Natural history, guidelines and performance measures

20 Jul
2009

Most readers know that I frequently give talks on pharyngitis. Most recently I have focused on morbidity and mortality in pharyngitis patients.

I have collected a number of unfortunate stories about patients having prolonged illness or even death when their initial symptom was pharyngitis. I have written and thought about pharyngitis for almost 30 years. My initial approach to pharyngitis came from the emergency department – quick decision making – is it strep or not? My second approach to pharyngitis came from considering a broader differential diagnosis – non-group A beta strep, infectious mono, gonococcus – and considering empiric antibiotic therapy. More recently I have focused on the dangers of considering a sore throat JUST a sore throat. As I spend more time doing inpatient medicine, I see pharyngitis through a different lens – a lens of morbidity and mortality.

In analyzing the patient stories that I use, I find a commonality. Physicians too often consider pharyngitis JUST a sore throat. This error does not exist just for pharyngitis, but perhaps one more easily ignores the patient when approaching pharyngitis. We have guidelines and performance measures that tell us to do a rapid test, treat if positive, and otherwise reassure the patient.

These guidelines and performance measures have a major flaw – they ignore that patient. The authors consider pharyngitis as a simple dichotomous problem – strep or not strep. They assume that while not perfect, a rapid test is good enough, afterall little harm is done even if you do not give antibiotics to strep.

In all the sad stories that I share, physicians (or nurse practitioners) follow guidelines. Sometimes they even are nervous and prescribe empiric antibiotics. But in all the stories one can impute a lack of cognition. They either ignore natural history, or are ignorant of the natural history.

They do not seem to understand that sometimes a sore throat is not a simple sore throat. They fail to adequately exam the patient or take a careful history. Sore throat patients apparently do not deserve thought.

While I am talking specifically about sore throat patients, you should extrapolate this screed to all presenting signs and symptoms. Each patient deserves careful consideration. We should always see if the patient’s story and exam fit a common problem as described in the textbook. We should always reconsider the problem when the story does not fit our assumptions.

The rationale behind evidence based medicine and the guideline movement is too improve medical decision making. I fear that too often these guides become cookbook directions for caring for problems. Patient presentations are too often complex and do not fit the directions. We must individualize our clinical thought processes, taking into consideration the evidence, but also the patient.

In my frequent pharyngitis lectures, I emphasize the importance of natural history. I make clear the red flags in pharyngitis patients – reminding the audience and myself when to deviate from “the protocol.”

I fear that guidelines and performance measures encourage us to forget the basic detective approach to pharyngitis. When all the clues are not explained simply, then we should recheck the clues and more important recheck the denouement.

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In: Medical Rants

5 Responses to Natural history, guidelines and performance measures

Web Media Daily – July 20, 2009

July 20th, 2009 at 9:09 am

[...] Natural history, guidelines and performance measures… DB’s Medical Rants [...]

Bohdan A. Oryshkevich, MD, MPH

July 20th, 2009 at 11:32 am

I agree. But why not just say that the physician has to gather the chief complaint, the history, do the vitals, and do an exam.

The vast majority of mistakes in pharyngitis come from the fact that the vital signs are not taken, no one looks at the HEENT and no one feels the tonsils.

I have seen a variety of conditions missed because someone did not take a pulse. The patient was actually complaining of pounding of the neck: he had atrial flutter not strep.

Or the patient had a peri-tonsillar abscess which was missed because the tc was negative? No one looked at the throat.

The recent case here with a young girl with strep toxic shock syndrome was a case in point. Despite an extensive literature search I could find no report of an active pharyngitis leading to strep toxic shock syndrome. It may be a similar bacterium but it is not necessarily the same disease. This patient did appear to have localized pain. Localized pain is a feature of strep toxic syndrome. But we have no information about what the doctors saw or did except for the fact that she apparently had a throat culture twice. That is not a screen for toxic shock syndrome.

In reality, what every doctor needs to do is know the basics. A seemingly straightforward strep throat with an exceedingly high temperature may occur in atrial septal defect. One does not need to do anything fancy just listen to the heart the next time the patient comes and when the pulse is slower. Know the differential and think of it every time.

I think that too often doctors ignore the chief complaint or jump to the conclusions. I found that the nursing assistants in my clinic could not even get the chief complaint right so one had to start all over and often get them to take the temperature properly as in that case of strep throat and ASD and a temperature of 105 that I had some years ago. She had a very fast pulse and a low temperature. The pulse gave me a clue to her temperature. A double check on my nursing assistant.

Bohdan A. Oryshkevich, MD, MPH

July 20th, 2009 at 3:31 pm

I guess I would say why not teach universally applicable rules of history taking, physical diagnosis, and diagnosis rather than mechanical one diagnosis based guidelines.

Bohdan A. Oryshkevich, MD, MPH