Guidelines, screening

I'm cleaning off my desk today

Items in the pile:

a) Junk mail from Life Line Screening Radiology.  It's targeted to our zip code — not just physicians.   Like the Bookmibile … they'll be in the area next week.  It looks like they set up shop in the parking lot of a local church.  I can get a carotid u/s for $45 … Screen for an AAA for another $45 .. etc .. or  a "complete package" for $99.

I'm not sure what to think about this.  It's certainly not indicated in young people.  I wonder who shows up at such events. 

b) Another version of treatment guidelines for community acquired pneumonia.  As usual, this one suggests that we use:

  • A macrolide such as erythromycin, clarothromycin, or azithromycin
    • or
  • Doxycyxline
    • or
  • An extended spectrum quinolone

When I was in training, I recall wondering what the "right" answer was.  I thought I was stupid because I didn't get it .. that somewhere in the guts of the guideline was the right answer hiding from me.  Instead .. it seemed elusive.  "You CAN do this …  you could choose one of these .. " It all seemed so ambiguos.

Now that I'm a jaded mid-career 40 year old physician .. I see that these things are vague because no one has the right answer, and they are fearful in such a guideline to dictate what the physician shoudl do.

This is odd.  We need more clarity .. not more ambiguity.   We all end up at an answer when we reach for the prescription pad.   Are some answers better than others?  Yes.  Why?  … ooh .. we're getting closer.

So the guidelines need to help physicians parse out the distinctions.

Why is azithromycin NOT my first choice for community acquired pneumonia?

    • It's expensive
    • It's too broad-spectrum
    • It causes resistance in all macrolides – likely due to its very long half-life and the verly long time that it remains in tissue at levels below MIC