Certain medical problems are a pleasure to treat–when the diagnosis can be made with confidence and no major inconvenience to the patient, when the treatment is effective and safe, when the cure is complete. By all rights, strep throat should be one of these diagnoses.
Sure enough, the suckers grow. And thanks to the wonders of antibiotics, Missy is able to return to choir practice. In a voice-over, Peck muses: “The specter of rheumatic fever, which used to lurk behind every sore throat, no longer haunts our children. Penicillin has brought us into a new age.” Perhaps Missy isn’t aware that the reason Dr. Peck is so satisfied with himself is that he has prevented a case of rheumatic fever. But she doesn’t bother the doctor with questions: she’s better and she’s grateful. At the concert, she sings out to him in the audience, and he smiles wisely back.
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Rheumatic fever, on the other hand, is serious business. Many of us who grew up with antibiotics have never seen a case of the disease, but the “major criteria” and “minor criteria” for its diagnosis are part of the lore of the old days. About 2 percent of patients with untreated strep throats go on to develop an illness of three to six months’ duration, characterized by fever, involuntary movements, heart damage, arthritis, and skin rashes. No one knows for sure why this happens, but the leading theory is that the people who succumb to rheumatic fever have immune systems that go haywire fighting the streptococcal bacteria and end up fighting their own tissue. Some patients make a complete recovery, but others are left with permanent heart damage, which was a common cause of premature death in the preantibiotic era. Even now, in third-world countries, experts estimate that rheumatic heart disease causes 25 to 40 percent of all cardiovascular disease. The peak age of strep infections–and thus of rheumatic fever–is between five and fifteen, so these are patients in the prime of life suffering from an eminently preventable disease.
The conquest of rheumatic fever is a tale that stirs the heart of every red-blooded health worker. Even the staid journal of the American Medical Association exulted in an editorial in 1986, “The remarkable change in the natural history of group A beta-hemolytic streptococcal pharyngitis and its sequelae is one of the great success stories of the 20th century.” But the exquisite irony of the clinical situation is that 90 percent of sore throats are caused by viruses, which don’t respond to antibiotic treatment. Yet patients with sore throats seek antibiotics for the relief of symptoms, and are less than impressed with the physician who simply informs them they don’t have strep.
Most physicians are familiar with this data, but there is no consensus on how it should be used. A survey in The Annals of Internal Medicine showed that 23 percent of primary-care physicians never use throat cultures, 25 percent always do, and 52 percent selectively culture. This is not as crazy as it sounds, since different patients require different strategies. In a transient emergency-room population, where many patients have no telephone, it doesn’t make sense to culture much, since it will be impossible to reach the patient with the results in 24 hours. Better to treat those with two or more signs and forget it. In a stable suburban practice, with a lower prevalence of strep anyway because of less crowding, it makes sense to rely more on cultures, since in this era of the answering machine, car phone, and beeper, those folks are not hard to reach.
Joe Girard, the champion car salesman who wrote How to Sell Anything to Anybody, has a “rule of 250.” He says that no salesperson can ever afford to alienate even one customer, because the customer has contacts with about 250 other people who will certainly hear about a negative experience (but not necessarily a positive one). The rule of 250 explains why polls show people like their own doctor, but think the rest of them are jerks. It also implies that a problem like a sore throat, where most of the time the doctor’s treatment will (quite properly) run counter to the patient’s preference, can wreak as much havoc with public confidence as actual negligence.
