sons.