Doctors work miracles now and then and provide genuine help most of the time. In one area, however, we are no different from physicians from bygone eras, alternative medical practitioners today, and quacks: patients who consult us must feel in the presence of someone with great healing powers. At the visit’s end, they must feel they have experienced those powers.

Only rarely can doctors do this dramatically; removing a sliver or a foreign body from the eye qualifies as the most gratifying experience for both of us. Mostly, patients judge us on our behavior. Both are important, but an air of absolute confidence trumps a good bedside manner. As an aside, because almost everyone we see either suffers an illness that will go away on its own or has a serious illness but looks sick, a quack with a professional manner who dispenses useless treatment can practice for years before a catastrophe unmasks him.

Nowadays, a patient does not expect the doctor to dance, burn incense, cast spells, or fall into a trance, but that does not mean he doesn’t “expect” something. Most Americans would deny they expect medicine, but no doctor believes this.

I can’t count the times (tens of thousands) when I’ve seen someone with a self-limited illness (for example “bronchitis,” i.e. a bad cough). After listening to the story and doing an exam, I reveal the diagnosis and its cause, estimate how long it will last, explain that no drug shortens the course, and suggest remedies that will make him feel better. There is always tension at the end of my recital as I await one of three responses. The patient might simply thank me before I leave, and it will be a grateful thank-you. I can tell. Doctors love gratitude, and we’re extraordinarily sensitive to the genuineness of your thank-you. He or she might also depress me by delivering a polite thank-you. Few patients will argue with a doctor, but I can see the disappointment in their eyes. Time and again, my sensitive ears have picked up “he didn’t do anything” as I close the door behind me. Less often but not rarely, a patient expresses frank dissatisfaction. He explains that others call a doctor for minor illnesses but not him. He’s sick, and he needs something to knock this out. Other doctors have understood this and given him what he needs.

He is not lying. Prescribing antibiotics for viral respiratory infections is so common it’s not a sign of incompetence. Good doctors do it routinely. An expert called this avalanche of unnecessary antibiotics one of our greatest environmental pollutants. Sadly, experts do not practice, so they don’t have to deal with the fifteen percent of all acute illness which are viral infections. During the winter in the walk-in clinic where I once worked, this tripled. A doctor who prescribes antibiotics for every respiratory infection may feel uneasy over their long-term harm, but the immediate outcome is entirely pleasant: a quick visit ending with gratitude. Not prescribing an antibiotic always requires an explanation, resulting in a longer visit and sometimes a disappointed patient. And, very rarely, a loud announcement that he came for help which I denied him and that I am unfit to practice medicine. “Very rarely” in the context of tens of thousands of visits means it’s happened a few dozen times.