Magical thinking, and the persistent ear infection

Over the years, experienced clinicians develop a sensitive and largely unconscious radar that supplements their cognitive analysis of patients. From the moment we enter the room, we are processing multiple subtle and seemingly irrelevant clues: how sick does she look, how nervous, how is he dressed, does he make eye contact, is he alone or accompanied, what is her mood?  Mostly we let this intuition work undisturbed, drawing on it selectively when we want - or on those occasions when it speaks up unbidden - but walking into the exam room to see Ms. J with her persistent ear pain was like turning on a car radio without knowing that the previous driver had left the volume turned all the way up. She was so angry it seemed to fill the air and charge even the exam rom equipment with a spring-loaded sense of impending attack.

She was spitting mad.

“Those f... jerks at the ED. It’s been three days and my ear still hurts.”

She had called late on a Tuesday afternoon, complaining that her ear still hurt, which she blamed on the incompetence of the emergency room physician. The triage nurse buzzed me to ask what to do with ‘a steaming lady with a possible hot ear’ Her regular physician, one of my partners, was not in and our acute slots were filled. Since I was on call for our practice that day, and because it is very difficult to evaluate an ear over the telephone, I had the triage nurse add her to my schedule after regular hours.

As soon as I entered the room, it was clear that the triage nurse had not exaggerated how angry she was. She’d had three days of constant left ear pain. She had wasted her money and time going to the emergency room. The emergency room physician must be incompetent (“drunk or f... stupid” in her words). This did not seem like a good time to point out to her that, had she called us when her ear started hurting, she would have been seen in the office by her regular physician and would not have had to waste her money seeing a physician she felt was substandard.

Her story was fairly straightforward, though not easy to elicit, as she preferred to talk about the evils of the ED. She had had a cold for several days and developed ear pressure that progressed to ear pain. After it kept her up all Friday night, she presented to the emergency room the following morning where she was diagnosed with acute otitis media with the standard treatment plan of antibiotics, ibuprofen, and to have a follow-up visit in 10-14 days to document clearing. It was now three days later and her pain was unchanged. And she was spitting mad.

On exam, she was an articulate and well dressed woman in her mid-30s, afebrile, somewhat agitated and overtly hostile towards anyone even remotely associated with the hospital Emergency Room, with a bright red, thickened and bulging less manic membrane consistent with the previously diagnosed acute otitis media. Her game was otherwise unremarkable.

A generation ago, this would have been treated with myringotomy. This is a procedure where a small knife is used to make an incision in the eardrum to release the infected contents. While the treatment itself is extremely painful, it generally provides nearly immediate relief of the presenting complaints. This treatment has largely been replaced with antibiotics.

I told her that we would change her antibiotics, as the current one was clearly not working. This was in the era before instantaneous transmittal of electronic records, so I asked her what antibiotics she had been given. She couldn’t tell me. This is not unusual: many patients find it difficult or impossible to remember or pronounce words in what to them is a foreign language. Sometimes the directions can help so I asked whether it was once a day, twice a day, three times a day, a pill or liquid, or what color? Again, she had no information for me this was beyond strange. I asked her if she’d fill her prescription. She said no.

I now understood why her infection had not begun to resolve. But this left me with other questions.

“Mrs. Smith,” I said. “I think I understand what your ear infection is no better. I am puzzled though about something else. The emergency room physician seems to me the correct diagnosis and prescribe the medication which he did not take. If you did not take the antibiotics, why did you think you should get better?”

Her answer? “I went to the emergency room.”

I briefly entertained asking if she drove through the parking lot of a restaurant when she was hungry or past a gas station when her car needed fuel. I thought better of it. But I could not resist one last dig.

As I handed her a prescription for amoxicillin, I met her eyes and paused and said slowly for emphasis, “this is a very special medication. There is something very important you need to know about it. If you don’t take it, it definitely will not work.”



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