A Hamburger Tale

Back in 2003, as a coach of a girls youth soccer team, I used to take the kids to a hamburger stand after each game.  The owner always greeted me warmly.  “Hey doc, how many burgers today?”

“Ten,” I said one day.

The owner looked distressed.  “Hmm.  I might not have that many.”

“I have 10 hungry kids,” I interjected.  “They’ll be disappointed if they don’t each get a burger.  This was our last game, you know.”

“I’ll check again,” he replied.  Soon he returned with 10 burgers.  “Got lucky.  Sorry about the scare.”

“No problem.  That’s why I come here.  I always get what I want.”

The next day a player’s mom called to say her daughter had diarrhea and was vomiting.  “Could it be food poisoning?” she asked.

I told her I would find out.

I called the hamburger stand owner and told him that one of the kids was sick, and asked if the burgers could be responsible.  To my surprise, he said “Yes.”

“Remember, I didn’t think I had enough burgers, then came back with 10?” he said, without a hint of distress.  “Well, I only had 9 that I knew were good.  The 10^th burger had been sitting around for a few hours.  I thought it might be bad, but decided to take the chance.”

“You what?” I asked, incredulous.

“You know I always try to keep my customers happy.  What’s the fuss?  Only one kid got sick, and all she got was diarrhea.”

Needless to say, I was flabbergasted.  How much irresponsibility did he think was acceptable in the name of satisfaction?

Whenever I tell this story, the response is typically an incredulous look and a recommendation that usually is somewhat along the lines of opinion that the owner of the stand should be boiled in oil.

Then I tell the truth:  This incident never happened.  It’s a parable I like to tell residents or medical students when we discuss the unnecessary use of antibiotics.  You see, if you replace the word “hamburger” with “antibiotic,” and replace “stand owner” with “family doctor,” the story is virtually the same.

When a doctor gives a patient unnecessary antibiotics just to keep them happy, the doctor is doing exactly what the owner did.  Same principle, and same consequences (actually, probably worse since antibiotics wipe out much of the entire gut flora for a long time).  So why do most doctors think the hamburger story is ghastly, yet continue to prescribe unnecessary antibiotics?

According to the CDC* and the New England Journal of Medicine** studies indicate that nearly 50% of antibiotics are unnecessary but some patients are happier when we prescribe them.  Yet antibiotics have a number needed to harm (NNH) of about 10 if we define harm as antibiotic associated diarrhea (that means that for every 10 people who take an antibiotic, 1 of those 10 will end up with diarrhea).  This is the same as in the hamburger story.  Of course, that’s without counting the growing threat of antibiotic resistance and without considering the likely longer term health consequences.

So, if you’re a patient, the next time you’re tempted to demand antibiotics unnecessarily, consider this story.  Or, if you’re a doctor, the next time you’re tempted to prescribe an unnecessary antibiotic to keep a patient happy, tell the patient this story instead.

*Get smart for healthcare. Centers for Disease Controland Prevention Web site. 

**Hicks LA, Taylor TH Jr, Hunkler RJ. US outpatientantibiotic prescribing, 2010. N Engl J Med. 2013;368:1461-1462.

Note:  The inspiration for writing this story came from an article in The Journal of Family Practice, November 2013, Vol 62, No 11, Pg 620.  I used their story and made it my own.


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