American College of Physicians: Internal Medicine — Doctors for Adults ®

Thursday, July 16, 2015

Lessons learned by studying sore throats for 35 years

Thirty-five years ago I started collecting data in a non-acute emergency room. Over approximately 3 months the residents enrolled slightly more than 300 patients into the initial sore throat study. Spending the next 3 months learning how to analyze the data, I began a long journey that continues today.

Learning medicine rarely includes having epiphanies. Learning medicine requires patients and reading. But we who teach medicine can help our learners speed that process if we help them focus on some key features.

My colleagues and I often cite Judy Bowen's classic article: Bowen, Judith L. “Educational strategies to promote clinical diagnostic reasoning.” New England Journal of Medicine 355.21 (2006): 2217-2225. In that article she introduced many to the concepts of problem representation and illness scripts.

Lesson #1 We need to be precise in defining illness scripts. Problem representations depend upon illness scripts as these 2concepts interact. Back in 1980 when this journey started, I thought of a sore throat rather simply. Today I understand that there are a series of potential sore throat illness scripts.

Script #1 Acute sore throat 3 days or less in duration with or without various other symptoms (cough, coyrza, fever and difficulty swallowing) and various examination features (exudates, adenopathy, measured temperature, erythema, tonsillar swelling). The discomfort should be in the throat, not the external neck.

Script #2 Non-resolving sore throat that starts as an acute sore throat, but worsens rather than improves. It may include asymmetry of the neck, unilateral tonsillar swelling, deviated uvula, persistent fever, rigors and/or night sweats.

Script #3 Neck pain but no actual throat pain. This usually is recognized as different from the other 2 scripts. Script #1 and #2 have very different implications. However, few clinical educators have taught that difference, and probably few have considered sore throats enough to distinguish between scripts #1 and #2, yet the underlying differential diagnoses are quite different.

The problem is actually more complex, because over the years it became quite clear that pre-adolescent pharyngitis differed greatly from adolescent/young adult pharyngitis (Mitchell, Michael S., Annalise Sorrentino, and Robert M. Centor. “Adolescent Pharyngitis A Review of Bacterial Causes.” Clinical pediatrics 50.12 (2011): 1091-1095.) While the general scripts are the same, the potential etiologies differ. Adolescents/young adults have a much broader infectious differential diagnostic spectrum and that differential has major implications.

We should apply the general concepts here to teaching clinical medicine. For example, consider your illness script for community acquired pneumonia. How long should the patient have symptoms and at what point does the history no longer fit CAP? How do classify patients who do not improve with adequate antibiotic coverage? Do we think differently about atypical infections from classic bacterial pneumonia? And you can ask some further questions.

Take chest pain, how many illness scripts could you develop for chest pain? How does one proceed to match these illness scripts against a careful patient problem representation? The illness scripts should influence the data you collect.

We must define data carefully. A wonderful question asked in Japan helped me understand that many listeners had a different understanding of the term data. In medicine I consider 4 classes of data: the history, the appropriate physical examination, laboratory tests with accurate interpretation, appropriate imaging studies.

Each illness script should include at least the first 2 data classes, but often we should add the third and fourth. And the illness script influences how we describe the patient, and what data from classes 3 and 4 we need. But the illness scripts also influence our history and physical data acquisition.

Lesson #2 We must appropriately keep an open mind as we learn new concepts that might apply to the clinical problem. I learned this slowly over the last 13 years as the Fusobacterium necrophorum story started to crystallize. Again I did not have an epiphany, but rather I developed a profound curiosity about this bacteria and its potential role in explaining some adolescent and young adult pharyngitis.

This concept seems simple, but actually we resist changing our understanding of disease. Two great examples come to mind – Helicobacter pylori causing ulcer disease and beta-blockers treating systolic heart failure. We resisted these changes even as the evidence supporting the changes were becoming very clear.

Lesson #3 Demographics can matter. In pharyngitis, I have already written about the differences between pre-adolescents and adolescents & young adults. Some illness scripts differ by gender, or socioeconomic status, or country of origin. We should not ignore these factors.

Lesson #4 Every medical problem is complex. Many physicians and patients consider sore throats as a simple medical condition. But our sore throat illness script should include some red flags. Duration of symptoms is a red flag. Sweats or rigors is a red flag. An asymmetric bulge in the neck is a red flag. Every medical problem has red flags and we must do a better job of teaching those indicators of seriousness.

As educators we have a responsibility to understand clinical problems in a different way and to teach clinical medicine in the way expert clinicians think. I suspect that some readers can identify a few clinical educators who approach clinical teaching in such a manner, but that most educators do not have this understanding. Am I right or wrong?

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.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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