I have practiced medicine for over 18 years and have gotten a lot of CMEs over that time. The lectures I have enjoyed the most have tended to be those exposing the myths of modern medical practice. You probably know the ones that I mean. These are the lectures comparing some common medical practice with the literature only to find that the practice doesn’t work—belief in its efficacy is a myth. In fact, just prior to its lamentable demise, The Western Journal of Medicine had a regular series devoted to debunking medical myths.
Myth-busting like this is part of the overall movement toward evidence-based medicine. In a nutshell, evidence-based medicine states we should compare all of the stuff we do as doctors with the scientific evidence of its effectiveness. When we do that, we will find there is a solid base in the evidence for only some of the things we do. Some of our practices have inadequate support in research—nobody really knows whether they are truly effective or not. And some of what we do is flat out contradicted by the evidence. Every year, important research emerges that should make us change the way we practice medicine. However, we too often do not change.
We all know doctors who seem frozen in time; practicing medicine the way it was taught to them in medical school and residency. We ask ourselves, “Why is he still doing THAT?” However, that doctor is most of us. If we critically compare many of our habits with the medical literature, we will invariably find that we ourselves have habits we should abandon.
In fact, failure to change practice based on new findings has been identified by many sources as a major problem with modern medicine. There is a gap, sometimes of many years, between what is known and what is practiced. Over the years, some information in medicine’s knowledge base is verified, and some is refuted. Whenever a new “fact” has been added to the overall medical knowledge base through good and repeated research, it usually takes many years until that knowledge is incorporated into most physicians’ practice.
Even a casual review of medical textbooks and the literature will demonstrate several well-demonstrated medical facts that are not widely practiced by US physicians. One area getting a lot of press is the overuse of antibiotics. We doctors still commonly prescribe antibiotics (and often very expensive antibiotics) for viral illnesses such as pharyngitis, bronchitis and sinusitis despite the enormous amount of literature condemning the practice.
We all have heard about the emergence of resistant bacteria as a consequence of our national over-prescription of antibiotics. We don’t so often hear of another downside to prescribing unneeded antibiotics—it is expensive. In fact, most evidence-based medicine principles are like that—if you adopt them, you will save money. What could be better than that? We provide better medical care to our patients, and save money to boot!
One great example is evidence-based treatment of pharyngitis, the infamous “sore throat.” It seems like this is one of the single most studied topics in medicine. There have been literally hundreds of articles published on this topic. Fortunately, the Centers for Disease Control (CDC) in Atlantahave published an excellent review article along with their recommendations that can serve as a basis for your jail’s “Sore Throat Protocol.” It was published in the March 20, 2001edition of the Annals of Internal Medicine, along with similar guidelines for the treatment of sinusitis and bronchitis. It can also be found online at www.cdc.gov/ncidod/dbmd/antibioticresistance/.
In their article, the CDC makes the point that only around 10% of cases of sore throat are caused by Group A Beta Hemolytic Streptococcus (the so-called “strep throat”). Almost all of the remaining 90% of cases are viral in origin. Despite this, 75% of adults who present to a doctor with a sore throat will be prescribed antibiotics! What is the rate of antibiotic prescriptions for sore throat at your facility? It would be well worth the effort to pull the last 100 charts where the chief complaint was “sore throat,” and see how many of these patients received antibiotics.
The CDC recommends instead that antibiotics be limited to those patients who are most likely to have strep throat based on four easily evaluated clinical findings:
(1) tonsillar exudates; (2) tender anterior cervical lymph nodes; (3) fever; and (4) absence of cough.
You then use these four criteria to determine who gets antibiotics in one of the following ways:
1. If the patient has 0, 1, or 2 of the criteria, no antibiotics should be prescribed. If a patient has 3 or 4 criteria, then antibiotic treatment may be used. I prefer this strategy at my jail because it does not require the use of rapid strep screens, which cost $5.00 to $10.00 each.
2. If you prefer to use the rapid strep test, the CDC recommends no treatment for patients with 0 or 1 criterion, and rapid strep testing for those with 2, 3 or 4 criteria. You then treat those where the rapid strep test comes back positive.
The CDC recommends throat cultures NOT be routinely performed. This is important because many lab facilities routinely follow up all rapid strep screens, whether positive or negative, with a $60.00 culture. Throat cultures should be reserved for special circumstances, such as tracking epidemic outbreaks of streptococcal disease, or if there is a suspicion of another bacterial pathogen, such as gonococcus
Finally, the antibiotic preferred by the CDC for the treatment of strep throat is plain penicillin. Not amoxicillin. Not Keflex. Definitely not Augmentin! If the patient is penicillin allergic, erythromycin should be used in its place. This point is important enough to say again: do not use expensive, broad-spectrum antibiotics to treat routine strep throat.
These guidelines do not apply to complicated patients, such as immunocompromised patients, or those with other significant medical problems, such COPD or a history of rheumatic fever. The guidelines also assume the practitioner will carefully exclude other serious throat disorders, such as peritonsillar abscesses or epiglottitis. Still, at my jail, the guidelines apply to over 95% of the patients who present to our medical clinic with sore throat.
Here is how these guidelines apply to a typical case. A healthy 35-year-old male presents to the jail medical clinic with a sore throat. His temperature is 97.6F. He has large red tonsils but no exudate. He has 2+ tender anterior lymphadenopathy. He has been coughing frequently. Physical exam shows no evidence of abscess or other complications. This patient has only one of the CDC’s four clinical criteria. According to the CDC guidelines, he should not have a rapid strep screen performed nor a prescription for antibiotics. Instead, he would be treated symptomatically with acetaminophen, increased fluids and rest.
I would like to encourage everyone to read the original CDC report. It is concise, well written, and authoritative. The four basic clinical criteria are easy to incorporate into a clinical decision model or a flow chart for your facility. I believe that if your facility adopts these guidelines, the quality and consistency of your medical care for sore throat will improve and your medical costs will fall.