I returned to the exam room with the results of the five minute rapid strep test on an elementary school boy whose mom had brought him in with a complaint of a very sore throat. “His strep test is negative Mrs. Thompson.”
“Well that’s a relief!”
My own thoughts about it were a little more mixed. Most of the non-strep throat infections are viral so you are left to just letting them run their course.
Pharyngitis is the medical term for infection or inflammation of the throat, generally causing the symptom of a sore throat. The problem is, someone with a bad sore throat is usually hoping for antibiotics to help them get better. In fact up to 70% of patients going to a doctor for a sore throat (and there are about 15 million people in the U.S. who see the doctor for a sore throat every year) receive antibiotics. At the same time, only about 20 to 30 percent of children and just 5 to 15 percent of adults with a sore throat have strep. Most of the rest have viral infections where antibiotics only contribute to side effects and more resistant infections, while providing no benefit..
So how do we sort out which infections are strep and which are probably viral? First there are other symptoms that help greatly. If there is a runny nose or cough with the sore throat it is almost certainly viral and not strep. A classic strep throat has fever and sore throat without runny nose and congestion, but often with nausea or headache. Also, age matters: strep is uncommon under 3 years of age, peaks between 4-7 years of age, and becomes less common in adults, though still showing up sporadically.
It has been shown repeatedly that even experienced doctors can’t reliably tell a strep pharyngitis from a viral one just by looking – there is too much cross-over in how they appear. So a rapid strep test really is needed for accurate diagnosis. These are up to 90-95% accurate and only take a few minutes. Recently it has been recommended that the old routine of double-checking a negative rapid strep test with a throat culture be abandoned as it adds cost without any measurable additional benefit.
Here is a question that is not as obvious as it first appears: why do we even want to treat strep throats with antibiotics. It surprises most people to hear that strep throat will usually clear up in a few days (about 7 days on average) even without antibiotics. The benefits of the antibiotic (usually penicillin unless a person is allergic to it) are that they:
- Slightly shorten the course of the infection (by 12-16 hours)
- Render the person non-infectious more rapidly (usually within 24 hours of starting the antibiotic)
- May minimally reduce complications such as abscesses of the tonsils or ear infections
- May possibly help prevent serious other complications of strep pharyngitis. But this is controversial as they have never been proved to prevent the kidney disease called post-strep glomerulonephritis. Likewise many argue that rheumatic fever (a serious complication permanently damaging the heart) doesn’t seem to be caused by the vast majority of the strains of strep currently occurring in the U.S.
So the benefits of antibiotics for treating strep throat are sketchier than they were once thought to be. And on the other side of the coin, about 10% of those treated with antibiotics get diarrhea, occasionally a serious type caused by C. difficile. Also 0.24% have a life-threatening allergic reaction. This means that out of 10 million patients treated with antibiotics, as many as 24,000 of them will have fatal or near-fatal allergic reactions.
Most sore throats get better without treatment, even including strep pharyngitis. So the decision to test and treat is a bit more complicated than it was once thought and deserves some individual thought on a case-by-case basis. As a little side note, that’s why the emergence of telemedicine (where patience are diagnosed and treated by phone) holds as much concern as promise. The tendency to misdiagnose illnesses and misuse prescriptions will only grow with this looser connection between patient and physician.
So who thought something as “simple” as a sore throat would take two articles just to summarize? But we haven’t even mentioned mono or the non-strep bacterial culprits that can be other serious causes of your sore throat. More on that next time.
I will be staffing Trinity’s walk in clinic tomorrow, Saturday June 2nd, 2016. DPC patients and members are eligible to use this time to be seen for urgent issues as part of their membership with no per visit fee. Please feel free to come in during our open hours of 8:30 to 11:30am. No appointment is necessary.
In 1993, MTV’s new hit reality show The Real World: Los Angeles was in its second season. During that season Tami Akbar Roman famously had her jaw wired shut in an attempt to lose weight. From her perspective it was a simple enough idea, if she can’t eat food, then she should lose weight, right? It was one of the first of a long line of reality show TV stunts that are all too familiar today. Twenty three years later, I’m sad to say that a panel of international experts on diabetes has recommended something very similar as their preferred treatment for obesity in diabetics. They go on to extend these surgical recommendations all the way down the line to diabetics with class I obesity (BMI of >30kg/m2) who have poor glycemic control. That means a 222lb man standing 6 ft tall with poor blood sugar control on medications should consider bariatric surgery as his next best option.
Metabolic Surgery in the Treatment Algorithm for Type 2 Diabetes: A Joint Statement by International Diabetes Organizations
Even in 1993, long before I started my medical training, I understood that physically preventing food from entering the body was a poor way to lose weight and become healthier. It must start with a change of heart and an improvement in understanding. A point that Tami was happy to prove for me as she attempted to take all her normal foods and puree them through a blender. I seem to remember a cheeseburger slurry showing up during one of the episodes.
That’s the story with so many patients who undergo surgical weight loss. Without the change of heart and change of understanding, the recidivism rate is quite high. Lest you think I’m pointing a finger, let me explain that I understand their dilemma all too well. I teach nutrition. I treat diabetes. I see the heartache and pain associated with blindness, kidney failure, amputation, and neuropathic foot pain and yet I still really like Double Stuf Oreos. “Like” is too soft a word. I long for Double Stuf Oreos. Every summer I’m tempted mightily by these wonderful little chocolate promises of happiness.
Don’t give up what you want most for what you want now
What are we to do? How do we change? How can we go from surgically altering our bodies in an attempt to irrevocably force limited food consumption to choosing life-giving options that promote our wholeness physically, emotionally, and spiritually?
For me, I believe it starts with a change of my heart and a change of my understanding. I’ve learned more about nutrition in the last 15 years then any other medical topic. My understanding has been refined through trial and error in my own life as well as when I work with patients through their struggle. This self-education was fostered by friends as early on as medical school and continues to this day as my fellow Trinity physicians and clinicians challenge me with new research. I love being part of a practice culture that works so hard with individual patients in their understanding of how nutrition shapes health. The continual education and re-education of nutrition has been the easy part for me.
Love… faithfulness, and self-control
As Paul fought against Jesus’ calling in his life so too does my heart still kick against the goads of my soul. I am coming to believe more that for us to truly change our behavior in nutrition, among many other areas of lives, we must first change our heart’s desire. I recently heard it said that you “Don’t give up what you want most for what you want now”. Similarly, in Galatians 5:22-23 Paul pens the fruit of the Spirit as love, joy, peace, patience, kindness, goodness, faithfulness, gentleness, and self-control. I believe that if my love is rightly fix on something worthy of that love, if what I want most in my life is the growth of that love relationship, then the natural outcome will be the fruit of the Spirit including faithfulness and self-control. Faithfulness in choosing well when someone else’s interests are at stake (ie, how I parent, how I practice medicine, how I treat my neighbor, etc…) and self-control in choosing well when only my own interest’s are at stake (ie, what I eat, how I exercise, my personal time, etc…). (Notice that fruit is singular not plural. That’s important because the fruit comes as a single unit not multiple fruits from which we get to pick and choose those that taste good while avoiding those that are unpleasant to us. We produce these traits as a collective whole.)
So that begs the question, “What should I love?” If the direction of my heart’s affection changes the choices I make and how I live my life, then what should be my heart’s desire? There is only one thing worthy of your love and worship. It isn’t health, or your family, or your self-image, or even the promise of less pain in your life. It isn’t the hope of a cured cancer or the re-opening of clogged arteries that is worthy of our utmost desire. Only God is able to receive worship properly. Paul writes to the Corinthian church, “whether you eat or drink, or whatever you do, do all for the glory of God.” When our first thought at every intersection of our lives is “how do I glorify God in this situation?”, then we fundamentally start changing the things we do. Our choices are now informed by a true and perfect set of guidelines that lead to our ultimate good. They very often lead to our physical good, a healthier or more functional body, but that isn’t their goal. The goal of our actions is to glorify God. In that power, we can choose well the foods we eat or avoid.
Biblical counseling is nutritional counseling is Biblical counseling.
However, the fruit of the Spirit isn’t the fruit of my spirit but the fruit of THE Spirit. It is God’s Spirit dwelling in me to grow in faith and love of God Himself. It is much deeper than following a 12 step program of reform. It is much more fundamental than even just adhering to the 10 commandments of scripture as though they are highway guard rails that keep us pointed in the right direction hopeful that we might finish the race before we screw up too badly. Instead, we are to be driven by the hope within us in Christ’s finished accomplishment. As God works in our lives, His fruit is produced.
Trinity’s Biblical counseling program was built on this foundation so that we can help our patients understand what their heart’s desire should be. We saw the need to help our patients understand the hard moments of their lives in the light of God’s worthiness to receive worship. It was only natural for us with this counseling mindset to extend our help for patients into the area of nutrition and exercise with our VitalSigns program.
I urge you as we all walk together through your life to reach out to us and begin to understand the choices that will truly fulfill you. Please call us at 539-0270 to set up an appointment with your physician or clinician to begin this discussion. Call and set up an appointment our Biblical Counselors or our Medical Nutrition Management clinicians to start addressing the fundamental issues that shape our lives. Don’t let another set of superficial, hollow medical guidelines lead you further away from the truth.
…in the waiting room because the doctor is running late (again)!
In the DPC model of care, I get to spend more time with each patient. I don’t have to try and polish my skills at polite interruption because I have other patients waiting. Instead, each visit is long enough to cover the majority of concerns a patient my have. If not, we can easily prioritize which concerns to cover and schedule a follow up visit (again, with no per visit fee) to address the rest. That means I can stay on time virtually all of the time. Many of my DPC patients don’t even have the chance to sit down in the waiting room before being shown to their room and I’m ready to walk in as soon as they are settled. I love this model of care and I think my patients do too. I do feel sad for all the leisure reading my patients will miss out on while waiting in my lobby.
If you’re interested in learning more about Trinity’s Direct Primary Care program, then send me an email at email@example.com or call my DPC coordinator, Mel Moss, at 244-1800. We’d love to talk to you more about the program and explain how it can benefit you and your family. When you’re ready to experience the Direct Primary Care program you can sign up at Trinity Direct Primary Care Sign Up.