An instructive tale about “hamburgers”



As coach of a youth 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?”

“Eleven,” I said one day.

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

“I have 11 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 11 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 son 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 11?” he said, without a hint of distress. “Well, I only had 10 that I knew were good. The 11th 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 he got was a little 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 usually an incredulous look and a recommendation that the owner of the hamburger stand be boiled in oil.

Then I tell the truth: This incident never happened. It’s a parable I like to tell residents 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 we give patients unnecessary antibiotics just to keep them happy, we are doing exactly what the owner did. Same principle, and same consequences. So why do most doctors think the hamburger story is ghastly, yet continue to prescribe unnecessary antibiotics?

Studies indicate that nearly 50% of antibiotics are unnecessary,1,2 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 diarrhea3—about the same NNH as in the hamburger story. (That’s without counting the growing threat of antibioticresistant organisms, the topic of a new CDC report4 and this month’s audiocast.)

So the next time you’re tempted to prescribe an unnecessary antibiotic to keep a patient happy, hand the patient a copy of this story instead.

T. Grant Phillips, MD
Washington, Pa

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