Blog | Friday, May 29, 2015

Why does sore throat diagnosis and management cause controversy?


In 2007, Malcolm Gladwell spoke to the Society of Medical Decision Making in Pittsburgh. In his talk concerning decision making, he used sore throats as an example of “easy decision making.” Of course I stood up after his talk to point out that even sore throats raise complex decisions.

Just this year, my friend and colleague Jeffrey Linder titled his editorial about our recent pharyngitis paper: ”Sore Throat: Avoid Overcomplicating the Uncomplicated.” Sore throats often are uncomplicated. They often represent “just a sore throat”. But sometimes they portend more serious illness.

Many diagnostic delays occur because we physicians blow off the patient's complaints as simple or uncomplicated. But sometimes serious consequences follow these routines complaints. Talk to any college health physician and they will tell you that they worry about sore throats; they worry about missing something more serious.

What could they miss? Obviously, I am obsessed with the Lemierre Syndrome, which is relatively rare (I estimated in 2009 one in 70,000 adolescents or young adults each year) but often devastating. They could miss a peritonsillar abscess (or at least delay diagnosing it). Sore throats can precede acute rheumatic fever (not very often in the U.S. or Europe these days). Or sore throats can represent the initial presentation of HIV infection.

I could provide an even longer differential diagnosis for sore throats and often do that, boring the heck out of my colleagues and learners.

But back to the question I raised. I am sore throat obsessed. I see every sore throat as a potential diagnostic challenge. I write about sore throats and understand the red flags. Prior to assuming that the patient has an uncomplicated sore throat, I check off expected signs and symptoms and exclude the warning signs of something different. But then I am obsessed.

If we teach that sore throats are self-limiting and uncomplicated we will be correct over 90% of the time. But we have a responsibility to worry about the less common problems that present as “just a sore throat.” We need to know when to worry. Jeff should have titled his comments: “Sore throats—usually uncomplicated”.

We must teach more about when to worry. To label sore throats as uncomplicated without also presenting the fine print is potentially harmful, and can lead to diagnostic laziness.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.