Influenza is caused by an RNA virus, not DNA, as stated in an Outlook article Sunday. The article also overstated the flu vaccine's effectiveness, which is about 70 to 90 percent, depending on the age and health of the patient. (Published 01/25/2000)
"Stay away from doctors--they'll only make you sick." This cranky tidbit of advice comes from my father, a retired general practitioner. And in the depths of flu season, I wish more people would take it. Swarms of patients flood medical offices and emergency rooms, leading me to wonder, as I do every winter: Why are you here? We all know how little a doctor can do to relieve your misery, so why didn't you stay home in bed? Wouldn't you be cozier there?
Of course, I know the answers. You're here because you're a lot different from the patients my father treated 40 years ago. You're better informed, more demanding, less sure that the flu symptoms aren't masking some far more sinister disease. And while at the end of the day I might think I haven't helped you much, I do understand how you feel--and why.
The influenza virus is a nefarious little packet of DNA wrapped in proteins shrouded by glycoproteins. This outer glycoprotein coat changes with each year's strain, enough so that a flu shot should be an annual ritual. Influenza is not a cold virus or a "stomach flu" virus, though all three blow into D.C. at about the same time each year. The real flu is a distinctive and remarkably fast-moving malady. You wake up feeling a little sniffly and within eight to 12 hours you feel pain in every fiber of your being, accompanied by an overwhelming desire to do nothing but lie undisturbed for a month or two until your broken body begins to recover. This accounts for the desire to seek professional help: Nothing should feel this bad. And if it does, by cracky, there ought to be something a doctor can do about it.
Truth is, there is and there isn't.
Let's assume, if you're sick, that you missed your chance to get a flu shot. A good assumption, since the vaccine is 99 percent effective. (Many people catch one of the other minor contagions and blame vaccine failure, but they're wrong.) So you languish for hours in a waiting room along with everyone else who has the flu--and a few other germs that you haven't gotten yet and might not otherwise be exposed to.
When you finally get to see the doctor, one of two things happens: You get a quick clinical diagnosis (based on the doctor examining you and taking a history), or some kind of lab work-up. There are accurate tests to detect influenza virus, but most doctors know when it's flu and when it isn't. The lab work is just to rule out something else.
So once we tell you what you already know, which is that you've got the flu, what can we do for you? Well, we can recommend over-the-counter decongestants and cough medicine, but that's so been there, done that. We can prescribe antibiotics. We can also bark at the moon: Antibiotics kill bacteria, not viruses. Viruses are as safe from antibiotics as the driver of a Lincoln Navigator is in a head-on collision with a Volkswagen Beetle.
We can, however, prescribe antivirals. A drug known as Amantadine has been around for several years, and is actually quite effective if you have influenza A (Amantadine can't get past the glycoprotein coat of the B strains), if you take it within 24 hours of experiencing symptoms, and if you think that feeling better in four or five days instead of five or six is worth the risk of the side effects, which include dry nose and dream abnormality.
This year, we can also offer Relenza. This, too, might shorten the illness by a day or two, and shortens the period of contagiousness (which is a valuable public health benefit). The risk of adverse reactions is fairly minor, unless you're asthmatic or suffer from emphysema. Still, there's a major downside to any antiviral therapy. Influenza viruses quickly become resistant to these drugs. So folks treated in December spread a drug-resistant version of the virus to other people, and by January the newly circulating strains can't be treated. Remember what Dad said about doctors making you sick? As for what we cannot do: We cannot make chicken soup for you. The Second Avenue Deli in New York can. Very few, if any, places in goyische Washington, come close. (Please contact me if you know of one.) My wife makes a wonderful chicken soup, and matzoh balls that positively float like air, but this hardly counts as a public health remedy.
And we can't prevent you from getting sick with something else the moment you get over the flu. In fact, our waiting room may have been where you picked up that next cold (see above).
I'm not the doctor my dad was, in ways both good and bad, but patients aren't the same, either. My father learned medicine in France in the 1930s--in other words, a world away and a lifetime ago. He understood more about the fine art of laying hands--and eyes, ears, even nose--on a body to probe its mysteries than I or most of my colleagues ever will. The trade-off, though, is probably worthwhile: I'd rather have a late-model MRI scanner and a vial of Zithromax when I really need it, and so would my patients.
My dad's patients knew when to seek his help and when not to. Got the flu? Stay home in bed, drink lots of fluids. Thus went many a century.
But a 21st-century patient doubts that it's only flu. People getting sick nowadays know a lot more about disease than they did 20, 30, 50 years ago. Once again, that's both good and not so good. It's good because people expect more from their docs, and their docs have a lot more to deliver. But it's bad because trying to disprove their deep-seated, generally unfounded fears--cancer, AIDS, poisoning--is expensive, time-consuming and runs the risk of occasionally coming up with falsely worrisome results.
Missing from both sides of the equation is trust. A healthy dose of listening is a fairly expensive proposition, when you get it from a doctor, but that's what makes a patient really feel better. Doctors don't spend the kind of time needed with patients to earn that trust (the health plans won't let them, and besides, there are two dozen other patients in the waiting room with the flu!), and many patients don't feel they've had a fair shake unless they've been ministered to by some sort of advanced technology.
My father's patients came in when something was seriously wrong. My patients come in when there's a hint that something could be the matter and expect to receive some kind of prescription. Maybe next year, or the year after, we'll have more to offer: nasally inhaled vaccines, effective antiviral medicine, a branch of the Second Avenue Deli in Bethesda.
But for this year, one last piece of advice from Dad: "If I give you antibiotics, you'll be better in seven days. If you go home and take chicken soup, you'll feel fine in a week."
J.B. Orenstein is a Washington area emergency room physician.