Perspective
Antibiotics, Por Favor
By Therese Zink, M.D., M.P.H.
A clash of cultures over the treatment of the common cold shows that there can be much more than a language gap between patients and their doctors.
The afternoon sun streams through the windows of the exam room in the newly refurbished Rochester migrant clinic. The walls show no hint of wear or tear, and the exam table still holds remnants of plastic wrap. I have explained to the woman and her daughter why it is not good to treat viral infections with antibiotics. They jabber in Spanish, hands flying. The señora’s gray hair is pulled tightly into a bun, emphasizing the lines of living in her face. Her calloused hands speak of pounding corn, making tortillas, and cleaning. A bleached-white apron encases her bosom and abdomen and hides her floral-patterned dress. The daughter, a younger version of her mother, wears a stylish blouse and slacks. Her gray roots are concealed by orange-brown hair dye.
The interpreter translated my several-minute explanation into one sentence—something got lost. The women’s expressions are somber, and their voices hiss with dissatisfaction. Now they are questioning the interpreter. I understand words and phrases. The conversation stops, and the interpreter says to me: “She wants a penicillin injection.”
My heart sinks. Helping patients understand why the common cold should not be treated with antibiotics is exhausting. Sometimes, it would be easier just to give them what they want. After years of receiving antibiotics for most maladies, patients are disappointed when I won’t prescribe them. Because of the rapidly increasing number of organisms that are antibiotic resistant, there has been an international effort to limit the use of antibiotics. However, patients still expect them, especially patients from other countries such as those in Latin America, where antibiotics can be purchased over the counter.
The señora reports having a stuffy nose, cough, and sore throat for two days, but no fever. Antibiotics are not indicated—and definitely not a penicillin injection. With a deep breath, I shove my frustration aside and try again. I ask the interpreter to translate each sentence:
“Penicillin doesn’t treat viral infections.”
“If I give you a penicillin shot, it will make your hip sore and help the bacteria grow stronger.”
“Your body can fight the virus on its own.”
“Get rest. Drink lots of liquids.”
I talk about using Tylenol or ibuprofen and returning for a recheck next week if she is not better.
The señora’s frown deepens, her daughter shakes her head.
“Lo siento mucho, señora. Regrese usted en una semana,” I say, recalling my month of Spanish immersion in Mexico three months earlier. Mornings I observed at the Cruz Rojo (Red Cross) clinic for the poor and uninsured. Afternoons were spent practicing Spanish with my maestra (teacher). I lived with a family, and we spoke only Spanish. My Spanish improved, but not as much as I’d hoped. I still could not have a complex conversation with a patient on my own.
As I walked through the swinging doors into the Cruz Rojo clinic, the smell of ammonia greeted me. Despite its cleanliness, the facility exhibited the slightly beleaguered appearance of many Latin American medical centers—scuffed walls, frayed gurneys with no paper on them, and medical supplies locked in a central location. Nurses dressed in white pant suits, and nursing students wore starched red-and-white striped uniforms and caps perched on their heads. Staff greeted each other by brushing cheek against cheek or lips. I felt my personal space had been invaded when the administrator of Cruz Rojo greeted me this way after having met me only once. Eventually, I learned to do as the Mexicans.
Dr. Roberto, the urgent care physician at Cruz Rojo, was dark-skinned with acne scars on his face and a protruding belly. He spoke little English, but he was patient with my efforts to speak Spanish and gently corrected my pronunciation. In return, he asked me to enunciate a medical diagnosis in English, then he’d practice it the rest of the morning: seizure, seizure, emphasis on the zure. Like many U.S. physicians, he draped his stethoscope around his neck and wore a white coat with his name embroidered in red on the pocket. A physician at the clinic for 10 years, his seniority allowed him to work only the day shift. His younger colleagues, who rotated shifts, flirted with the nurses and had little time for me. Since Dr. Roberto was genuinely interested in helping me, I shadowed him. He introduced me to patients: “Doctora Theresa vive en los Estados Unidos. Estudia español para ayudar los inmigrantes de Mexico.”
As in the United States, nurses set up and cleaned up after the doctors. Nurses and doctors shared treats—dulces and patatas fritas—that they carried in their pockets from the break room or hid in drawers at the nurses’ station. Pharmaceutical representatives from the same companies that called on me in the United States visited Dr. Roberto and left samples, shiny pamphlets, journal reprints, pens, and pads of paper with logos.
When a patient was ready for evaluation, a half-sheet of computer-generated paper appeared in the box hanging on the door of the intake office. Dr. Roberto picked up the paper, walked to the waiting area and called the patient into his office. The patient was typically accompanied by a family member, and they were invited to sit in the hard-back chairs across from Dr. Roberto’s desk. A computer screen displaying a web-based pharmaceutical desk reference was on his right. Across the room, an exam table that wore the same paper sheet for days was parallel to the wall. Pharmaceutical samples were kept in the unlocked closet. The bathroom where he fastidiously washed his hands between patients was next to that closet.
I sat or stood next to the patient. Dr. Roberto invited the patient to describe symptoms, then asked questions. If I could organize my Spanish words into what I wanted to say, I also posed questions. Then Dr. Roberto performed an exam and handed me his stethoscope or flashlight so I could do the same. He religiously checked throats and rarely looked in ears. If there were abdominal complaints, he palpated the abdomen. Often, he asked me what I thought: “Tratamiento?”
I tiptoed around the differences in our approaches. In the United States, we always looked in the ears of children and were less concerned about throats in toddlers younger than 2 years. Despite patients’ requests for antibiotics for a cold or viral infection, I refrained from prescribing them despite their disappointment. In contrast, Dr. Roberto treated them with an antibiotic and at least three other pills (one for the cough, another for the congestion, Tylenol or ibuprofen for discomfort). Abdominal complaints were also treated with antibiotics and an antispasmodic medicine, usually given through an intravenous line.
Dr. Roberto carefully wrote the prescriptions and his instructions on a single half-page of paper with the Cruz Rojo emblem, stamped it with his title, and then scrawled his name. The directions included symptomatic treatments such as drink liquids, avoid caffeine or refrescos (pop), and rest. Prescriptions were purchased at the Cruz Rojo pharmacy, which was more economical than private pharmacies. Patients were usually encouraged to return in a few days for a recheck. “Patients love their penicillin injections and antibiotics,” Dr. Roberto told me. “In Mexico, they can buy them from any pharmacy without a prescription.”
When we discussed the treatment of a patient, I highlighted the similarities and cautiously explained our differences. The antibiotic issue was a challenge. As an example, I described the rapid strep test to Dr. Roberto. Studies had shown that physicians were not particularly good at distinguishing strep from other viral throat infections. By swabbing the throat, then placing the swab in reagents for five to 10 minutes, the rapid strep test provided a highly sensitive indication of whether the patient had strep growing in his or her throat. The test had greatly reduced the use of antibiotics for pharyngitis in the United States.
Dr. Roberto was impressed and asked, “Cuanto cuesta?”
“About $25 per test kit,” I explained.
“Muy caro!” he exclaimed. And by Mexican standards, this was expensive.
One afternoon, I went to a pharmacy to practice my Spanish and to check on the cost of certain drugs. Twelve 500 mg tablets of Amoxicillin cost approximately $6 U.S. At home, I usually prescribed 20 for strep throat, at a cost of just under $12, or half the cost of a rapid strep test.
To put this in perspective, a Mexican who worked at McDonald’s in Mexico and was employed part-time received no health benefits and made $1 U.S. an hour. He or she would need to work 25 hours to pay for the rapid strep test and half that to pay for the Amoxicillin.
Despite his willingness to give patients what they wanted, Dr. Roberto was worried about antibiotic resistance. He had heard the messages of the international campaigns: treatable illnesses become untreatable. We talked about “los problemas con resistencia a antibioticos” and “fuerte bacteria.”
Why then did he continue to give antibiotics for what was clearly a viral infection? Was he pleasing patients or was I missing something? I mulled this over for several days and while pouring a glass of purified water from the dispenser at my family’s home, an idea occurred to me. Folks with money, like my host family, purchased 10-gallon jugs of purified water. But the poor would not have the resources for this. In the clinic, stomach cramps were a common complaint. I asked Dr. Roberto about this and he confirmed the “contaminación del agua.” Dr. Roberto usually prescribed a Ciprofloxacin equivalent and an injection for spasms of the colon. Perhaps he was treating a bacterial problem. However, in the United States we refrained from using antibiotics for diarrhea unless there was blood in the stool, a fever, or copious diarrhea.
At the monthly staff meeting, Dr. Roberto, the physician rotating on days, and the nurses gathered in a room with paintings of local city scenes hanging on the walls. After presenting the case of an adolescent who had died from a severe reaction to a scorpion bite, Dr. Roberto opened the floor to other topics of concern. The head nurse brought up the issue of giving injections to patients without prescriptions. Because patients could purchase injections and syringes over the counter, they sometimes came to the urgent care clinic asking a nurse to administer the shot. Dr. Roberto was adamant about not providing this service, then he asked me to explain the necessity of prescriptions for many medications in the United States.
In my hesitant Spanish, I talked about the fact that most medications like antibiotics, anti-hypertensives, birth control pills, and medicines for diabetes required a prescription and how even the syringes for insulin couldn’t be purchased without a prescription. As a result, patients in the United States could only receive an injection through the order of a physician. Dr. Roberto repeated what I had said, translating my Spanish into Spanish. I smiled to myself; at least I understood everything he said.
Now at the Rochester migrant clinic, I face the Mexican señora and her daughter. They scowl at me, deep furrows carved in their brows. Their years of medical care in Mexico have taught them that good care means pills, several types of pills, and sometimes injections. For this illness, they have received only words of reassurance. They are wondering why they bothered to come see me. Graciously, they take my hand and thank me, but I hear them commiserate in Spanish, shaking their heads as they walk out the door. The interpreter, a younger woman, smiles at me and shrugs her shoulders. We watch them leave, their confidence in the medicine they have always known as strong as ever. I stand alone with my impotence. So much they needed; so little I could do. MM
Therese Zink is an assistant professor in the department of family and community medicine at the University of Minnesota.