Cold and flu season can feel overwhelming whether you’re in the urgent care or doing telemedicine. But don’t feel defeated, I’ll share some tricks with you here that will make it easier for you to get through the cold and flu season and help you see more patients per hour. 

We’re not alone in addressing these cyclical issues; during the summer months the HVAC people work long hours because of broken down A/C’s. They charge extra fees for same-day calls so it’s not all bad. 

On hot days in Los Angeles where the days are longer, the police have to break up more fights and deal with more gang violence. Cops, too, earn a premium for working overtime during these days. 

Finally, don’t forget our poor pharmacy colleagues who get demolished because doctors are dishing out meds just to be able to exit the room and get to the next patient.

Listen to a brief recording on the topic if it’s easier:

Cold and Flu Season

Patients visit and urgent care or resort to telehealth for their cold and flu symptoms for two main reasons:

1. frustrated with their symptoms 
2. worried about complications from a missed infection

As clinicians, we know that the majority of these upper and lower respiratory tract infections resolve on their own. No matter how much the CDC and medical specialty groups try to scare us, even pneumonias and ear infections resolve on their own without intervention. 

Most symptoms are often allergy related and the rest are viral. A few are bacterial and will require further workup such as chest x-rays or blood work or that thing where you touch the patient with your stethoscope.

Medications

Patients desire medications because as US consumers they have gotten accustomed to spending money in order to purchase a solution. The stronger the antibiotic or the more expensive, the more potent it must be. 

Quite a few will ask for double coverage of antibiotics or for a “second round”. Though, many will also prefer something more convenient such as the Z-pack. 

We have to blame marketing and poor consumer education for this medication craze. It is what it is. What can we do about it to have a sane cold and flu season?

Prescribing symptom medication isn’t a good solution. It creates more work for you as a clinician, it’s not a good health option for the patient, and it can increase litigation risk for you.

• albuterol
• Tessalon
• meloxicam
• Singulair
• Qvar
• Cheratussin
• prednisone
• Medrol pack

The above are a list of medications I commonly see prescribed during telemedicine visits. Doctors assume that patients will leave unhappy unless they leave with a medication.

I don’t think that’s true with telemedicine as I explained in this previous post. The patient might appear to want to have something prescribed but if you hold your ground and come across as genuine and knowledgeable, the patient will be adequately content leaving empty-handed.

Lawsuits

I want to talk about lawsuits first before I talk about efficient telemedicine cold and flu practices. Lawsuits and patient complaints are a real risk for us and it’s good to review this. 

Patients can sue. Their family members can sue. The medical board can come after you because of a complaint. Your employer can investigate you. In the end, you’ll have one big giant pile of shit to deal with, often because you intervened – lemme ‘splain. 

It’s far more likely that you will get into trouble for ordering antibiotics and prescribing medications than if you simply reassured the patient or sent them to a higher level of care facility. 

This isn’t true for ER doctors or when you see patients in the urgent care. In such higher acuity settings, unlike telemedicine, the things you don’t do can get you into more trouble than the things you don’t do. 

Telemedicine Cold and Flu 

I have a systematic flow which I follow for every patient. Even though I try to treat each person as an individual, the flow is the same. 

Cold and flu season is my favorite time of year – it’s my fucking Christmas. The cases are predictably easy. There is very little thinking involved. And I am comfortable saying no to patients. 

I have a feeling that for most family medicine doctors it’s not that cold and flu season is challenging, rather, they don’t like saying no because it hurts us to have to make a patient feel bad.

1. Have a System in Place

My system is as follows:

1. introduce myself
2. verify patient identifiers
3. open-ended question about why they made an appointment
4. ask a few pointed questions
5. offer my impression
6. close the encounter

#1 and #2 are obvious.

But #3 is important. I let the patient talk with a leading open-ended question about what’s going on with them. If I know the particular chief complaint then I lead with that and have them expand on it. 

#4, I thank them for the information and sometimes express the fake empathy we’ve all been taught in medical school and residency. I then ask very specific questions and have the patient do a self-exam by looking in the mirror at their throat, feeling for lymph node, press on their belly, etc. 

Once I have all the information, and this is important, I offer my final impression which includes my assessment and plan, #5. This isn’t negotiable. It’s the final verdict and I will only change it if the information which I collected changes. 

You want to offer as much information in your impression as possible so that there is nothing left for the patient to question. I talk fast but I’m concise. I explain my rationale without going into too much detail.

“Thank you for the information you provided Sally. Based on everything that you’ve said, my impression is that you have a viral sinus infection that’s been going on for the past two weeks. There’s no indication of a bacterial infection which would require antibiotics per current Infectious Disease Society of America recommendations. I do recommend that you increase your usage of fluticasone and add Zyrtec as well as Sudafed which are over the counter meds. I would also recommend that you start doing sinus washes several times per day using something like Neti Pot or NeilMed. I suspect that your symptoms will still last another 10 to 14 days. If at any time you start getting worse it would be necessary for you to be seen in the clinic in person.”

The patient may question you but you have already explained yourself. Reopening that wound would be useless for both of you. If the patient insists on antibiotics then you can repeat back to them that you don’t think antibiotics are indicated and that they would likely cause more harm than good.

2. Triage

One way to end an appointment quickly is when a patient tells you they are having shortness of breath and coughing and fevers. That they are wheezing and can’t get through the night and that they have tried over the counter medications and …. that it’s time for an antibiotic.

“It certainly sounds like you’ve tried several things and that your symptoms are leaning towards a potential bacterial infection, George. However, I can’t assess that over the phone and because of those symptoms it would be best for you to be seen in the urgent care because usually patients with those severe symptoms have a pneumonia.”

The patient may backtrack and say that their symptoms aren’t as bad. Suddenly they don’t have a fever, their SOB is gone now, and they are feeling well except for a little cough.

Since the story changed so much, I don’t spend much more time other than recommend that they be seen if the initial symptoms they described. And then I recommend my usual list of over the counter medications and I’m done with that visit.

3. Collect Information

When you are ready to deliver your impression to your patient and you want that to be the last exchange with the patient, it’s best that you spend the time to collect all the necessary information.

Figure out why the patient made the appointment, maybe it’s just that they can’t sleep at night. Figure out what exactly they are worried about, maybe a pneumonia. And get all the relevant symptoms and durations and exacerbating factors.

• What’s the one symptom that’s bothering them the most?
• What is they were worried about?
• What were they hoping to get from this visit?

4. Explain Your Rationale

In my impression monologue, I also offer a rationale if the time allows. I explain why I believe it’s allergies – maybe because they get it the same time every year. I explain why it’s not a bacterial infection or at least not a bacterial infection which needs antibiotics.

When you explain your rationale and you do it concisely, professionally, and without judgement, the patient is far more likely to accept your final decision.

5. Diffuse the Situation (bag of tricks)

I don’t write a lot of antibiotics and don’t give a lot of symptom medications and I still manage to get stellar patient satisfaction scores. This should be proof of concept for those who want to emulate.

My patient volumes are also in the 8-12 patients/hour range. The longer the shift, the higher my range. Spending more time per patient on the phone just creates a poorer experience for both of us.

When I have an upset patient then I usually will apologize that they weren’t happy with my decision. I sometimes will take one step towards them and let them know that it would be harmful for me to give them a medicine which I think they didn’t need – I appeal to their rational side but don’t undermine their feelings.

“I know this isn’t what you expected but I’m certain that you will improve if you try to follow the suggestions I’ve made.”

Then I ask if there is something else that maybe they are worried about which they haven’t mentioned yet. After all, I’m convinced that they will get better with what I have recommended.

I ask if they might benefit from a work note. Little things like that, strategically placed at the end of the visit to defuse the situation, will turn that 1-star into a 3 or 4-star. And with the rest being 5-star, you’re golden, baby.

Still have a hard case? Here is a list of potent shit I like to dish out to the difficult patients.

Antibiotics Cause…

I mention that Azithromycin can cause abnormal heart rhythms. It can cause a heart attack, etc.

That amoxicillin can cause resistance in other organisms and increase the risk of colitis. It can cause a severe anaphylactic reaction, yeast infections, and diarrhea which can last several weeks.

I mention that respiratory fluoroquinolones can damage the tendon and increase the risk abdominal aortic aneurysms. It can cause neuropathy or low hypoglycemia.

Virus Types this Season…

I tell the patient that their symptoms could be caused by over a hundred different viruses and I start rattling off some names:

• parainfluenza
• coronavirus
• RSV
• metapneumovirus
• rhinovirus
• adenovirus

Your state’s health department will have a list of current, active respiratory viral outbreaks. Look that up sometime in the cold and flu season and you’ll appear more trustworthy.

Home Remedies…

I used to have a list on a piece of paper next to me for the different things a patient can try at home. This is especially useful when the patient tells you that they have done everything and you can blow them away with all the things they haven’t done.

If they question you, then you start explaining exactly how the sinus wash gets rid of the mucus which collects in the lower respiratory tract overnight and makes you cough all day.

• sinus wash (Neti Pot, NeilMed, Ocean Spray)
• humidifier (or hot steam from the sink)
• fluticasone, budesonide, triamcinolone nasal sprays
• Afrin (can be used for >3 days if used with a nasal steroid)
• pseudoephedrine, phenylephrine
• guaifenesin
• chlorpheniramine (for the hypertensives)
• Tylenol cold and sinus
• Advil cold and sinus
• Alka-Seltzer cold and sinus
• dextromethorphan
• ibuprofen (recommending higher doses)
• tylenol
• aspirin (recommending higher doses)
• Theraflu
• Vicks
• Benadryl

This is the stuff they can find in their local pharmacy. I also know exactly why and how to use one over and another.

Next, I have a list of herbal remedies. I get my list and information from drugs.com, though, there are other great resources. If you have them, share them in the comments.

• garlic
• onion
• ginger
• lemon
• cayenne
• sage
• cinnamon
• nettle leaf
• peppermint
• oregano oil
• vitamin D supplements
• omega fatty acids
• cutting back on sugars and grains

Ponder This

Should we as clinicians give out less medication in order to preserve our careers and income? It seems that more medication prescribing creates more stress on the system. It causes more side effects in patients and makes their health more brittle. But it also creates a very high revenue for us in this disease-based healthcare system.

If we change the culture and prescribe less, then there wouldn’t be much of a cold and flu season. I wouldn’t earn $250/hour doing telemedicine. I wouldn’t be able to pick up unlimited shifts in the urgent care.

Are we incentivised to prescribe more or prescribe less? That depends on what motivates us, whether a sustainable practice of medicine or the income from medicine.