Undo the Flu

Yesterday I was driving to work and saw those words on a billboard.  It was an advertisement for a local urgent care center.

You cannot be serious, I thought.

[Flashback to the early 1980s.  Professional tennis player John McEnroe was my favorite, not because of his whiny, bad boy personality but because he was a magician at the net.  I see him standing on the court, hands on hips, one of them holding a tennis racquet, staring in disbelief at an official who has just made a call with which McEnroe plainly disagrees.  "You cannot be serious!" McEnroe yells.  This phrase later became the title of his autobiography.]

"Undo the Flu."  You cannot be serious.  This is wrong, on so many levels.

First, one cannot "undo the flu."  One can treat the symptoms: fever, sore throat, cough, headache, muscle aches.  This constellation of symptoms comprises what we call an "influenza-like illness."  At the peak of flu season, the statistical likelihood that such an illness is caused by the influenza virus, as opposed to one of several other viruses that can cause the same syndrome, is about 50%.  Why does this matter?  We have anti-viral drugs that have activity against the influenza virus but not the others.  So, if you get "the flu," there's only a 50-50 chance it's influenza and a drug that works against the virus might help.

There is a test (by swabbing the inside of your nose) that is pretty fair at distinguishing whether it really is the influenza virus.  If it's positive, the doctor might prescribe an anti-viral drug.  If you watch TV, you've probably seen the commercial for the most popular one, called oseltamivir, marketed under the trade name Tamiflu.  When it first came out, I joked that I would prescribe it only for patients named Tami.  (I'd be flexible on the spelling, so Tammy could have a prescription, too.)

Why was I unimpressed with it?  For the typical patient with influenza, if the drug is started within 48 hours of onset of illness, it shortens the duration by about a day.  Beyond 48 hours, it probably makes little or no difference.  There are some patients for whom the drug is clearly recommended: patients sick enough with influenza to require hospitalization, for example.  But for most people it will make a very modest difference, and only if it's actually the influenza virus, and only if it's started very early on.

It does not "undo the flu."  If you really want to undo the flu as a public health problem, get on the bandwagon of advocacy for widespread vaccination.  The vaccine is not perfect, because it is not 100% effective, and (like any medical intervention) it can have side effects, and it doesn't protect against those other viruses.  But if undoing the flu is your goal, prepare your immune system to fight it off before you get it.

Is there anything else you could accomplish by seeing a doctor for an influenza-like illness?  The symptoms can all be treated with medicine you can buy in a drugstore without a prescription.  If you're not sure what to buy, because you don't watch TV commercials, just ask the pharmacist.  What can a doctor prescribe that's better?  Well, there is one thing.  You can get a prescription for a narcotic.

For many centuries, human beings have known the effects of the opium poppy. The active substance derived from that plant is morphine, and we've made numerous modifications to the morphine molecule.  Some of them are used as pain relievers and cough suppressants.  They also elevate mood for most people, which is what makes them potentially addictive.  So if you want to feel better by suppressing cough, relieving pain, and improving your mood, you could hope the doctor will prescribe a narcotic.  But don't count on that, because the heavy emphasis on how prescription narcotics are turning us into a nation of addicts, and killing us in droves through overdoses, has made many doctors skittish about prescribing them for anyone who doesn't have cancer pain or a broken bone.

By now it should be obvious that I'm saying influenza is - for most people - an acute, self-limited illness.  Translation from medical jargon: it comes and it goes, and nothing much makes any difference in the natural history of the illness. Medicines may ameliorate the symptoms, and most of them can be had without a prescription.  Nothing makes the illness go away faster, with the very modest exception of oseltamivir, prescribed under just the right circumstances, as I've explained.

So the "Undo the Flu" billboard is encouraging you to consult a health care professional for an illness which, most likely, will not benefit from professional health care.

I am now picturing the look on the face of Joseph Califano if he were reading this billboard.  Califano was Secretary of Health, Education & Welfare (HEW) in the Carter Administration.  Califano believed that in medicine supply generates demand.  He was the architect of US health policy that led to dramatic slowing of the growth in the supply of doctors.  As a result, that supply has not kept pace with demand, and today everyone agrees there is a shortage of doctors, especially in primary care, and for the next few decades there won't be enough of them to meet the medical needs of an aging population.

But the proliferation of urgent care centers, and the marketing of their services, is a spectacular proof of Califano's thesis about supply generating demand, and nothing captures the phenomenon better than a billboard encouraging people to seek professional health care of very modest (if any) benefit.

Urgent care facilities certainly have a niche to fill.  Plenty of patients do need to see a doctor (or a nurse practitioner) for episodic care, and not everyone has a primary care doctor who can offer a timely or convenient appointment.  But we have developed a habit, in the US and many other affluent nations, of seeking professional health care for every minor illness and every trivial injury.  That is a costly habit.  I don't know the size of its contribution to our ever-increasing national health care budget, but I think it is significant.  And I think we should not be fostering it.


A few years ago I had the privilege of caring for a professional bull rider who'd been thrown and stomped.  He had serious injuries to internal organs in the chest and abdomen.  Over his protests, his buddies put him in the back of a pickup truck and brought him to the hospital. When I explained my findings and told him he needed to be under the care of a trauma surgeon, he told me he really thought he'd be fine.  He thought he could just walk it off.

Of course he was wrong, but an awful lot of us see doctors when we really could just walk it off, because seeing a doctor won't make any real difference.  Maybe we all need a little bit more of the cowboy in us.